1. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Infants in respiratory distress

2. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Case 1: 6 months old boy 1 week cold, general condition OK then 1,5 day: –mild fever –wheezing –coughing –able to fulfill meals with short breaks No previous history of bronchial obstruction or atopy

3. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Examination Unhappy, resists examination Coughing attacks during consultation Retractions intercostal and subcostal RR 45, HF 130, T 38,5, SaO2 95% Auscultation: moderate crepitations, some expiratory wheeze Skin turgor, capillary refill 1-2 sec, mucous membrane wet

4. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Lab CRP 30 pH 7.30, pCO2 5,0 Diagnosis? Admit to hospital? Other solutions?

5. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Acute viral bronchiolitis

6. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat History Wheezing, degree of respiratory distress Duration of symptoms, developing from common cold? Eating: able to complete meals? Urine output 2 year older sibling in kindergarden (atopic excema, previous BO, family history)

7. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Clinical examination Retractions –Jugular, Intercostal, Subcostal Respiratory frequence Conciousness/general appearance Auscaltation –Fine crepitations –Prolonged expirium –Expiratory wheeze SaO2 Nasal flaring

8. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Clinical examination Hydration level –(skin turgor, capillary refill, mucus membrane, fontanel) Heart rate

9. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Laboratory investigations Blood gases – pH, pCO2 Dehydration assessment –bicarbonate, urea, BE Na, K, Hb, WBC, glukose, kreatinin

10. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Imaging Chest x-ray

11. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Treatment Oksygen Nutrition –Nasogastric tube Intravenous fluid Respiratory support –CPAP –Conventional respirator Nasal spray

12. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Treatment Inhalations? –Saline –Racemic adrenaline (epinephrine) –Salbutamol? –Hypertonic saline? Corticosteroids?

13. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Case 2: 4 weeks old girl 2 year old brother in kindergarden with a cold last week Upper airway infection 3 days Much coughing last 24 hours 2 apnoes of 10 seconds each last 12 hours eats OK, but must have some breaks

14. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Examination Smiles, excellent contact. Good activity Mild subcostal retractions Auscultation: some fine crepitations, no ekspiratory wheezing or prolonged expirium HR 140, RF 55 (Capillary refill time 2 sec, mucus membranes wet, turgor OK)

15. Medisinsk Fakultet, Institutt for Klinisk Medisin, Oslo Universitetssykehus, Barneklinikken, Håvard Ove Skjerven, Klinisk Stipendiat Lab CRP 7, pCO2 6,5 Admit to hospital?