Sunil Kamath MD

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Pediatric Pulmonary Case Conference

• Sunil Kamath MD
• Post-Doctoral Fellow
• Childrens Hospital Los Angeles

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HPI

• 6 month old male with no significant PMH
• 3/17
• cough, rhinorrhea, nasal congestion, Fever 101
• cranky and NBNB emesis x 1
• 3/18
• "moaning" while breathing
• PMD diagnosed a URI and pt. was sent home
• developed subcostal retractions and taken to
  outside ED where he received breathing
  treatments, improved, and was discharged home
• 3/19
• Irritable and had subcostal retractions
• Returned to outside ED

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ED Course

• Persistent retractions and pale
• SpO2 71 ? placed on O2 ? pinked up
• Received continuous aerosol treatments
• Transferred to outside hospital PICU for further
  care with the presumptive diagnosis of
  bronchiolitis

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• FT, NSVD, no complications, home on DOL 2
• Surgical history none
• NKDA
• Immunizations has not received 6 month
  vaccinations
• Diet Enfamil 6oz TID, baby foods
• Family History father with bronchitis as a child
• Social History Lives with mother, father and 2
  yo sister, no tobacco exposure, no pets
• All other ROS negative

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Outside Hospital Physical Exam

• VS
• Temp 36.7 C
• HR 174 bpm
• RR 53 breaths per minute
• BP 98/67 mmHg
• SpO2 98 on 1.5 LPM via NC
• PE
• General Awake in mild/moderate respiratory
  distress with subcostal retractions
• Resp Coarse breath sounds bilaterally.
  Rhonchi. No Wheezing.
• Heart RRR. Normal S1 and S2

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Labs

• 18.3 \ 10.7 / 334
•   / 36 \
•  149 107 8 149 Ca9.8
• 5.1 21 0.4
• Respiratory culture Negative for bacteria
• RSV DAA negative
• Influenza DAA negative
• Total IgG, IgA, IgM, IgE normal
• CXR

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Outside Hospital Course

• 3/20 Intubated for worsening respiratory distress
  ? HFOV x 1 week
• Started on ABX and steroids
• 3/25 ETT viral culture Adenovirus (not typed)
• 3/30 DVT of right leg Rx Lovenox
• 4/11Extubated to HFNC and steroids were weaned
• Developed wheezing, prolonged expiratory phase,
  increasing distress
• IV steroids were re-started and patient improved
• 5/4 Changed to Prednisone 5mg BID and transferred
  to the floor
• 5/5 MSSA bacteremia Rx oxacillin
• 5/6 Developed increased tachypnea with nasal
  flaring and fatigue during feeding
• 5/6 Chest CT

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• consolidation of RLL and LUL with associated
  cylindrical bronchiectasis

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5/7 Transferred to CHLA

• VS
• Temp 37.9 deg C
• HR 148 bpm
• RR 38 Breaths/Min
• BP 144/90 mm Hg
• SpO2 99 on ½ LPM
• PE
• General Appearance laying in bed, moderate
  respiratory distress, becomes fearful with exam
• Chest symmetric chest rise, subcostal
  retractions
• Respiratory diffuse crackles, wheezing, forceful
  expiration with grunting
• Cardiovascular RRR, no m/r/g, 2 pulses

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Labs

• 18.72 \ 11.5 / 557
•   / 35.9 \
• Segs 44, Bands 0, Lymph 42, Mono 13, Baso 0, Eos
  1
• 139 97 11 123 Ca9.9
• 5 32 0.2
• CBG 7.46/50//36

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The lungs are hyperinflated. There is streaky
perihilar disease with peribronchial thickening
bilaterally.
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What is your assessment and plan?
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Hospital Course

• Plan chest CT, bronchoscopy, lung biopsy, and
  iPFT when stable
• 5/10 SCINTI normal
• 5/11 ECHO
• Small secundum atrial septal defect vs. patent
  foramen ovale.
• No evidence of PHTN
• 5/13 MBSS normal
• 5/18 Wheezing. Prolonged expiratory phase.
  Increasing respiratory distress. Prednisone ?
  Solumederol
• 5/21 Admitted to the PICU for stabilization and
  repeat CT scan
• 5/24 RV panel negative
• Immunology workup unremarkable

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Template

• progression of bronchiectasis and scattered areas
  of groundglass opacity

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What is your management plan?
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Management

• Bronchiolitis Obliterans
• Azithromycin (5mg/kg QMWF)
• Methotrexate (10-15mg/m2/dose SQ Qwk)
• Continued IV steroids
• 5/25 Developed thick secretions and was difficult
  to ventilate
• Empirically started on Vanc and Zosyn
• Trach cult (Many Haemophilus influenzae, Beta
  lactamase negative) ?Ceftriaxone

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ABX started
Intubated
IV steroids
PICU admit
Extubated
MTX
Azithro
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Bronchiolitis Obliterans

• Rare form of chronic obstructive lung disease
  that occurs after an insult to the lower
  respiratory tract
• Etiology

• Bronchiolitis Obliterans in Children. Pediatric
  Pulmonology 39193-208 (2005)

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• Pathophsiology
• Inflammation and fibrosis of the terminal and
  respiratory bronchioles ? narrowing and/or
  complete obliteration of the airway lumen

• Bronchiolitis Obliterans in Children. Pediatric
  Pulmonology 39193-208 (2005)

Kumar Robbins and Cotran Pathologic Basis of
Disease, Professional Edition , 8th ed.
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• Diagnosis
• CXR
• PFT
• Bronchoscopy - neutrophilia
• HRCT mosaic pattern
• Open lung biopsy
• Sampling error due to patchy airway involvement
• 2 categories
• proliferative bronchiolitis (intraluminal polyps)
  
• constrictive bronchiolitis (peribronchiolar
  fibrosis)
• Treatment
• Supportive care
• Steroids
• Immune modulators

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Thank You