M. Pneumoniae or Chlamydia pneumonia. Diffuse bilateral infiltrates. Can have extrapulmonary manifestations such as rash, CNS involvement, hemolytic anemia, and arthritis.. Treat with macrolides. Can get cold agglutinins.
Patient may appear to have bacterial (Ped Infect Disease J. 1995; 14:471)
Can try to get PEFR, but often difficult during acute attack
Consider x-ray in first episode of wheezing to evaluate other causes
MDI c spacer is at least as effective as nebs (2-4 puffs for young children, 4-6 for older children, 4-8 for adolescents.
.15 mg/kg per dose in 2.5 cc diluent (Can use atrovent) or give .5 mg/kg/hr in 27 cc of diluent.
If you need magnesium give 50-100 mg/kg over 20 minutes
Terbutaline .01 mg/kg up to max of 0.25 mg
Solumedrol 1-2 mg/kg IV or Prednisone 1-2 mg PO
Over 500 children in the ED were randomized to receive either 0.6 mg/kg of DEX or 2 mg/kg of PRED. At ED discharge, those in the DEX group were provided one additional 0.6 mg/kg dose of DEX to take the next day while those in the PRED group were prescribed 4 daily doses (1 mg/kg/dose) of PRED for 4 days. Study drugs were DEX phosphate USP tablets and either liquid prednisolone (Prelone) or PRED USP tablets. There were no differences between the 2 groups in relapse rates, hospitalization rates from the ED or after relapse, or in symptom persistence at 10 days. However, significantly more PRED patients vomited the study drug in the ED and were noncompliant with it at home.(Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr. 2001; 139:20-26.)
most common lower respiratory tract infection
inflammation of the terminal bronchioles
obstruction from mucus, edema, and cellular debris leads to air trapping and hyperinflation
RSV is not synonymous
RSV can reinfect the same host many times
typical presentation is 1-3 days of viral illness with low grade temp then an onset of cough at night. Wheezing is not from bronchospasm but from airway narrowing . Peak of airway effects is at 48-72 hours.
Predictors of severe disease
Ill or toxic apppearance
O2 Sat <95
Gestational Age <34 weeks
Atelectasis on C-XR
Age <3 months
nasal swab for RSV has sensitivity >90%
X-rays for 1st time wheezers are controversial
give fluids and enough O2 to keep the sat>92%
epi has no proof behind it but is a better choice than albuterol
upper and lower resp tract disease. Peak incidence is in the winter, most commonly effecting children <2 yrs old. RSV accounts for ~80% of cases. Viral culture or rapid antigen testing. Give inhaled epi (3cc of 1:1000).
Dexamethasone may help in moderate to severe disease with clinical benefit and decreased need for admission. Dose was 1 mg/kg accompanied by albuterol. 4 hour observation period. Small number of patients so validation needed. (J Pediat 140:27-32, 2002)
No role for nebulised ß agonists or epinephrine in bronchiolitis
This study directly investigated the issue of whether nebulisedß2 agonists or epinephrine have any role in the treatmentof previously well infants with bronchiolitis. Children wererandomised to receive either epinephrine, albuterol, or placebosaline nebulisers. The primary outcome measure was length ofstay in hospital. The study was double blind and powered todetect a mean decrease of 24 hours in length of hospital stay.The results revealed no significant difference between any ofthe intervention groups. The authors recommend that normallywell infants admitted to hospital with acute bronchiolitis shouldbe given oxygen and supportive fluids. Notably, the study didnot include children directly admitted to the intensive careunit, so the results cannot necessarily be extrapolated to severelyunwell babies.
Patel H, Platt RW, Pekeles GS, et al. A randomized, controlledtrial of the effectiveness of nebulized therapy with epinephrinecompared with albuterol and saline in infants hospitalized for acute viral bronchiolitis. J Pediatr 2002;141:81824
NEJM Volume 349:27-35 July 3, 2003 Number 1 A Multicenter, Randomized, Double-Blind, Controlled Trial of Nebulized Epinephrine in Infants with Acute Bronchiolitis Conclusions The use of nebulized epinephrine did not significantly reduce the length of the hospital stay or the time until the infant was ready for discharge among infants admitted to the hospital with bronchiolitis. As opposed to: Hypertonic saline may be helpful if used as diluent or maybe alone. (Chest 122(6):2015, 2002) meta-analaysis on no role for epi or albuterol (Arch Ped Adole Med V 157, Oct 2003)
Lower Airway Foreign Bodies
Chest radiographic. A. Note that the right lung is more radiolucent than the left. Note also that the trachea is bowed to the right, indicating that the film was obtained by expiration. B. Magnified view of the region around the carina demonstrates the absence of the right main bronchus air column consistent with the interrupted bronchus sign (arrow). C. Chest radiograph obtained 24 hours later demonstrates slight opacity of the right lung consistent with decreased air entry secondary to some residual endobronchial mucosal edema.
The chest film illustrated in Fig. 2A is absolutely diagnostic of a foreign body on the right. The reason for this is that it is a film obtained during expiration, not on purpose but just because of happenstance. Inspiratory-expiratory chest films are indispensable for the demonstration of airway foreign bodies, and an expiratory film would have been requested even after an regular chest radiograph, taken in full inspiration, was obtained. In fact, if one suspects a foreign body in the airway, one should request inspiratory-expiratory chest films. In our patient, strictly by serendipity, the first radiographic study of the chest obtained was an expiratory chest film.
What makes this film diagnostic? The first abnormal finding that should catch one’s eye is that the lungs are of different lucency. The right lung is more radiolucent than the left. This could mean that the right lung is overaerated or the left lung is underaerated. However, if one looks at the trachea, one will notice that the trachea is bowed to the right. This is a typical configuration suggesting an expiratory film for, on expiration, the trachea moves or deviates to the right and often is buckled in its upper third. Therefore, even without asking any questions, one could know that this is an expiratory film.
Now that one has decided that the film was obtained during expiration, radiolucency of the right lung becomes very important. It suggests that the right lung is obstructed (ie, obstructive emphysema). In addition, if one looks at the film more closely, one will notice that there is no air in the right bronchus and that the air column is cutoff at the carina (Fig. 2A and B). The finding has been described as the “interrupted bronchus” sign. 3 Because the patient was not believed to be in any serious respiratory compromise, bronchoscopy was postponed to the next morning. At that time, a sunflower seed was found in the right bronchus, just at the takeoff of the bronchus from the carina.
Foreign body aspiration (inhalation) in infants and young children is very common. It is often believed that more foreign bodies go to the right than to the left, but actually there is ~50/50 incidence of right and left foreign bodies. 4 Foreign bodies, which are oily or otherwise irritating (popcorn, sunflower seeds, peanuts, and other nuts), produce irritation to the bronchial mucosa very rapidly. The ensuing edema, with the foreign body, soon set up the mechanism for airway obstruction. Initially, air enters around the foreign body on inspiration, and because normal physiologic constriction of the bronchus occurs during expiration, the bronchus tends to clamp down around the foreign body. In the early stages, some air is allowed to escape, but eventually most of the air is trapped in the lung and it becomes large and emphysematous. Indeed, it may be normal in size and hyperlucent as in our patient.
A follow-up chest x-ray 24 hours later demonstrated relatively normal lungs, but the right lung was slightly less radiolucent than the left (Fig. 2C). This was because it still was not accepting air normally. It does take 1 or 2 days for the edema induced by the foreign body to subside and for the airway to function normally.
In conclusion, our patient probably would not have encountered the problem had the patient not been gagged in an effort to make him spit up the sunflower seeds. However, one cannot fault the mother’s good intentions. Thereafter, however, the case is rather classic, and just by chance, the first chest film obtained in this patient was diagnostic. It was diagnostic because it was an expiratory film. Usually, the first film is an inspiratory film, and then if a foreign body is suspected, an expiratory film is subsequently obtained. Our patient recovered fully.
Pediatric Emergency Care 2003; 19(5):370-372
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