[醫如往常] Junior Clerkship Day 34: Pediatrics: Acute bronchiolitis

20151020 Morning Meeting: Acute bronchiolitis

Intern Dr. Lee.

DDx

Hypersensitivity airway : bronchodilator才有用

(tachycardia with bronchodilator)

Heart failure: Poor appetite, vomit, prolonged wheezing

Acute bronchiolitis

< 2 y/o with weezing for 3-7 days, cough for 1-2 weeks.

After URI 48-72hr  

Virus infection: 50% RSV
Mycoplasma 比較看不到cluster, 跟3-5 y/o同住的比較有可能

Zithromax, 主要功能anti-inflammation，也可用在Pertussis, Chlamydia

"Azithromycin作用機轉主要是和細菌的50s核醣體結合，阻止胜肽之移位作用進而抑制細菌蛋白質的合成。http://www.ktgh.com.tw/Medicament_tbDrug_Look.asp?CatID=124&ModuleType=Y&NewsID=207"

Clinical Presentation:

Rare in 1st month, peaks at 2-5 months
 Upper Respiratory Infection
o Rhinitis
 Lower Respiratory Disease
o Tachypnea
o Wheezing 考慮吃個dilator再測
o Cough
o Crackles
o Use of accessory muscles
o Nasal flaring
 Fever in approximately 30%

Pneumothorax, atelectasis, interstitial infiltration

應該給O2 tent

不過這次缺貨

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RSV TX
Ribivirin
hyperimmune RSV IVIG
I.M. palivizumab (anti-Protein F)

1. preterm <28 weeks
2. chronic lung disease (6 month) with medication
3. congenital heart disease

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補充

Loss of stool跟diarrhea不太一樣

Ddehydration可以看urine specific gravity

"A specific gravity greater than 1.035 is consistent with frank dehydration. In neonates, normal urine specific gravity is 1.003. Hypovolemic patients usually have a specific gravity >1.015."
https://www.wikiwand.com/en/Urine_specific_gravity

Ribs count

"The anterior end of approximately 5-7 ribs should be visible above the diaphragm in the mid-clavicular line."
http://radiologymasterclass.co.uk/tutorials/chest/chest_home_anatomy/chest_anatomy_page11.html

Over flextion
Flat Diaphragm
Atelectasis

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• Bronchodilators:

1. Short-Acting Beta-Agonists
2. Racemic Epinephrine (No evidence for repeated dosing or prolonged use in inpatients)
3. Albuterol (No routine use )

• Corticosteroids (Not recommended)
• Leukotriene Receptor Antagonists (Not currently recommended) Hypertonic Saline (May be useful in inpatient setting, likely not useful in emergency department)
• Antibiotics (UTI, AOM; acute otitis media)
• High-Flow Nasal Cannula
• Continuous Positive Airway Pressure (CPAP) (Insufficient evidence)
• Helium-Oxygen (Heliox)(Insufficient evidence)
• Surfactant(Insufficient evidence)
• Home Oxygen Therapy (Insufficient evidence)

Ref.

APA建議

Management of Bronchiolitis: A Clinical Update
https://www.meadjohnson.com/pediatrics/us-en/sites/hcp-usa/files/PCOWebinar-Bronchiolitis_Final.pdf 

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Cholestasis in infancy

Prof. Chen

α-fetoprotein: 後來的albumin
>2 weeks prolonged jaundice

Bile acid: liver氧化傷害 apoptosis

biliary cirrhosis: portal area extension

HBV cirrhosis不一樣，是post necrosis cirrhosis

CMV 是最常見造成新生兒肝炎的病原。 

其他像是Medical history: TPN（全靜脈營養）, Ischemia, Sepsis, Drugs 

Chronic Cholestasis 要補充MCT(中鏈脂肪酸), Vit. ADEK

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Allergy

Dr. Lin
Asthma

Reliever

β2-agonist可隔 15 到 20 分鐘再使用一次。 

若使用了三次，仍覺不適，或最大吐氣流量數值仍是平常的百分之八十以下，就應到醫院治療。

出院後六小時吸一次， 吸三天

Controller：預防性的藥物 

七天內都算同一次， 一個月內發作兩次就要給controller

連用三個月沒有發作可以停藥

Allergic rhinitis

Most common

child 2/3, adult 1/3

 症狀  :  超過七天的流黃膿或綠膿鼻涕、黃膿或綠膿鼻涕倒流(鼻塞、咳嗽、清喉嚨的聲音)

α agonis噴鼻型血管收縮劑  :  只在已使用噴鼻型類固醇者，當呼吸道感染或鼻竇炎時嚴重鼻塞時使用，一次使用不可超過五天

real cough 超過三聲

清喉嚨一聲

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Viral Hepatitis in Children 

Prof. Chang

HBV

Prof. Beasley發現越年輕感染越容易變成帶原者。 

吳嘉峰教授發現在宿主免疫能力方面，體內高濃度 IL-10,IL-12 較容易發生HBeAg seroconversion。以醫師的角度來說Seroconversion 能越早出現越好，能降低病毒的表現。 

倪衍玄教授發現 HBV B-type較 C-type 容易轉換進入 inactive phase。

HCC 80% has cirrhosis

張美惠教授發現5%出生就有Anti-HBsAg: intrauterine infection

陳慧玲教授發現Viral load 跟傳染力的關係

Operation room針扎很多要小心

Maurice Ralph HillemanAdjunct Professor of Pediatrics at the University of Pennsylvania in Philadelphia.
Maurice Ralph Hilleman (August 30, 1919 – April 11, 2005) was an American microbiologist who specialized in vaccinology and developed over 40 vaccines, an unparalleled record of productivity. Of the 14 vaccines routinely recommended in current vaccine schedules, he developed eight: those for measles, mumps, hepatitis A, hepatitis B, chickenpox,meningitis, pneumonia and Haemophilus influenzae bacteria.  He also played a role in the discovery of the cold-producing adenoviruses, the hepatitis viruses, and the cancer-causing virus SV40. 

https://www.wikiwand.com/en/Maurice_Hilleman