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Chapter 2 Index
A. Evaluation by system:
1. General
2. HEENT 3.
Cardiopulmonary
--Heart Murmurs: When to Refer
--How to Feed Infants with Heart Disease
--Syncope in the Pediatric Age-Group
--Asthma: Classification and Management
--Asthma Medication
--Exercise Induced Asthma (EIA)
--Home Monitoring: The Role of the Pediatrician |
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Bronchiolitis
Definition: A disease of the lower respiratory tract
characterized by wheezing and respiratory distress. Peak incidence 6 months
of age; occurs up to 2 years of age. Disease results from inflammation
leading to obstruction of small airways. Worse with tobacco smoke exposure.
Etiology: RSV: 50%; also parainfluenza 3, mycoplasma,
adenovirus. NOT bacteria
Symptoms: URI that becomes copious, tachypnea,
cough, irritability, fever, decreased appetite, can be hypothermic,
cyanotic, etc. Average length of illness: 1-3 days.
Physical Exam: In addition to irritability,
pulmonary findings, also can have easily palpated liver and spleen (from
lung hyperexpansion), flaring, rales, prolonged expiration, areas of
consolidation from atelectasis.
Laboratory Data: Normal WBC and differential. If need
admission, get blood gases. Chest X-ray often done to rule out
concurrent pneumonia. RSV rapid testing from nasopharynx. Serum eosinophil
cationic protein (ECP) has been found high in RSV positive children with
bronchiolitis. Also Interleukin 5 can be elevated, but neither test is
specific.
Differential Diagnosis: How do you distinguish
bronchiolitis from asthma? Asthma usually later in the first year of life;
repeated bouts more common in asthma; good response to bronchodilators. May
be a relationship that one causes the other. Statistics: about half end up
with RAD if ever need admission to hospital.
Treatment:
- Cold humidified air or oxygen in a tent: home made versus tents that
can be obtained in medical supply stores. Goal to get pO2 over 70.
- Sit upright in a 30-40 degree angle
- Role of albuterol: up to about 40-50% of children will respond to
albuterol (See editorial in Nov 96 Archives of Pediatrics). A number of
recent studies that indicate that no need to use if no response early on.
(Pediatrics 1994;93:907-12; J of Peds 1994;124:131-8) BIAS: if no
response, less likely to have RAD later; if a response: may be predictive.
- Role of Ribavirin: Red Book Committee keeps changing its
recommendations; should be used sparingly if at all in ex-premies with
underlying cardiac, neurological problems. (most recent statement in Jan
96 from AAP: Pediatrics 1996;97:137-40).
- Steroids: uncertain effects and is used infrequently; some studies
show positive effect of inhaled budesonide as well as cromolyn.
- Epi jet nebs may be preferable to other forms of treatment.
- Salbutamol and Ipratropium bromide: no role for these in treatment of
bronchiolitis.
- Ventilation and Intubation: rarely needed - key guideline to follow:
pCO2 > 60.
- Nebulized budesonide does not work for bronchiolitis as it does for
croup.
Prognosis: Usually self-limited disease; death rare: if
occurs usually due to apnea. About half of children hospitalized for
bronchiolitis end up with asthma.
Prevention:
- General approach: hand-washing before and after seeing patient,
gown, mask
- Palivizumab- Synagis -(a monoclonal antibody preparation for RSV-IGIV
prophylaxis) given to children < 2 yrs of age with chronic lung disease
who have required medical therapy within 6 mos of respiratory disease
season; all infants less than 32 weeks; do not give to congenital heart
disease patients; no effect on other vaccines. Give monthly IM throughout
respiratory disease season. Advantage over Respigam: given IM not IV -
expensive but not as expensive as Respigam ($1000/injection for
Palivizumab)
- Vaccine: terrible problems with initial RSV vaccine.
Case Presentations: What tests order, what treatment, who
should be admitted:
- Full term baby, normal 1 month old with URI, RSV negative; chest clear
- Full term baby, normal 1 month old with URI, RSV positive; chest clear
- Full term baby, normal 1 month old with URI, RSV positive, wheezing
and in no major respiratory distress but decreased feeds. Blood gases
normal.
- Full term baby, normal 1 month old with URI, RSV positive, wheezing,
pO2 55; pCO2 62.
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