Transcript Neonatal Sepsis

Pharma Conference
Difficulty in breathing

•Known case of bronchial asthma since September 2009
•via salbutamol challenge test
•Salbutamol nebulization as needed
•No maintenance
•No regular follow up done
6 weeks PTA

• occasional dry cough
• night awakenings due to cough ( 2-3 / week)
• give Salbutamol neb every 4 hours
•Improved by having a good sleep after
• no consult was done
2 weeks PTA
• Still persistent dry cough

•Night awakenings due to cough (3-4 x/ week)
consulted consulted at local health clinic
> had chest X ray
showed pneumonitis w/ lymphadenopathies
* given with
* loratidine ( loraped) once daily
* cefaclor 5mL for 7 days
* asked to come back after 3 days
10 days PTA
• according to mother after 3 days

• noted decrease frequency of dry cough
•Decrease night awakening
• At follow up
• Loratidine was replaced with Citirizine 2.5 mL
every 4 hours
•Cafaclor was continued for another 4 days
1 day PTA

•Still there was cough
•Fever ( highest temp 38.2C)
•Watery nasal discharge
•Post-tussive vomiting of previously ingested milk
•Mother gave
•5mL paracetamol (125mg/5ml)
for every 4 hrs
•Salbutamol nebulization
(1/2 nebule + 1cc NSS) every 4 hours
• there was improvement after nebulization
however the symptoms re occur after several hours
which prompt consult at UST - ERCD

Gen: no weight loss, no decrease in appetite
HEENT: no headache, no eye discharge, no epistaxis,
no sore throat
Cardiovascular: no bruises, no syncope
GI: no diarrhea, no melena, no hematocheiza
GU: no difficulty in urination
Endocrine: no tremors,
Musculoskeletal: no bone pain, no muscle pain,
no limitation in range of motion
Nervous System: no seizure, convulsions, weakness
Feeding history

• Breast fed until 1 week of life and fed after with milk formula
• Started complimentary feeding at 6 months
• Now, the patient was fed with mixed diet with Nido with 1:1
dilution, 8 ounce 3/day
24 food recall
Food
CHO (g)
CHON (g)
FATS (g)
Calories

Breakfast
Lunch
1 cup soy milk
Pancit Canton
Beef nilaga with 2
pc meat
½ cup rice
Merienda
4 pcs wafer
1 juice tetrapack
Dinner
Beef nilaga with 2
pc meat
1/4cup rice
Midnight snack
French fries
Milk 3 ounces
1.5
23
2
2
21.5
100
2
23
16
2
82
100
11.5
6
1
8
50
1
41
11.5
1
50
23
18
2
12
100
253
15
ACI
%
919.5
(86%)
RENI
1070
Developmental History

• Gross Motor: Run well with out support, can jump
• Fine Motor: feeds self with spoon
• Language: produces 2 words sentences, can point what
he wants
• Social: plays with other kids
Immunization

• Patient completed the EPI program in our OPD-CD however cant recall the
exact dates
• BCG 1 - dose
• Hep B – 3 doses
• DTP – 3 doses
• OPV – 3 doses
• Measles – 1 dose
• Hib – 1 dose

Admtted last December 2009 for pneumonia

No skin allergies, No surgeries, no blood transfusion

(+) Asthma (father, uncle maternal side)

(+) hypertension (grandfather – maternal side)

(+) heart problem ( grandmother – paternal side)

(-) DM, skin allergy , anemia, leukemia, renal disease,
seizures

Name
Age
Relation
AS
46
LS
52
KR
27
Grand
father
Grand
mother
Father
CR
25
Mother
LS
33
Aunt
RS
21
Uncle
Educational
Attainment
Occupation
Health
Graduate Technician (+)HPN
Vocational
Healthy
High School Housewife
graduate
College
Technician (+) asthma
graduate
Healthy
Graduate
Housewife
Vocational
Graduate
None
Healthy
vocational
Highschool
None
Healthy
graduate


lives with his parents, maternal grandparents, uncle and
aunt
2 storey building made of cement

Well lit, well ventilated with 2 bedrooms and 1 comfort room

Drinking water is brought from a refill station

Garbage not segregated but collected daily


No nearby factories, no pets in the house, no second hand
smoke exposure
There was planted flowers in front of their house which they
noted the patient to cough every time he passes by
HR: 120bpm
RR: 38/min
Wt: 14kg (Z score O)
Ht: 86.6 (Z score 0)
HC: 48 cm (above 0)
Temp: 37.1 C
Awake, good activity and crying
Skin: Warm, moist skin, no active dermatoses,
no jaundice, good skin turgor
HEENT: closed fontanels, Pink palpebral
conjunctivae, anicteric sclerae, no opacities,
normal direct pupillary light reflex, pupils
2-3mm ERTL; nonhyperemic EAC and intact
tympanic membrane, AU, no aural
discharge; no alar flaring, septum in
midline, congested turbinates, (+) whitish
nasal discharge; hyperemic posterior
pharyngeal wall w/ no exudates, uvula
midline, tonsils not enlarged
Neck: Supple neck, (-) palpable cervical
lymph node
Lungs: Symmetrical chest expansion, no
lagging, (+) suprasternal, intercostal,
subcostal retractions, (+) wheezes on both
lung fieds, (+) coarse crackles on both lung
fields
Heart: Adynamic precordium, apex beat at 4th
LICS MCL, no thrills, heaves, lifts, murmurs
Abdomen: globular soft abdomen, NABS, no
palpable masses, no tenderness upon
palapation
Extremities: Full and equal pulses on all
extremities, no edema, no cyanosis, no
limitation in movement
Genitourinary: bilaterally descended testes,
no discharge, no masses
Alert, awake, crying and irritable
CN I-XII were intact
Motor: all extremities moves spontaneously
Sensory: No sensory deficits
Reflexes: All DTR +2, (-) babinski
(-) nuchal rigidity, kernig’s and brudzinski
*
*
*
*
*
2years old/ male
(+) family history of asthma
known bronchial asthma
dry cough, noucturnal awakenings
noted coughing when the pastient passes by infront of the
house where there are flowers
* good response to salbutamol neb
* RR 38/min , (+) suprasternal, intercostal, subcostal
retractions, (+) wheezes on both lung fieds, (+) coarse
crackles on both lung fields
Approach to diagnosis
Look for a symptom, sign, or laboratory
finding found in the least number of
diseases
Shortness of breath
Cough
Wheeze
•Asthma exacerbation
•Acute bronchitis
•Vocal cord dysfunction
•Foreign body aspiration
•Gastroesophageal reflux
Asthma
 common
chronic inflammatory disease of
the airways characterized by variable
and recurring symptoms, airflow
obstruction, and bronchospasm.
 Asthma is caused by environmental and
genetic factors. These factors influence
how severe asthma is and how well it
responds to medication.
Asthma



Asthma predominantly occurs in boys in childhood,
with a male-to-female ratio of 2:1 until puberty, when
the male-to-female ratio becomes 1:1.
Asthma prevalence is increased in very young persons
and very old persons .
Asthma symptoms may include the following:
• Cough, worse particularly at night
• Wheezing
• Shortness of breath
• Chest tightness
• Sputum production
• Decreased exercise tolerance
Asthma




General asthma physical findings
• Evidence of respiratory distress manifests as increased
respiratory rate, increased heart rate, diaphoresis, and use of
accessory muscles of respiration.
• Marked weight loss or severe wasting may indicate severe
emphysema.
Pulsus paradoxus
Depressed sensorium
Chest examination
• End-expiratory wheezing or a prolonged expiratory phase is
found most commonly, although inspiratory wheezing can be
heard.
• Diminished breath sounds and chest hyperinflation
Acute Bronchitis
 clinical
syndrome produced by inflammation of
the trachea, bronchi, and bronchioles
 usually occurs in association with viral
respiratory tract infection
 Characteristic symptoms include productive
cough, shortness of breath and wheezing.
 clinical course of acute bronchitis is selflimited, with complete healing and full return to
function typically seen within 10-14 days
following symptom onset.
Acute Bronchitis
 The
incidence is equal in males and
females
 occurs most commonly in children
younger than 2 years, with another peak
seen in children aged 9-15 years.
 begins as a respiratory tract infection that
manifests as the common cold.
Acute Bronchitis
 Symptoms
often include coryza, malaise,
chills, low grade fever, sore throat, and back
and muscle pain.
 The cough in these children is usually
accompanied by an initial watery nasal
discharge.
 Crackles, rhonchi, or large airway wheezing,
if any, tends to be scattered and bilateral
**There is no specific therapy. The disease is
self-limited
Vocal Cord Dysfunction
 abnormal
adduction of the vocal cords
during the respiratory cycle (especially
during the inspiratory phase) that produces
airflow obstruction at the level of the larynx.
 Presents with wheezing, cough, and
dyspnea
 This condition is predominantly observed in
females
 This condition predominates in people aged
20-40 years, but it can occur in people aged
6-83 years
Vocal Cord Dysfucntion
History
 Wheezing
 Cough
 A feeling of tightness in the throat
 Hoarseness and voice change
 Stridor
 Shortness of breath
 Dyspnea on exertion
 Inspiratory difficulty
 Unresponsiveness to bronchodilators and corticosteroids
Physical Exam
 Laryngeal auscultation may reveal harsh stridulous sounds during
symptoms.
 Wheezing may be heard in the chest (transmitted from the upper airway).
Foreign Body Aspiration
 The
male-to-female ratio is 2:1
 Children, especially those aged 1-3 years
 Choking or coughing is present in 95%
of patients
 Approximately 50% of children have
inspiratory stridor or expiratory
wheezing, with prolongation of the
expiratory phase, and medium-to-coarse
rhonchi.
Foreign Body Aspiration
 Tachypnea; nasal
flaring; intercostal,
subcostal, and suprasternal retractions;
and differences in percussion between
hemithoraces also are common findings
 Fever and central cyanosis are less
common
 consider the possibility of foreign body
aspiration, particularly with unilateral
wheezing
Gastroesophageal reflux
 Immaturity
of lower esophageal
sphincter (LES) function, manifested by
frequent transient lower esophageal
relaxations (tLESRs) that results in
retrograde flow of gastric contents into
the esophagus.
 Gastroesophageal reflux has been
associated with significant respiratory
symptoms in infants and children
Gastroesophageal reflux


Signs andsymptoms of gastroesophageal reflux in infants and young children
• Typical or atypical crying and/or irritability
• Apnea and/or bradycardia
• Poor appetite
• Vomiting
• Wheezing
• Abdominal and/or chest pain
• Stridor
• Weight loss or poor growth (failure to thrive)
• Recurrent pneumonitis
• Sore throat
• Chronic cough
• Hoarseness and/or laryngitis
Signs and symptoms in older children - All of the above, plus heartburn and
history of vomiting, regurgitation, unhealthy teeth, and halitosis
CLINICAL DIAGNOSIS
Bronchial asthma, mildly persistent,
in moderate exacerbation
Course in The Ward (1st HD)
 Please
admit the patient under the service
of Dr. Moral-Valencia at bed 320G
 Diet for age with strict aspiration precaution
 Hold feeding of RR > 40cpm
 Medications given were salbutamol
nebulization, 1 neb every 1 hour,
hydrocortisone 60mg/SIVP now then every
6 hours, paracetamol 125 mg/5ml, 6 ml
every 4 hrs for fever >38.5C, 0.65% NaCl
drip
 Patient was given O2/cannula at 1-2 lpm as
needed. IVF D5IMB 500ml to run at 37-38
ml/hr
Course in The Ward (2nd HD)
 Salbutamol
+ ipratropium bromide was
started, alternating with salbutamol
nebulization every 6 hours
Course in the Ward (3rd HD)
 Salmeterol
+ fluticasone propionate
(seretide inhaler) 1 puff BID
 Prednisolone 20mg/5ml 4.5ml
SANE Criteria
 Safety
 Affordability
 Need
 Efficacy
Problems in the Patient
 Pharmacologic
therapy to address
• Bronchial asthma, mildly persistent, in moderate
exacerbation
Drugs for Acute Asthma
 Bronchodilators
• Anticholinergics
• Methylxanthines
• Sympathomimetics
 Catecholamines – epinephrine
 B2 agonists
 SABA
 Anti-inflammatory
• Corticosteroids
 Systemic
 Inhaled
Relievers
 Quickly
reverse bronchoconstriction
during acute exacerbation or
breakthrough symptoms; taken prn
 Bronchodilators
• SABA, epinephrine, methylxanthines
 Anti-inflammatory
• Systemic steroids
agents
Controllers
 Have
to be taken continuously on a
maintenance basis to control asthma
 Bronchodilators
• LABA
 Anti-inflammatory
• Inhaled
• Systemic
• LT antagonists
• Mast cell stabilizers
agents
Bronchodilators
 MOA: activation
of B receptors ->
activation of Gs coupling proteins ->
cAMP -> phosphorylation of target
enzymes -> relaxation of bronchial
muscles
 Epinephrine
 B2 agonists
Epinephrine
 For
anaphylaxis
 Not effective in oral intake
 Rapidly conjugated and oxidized in GIT and liver
 a1=
a2 ; B1=B2
 Triggers sympathetic response, fear,
anxiety, tenseness, restlessness, cardiac
arrythmias
 Not used in acute asthma, unless not
responsive to B2 agonist or asthma is
caused by anaphylaxis
SABA
 Terbutaline
 Salbutamol
 After
oral inhalation, 10% deposited in
bronchial airway where absorption takes
place -> systemic circulation.
 No substantial effect on inflammation
B2 Agonists
 SABA
• Oral
 Peak effect 2 hrs
 Duration of action 4-8 hrs
• Inhaled
 Peak effect 30-90 mins, 75% of maximum
bronchodilation by 5 mins
 >4 hrs
Adverse Effects of B2 agonists
 Skeletal
muscle tremors
 tachycardia,
 arrthymias
 increased bronchial hyperreactivity and
deterioration of disease control
Anticholinergic Drugs
 Ipratropium
bromide: treatment for
asthma
 Binds M2 and M3 receptors with equal
affinity, competitive antagonist to
acetylcholine at M3 receptors on smooth
muscles -> blocking bronchospasm ->
decrease mucus secretion
 In combination with SABA, provides
quick relief for acute asthma attack
Combivent
 contains
a microcrystalline suspension of
ipratropium bromide and salbutamol in a
pressurized metered-dose aerosol unit for
oral inhalation administration.
 The 200 inhalation unit has a net weight of
14.7 grams. Anticholinergic bronchodilator
 Each actuation meters 21 mcg of
ipratropium bromide and 120 mcg of
salbutamol from the valve and delivers 18
mcg of ipratropium bromide and 103 mcg of
salbutamol from the mouthpiece.
Dosage
2
inhalations four times a day.
 Patients may take additional inhalations
as required; however, the total number of
inhalations should not exceed 12 in 24
hours.
 Safety and efficacy of additional doses of
COMBIVENT Inhalation Aerosol beyond
12 puffs/24 hours have not been studied.
All Adverse Events (in
percentages), from Two
Large Double-blind,
Parallel, 12-Week
Studies of Patients with
COPD
Methylxanthines
 Theophylline
– both bronchodilator and
anti-inflammatory actions
 inhibits PDE -> increases cAMP ->smooth
muscle relaxation
 High level of toxicity; narrow therapeutic
index
 AE: nausea, vomiting, GIT disturbances,
headache,
Corticosteroids
 Anti-inflammatory
effects due to
inhibition of production of proinflammatory cytokines -> decreased
trafficking of lymphocytes, eosinophils ->
decreased bronchial hyperreactivity
 Potentiates B2 agonist effect by
increasing synthesis of B2 receptors
 Decrease mucus production
Corticosteroids
 Systemic
steroids
• Oral: prednisone, prednisolone,
methylprednisolone
• Parenteral: hydrocortisone, methylprednisolone
 Inhaled
steroids
• Budesonide, fluticasone
Indications of CS
 Systemic
steroids
• For relief of acute asthma exacerbations
• Control of severe persistent asthma
 Inhaled
steroids
• As maintenance therapy for all levels of
persistent asthma
Adverse Effects of CS
 Inhaled
CS adverse effects:
hoarseness/dysphonia, oral candidiasis,
throat irritation and cough
 Systemic CS adverse effects: truncal
obesity, moon facies, buffalo hump,
osteoporosis
Anti-Asthma Drugs
Safety
Affordability
Need
Efficacy
Combivent nebulizer
(salbutamol + ipratropium bromide)
++++
++++
P33.25
++++
++++
Theophylline 300mg/tab
++
+++++
P1.50
++
++++
Epinephrine HCl 1ml
+++
P40.00
++
++
Prednisone 20mg/5ml, 3ml
++
P6.25
++
++
Methylprednisolone 500mg/IV
++
+
P3509.75
++++
++++
Salmeterol + fluticasone propionate
+++
++++
++++
Hydrocortisone 100mg/IV
+++
++++
+++
+++
P40.75
Pre
Post
Pre
Post
Pre
Post
Time
7:30AM 8AM
815AM
842AM
9AM
920AM
Spot O2
96
96
94
93
96
96
RR
38
34
34
32
32
40
CR
120
128
128
130
148
140
Temp
37.1
37.5
38
38
38.1
37.8
Air entry
Fair
Fair
Fair
Fair
Fair
Fair to
good
Retractions
-suprasternal
+
+
+
-
+
+
-intercostal
+
+
+
+
+
+
-subcostal
+
+
+
+
+
+
-supraclavicular
+
+
+
+
+
+
Alar flaring
-
-
-
-
-
-
Wheezes
+
+
+
+
+
+
Crackles
+
+
+
+
+
+
Rhonchi
+
+
+
+
+
+