Chapter 4 Cough or Difficult Breathing Case II

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Chapter 4Cough or Difficult BreathingCase II
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Case study Ratu
Click on the photo to play video
11 month old boy with 5 days of cough and fever,
yesterday he became short of breath and unable
to feed
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• What are the stages in the management of any sick
  child?

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Stages in the management of a sick child (Ref.
Chart 1, p. xxii)

• Triage
• Emergency treatment
• History and examination
• Laboratory investigations, if required
• Main diagnosis and other diagnoses
• Treatment
• Supportive care
• Monitoring
• Plan discharge
• Follow-up

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Have you noticed any emergency or priority signs?

Click on the photo to play video
Temperature 39.70C, pulse 180/min, RR 70/min,
cyanosis visible suprasternal and subcostal
recession, grunting respiration
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Triage

• Emergency signs (Ref. p. 2, 6)
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
• Coma
• Convulsions
• Severe dehydration

• Priority signs (Ref. p. 6)
• Tiny baby
• Temperature
• Trauma
• Pallor
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, irritable, lethargic
• Referral
• Malnutrition
• Oedema of both feet
• Burns

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Triage

• Emergency signs (Ref. p. 2, 6)
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
• Coma
• Convulsions
• Severe dehydration

• Priority signs (Ref. p. 6)
• Tiny baby
• Temperature
• Trauma
• Pallor
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, irritable, lethargic
• Referral
• Malnutrition
• Oedema of both feet
• Burns

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What emergency treatment does Ratu need?
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Emergency treatment

• Airway management?
• Oxygen?
• Intravenous fluids?
• Anticonvulsants?
• Immediate investigations?
• ? Check SpO2 and blood glucose

(Ref. Chart 2, p. 5-6)
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How to give oxygen

• Place the prongs just inside the nostrils and
  secure with tape.

• Use an 8 F size tube
• Measure the distance from the side of the nostril
  to the inner eyebrow margin with the catheter
• Insert the catheter to this depth and secure it
  with tape

(Ref. Chart 5, p. 11 p. 312-315)
Start oxygen flow at 1-2 litres/minute, in young
infants at 0.5 litre/minute
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Emergency treatment (continued)

• ? Blood glucose 1.8 mmol/l How do you treat
  hypoglycaemia?
• ? Give IV glucose (Ref. Chart 10, p. 16)

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• Give emergency treatment until the child is stable

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History

• Ratu is a 11 month old boy with 5 days of cough
  and fever. Yesterday he became short of breath
  and was unable to feed.
• He was apparently well 5 days ago. Then he
  developed fever with cough. He was taken to a
  local medical shop, where he was given two types
  of syrupy medicine. He deteriorated over two days
  with worsening fever, increased difficulties in
  breathing and today he is unable to feed.
• Past medical history no significant past
  history.
• Family history Ratu's grandmother had
  tuberculosis, which was treated 3 years ago.
• Social history he lives with his parents and
  grandmother in a small semi-permanent house

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Examination

• Ratu was pale, ill-looking and cyanosed. He had
  fast breathing with visible suprasternal and
  subcostal recession and with grunting
  respiration.
• Vital signs temperature 39.70C, pulse 180/min,
  RR 70/min
• Oxygen saturation SpO2 82 on room air
• Weight 11 kg
• Ear-Nose-Throat dry mucus membranes, red
  pharynx, blue lips, slightly reddened eardrums
• Chest bilateral course crepitations with
  suprasternal and subcostal recession, grunting
  and wheeze
• Cardiovascular three heart sounds were heard
  with gallop rhythm the apex beat was displaced
  laterally to the anterior axillary line
• Abdomen liver was palpable 4 cm below the right
  costal margin
• Neurology tired but alert no neck stiffness

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Differential diagnoses

• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to confirm (Ref. p. 77-79, p. 93)

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Differential diagnoses

• Pneumonia
• Congenital heart disease
• Tuberculosis
• Foreign body
• Effusion/empyema
• Pneumothorax
• Pneumocystis pneumonia
• Severe anaemia
• Asthma
• Bronchiolitis

(Ref. p. 93)
(Ref. p. 77-79)
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Additional questions on history

• Prior illnesses
• Locally important illnesses
• Immunization history
• Nutritional history
• Tuberculosis in family

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Additional questions on history

• Prior illnesses
• Locally important illnesses
• Immunization history
• Nutritional history
• Breast fed for 3 months, now on powdered cows
  milk, 2 meals a day, eats fruits (banana,
  papaya), rarely eats meat or vegetables, some
  cereals and biscuits
• Tuberculosis in family

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Further examination based on differential
diagnoses

• Palmar Pallor indicating severe anaemia (Ref.
  p. 166). In any child with palmar pallor,
  determine the haemoglobin level
• Check also conjunctiva and mucous membranes

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Further examination based on differential
diagnoses (continued)

• Assess cause of respiratory distress
• - Pneumonia crepitations, bronchial breathing,
  effusion, cyanosis
• - Heart failure tachycardia gt 160/min (Ref. p.
  120), gallop rhythm, enlarged liver, fast
  breathing, severe palmar pallor, no murmer
• Look for signs of anaemia
• Palmer pallor (Ref. p. 121, 199, 307)
• If from a malaria area, Look for signs of malaria
• - Fever, enlarged spleen, anaemia (Ref. p.
  156-165)
• Assess nutritional state
• - Weight-for-length (or height) lt 70 or lt -3SD
• - Look for oedema of feet (Ref. p. 198)

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What investigations would you like to do to make
your diagnosis?
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Investigations

• Oxygen saturation (SpO2)
• Full Blood Examination and blood film
• Group and cross-match
• Malaria RDT, thick and thin blood film
• Chest x-ray
• ? What are the indications for chest x-ray
• Severe pneumonia with complications (e.g.
  hypoxaemia)
• Suspicion of effusion, empyema, pneumothorax
• Unilateral changes on examination
• Clinical signs of heart failure
• If tuberculosis is suspected (Ref. p. 77, p.
  85)

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Full blood examination

• Haemoglobin 5.9 g/dl (105-135)
• Platelets 858 x 109/l (150-400)
• WCC 30.6 x 109/l (6.0-18.0)
• Neutrophils 17.4 x 109/l (1.0-8.5)
• Lymphocytes 3.4 x 109/l (4.0-10.0)
• Monocytes 1.2 x 109/l (0.1-1.0)
• Blood glucose 4.5 mmol/l (3.0 - 8.0), after IV
  glucose

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Blood film hypochromic microcytic anaemia
Hb 5.9g / dL No malaria parasites, RDT negative
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Chest x-ray
SpO2 82 on room air
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Diagnosis

• Summary of findings
• Examination severe respiratory distress, central
  cyanosis, palmar pallor, fever, bilateral course
  crepitations with suprasternal and subcostal
  recession, grunting and wheeze three heart
  sounds were heard with gallop rhythm and
  tachycardia
• Chest x-ray shows enlarged heart and bilateral
  opacities
• SpO2 82 on room air
• Hypoglycaemia (1.8 mmol/L)
• Blood examination shows low haemoglobin,
  neutrophilia with left shift, thrombocytosis
• Blood film shows hypochromic microcytic anaemia

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Diagnosis (continued)

• Very severe pneumonia
• Heart failure
• Severe anaemia
• Severe iron deficiency

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How would you treat Ratu?
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Treatment
? Very severe pneumonia
(Ref. p. 82)

• Oxygen therapy
• Antibiotic therapy

(Ref. p. 82)
? Heart failure
(Ref. p. 120-122)

• Diuretics

? Severe anaemia (with heart failure)
(Ref. p. 307-308)

• Blood transfusion
• Iron therapy (when improved)
• Diet change

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What supportive care and monitoring are required?

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Supportive care

• Fever management (Ref. p. 305)
• Fluid management
• Avoid overhydration! Ratu has very severe
  pneumonia, heart failure, severe anaemia and he
  gets IV therapy and blood transfusion
• What type of fluid?
• Appropriate nutrition (Ref. p. 294-303)
• Insert a nasogastric tube and give appropriate
  feeds.

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Monitoring

• Use a Monitoring chart (Ref. p. 320, 413)
• Vital signs, fluid balance, treatments given
• Feeding / nutrition
• Blood glucose
• Oxygenation
• Response to blood transfusion
• The child should be checked by nurses frequently
  (at least every 3 hours) and by a doctor at least
  twice a day
• Further investigation
• Cardiac echo when possible (normal in this case)

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Discharge planning and Follow up

• When is it OK for Ratu to be discharged?
• What follow-up is needed

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Discharge planning and Follow up

• When is it OK for Ratu to be discharged?
• Respiratory distress resolved
• No hypoxaemia
• Completed course of parenteral antibiotics
• Able to take oral medications
• Check Hb shows improvement
• Started on iron
• Cardiac echo normal
• Parents understand the problems
• What follow-up is needed
• Anaemia
• Nutritional

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Summary

• Seriously ill children may present with one
  symptom but may have multiple problems
• Severe respiratory distress due to
• Pneumonia
• Anaemia, due to iron deficiency
• Heart failure due to anaemia and severe pneumonia
• Emergency treatment is life saving
• Need to identify and treat each problem if the
  child is to survive
• Monitoring and supportive care are vital
• Dont forget follow-up