Diagnostic Dilemma

Tachypnea with hyperinflated chest

A 4 months old boy born of third degree consanguineous marriage presented with cough and cold for 7 days and increased rate of breathing for 3 days. There is no fever, refusal of feeds, lethargy. He is on exclusive breast feeds and has been immunized till date. On examination, he has heart rate of 110/min with respiratory rate of 52/min without chest retractions. His weight is 5.75 kg and length is 60 cm. Anterior fontanelle is open. On systemic examination, bilateral hyper resonant note over lung fields with obliteration of cardiac dullness and bilateral crepts and rhonchi. Liver and spleen are palpable. Other systems are normal.

How should this child be managed?
Expert Opinion :
This child has presented with complaints of cough and cold to begin with which has now led to tachypnea. There is no fever. Child is not toxic. Hence one should suspect a viral infection rather than a bacterial infection here. Since the chest appears to be hyper inflated with obliteration of cardiac dullness and hyper resonant note over the lungs, suspicion of bronchiolitis is very strong especially considering the age group and symptoms in a well nourished child.
Bronchiolitis usually leads to hypoxia and hence the child has tachypnea. Also due to increased work of breathing, there is more loss of water through the lungs. Hence treatment should be to treat hypoxia and prevent dehydration. Bronchiolitis is usually caused by respiratory syncitial virus (RSV), adenovirus or parainfluenza virus and is a self limiting disease. Thus, no specific treatment is required to treat the virus except in an immunocompromised child, or preterm baby or in a child with underlying cyanotic heart disease.
Thus, this child needs to undergo a pulse oximetry to check for hypoxia and thus to decide on amount of oxygen that is required. Also child should receive almost 25% to 50% of more fluids than normal requirement to maintain hydration. Initially fluids should be given intravenously and subsequently once the tachypnea settles, child can be shifted to maintenance to oral feeds.
There is no role of antibiotics in this child.
Answer Discussion :
iqtidar hussain
1. CXR
3. Nasopharyngeal swab inc RSV
4. NG feed
5. monitoring of Spo2, RR, HR, temp
6. Oxygen PRN via nasal prongs
7. High flow PRN
9. ABx +/- according to inflammatory markers, CXR and blood cultures.

2 months ago
treatment with oxygen by nasal prongs , if worsens 3%saline can be used for nebulization

2 months ago

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