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Pediatric Pulmonary Case Conference

Pediatric Pulmonary Case Conference. Sunil Kamath MD Post-Doctoral Fellow Childrens Hospital Los Angeles. HPI. 6 month old male with no significant PMH 3/17 cough, rhinorrhea, nasal congestion, Fever 101 cranky and NBNB emesis x 1 3/18 "moaning" while breathing

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Pediatric Pulmonary Case Conference

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  1. Pediatric Pulmonary Case Conference Sunil Kamath MD Post-Doctoral Fellow Childrens Hospital Los Angeles

  2. HPI 6 month old male with no significant PMH 3/17 cough, rhinorrhea, nasal congestion, Fever 101 cranky and NBNB emesis x 1 3/18 "moaning" while breathing PMD diagnosed a URI and pt. was sent home developed subcostal retractions and taken to outside ED where he received breathing treatments, improved, and was discharged home 3/19 Irritable and had subcostal retractions Returned to outside ED

  3. ED Course Persistent retractions and pale SpO2 71%  placed on O2  “pinked up” Received continuous aerosol treatments Transferred to outside hospital PICU for further care with the presumptive diagnosis of bronchiolitis

  4. FT, NSVD, no complications, home on DOL 2 Surgical history: none NKDA Immunizations: has not received 6 month vaccinations Diet: Enfamil 6oz TID, baby foods Family History: father with bronchitis as a child Social History: Lives with mother, father and 2 yo sister, no tobacco exposure, no pets All other ROS negative

  5. Outside Hospital Physical Exam VS: Temp: 36.7 C HR: 174 bpm RR: 53 breaths per minute BP: 98/67 mmHg SpO2: 98% on 1.5 LPM via NC PE: General: Awake in mild/moderate respiratory distress with subcostal retractions Resp: Coarse breath sounds bilaterally. + Rhonchi. No Wheezing. Heart: RRR. Normal S1 and S2

  6. Labs 18.3 \ 10.7 / 334   / 36 \ 149 107 8 149 Ca:9.8 5.1 21 0.4 Respiratory culture – Negative for bacteria RSV DAA – negative Influenza DAA – negative Total IgG, IgA, IgM, IgE – normal CXR

  7. Outside Hospital Course 3/20 Intubated for worsening respiratory distress  HFOV x 1 week Started on ABX and steroids 3/25 ETT viral culture: Adenovirus (not typed) 3/30 DVT of right leg Rx Lovenox 4/11Extubated to HFNC and steroids were weaned Developed wheezing, prolonged expiratory phase, increasing distress IV steroids were re-started and patient improved 5/4 Changed to Prednisone 5mg BID and transferred to the floor 5/5 MSSA bacteremia Rx oxacillin 5/6 Developed increased tachypnea with nasal flaring and fatigue during feeding 5/6 Chest CT

  8. consolidation of RLL and LUL with associated cylindrical bronchiectasis

  9. 5/7 Transferred to CHLA VS Temp: 37.9 deg C HR: 148 bpm RR: 38 Breaths/Min BP: 144/90 mm Hg SpO2: 99% on ½ LPM PE General Appearance: laying in bed, moderate respiratory distress, becomes fearful with exam Chest: symmetric chest rise, subcostal retractions Respiratory: diffuse crackles, wheezing, forceful expiration with grunting Cardiovascular: RRR, no m/r/g, 2+ pulses

  10. Labs 18.72 \ 11.5 / 557   / 35.9 \ Segs 44, Bands 0, Lymph 42, Mono 13, Baso 0, Eos 1 139 97 11 123 Ca:9.9 5 32 0.2 CBG: 7.46/50//36

  11. “The lungs are hyperinflated. There is streaky perihilar disease with peribronchial thickening bilaterally.”

  12. What is your assessment and plan?

  13. Hospital Course Plan: chest CT, bronchoscopy, lung biopsy, and iPFT when stable 5/10 SCINTI: normal 5/11 ECHO Small secundum atrial septal defect vs. patent foramen ovale. No evidence of PHTN 5/13 MBSS: normal 5/18 Wheezing. Prolonged expiratory phase. Increasing respiratory distress. Prednisone  Solumederol 5/21 Admitted to the PICU for stabilization and repeat CT scan 5/24 RV panel: negative Immunology workup: unremarkable

  14. Template progression of bronchiectasis and scattered areas of groundglass opacity

  15. What is your management plan?

  16. Management Bronchiolitis Obliterans: Azithromycin (5mg/kg QMWF) Methotrexate (10-15mg/m2/dose SQ Qwk) Continued IV steroids 5/25 Developed thick secretions and was difficult to ventilate Empirically started on Vanc and Zosyn Trach cult (Many Haemophilus influenzae, Beta lactamase negative) Ceftriaxone

  17. ABX started Intubated IV steroids PICU admit Extubated MTX Azithro

  18. Bronchiolitis Obliterans Rare form of chronic obstructive lung disease that occurs after an insult to the lower respiratory tract Etiology: Bronchiolitis Obliterans in Children. Pediatric Pulmonology 39:193-208 (2005)

  19. Pathophsiology: Inflammation and fibrosis of the terminal and respiratory bronchioles  narrowing and/or complete obliteration of the airway lumen Bronchiolitis Obliterans in Children. Pediatric Pulmonology 39:193-208 (2005) Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed.

  20. Diagnosis: CXR PFT Bronchoscopy - neutrophilia HRCT: mosaic pattern Open lung biopsy: Sampling error due to patchy airway involvement 2 categories: proliferative bronchiolitis (intraluminal polyps) constrictive bronchiolitis (peribronchiolar fibrosis) Treatment Supportive care Steroids Immune modulators

  21. Thank You

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