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Treatments of croup most afebrile children with spasmodic croup

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Treatments of croup most afebrile children with spasmodic croup Powered By Docstoc
					Treatments of croup :---
  most afebrile children with spasmodic croup & mild ALTB can
usually be safely effectively managed at home .

 Treatments of underlying & often unsuspected G.E.R.
 may prevent spasmodic croup .
 Treatment at home by :---
    1-steam from a shower or bath in a close bath
 room.      Or
    2-steam from a vaporize or
    3- cold steam from a nebulizer .
  this will result in terminating in acute laryngial spasm
 & respiratory distress within minutes ( same effect by
 cold night air )
Also can use IPECAC to induce vomiting .
In hypoxic infant , given O2 of less than 100% saturated with H2O
vapor resulting in mucosal cooling leading vaso constriction & decrease
edema
Treatments of patients at hospital :-- •
     indication of admission :-- •
            1- highly or suspected epiglotitis 2- progressive stridor •
            3- sever stridor at birth         4- sign of resp. distress like •
              hypoxia , irritable , cynosis , sever pallor , depresed        •
               sensorium . •
For patients who admitted :--- •
    1- chart observation ( PR ,RR ). •
    2- parenteral fluid . •
    3- sedation is C.I ( because of restless is used as clinical indices •
       of severity of obstruction & need for tracheostomy or •
endotracheal intubation ) .
    4-children should be kept calm as possible to reduce resp. effort •
   5-O2 to alleviate hypoxia ( humidified O2 ) •
   6- brocho-dilator & expectorant are not helpful & A.B. is not indicated •
   7-Racemic epinphrine ( o.25 -0.75 ml in 3 ml normal saline can be used    •
Or used L-epinpherine ( 5 ml of 1:1000 solution ) is equally effective as
Racemic epinpherine .
Nebulized epinpherine should still be used cautiously in patient with

Tachycardia or heart condition like TOF, ventricular outlet •
obstruction .
   8- cortico steriod to reduce inflamatory edema & prevent •
destruced celiated epithilial ( aral dexamethazone 0.6 mglKg as
Single dose & may be 0.15mglkg may be just effective . •
 I.M decadron & nebulized budesonide have an equally effective •
   9- tracheostomy in sever cases with progressive stridor & cynosis. •
Indication of laryngoscope in croup :-- •
    1-very young of less than 4 month of age . •
    2- if symptom continue of more than 6 wk •
    this is to exclude sub-glotic stenosis or hemangioma. •
                           --3   •
Bacterial trachitis ;---
  is acute bacterial infection of trachea which able to obstruct air way
age of incidence of less than 3 years but in more recent cases , the

Mean age has been between 5& 7 years •
  causes by staph. Aureus (most common ) but PIV type 1 & H •
influenza , moraxalla catarrhalis & anarobic organism also been
implicated .
Usually follow viral resp. infection especially croup . •
ClF :--- •
      1- history of croup, followed by high fever , toxic associated •
        respiratory distress or may occur few days after improvement .     •
      2- patients lie flat , not drool , no dysphagia . •
      3- not respond to general treatment of croup . •
    intubation & tracheostomy is usually required ( but in more recent     •
    series , only 50-60 % of patients required intubation ) •
                             --4-- •
Pathology :--
    1- mucosal swelling at level of cricoid cartilage .
    2- thick copious , purulent secretion .

Diagnosis :-- •
     1- ClF     2- WBC leucocytosis with band form •
     3- X-ray is not needed , &may show classical feature pseudo •
        membrane detachment in the larynx . •
     4- laryngoscopy shows purulant material bellow cord . •
Treatment :-- •
  1- supporting :- O2 therapy , I.V fluid , intubation in sever cases •
  2- specific therapy by A .B ( anti staph ) •
CX :--- •
   1- resp. obstruction leading to resp. arrest •
   2- infection go down to parenchymal or bronchiol leading to pneu. •
   3- toxic shock syndrome •
Prognosis :- become afebrial patient within 2-3 days but may be prolonged   •
Hospitalization may be nesessory ( mean duration is 12 days ) •
                          ---5-- •
DD :-- of wheezing :---
     1- infection :- bronchiolitis , pneumonia .
     2- asthma

      3-anotomical abnormalities like :- A– central air way like •
             malasia of larynx , trachea, bronchi . •
             B-extrinsic air way anomalies by compression like •
vascular ring , mediastinal LAB , F.B in esophagus .
             C- intrinsic air way anomalies like hemangioma , cyst ,   •
               sequestration , F.B, CHD( LF to Rt shunt ) . •
         4- cystic fibrosis , bronchioactasis . •
         5- aspiration pneumonia , G.E.R •
         6- H.F 7- interstitial lung disease like bronchiolitis •
obliterance       8- anaphylaxis .
                            --6-- •
Bronchiolitis :---
   is common dis. Of LRTI of infant , is resulting from infla.
   Obst. Of small air way , characterized by wheezing .

occur in Ist year of life with peak incidence of 6 month , Its incidence •
 is highest in the winter & early spring .
     illness occurs sporadically & epidemically . •
Etiology :-- •
           is viral in origin in more than 50% by RSV. •
         is more common in male infant ( 3-6 month) who not breast •
fed infant , lived in crowded condition .
        also other member of family is ill . •
Pathophysiology :--- •
       0n overhead •
                          ---7--- •
   ClF :-- 1- usually other member of family were ill by viral infection .
   2-usually proceeded by URTI of few days before onset of resp. distress




    3-low grade fever 38.5—39c & other systemic manifestations like •
vomiting & diarrhea are usually absent.
    Apnea more prominent than wheezing in early course of dis. In •
   very young infant of less than 2 month of age or former premature infant   •
.
On Examination :- -- •
     1- resp. distress which variable from mild to sever . •
     2- in sever distress with sever hypoxia lead to convulsion & •
       dehydration due to insensible water loss . •
  Diagnosis :---- •
            1- ClF        •
            2- X-ray finding ( hyper inflation of chest , scattered area •
               of consolidation •
           3- WBC & diffrential count are usually normal . •
                         --8-- •
DD :-- 1-asthma       2- bronchopneumonia 3- F.B aspira.
       4- cong. H.F 5- poisoning 6- pertusis
       7- cystic fibrosis

Note :-- 50% of sever bronchiolitis may going to asthma •
Course :-- most critical period is 2-3 days after onset of cough & •
           dyspnea. & then improvement occurs rapidly & recovery •
          is completely within several days ( 10-14 days ) •
Death rate :-- is about 1—4% ( higher figures associated with higher •
              risk groups ) , caused by :--- •
                 1- prolong apneic spell •
                 2- sever uncompansated resp. acidosis •
                 3- profound dehydration •
Infant are more liable to morbidity & mortality if associated :--- •
   1-CHD       2- BPD 3-Cystic fibrosis 4- immune def. dis. •
H.F is rare Cx except if underlying heart dis. •
                        ---9--- •
Infant with bronchiolitis who developed asthma , are more likely to
 have :-- 1-family history of asthma & allergy
          2-prolong acute episode of bronchiolitis
          3- exposure to cigarette smoking

Treatment of bronchiolitis :-- •
    depend on severity of illness :-- •
   most children have mild illness & can be managed at home with •
   supporting measures . •
  5% of patients needs hospital admission :----indication of •
admission :---- 1-younger patients of less than 6 months .
                 2-moderate to marked resp. distress ( sleeping R.T •
                   of more than 50-60 breath l minutes or higher) •
                3- hypoxemia ( po2 of less than 50-60 mmHg ) or •
                    o2 saturation of less than 92% on room air •
                4- episode of apnea •
                5- inability to tolerate oral feeding •
               6-lack of appropriate care at home •
(children with CHD, BPD , NMD, immune def. ---- increasing risk of •
Supporting measures :--
     1- adequate fluid to maintain normal hydration
    2- antipyretic for febrile patients

     3- humidified o2 in sufficient concentration to maintain pao2 •
         70-90 mmHg & o2 saturation of more than 92% •
     4- broncho-dilator like B-agonist produce short term •
         improvement in clinical feature . •
        nebulized epinpherine may more effective than B-agonist. •
        cortico-steriod are often negative •
Specific therapy :-- •
       1- ribavirine is antiviral agent administered by aerosol has •
          been used for infant with CHD or chronic lung dis. •
       2- no support for RSV immune globuline administered •
          during acute episode of RSV . •
                          ---11-- •
Bronchiolitis obliterane :--
   caused by adeno virus , measles , pertusis , in which ,there is
     damage of bronchiol & smaller air with attempt repaired by granulation
tissue that obstruct the air way , evantually obliterate of lumen with nodular

Masses of granulation & fibrosis . •
ClF :-- gradual progressive resp. distress •
  X-ray :- ranged from normal to a pattern suggest of milliary T.B •
Bronchography --- :-obstruct of bronchus •
No specific therapy •
Congenital lobar emphysema :--- •
  is overinflation of one lobe ( most often left upper lobe ), which •
  produced resp. distress because of surrounding lung tissue •
become compressed leading to shifting mediastinum
Treatment by lobectomy may be required if resp. distress is sever or •
   progressive .                ---12--- •
                        thank you •

				
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posted:11/14/2011
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