Cough or Difficult Breathing Case II

Chapter 4

Case study: Ratu

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11 month old boy with 5 days of cough and fever, yesterday he became short of breath and unable to feed

What are the stages in the management of any sick child?

Stages in the management of a sick child

1. 2. 3. 4. 5. Triage Emergency treatment History and examination Laboratory investigations, if required Main diagnosis and other diagnoses

(Ref. Chart 1, p. xxii)

6.
7. 8.

Treatment
Supportive care Monitoring

9.
10.

Plan discharge
Follow-up

Have you noticed any emergency or priority signs?

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Temperature: 39.70C, pulse: 180/min, RR: 70/min, cyanosis visible suprasternal and subcostal recession, grunting respiration

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

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

What emergency treatment does Ratu need?

Emergency treatment
Airway management? Oxygen?

Intravenous fluids?
Anticonvulsants?

Immediate investigations?

Check SpO2 and blood glucose

(Ref. Chart 2, p. 5-6)

How to give oxygen

Place the prongs just inside the nostrils and secure with tape. (Ref. Chart 5, p. 11 p. 312-315)

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

Start oxygen flow at 1-2 litres/minute, in young infants at 0.5 litre/minute

Emergency treatment (continued)

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

Give emergency treatment until the child is stable

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

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

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

Differential diagnoses
Pneumonia Congenital heart disease Tuberculosis Foreign body Effusion/empyema Pneumothorax Pneumocystis pneumonia Severe anaemia Asthma (Ref. p. 93) Bronchiolitis

(Ref. p. 77-79)

Additional questions on history

Prior illnesses Locally important illnesses Immunization history Nutritional history

Tuberculosis in family

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

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

Further examination based on differential diagnoses (continued)

Assess cause of respiratory distress: - Pneumonia: crepitations, bronchial breathing, effusion,
cyanosis

- Heart failure: tachycardia > 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) < 70% or < -3SD

- Look for oedema of feet (Ref. p. 198)

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

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)

Full blood examination

Haemoglobin Platelets 5.9 g/dl (105-135) 858 x 109/l (150-400)

WCC
Neutrophils Lymphocytes

30.6 x 109/l (6.0-18.0)

17.4 x 109/l (1.0-8.5) 3.4 x 109/l (4.0-10.0)

Monocytes
Blood glucose

1.2 x 109/l (0.1-1.0)

4.5 mmol/l (3.0 - 8.0),
after IV glucose

Blood film: hypochromic microcytic anaemia

Hb 5.9g / dL No malaria parasites, RDT negative

Chest x-ray

SpO2 : 82% on room air

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

Diagnosis (continued)
Very severe pneumonia
Heart failure

Severe anaemia
Severe iron deficiency

How would you treat Ratu?

Treatment
Very severe pneumonia
Oxygen therapy Antibiotic therapy Diuretics (Ref. p. 82) (Ref. p. 82) (Ref. p. 120-122)

Heart failure

Severe anaemia (with heart failure)

Blood transfusion (Ref. p. 307-308) Iron therapy (when improved) Diet change

What supportive care and monitoring are required?

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.

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)

Discharge planning and Follow up

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

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

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