1. Chapter 4 Cough or Difficult Breathing Case II

2. Case study: Ratu 11 month old boy with 5 days of cough and fever, yesterday he became short of breath and unable to feed Click on the photo to play video

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

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii) 1.Triage 2.Emergency treatment 3.History and examination 4.Laboratory investigations, if required 5.Main diagnosis and other diagnoses 6.Treatment 7.Supportive care 8.Monitoring 9.Plan discharge 10.Follow-up

5. Have you noticed any emergency or priority signs? Click on the photo to play video Temperature: 39.7 0 C, pulse: 180/min, RR: 70/min, cyanosis visible suprasternal and subcostal recession, grunting respiration

6. 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

7. 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

8. What emergency treatment does Ratu need?

9. Emergency treatment Airway management? Oxygen? Intravenous fluids? Anticonvulsants? Immediate investigations? □ Check SpO 2 and blood glucose (Ref. Chart 2, p. 5-6)

10. 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 How to give oxygen (Ref. Chart 5, p. 11 p. 312-315) Start oxygen flow at 1-2 litres/minute, in young infants at 0.5 litre/minute

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

12. Give emergency treatment until the child is stable

13. 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

14. 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: 39.7 0 C, pulse: 180/min, RR: 70/min Oxygen saturation SpO 2 : 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

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

16. Pneumonia Congenital heart disease Tuberculosis Foreign body Effusion/empyema Pneumothorax Pneumocystis pneumonia Severe anaemia Asthma Bronchiolitis (Ref. p. 77-79) (Ref. p. 93)

17. Additional questions on history Prior illnesses Locally important illnesses Immunization history Nutritional history Tuberculosis in family

18. 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

19. 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

20. 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) Further examination based on differential diagnoses (continued)

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

22. Investigations Oxygen saturation (SpO 2 ) 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)

23. Full blood examination Haemoglobin5.9 g/dl (105-135) Platelets858 x 10 9 /l (150-400) WCC30.6 x 10 9 /l (6.0-18.0) Neutrophils17.4 x 10 9 /l (1.0-8.5) Lymphocytes3.4 x 10 9 /l (4.0-10.0) Monocytes 1.2 x 10 9 /l (0.1-1.0) Blood glucose4.5 mmol/l (3.0 - 8.0), after IV glucose

24. Blood film: hypochromic microcytic anaemia Hb 5.9g / dL No malaria parasites, RDT negative

25. Chest x-ray SpO 2 : 82% on room air

26. 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 SpO 2 : 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

27. Diagnosis (continued) Very severe pneumonia Heart failure Severe anaemia Severe iron deficiency

28. How would you treat Ratu?

29. Treatment □ Very severe pneumonia □ Heart failure □ Severe anaemia (with heart failure)  Blood transfusion  Iron therapy (when improved)  Diet change  Diuretics  Oxygen therapy  Antibiotic therapy (Ref. p. 307-308) (Ref. p. 120-122) (Ref. p. 82)

30. What supportive care and monitoring are required?

31. 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.

32. 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)

33. Discharge planning and Follow up When is it OK for Ratu to be discharged? What follow-up is needed

34. 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

35. 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 Don’t forget follow-up