Health rapid breathing by liaoqinmei


									10      Thursday 4th June, 2009                                  The Island
                                                                                                                                     underlying pneumonia in children of all         have to be made without knowing the
                                                                                                                                     age groups The first is an increase in the      causative bug, then the selection of the
                                                                                                                                     rate of breathing. A rate of over 60 per        antibiotics depends on several related fac-
                                                                                                                                     minute in the first month of life, over 50 in   tors. One relies a lot on the currently
                                                                                                                                     a child up to one year of age and over 40       prevalent types of organisms and one s
                                                                                                                                     per minute in those above one year of age                                       t e ts
                                                                                                                                                                                     own experience in treating pa i n in such
                                                                                                                                     are the general cut-off p i ts to demarcate      iutos
                                                                                                                                                                                     s t a i n . The emergence over the last
                                                                                                                                     significant increases in the rate of breath-    decade of some bacteria which are resist-
                                                                                                                                     i g These are resting rates of breathing        ant to one or more commonly used antibi-
                                                                                                                                     but it is noteworthy that these could be        otics are causing grave concern in many
                                                                                                                                                                       t o , e t-
                                                                                                                                     independently elevated by agita i n r s           r
                                                                                                                                                                                     pats of the world. Some of these types of
                                                                                                                                     lessness, crying and by fever.The other         organisms have been detected in Sri
                                                                                                                                     sign that is quite useful is the presence of    Lanka as well. These cases tend to
                                                                                                                                     in-drawing or retraction of the chest cage      respond poorly to treatment and oft n  e
                                                                                                                                     with breathing. These two features are not      need more recent, sophisticated and
                                                                                                                                     only useful in the diagnosis of pneumonia       expensive drugs for their management.
                                                                                                                                     but also in the assessment of the severity          n e tain situations, especially when
                                                                                                                                                                                        I cr
                                                                                                                                     of the disease. These features are so            h e i tance of the child is low or there is
                                                                                                                                                 riual n iw f h at ht
                                                                                                                                     valuable pa t c l r y i v e o t e f c t a       some sort of compromisation of the
                                                                                                                                     these can be usefully evaluated by non-         immune functions, pneumonia could be
                                                                                                                                     medical people and even by parents     .        much more severe and also may be
                                                                                                                                        High fever, vomiting, rapid breathing        caused by unusual or atypical organisms.
                                                                                                                                     accompanied by grunting, distressing                          r i u a l m o tant as the
                                                                                                                                                                                     These are pa t c l r y i p r
                                                                                                                                     cough, chest pains on breathing and noisy       antibacterials that work against these are
                                                                                                                                     breathing are other features that are seen,      ut i                                etv
                                                                                                                                                                                     q i e d fferent to those that are eff c i e
                                                                                                                                     particularly in the older children. Fever       against the usual or commoner organisms.
                                                                                                                                     may not be such a prominent symptom in          Some of these unusual organisms include
                                                                                                                                     some cases, especially in viral pneumo-         fungi and yeasts. Pneumonia caused by
                                                                                                                                     nias and pneumonias due to unusual              such bugs need protracted courses of
                                                                                                                                                                                        Following an attack of pneumonia that
                                                                                                                                                                                     has been adequately and appropriately
                                                                                                                                                                                     treated, the lungs will generally recover

                                                                                                                                                                                     completely. Even experienced clinicians
                                                                                                                                                                                     are sometimes surprised at the degree of
                                                                                                                                                                                     recovery that has been secured even aftr    e
                                                                                                                                                                                     rather large portions of the lungs are quite
                                  Dr. B.J.C.Perera

                                                                                                                                                                                     severely involved. It speaks so much for
                                     Consultant Paediatrician                                                                                                                        the powers of recovery of the human lung.
                                                                                                                                                                                                  f hr s n nelig
                                                                                                                                                                                     However, i t e e i a u d r y n
                                              l h i
                                           f a l t e d fferent types of respirato-                                                                                                   causative factor then the risk of a recur-


                                           ry diseases that occur in children,                                                                                                       rence is increased. Apart from these, there
                                           pneumonia deserves pride of                                                                                                               is no tendency for recurrences as a gener-
                                  place because of its importance regarding                                                                                                          al rule. Over the last decade or so it has
                                  morbidity and mortality together with the                                                                                                          become possible to protect against some
                                  perception of it as a rather severe disease                                                                                                        forms of pneumonia with vaccines. In this
                                  by the general public. It is responsible for                                                                                                       country, the recently introduced
Pneumonia is a very               a significant proportion of deaths in chil-                                                                                                        Haemophilus influenzae b (Hib) vaccine
significant cause of              dren under five years of age, especially in
                                  the developing world. The World Health
                                                                                                                                                                                     protects against one of the more severe
                                                                                                                                                                                     forms of pneumonia. The Hib vaccine has
morbidity and mor-                Organisation estimates that these dis-                                                                                                             beeen used in the West for several years
tality in children. It             ae il ilos n h hr ol.
                                  e s s k l m l i n i t e t i d w r d The                                                                                                            and has a proven track record. A pneumo-
                                        lt s ihs n h is w er f
                                  morta i y i h g e t i t e f r t t o y a s o                                                                                                        coccal vaccine, given for certain special
is quite a problem                 ie n hs s seily o n h is
                                  lf adti i epcal s i tefrt                                                                                                                          cases, protects against the commoner
in very young chil-                er f ie t s ey uh ra
                                  y a o l f . I i v r m c a t e table dis-                                                                                                           form of pneumonia caused by an organ-

dren, particularly                ease and it should be possible to lower
                                  this appalling morta i y r t w t t e c r-
                                                         lt ae ih h u                oped world while bacterial pneumonias           organisms. Several investigations such as
                                                                                                                                                                                     ism known as Streptococcus pneumoniae.
                                                                                                                                                                                     More recently a heptavalent pneumococ-
those in the first                rently available medical treatment strate-         predominate in the developing world. The        blood counts, blood cultures and x-rays of      cal vaccine effective against seven types
two years of life.                gies. Even in our countries, problems
                                  occur with this disease either due to delay
                                                                                     dfferentiation of viral from bacterial pneu-
                                                                                     monias is somewhat important as the
                                                                                                                                     the chest are useful in the diagnosis of the
                                                                                                                                     disease and in assessment of the possible
                                                                                                                                                                                     of the bacterium has been introduced. This
                                                                                                                                                                                     vaccine is quite expensive and costs thou-
Rapid breathing and               in seeking proper treatment or due to inad-        treatment strategies of the two groups o   f    causative organism. The x-ray of the chest      sands of rupees for each dose. It is an
chest indrawing are               equate and inappropriate treatment.                                               eet
                                                                                     conditions are somewhat diff r n .              is most useful as it could give information     optional vaccine available only in the pri-

very important fea-
                                     The term pneumonia literally means                           h ohsiae aiiis e
                                                                                     However, t e s p i t c t d f c l t e n c-       regarding the type and severity of lung         vate sector. It has produced very
                                  inflammation of the lung. Although some            essary for definitive diagnosis of viral        involvement. However in the case of chil-       favourable results in some countries of the
tures that point                   hns ie ri n
                                  t i g l k i r ta ts, inhaled noxious gases         pneumonias are not universally available        dren, particularly the very young, even in      developed world in which it is used rou-
towards the diagno-                      r ffin products such as kerosene
                                  and pa a
                                  are known to cause inflammation of the
                                                                                     in the developing world.
                                                                                        The commonest presentation of pneu-
                                                                                                                                     the presence of major involvement of the
                                                                                                                                     lungs, the changes in the chest x-ray may
                                                                                                                                                                                     t n l Unfortunately, there are no vaccines
                                                                                                                                                                                      i e y.
                                                                                                                                                                                     available against some of the other
sis. Early treatment              lung, the most important causes of pneu-           monia is a child showing signs of a cough       not be that extensive. Chest x-ray changes      microbes that cause pneumonia in chil-
helps to cure the                 monia include infection of the lung by                                             iute. t s
                                                                                     associated with breathing diff c l i s I i      are not essential for a diagnosis of pneu-      dren.
                                  viruses, bacteria and other microorgan-                                              h eeiy
                                                                                     usually associated with fever, t e s v r t      monia.                                             It is also true to say that the mere word
problem and there                 isms. The term pneumonia is reserved for           of which may vary widely. In some children                               s e i l y f o r p-
                                                                                                                                         The disease may, e p c a l i n t p o         pneumonia causes a great deal of dis-

is no significant
long-term lung
function abnormali-
ties after recovery.
                                  involvement of the aerated portions of the
                                  lung and it seriously interferes with the gas
                                  exchanging properties of the lung. In
                                  severely affected cases it simply leads to
                                     rsi euto n h rvso f ie
                                  adatcrdcini tepoiino lf-
                                  giving oxygen to the tissues of the entire
                                  body.Dfferent medical terminologies are
                                  used to delineate different types of pneu-
                                  monia. When the area of involvement is
                                                                                      h l n s tats l w y h l n t e s t
                                                                                     teiless r sol wie i ohr i
                                                                                     has an explosive onset. However, t e
                                                                                     presentation tends to vary with the age of
                                                                                     the child. In the very young child, pa t c
                                                                                     larly in the first couple of months, non-spe-
                                                                                     cific symptoms such as refusal of feeds,
                                                                                     lethargy and behaviour disturbances are
                                                                                     importa t f a u e o t e d s a e I i v ta
                                                                                             n etrs f h ies. t s i l

                                                                                                                            r i u-

                                                                                     to realise that although such symptoms do
                                                                                                                                     erly treated in the early acute stage, devel-
                                                                                                                                     op certain complications. One such prob-
                                                                                                                                     lem is progression of the disease to the
                                                                                                                                     ta e f e p r t r a l r
                                                                                                                                     s t o rsiaoyfiue.I ti s t       n h s ta e
                                                                                                                                     the lung damage is so extensive that it
                                                                                                                                     interferes with the normal functioning and
                                                                                                                                     gas exchange through the respiratory sys-
                                                                                                                                     tem. This type of scenario would generally
                                                                                                                                     need management in an Intensive Care
                                                                                                                                                                                     tress and panic amongst most parents I
                                                                                                                                                                                     conjures up unpleasant visions of severely
                                                                                                                                                                                     ill children and even fataiis Although it
                                                                                                                                                                                     could be a severe illness, in very many
                                                                                                                                                                                     cases it could be handled quite well with
                                                                                                                                                                                     the help of the currently available drug
                                                                                                                                                                                     armamentarium and the facilities available
                                                                                                                                                                                      n o p tas
                                                                                                                                                                                     i h s i l. The key to success is early
                                                                                                                                                                                     diagnosis. In the right hands a complete

                                  restricted to an anatomical area or lobe of        not directly point towards a primary lung        nt
                                                                                                                                     U i . Another complication is the situation     recovery could be expected in all but the
                                  a lung, it is known as Lobar Pneumonia             problem these are important symptoms            where the infection does not settle proper-     most severe cases or those that compli-
                                  while in situations where the areas of             that need expert evaluation. While in the       ly and leads to a state of what is called
                                  involvement are scattered around the fine          older children certain classical diagnostic      unresolved pneumonia . The furthermost         cate other major underlying illnesses. !
                                  branches of breathing tubes within the             sounds are heard using a stethoscope, in        tage of this is the formation of a lung
                                  lung it is known as Bronchopneumonia .             younger children these may even be              abscess. Once it progresses into this
                                     When all types of pneumonias are                entirely absent even in very severely           tage, very aggressive treatment may be
                                  assessed worldwide it is noted that viral          affected cases. However, there are two          needed. The pneumonia is sometimes
                                  pneumonias are commoner in the devel-              features that are reliable indicators of        complicated by the presence of fluid or
                                                                                                                                       pus in the chest cavity which accommo-
                                                                                                                                       dates the lungs. Unlike in a lung abscess
                                                                                                                                       where the pus is collected within the
                                                                                                                                       lung, in these cases the fluid or pus
                                                                                                                                       accumulates between the lung and the
                                                                                                                                       chest wall. If the amount of fluid inter-
                                                                                                                                       feres with the functioning of the lung then
                                                                                                                                       the fluid may need to be removed. The
                                                                                                                                       presence of pus in the chest cavity will
                                                                                                                                       necessitate surgical drainage. These lat-
                                                                                                                                       ter two complications are generally seen
                                                                                                                                       with bacterial pneumonias.
                                                                                                                                          When a definitive diagnosis is possi-
                                                                                                                                                             f ia n atra
                                                                                                                                       ble, the treatments o v r l a d b c e i l
                                                                                                                                       pneumonias vary significantly.There are
                                                                                                                                       no effective antiviral drugs against many
                                                                                                                                       of the viruses that cause pneumonia. In
                                                                                                                                       such cases ancillary measures are
                                                                                                                                       adopted and careful monitoring of the
                                                                                                                                       functioning of the lungs is employed. If
                                                                                                                                       things get out of hand, it may be neces-
                                                                                                                                        ay o
                                                                                                                                       s r t take over the breathing of the
                                                                                                                                       child using artificial breathing machines
                                                                                                                                        r etltr.
                                                                                                                                       o vniaos
                                                                                                                                          In the case of bacterial pneumonias,
                                                                                                                                                                       n oe n
                                                                                                                                       antibiotics play a very importa t r l i
                                                                                                                                                                  iut o eiiey
                                                                                                                                       treatment. When it is diff c l t d f n t l
                                                                                                                                       say whether it is viral or bacterial then           The writer would appreciate
                                                                                                                                       antibiotics are used empirically.The doc-         some feed-back from the read-
                                                                                                                                       tors would use their experience and                  ers. Please e-mail him at
                                                                                                                                       expertise to decide which of the wide   or write to him at
                                                                                                                                       range of antibiotics available should be             the following address :-
                                                                                                                                       selected in a given pa i n . I a c u a i e
                                                                                                                                                               tet f astv                  Dr, B.J.C.Perera, Consultant
                                                                                                                                       organism could be determined by the                Paediatrician, Asiri Medical
                                                                                                                                       t s performed then the selection of an
                                                                                                                                        e ts                                               Hospital, 181, Kirula Road,
                                                                                                                                       appropriate antibiotic is not that much of                  Colombo 5.
                                                                                                                                       a problem. When empirical decisions

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