Dr.Sivaramakrishnan

PICU

KKCTH

CASE 1

11/2 year old female child

Known wheezer on intermittent bronchodilators

Admitted with h/o cough for 2 days

Increased work of breathing for 1 day

Afebrile/sick looking

Severe respiratory distress (RR=80/min)

Bilateral wheeze/SCR/ICR/SSR

INVESTIGATIONS

Mild anaemia / leucocytosis / negative CRP

Normal RFT

IN ER

CXRay showed

bilateral increased

BVM

With haziness in

left lower zone

Child continuously nebulised

IV hydrocort/MgSO4/sc terbutaline given

Wheeze persisted

Distress worsened – shifted to PICU

Nebulization's continued

Child worsened further - intubated

ABG –PH-7.16/PCO2-86/PO2-179/HCO3-30/SPO2-

99%

Terbutaline & MgSO4 infusions started

Did not improve despite various ventilator

manipulations

CX-RAY

Child

worsened

further

ICD placed

Repeat X-Ray:

No improvement

PH-6.8 /PCO2-

199

/PO2-51

/HCO3-34

/SPO2-54%

FOREIGN BODY versus recalcitrant asthma

BRONCHOSCOPY PLANNED

BINGO

BRONCHOSCOPY

FOREIGN BODY

in rt. Main

bronchus

CULPRIT-thoor

dal

Edema of

bronchial

mucosa seen &

purulent

secretions

suctioned out

Dramatic improvement

ABG-PH-7.4/PO2-84/PCO2-48/HCO3-29/SPO2-

97%

Infusions gradually tapered off

Nebulisations frequency decreased

Extubated on 5th day of ICU stay

Unremarkable post extubation ICU stay

Post

extubation

Post ICU stay

2 yr old male child

Known wheezer since early infancy

Admitted with h/o cough 4 days

Increased work of breathing & fever 2 days

No H/S/O FB aspiration

On intermittent nebulisations

Irritable/sick looking

Tachypnoeic (RR-54/min)

Febrile/haemodynamically stable

B/L extensive wheeze

continuosly nebulised

IV hydrocort/mgso4/sc terbutaline given

INVESTIGATIONS

N counts with mild anemia/positive CRP

Normal liver enzymes & RFT

CX-RAY IN ER

Due to worsening

distress shifted to PICU

Child had persistent wheezing

O/E: sick,very irritable , tachypnoeic

ICR/SCR/SSR

Decreased breath sounds in LT

B/L crackles & wheeze

Nebulisations continued

Hydrocortisone continued

Following day

Marginal

improvement

Cont to be tachypneic

Cxray rpt

BRONCHOSCOPY

LT bronchial system:both lingula & UL bronchi are

filled with mucus cast suggesting PLASTIC

BRONCHITIS

RT bronchial system normal

Thorough bronchial lavage done

Cast removed by repeated saline wash

BRONCHIAL

CAST

Child improved dramatically

Nebulisations decreased

N acetyl cysteine nebulisations added

Steroids continued

Wheezing settled

Child shifted out next day for further care

POST

BRONCHOSCOPY

In HDU had resp

distress again , urgent

bronchoscopy done

again revealed a cast

similar to the first one -

removed intoto and

thorough lavage given.

Improved and shifted

to ward.

Child discharged on inhaled bronchodilators

Reviewed 1 week later

No symptoms of recurrence

Doing well

Formation of obstructive bronchial plugs or casts of

thick, tenacious mucus associated with involvement

of one or more lobes or even associated entire lung

may collapse.

FIBRINOUS/PSEUDOMEMBRANOUS/HOFFMAN’S

BRONCHIAL CROUP

First described as early as 1902

AGE – affects all ages

Youngest reported being 3 wks

PRECIPITATING FACTORS – commonly associated

with hyper reactive airway disease (asthma ,

pneumonia), cystic fibrosis , bronchiectasis ,

chronic bronchitis , inhalation of aeroallergens ,

CHD , bronchopulmonary aspergillosis or may

sometimes be IDIOPATHIC

MODERATE INFLAMMATORY CHANGES in

bronchial wall – most constantly associated.

May include congestion and edema of bronchial

wall or sometimes haemorrage and infiltration by

polymorphonuclear leukocytes , eosinophils or

lymphocytes

Signs of infection (fever , cough , dyspnea etc)

h/s/o underlying disease often present

wheeze –localised or bilateral

Decreased air entry in collapsed side

Resp distress

Adults – sometimes cough out cast

Mimics FB/status asthmaticus

CX-RAY – one or more areas of collapse

No predilection to any part of lung

Recurrent attacks may lead to fibrosis &

bronchiectasis

BRONCHOSCOPY – diagnostic and therapeutic

Cylindrical / adherent to bronchial wall

Pale grayish or greenish white

Peculiarly tough & viscid with smooth surface

2 types of cast

INFLAMMATORY : made up of fibrin & esonophil

infiltrates. Usually in underlying bronchial disease

ACELLULAR : mainly mucin with little fibrin, no

inflammatory infiltrates. Usually in CHD

SEER ET AL.

MUCUS PLUG PLASTIC BRONCHITIS

Small plugs

Causes segmental collapse

Not very tight

Can be expectorated

Large plugs

Collapse of entire

lobe/lung

Tightly adherent

Retained rather than

expectorated

Beta agonists

Steroids – beneficial but yet uncertain

NAC (breaks disulfide bonds in mucin thus lowering their viscosity)

Aerosolised urokinase / heparin have been tried

Aerosolised tPA (fibrin enhanced conversion of plasminogen to plasmin which initiates local fibrinolysis. Used in casts with high fibrin content. No definitive data, so can be tried in refractory cases)

Chest physiotherapy

BRONCHOSCOPY

FOLLOW UP

Recurrence very common

No strict pattern of recurrence

No preventive therapy

Bronchoscopy immediately if child comes with

recurrence

PROGNOSIS

good

ALL THAT WHEEZES IS NOT ASTHMA

High index of suspicion to any child presenting with

acute respiratory distress with wheeze refractory to

conventional medical therapy with unusual

radiographic picture – consider BRONCH SCOPY

sleigh johnson & E.G sita lumsden THORAX 1960

J.Y park,A.A elshemi EUR.RESPIR J,1996

John m.costeldo,david steinhom,PEDIATRICS

2002

D.Vijayasekaran,N.G.gowrishankar IP 2004

THANK YOU