1. Chapter 4 Cough or Difficult Breathing Case II

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

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)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Discharge planning
Follow-up

5. Have you noticed any emergency or priority signs?
Click on the photo to play video
Temperature: 39.70C, 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?
Immediate investigations?
□ Check SpO2 and blood glucose
(Ref. Chart 2, p. 5-6)

10. How to give oxygen
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
(Ref. Chart 5, p p )
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: 39.70C, pulse: 180/min, RR: 70/min
Oxygen saturation SpO2 : 93% on oxygen
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. Differential diagnoses
List possible causes of the illness
Main diagnosis
Secondary diagnoses
Use references to confirm (Ref. p , p. 93)

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

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. 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 )
Assess nutritional state
- Weight-for-length (or height) < 70% or < -3SD
- Look for oedema of feet (Ref. p. 198)

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

22. Investigations 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
Haemoglobin 5.9 g/dl ( )
Platelets 858 x 109/l ( )
WCC x 109/l ( )
Neutrophils 26.0 x 109/l ( )
Lymphocytes 3.4 x 109/l ( )
Monocytes x 109/l ( )
Blood glucose 4.5 mmol/l ( ), after IV glucose

24. Blood film: hypochromic microcytic anaemia
Hb 5.9g / dL, MCV 62
No malaria parasites, RDT negative

25. Chest x-ray

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
SpO2 : 82% on room air, 93% on oxygen
Hypoglycaemia (1.8 mmol/L, 4.5 mmol/L after glucose)
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
(Ref. p. 82)
Oxygen therapy
Antibiotic therapy
(Ref. p. 82)
□ Heart failure
(Ref. p )
Diuretics
□ Severe anaemia (with heart failure)
Blood transfusion
Iron therapy (when improved)
Diet change
(Ref. p )

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 )
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