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 laryngeal spasm & respiratory distress within minutes ( same effect by cold night air )

Also can use IPECAC to induce vomiting resulting decreasing spasm, although vomiting appear to break spasm .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 • progressive stridor 2- highly or suspected epiglotitis 1-

• sign of resp. distress like 4- sever stridor at rest 3-• hypoxia , irritable , cynosis , sever pallor , depresed

• sensorium .• :---For patients who admitted

• chart observation ( PR ,RR ).increasing resp. rate is first sign of hypoxia1- •

•given to replace insensible H2O loss or because of inability to take oral arenteral fluid :- -p2 .feeding & decreased risk of aspiration pneumonia

• sedation is C.I ( because of restless is used as clinical indices of3- •severity of obstruction & need for tracheostomy or endotracheal intubation ) .

•children should be kept calm as possible to reduce resp. effort4- •-O2 to alleviate hypoxia ( humidified O2 )5

• brocho-dilator & expectorant are not helpful & A.B. is not indicated 6- •-Racemic epinphrine ( o.25 -0.75 ml of 2.25% in 3 ml normal saline can be used 7

• every 20 minutes causing transient relief of symptoms through vasoconstriction of precapillary arteriol leading fluid resorption from interstitial space and decrease edema .

used L-epinpherine ( 5 ml of 1:1000 solution ) is equally effective as Or .Racemic epinpherine

Nebulized epinpherine should still be used cautiously in patient with•Tachycardia or heart condition like TOF, ventricular outlet

.obstruction•cortico steriod to reduce inflamatory edema & prevent destruced 8-

celiated epithilial ( 0ral 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 :--•very young of less than 4 month of age .1-

• if symptoms continue of more than one wk2- • patients with 2 or more episode of croup and that had history of intubation and 3-

had sever prolong disease required inpatient management .orage less than 3 years

•this is to exclude sub-glotic stenosis or hemangioma. •1- after 2-3hr period of observation , if safely discharge Pt can be

normal air entery,2- normal conscience,3- no stridor at rest 4-,received steriod,5- normal pulse oximetry .

•N.T ; very young pts of less than 4 month of age or symptoms continue more than one week , the pt should undergo laryngoscopy to exclude subglotic stenosis or

--3 hemangioma

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 recently , the mean age 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 :---

• history of croup, followed by high fever , toxic associated 1- • respiratory distress or may occur few days after improvement .

• patients lie flat , not drool , no dysphagia .2- • not respond to general treatment of croup .3-

• intubation & tracheostomy is usually required ( but in more recent • series , only 50-60 % of patients required intubation )

• --4--

Pathology :-- .mucosal swelling at level of cricoid cartilage 1-

thick copious , purulent secretion . 2-

•Diagnosis :--• WBC leucocytosis with band form 2- ClF 1-

• X-ray is not needed , &may show classical feature pseudo3- • membrane detachment in the larynx .

• laryngoscopy shows purulant material bellow cord .4- •Treatment :--

•O2 therapy , I.V fluid , intubation in sever cases :- 1- supporting • #by A .B ( anti staph ) 2- specific therapy

•CX :---• resp. obstruction leading to resp. arrest 1-

• infection go down to parenchymal or bronchiol leading to pneu.2- •toxic shock syndrome3-

• emperical therapy :-vancomycin + naficilin or cloxacillin & artificial air Now#way should be strongly considered .

• become afebrial patient within 2-3 days but may be prolonged Prognosis :-•Hospitalization may be nesessory ( mean duration is 12 days )

• ---5--

DD :-- of wheezing :---- infection :- bronchiolitis , pneumonia .1 asthma 2-

•-anotomical abnormalities like :- A– central air way like 3 • 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 ) .

• cystic fibrosis , bronchioactasis .4- • aspiration pneumonia , G.E.R 5-

• interstitial lung disease like bronchiolitis 7- H.F 6-obliterance 8- anaphylaxis .

• ----(((look to video of wheezing ))) •---6-

Bronchiolitis :---is common dis. of LRTI of infant , is resulting from infla.

heezing .cterized by wcterized by wrair way , chair way , chall amama Obst. Of s

•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 :--

also can caused by PIV is viral in origin in more than 50% by RSV, type 3 & some of adeno virus , mycoplasma .

• 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---

Inflamed bronchiol

mechanism

mechanism

usually other member of family were ill by viral infection .1- ClF :-- usually proceeded by URTI of few days before onset of resp. distress 2-

which include dyspnea , tachypnea , wheezing , intermittent cynosis

•low grade fever 38.5—39c & other systemic manifestations like 3- absent.vomiting & diarrhea are usually

•in early course of dis. In wheezing more prominent than Apnea •premature infant . very young infant of less than 2 month of age or former

•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 in 30% caused by atelectasis which

secondary to obstruction or inflammation of alveoli . • 3- WBC & diffrential count are usually normal .

• --8--

F.B aspira.3- bronchopneumonia 2-asthma -1 DD :-- pertusis 6-poisoning 5- cong. H.F 4-

cystic fibrosis 7-

•50% of sever bronchiolitis may going to asthma Note :--• most critical period is 2-3 days after onset of cough & Course :--

• dyspnea. & then improvement occurs rapidly & recovery • is completely within several days ( 10-14 days )

•is less than 1% ( higher figures associated with higher Death rate :--• risk groups ) , caused by :---

• prolong apneic spell 1- •sever uncompansated resp. acidosis 2-

• profound dehydration 3- •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 tofamily history of asthma & allergy 1- :-- have prolong acute episode of bronchiolitis 2- exposure to cigarette smoking 3-

• :--Treatment of bronchiolitis• :--depend on severity of illness

•most children have mild illness & can be managed at home with • supporting measures .

• of 5% of patients needs hospital admission :----indication younger patients of less than 6 months .1- :---- admission

•moderate to marked resp. distress ( sleeping R.T 2- • of more than 50-60 breath / minutes or higher) •hypoxemia ( po2 of less than 50-60 mmHg ) or 3-

• o2 saturation of less than 92% on room air • episode of apnea 4-

• inability to tolerate oral feeding 5- •lack of appropriate care at home 6-

•children with CHD, BPD , NMD, immune def. ---- increasing risk of (sever potentially sever dis.)

Supporting measures :-- adequate fluid to maintain normal hydration 1-

antipyretic for febrile patients2- • humidified o2 in sufficient concentration to maintain pao2 3-

• 70-90 mmHg & o2 saturation of more than 92% • broncho-dilator like B-agonist produce short term 4-

• improvement in clinical feature .•.nebulized epinpherine may more effective than B-agonist

cortico-steriod are often negative suction of noze & oral secretion is essential part and often provide relief of 5- freguent

is essential part of treatment of bronchiolitis )distress or cynosis (

•Specific therapy :--• ribavirine is antiviral agent administered by aerosol has 1-

• been used for infant with CHD or chronic lung dis.• no support for RSV immune globuline administered 2-

• during acute episode of RSV .• prevention ;-1-hyperimmune globulin to RSV,

•2-palivizumam :IM monoclonal Abs during and before season . ---11--

Bronchiolitis obliterane :--,there is in which , pertusis , measles , adeno viruscaused by

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 .• gradual progressive resp. distress ClF :--

• ranged from normal to a pattern suggest of milliary T.B X-ray :- • :-obstruct of bronchus ---Bronchography

•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 • by lobectomy may be required if resp. distress is sever orTreatment

• progressive . ---12---•