Respiratory Topics for DCH teaching 1_0.pdf · Differentiating between PCP and bacterial pneumonia...
Transcript of Respiratory Topics for DCH teaching 1_0.pdf · Differentiating between PCP and bacterial pneumonia...
Respiratory Topics for DCH
teaching
Outline
• IMCI approach
• Community acquired pneumonia
• Pleural effusion
• Approach to chronic cough
• Approach to stridor
• Approach to persistent/recurrent wheeze
• HIV-associated chronic lung disease
Baby P
• 8m old presents with fever and cough for 5days
• Previously well and thriving
• Mom HIV- and breastfeeding
• Exam: Temp 38, coryza and red throat
normal breathing
PLAN: ????
Baby P
• Returns 3 days later not better. Now poor feeding and vomiting.
• Exam T38.7; pink in RA ; RR 70 bpm; no air trapping; coarse crackles and BBr anterior on right
• DIFF DIAGNOSIS??
• INVESTIGATIONS?
• AETIOLOGY?
• MANAGEMENT?
CAP prevention
• General
– Good nutrition
– Breastfeeding
– PMTCT
– Micronutrient supplementation (Vit A in
measles, Zinc) NB in malnourish4ed and
HIV+
– Reduce ETS and biomass duel exposure
– Routine vaccination (BCG, Dip, Polio,
Pertussis, HiB, Pneumococcal, measles)
Specific vaccines
• Pneumococcal conjugate vaccine (PCV): 13-Valent vaccine now on EPI– 20-37% reduction radiological pneumonia in HIV –
children, and 13% in HIV+
– 2-3X greater reduction in clinical pneumonia (all
cause)
– 85% reduction in invasive Pneumoc disease (HIV-)
and 65% in HIV+
– Other indirect benefits:
• Decrease viral-assoc pneumonia by 32%
• Decrease penicillin resist IPD by 67%
• Decrease IPD in overall population and elderly
• Decrease child mortality in poor areas without healthcare
Polysaccharide 23-valent vaccine• Indicated for HIV- children > 2yrs at risk of IPD (XX??)
• Preceded 1 month prior by PCV in children 2-9 yrs
• C/I in HIV + adults (? Children)
Influenza vaccine
Prophylaxis
• Cotrimoxazole for PCP
– HIV exp: 6 weeks until PCR –
– HIV+: Until > 1 year (regardless of HAART)
Lifelong if no HAART
Until CD4% > 25% 6 months apart if on
HAART
• INH all TB exposed/infected < 5ys without disease
• RSV monoclonal antibody (Palizumab)
Baby P cont...
• After 2nd day Amoxicillin,
still febrile, coughing and
tachypnoeic. Sats 92%
RA; dullness Rt persists
with softer BS post on Rt
• WHAT ARE POSSIBLE
REASONS FOR
FAILURE TO IMPROVE?
• WHAT
INVESTIGATIONS?
• WHAT
INTERVENTIONS?
Pleural effusions
TB EFFUSIONS VS EMPYEMA
Management
TB effusions Empyema
ABC’s
Drain if large and symptomatic
Standard TB Rx
No role for steroids unless
complicated (pain, fever...)
Notify
Collect sputum for culture
Screen for HIV
ABC’s
Always needs drainage unless very
small. Drain in until afebrile 24 hrs and
no drainage
Antibiotics to cover Strep pneum and
Staph aureus; IV initially, change to
oral if afebrile > 48hrs.
Consider routine fibrinolytics or with
loculated empyema
Refer for surgery if unwell and febrile
despite antibiotics and drainage
Chronic cough
• Consider significant if > 3 weeks duration
• Pattern of cough NB ie persistent vs recurrent with
asymptomatic intervals
• Pointers on Hx and exam– Duration and pattern e.g. nocturnal only or disappears at night
– Creche attendance
– Dry vs Wet
– Acute onset and hx of choking
– TB contact? Household smokers or other environmental exposures
– HIV exposure/infection
– Vomiting and regurgitation
– Exercise induced cough and other signs of atopy or asthma eg wheeze
– Associated with URTI’s or not
– Look for signs of chronic lung disease ie FTT, halitosis clubbing, chest
deformity, persistent air trapping, wheeze or crackles
Investigate chronic cough only when...
• If probably post infective (viral/pertussis), watch ,
reassure and see. No role for OTC medications
• If suspicious of PAR or asthma, trial and Rx and then
review ie topical or inhaled steroids, antihistamines
• Suspected FB aspiration or associated “noisy
breathing”– refer bronchoscopy
• Investigate for TB if suspected
• HIV test
• Consider other investigations when indicated eg CXR,
sputum MCS, lung function and BDR in children> 5,
sweat test, aspiration studies, immune workup etc
Approach to stridor
• CROUP • Stridor= noisy breathing during
inspiration arising from the
laryngeal and sometimes proximal
tracheal obstruction
• Stertor= noisy breathing arising
from nasopharyngeal obstruction
• Noise level does NOT correlate
with severity of airway obstruction
• Distinguish stridor since
birth/chronic vs. Acute onset or
recurrent
Causes of stridor
Acute onset/recurrent Persistent/chronic
Infants Croup
Diptheria
Candida
CMV (HIV+)
Subglottic stenosis
congenital or post-
intubation
GORD
Congenital abnormalities
eg laryngeal, skeletal
abn =eg Pierre Robin
GORD
Vocal cord paralysis
Laryngeal papillomas
Subglottic stenosis
Subglottic haemangioma
Vascular ring
Toddlers/children Croup
GOR
Foreign body
above
CROUPSeverity Insp obstruction Exp obstruction Palpable pulsus
paradoxus
Grade 1 +
Grade 2 + Passive
Grade 3 + Active +
Grade 4 Grade 3 plus
marked retraction,
apathy and
cyanosis
• Grade 1and 2: supportive care; Adrenaline inhalations; avoid crying; systemic steroids
• Grade 3: O2; continuous adrenaline nebs; systemic steroids (pred 2mg/kg; IV dexa 0.6mg/kg); sedation if needed
• Grade 4: urgent intubation
• Antimicrobials: antibiotics (tracheitis); Acyclovir (herpes); fluconazole (candida); Gancyclovir (CMV)
Baby W
• 14 m old presents with
cough, runny nose and
wheeze
• 4th admission for similar
symptoms
• Growing well, HIV-, fully
immunised, well most of
the time
• Exam: T 37.7, Sats 88%
RA, RR 60;bilateral air
trapping; loud wheeze
and diffuse crackles
• WHAT OTHER HX
NEEDED?
• WHAT IS THE DIFF
DIAGNOSIS?
• WHAT
INVESTIGATIONS?
• WHAT IS YOUR
MANAGEMENT?
CXR Baby W
Recurrent and persistent wheeze
Recurrent Persistent
< 1 year Bronchiolitis
Aspiration episodes
Aspiration syndrome eg
GORD, laryngeal
incompetence
CF; cilliary dyskinesia
Post infectious PAO eg
BO from RSV,adenovirus
BPD
Tracheobronchial
obstruction eg vascular
ring, TB nodes
> 1 year Bronchiolitis
Episodic viral wheezeMulti-trigger wheeze
Asthma
Above PLUS
Uncontrolled asthma
Foreign body aspiration
TB nodes
Differential diagnosis of HIV+ children with respiratory symptoms
• Upper respiratory tract disorders
• Allergic conditions eg asthma, allergic rhinitis
• Lymphoproliferative disorders eg LIP
• Lower respiratory tract infections– common infections eg bacteria and viruses
– Opportunistic infections eg PCP or cytomegalovirus or fungal infections
– Tuberculosis
• Diseases of pleura eg pleural effusion
• Malignancy eg Kaposi Sarcoma or Lymphoma
• non-respiratory causes eg cardiac disease ; Aspiration syndromes or GORD; metabolic acidosis from diarrhoeal disease
Mechanisms of HIV-related pulmonary disease
Immunodeficiency
•Mucosal/local immunity
•Cell mediated immunity (CD4)
•Humoral immunity: Active
Passive
•Ineffective immunisations
•malnutrition
Opportunistic infections
eg PCP
Increased frequency and
severity of other common
infections eg bacterial
pneumonia and PTB
Lymphoproliferativedisorders
Immune dysregulation
Direct HIV infection and replication
in lung tissue causes immune –
mediated cytokine injury and
dysregulation
Lymphocytic interstitial pneumonitis (LIP)
Reactive airways disease
Hypersensitivities
Differential diagnosis of pulmonary conditions in HIV+ childrenInt J Tuberc Lung Dis 2006;10:1331-36
Illness CauseClinical features
Age range
Diagnosis
Tuberculosis M. Tuberculosis
Subacute onset, persistent and unremitting cough, weight loss, fever
All ages
Sputum microscopy/culture, TST, Hx of contact, CXR
Bacterial pneumonia
S. pneumoniae, H Influenzae, S. aureus, Gram neg organisms
Rapid onset, high fever, elevated WCC
All ages Blood culture
Viral pneumonia
RSV, Adenovirus, Influenza, CMV,EBV
Air trapping and wheezing infants>
older childrenClinical
LIPImmune response to EBV
Slow onset, cough, associated with gen LAD, parotitis, clubbing
Older children
Clinical
PCPPneumocystis jirovecii
Acute severe hypoxic pneumonia infants
Clinical, sputum for PCP IF
BronchiectasisRecurrent RTIs, LIP, TB
Slow onset, chronic productive cough, halitosis, clubbing
Older children
CXR
Differentiating between PCP and bacterial pneumoniaInt J Tuberc Lung Dis 2005;9:592-602
Feature PJPBacterial pneumonia
Age Infants (2-6 months) All ages
Fever Low grade or absent Usually febrile > 38.5C
Hypoxia Marked and persists > 48 hours
Variable and improves with treatment
Auscultation Clear or diffuse findings
Focal or diffuse findings
Response to usual antibiotics
Poor Good
CXR abnormalities Diffuse interstitial or hyperinflation
Usually focal
Outcome Very poor Usually satisfactory
Chronic/persistent lung disease in HIV –infected children
• CLD remains common as children continue to present late without ART, have repeated RTIs, Tuberculosis and LIP
• Differential diagnosis of children presenting with persistent (> 2 months) respiratory symptoms (cough, dyspnoea, wheezing, bronchial breathing or CXR abnormalities:– Lymphoid interstitial pneumonitis (LIP)
– Chronic HIV-associated lung disease / Bronchiectasis
– Tuberculosis (primary, complicated primary, miliary)
– Non-tuberculous mycobacteria eg M. avium; M .bovis
– Malignancy: Kaposi sarcoma, lymphoma
– Non-specific interstitial pneumonitis
– Aspiration syndromes eg GORD
Lymphoid interstitial pneumonitis
• A chronic lymphocytic infiltrative disease thought
to result from an dysregulated immune response
with HIV/Ebstein-Barr virus interaction
• Typical features are peribronchiolar lymphoid
follicles and lymphocytic infiltration of the alveolar
spaces
• Associated with a better outcome and seen more
in older children (> 2 years)
• Most common form of CLD in HIV+ children
LIP: clinical presentation
• Chronic cough (> 2 months) and variable
dyspnoea and even hypoxia (sats < 90%)
• May be asymptomatic in early stages
• Usually present with secondary respiratory
infections and LIP an ‘incidental finding’
• Co-infections and co-morbidity eg
bronchiectasis, pneumonia and TB are
common and may vary the presentation
LIP: Clinical features
• Lymphocytic proliferation in lymphoreticular organs > generalised lymphadenopathy, tonsilar and adenoidal hypertrophy, hepatosplenomegaly
• Auscultion findings vary
• Repeated respiratory infections eventually > bronchiectasis > cor pulmonale
• As HIV advances and CD4 count diminishes, less lymphoproliferation may result in disappearance of these features including pulmonary infiltrates
Digital clubbing Chest deformity Parotid enlargement
LIP: Diagnosis
• Compatible symptoms and
signs PLUS
• Exclusion of other
diseases/infections eg TB
PLUS
• Typical xray findings
– Bilateral reticulo-nodular infiltrates of varying size and distribution
– ± hilar LAD
– ± focal lung disease
LIP
Miliary TB*Lung biopsy not indicated anymore
Clinical and radiological features differentiating TB from LIP
Clinical features PTB Miliary TB LIP
Respiratory symptoms Common Uncommon Common
Persistent fever Common Common Common
wasting Common marked Variable
Generalised LAD Uncommon Uncommon Common
Parotid enlargement Rare Rare Common
clubbing Uncommon Rare Common
Marked HSM Uncommon Uncommon Common
CXR features
Focal parenchymal Common Uncommon Uncommon
Diffuse micronodular Negative Common Uncommon
Diffuse reticular Negative Negative Common
lymphadenopathy Common Uncommon Common
LIP: treatment
• Exclude and treat secondary bacterial infections
• Exclude TB co-infection
• Bronchodilators may be helpful
• Oral corticosteriods if significant symptoms or hypoxia
• Antiretroviral therapy is most effective treatment and most LIP will disappear with ART
Chronic HIV-associated lung disease (CHALD)
• Bronchiectasis/CHALD is the final common end-point of persistent/recurrent lung disease eg TB, recurrent pneumonia, LIP
• Present with chronic history of productive cough
• Clinical findings: wasting, digital clubbing, halitosis, focal abnormalities on auscultation, usually coarse crackles
• CXR: focal abnormalities; ±air trapping, atelectasis, consolidation, bronchial dilatation
CHALD: Treatment
• Treat intercurrent bacterial infections with appropriate antibiotics.
• Exclude TB co-infection
• Regular chest physiotherapy to promote drainage
• Bronchodilators if bronchodilator responsive
• Vaccinations against Step. Pneumoniae and Influenzaadvisable
• Regular cardiac function evaluation
• Antiretroviral Therapy is most effective to prevent further respiratory infections and improvement in general well-being
• Timeous ART should hopefully in future prevent and reduce the incidence and severity of CHALD