DIFFERENTIAL DIAGNOSIS OF BRONCHIAL OBSTRUCTIVE SYNDROME IN CHILDREN.

EMERGENCY ASSISTANCE AT ASTHMATIC STATUS.

           Bronchial obstructive syndrome (BOS) is a pathophysiological concept of violations of bronchial obstruction with a very wide range of acute and chronic disease  

        BOS - is a leading sign, which brings together a group of acute, recurrent and chronic lung disease, but it is not an independent nosological form and could not appear as a diagnosis. It should be noted that the BOS is not synonymous with bronchospasm, although in many cases, bronchospasm is important, and sometimes a leading role in the genesis of the disease. Usually BOS is diagnosed in children of the first four years of life, but can be diagnosed in older age.

In the genesis of bronchial obstruction are different pathogenetic mechanisms, which can be divided into:

• functional or reversible (bronchospasm, inflammatory infiltration, edema,

        mucociliary insufficiency, hypersecretion of viscous mucus)

• irreversible (congenital stenosis of the bronchi, their obliteration, etc.).

            Peculiar features of the children of the first three years of life have played the certain role in the development of bronchial obstruction:

Þ   narrowness of the bronchi and the entire respiratory system greatly increases

     aerodynamic resistance. Thus, swelling of the bronchial mucosa by only 1mm

     causes an increase in resistance to air flow in the trachea more than 50%.

Þ   softness of cartilage bronchial tract

Þ   lack of rigidity of the bone structure of the thorax, freely reacting indrawing of

     accommodating places to increase the resistance in the airways

Þ   particular position and the structure of the diaphragm.

             BOS in children may be substantially aggravated by structural features of bronchial wall, such as a large number of goblet cells that produce mucus, and

increased viscosity of bronchial secretions associated with high levels of cialic acid.

       Early childhood is characterized by the imperfection of immunological mechanisms: significantly reduced the formation of interferon in the upper respiratory tract, serum immunoglobulin A, secretory immunoglobulin A, and reduced functional activity of T-immunity system.                        

The scheme of the basic mechanisms of bronchial obstruction

1. material into bronchi (foreign body, mucous etc.)

2. edema of bronchial mucous membranes (obstructive dronchitis)

3. retraction of bronchial muscles (bronchial asthma)

4. compression out of bronchus (mediastinum tumor, dilatation of pulmonary artery

    at congenital heart diseases)

                                       Etiology

                BOS usually is infectious-allergic nature. Among the viruses that most commonly cause BOS are respiratory syncytial virus (50%), then parainfluenza, rarely - influenza and adenovirus. Recently, in the development of BOS big role is due to intracellular pathogens. According to modern data, chlamydia and mycoplasma infection are determined in 20% of children with BOS.

According to different authors, about 20-25% of bronchitis in children occur as an acute obstructive bronchitis (AOB), which is significantly higher than in adults.

               Especially high frequency of AOB is as a manifestation of acute respiratory infections (ARI) in infants. This is due to the fact that in the first half year of life 80% of the entire surface of the lungs is small bronchi (diameter less than 2mm), whereas a child 6 years old - already 20%. According to the Poiseul rule resistance of airways is inversely proportional to their radius in the 4-th degree. Obstructive syndrome of is the more probable in the distal lesion of the bronchi.

                                      Pathogenesis

                     

                Regulation of bronchial tone is controlled by several physiological mechanisms, which include complex interactions receptor-cell component and mediators system. These include cholinergic, adrenergic, neurohumoral regulatory system and, of course, the development of inflammation. Interleukin-1 is the main mediator, initiating the acute phase of inflammation. It activates a cascade of immune reactions that contribute to the exit in the peripheral blood of type 1 mediators (histamine, serotonin and others).

               Histamine is released during an allergic reaction in the interaction of allergen with allergen IgE. In addition to histamine, a type 2 (eicosanoids) play an important role in the pathogenesis of inflammatory mediators. Under the action of cyclooxygenase from arachidonic acid there are synthesing prostaglandins, thromboxane and prostacyclin, while under the influence lipooxidaze - leukotrienes.

              The result is increased vascular permeability, leading to swelling of the mucous membrane of the bronchi, hypersecretion of viscous mucus, the development of bronchospasm. The main mechanism in the pathogenesis of bronchospasm is activation of cholinergic nerve fibers, leading to increased production of acetylcholine and increasing concentrations of gualinatecyclase, which promotes the flow of calcium ions into smooth muscle cells, thereby stimulating of bronhoconstriction. Stimulation of α2-adrenoceptor catecholamines, as well as an increased concentration of cAMP decreases the manifestations of bronchospasm.

 

                                    Clinics of BOS

              The clinical picture of BOS in children is primarily determined by factors of bronhoconstriction. As noted above, in most cases BOS is associated with manifestations of acute respiratory viral infection (acute obstructive bronchitis).  So body temperature is rised up early, catarrhal changes in the upper respiratory tract and violation of general condition of the child appear. The severity and the nature largely vary depending on what the agent has led to the disease. Signs expiratory breathing difficulties may occur as the first day of illness, and in the process of viral infection (3-5-day sickness). Gradually there is increasing the breathing frequency and duration of exhalation. Breathing becomes noisy and whistling, which is due to the fact that with the development of hypersecretion, the accumulation of secretions in the lumen of the bronchi due to shortness of breath and fever change viscosity of the secret - he "dries up", which leads to buzzing (low) and whistling (high) wheezes.

           The defeat of the bronchi is widespread, and therefore hard breathing with dry whistling and buzzing wheezing are equally audible over the entire surface of the thorax. Rales may be heard at a distance. The younger the child, the more frequently he has, in addition to dry, the moist medium bubbling rales. If in the genesis of bronchial obstruction a major role plays spastic component, it auscultative data over lungs is generally more diverse and labile during the day. With increasing dyspnea important role of supporting muscles becomes increasingly - retraction of the intercostal spaces, epigastric and supraclavicular fossa, bloating (voltage) of the nostrils. Often there are revealed perioral cyanosis, pallor of the skin, the child becomes restless, trying to adopt a sitting position, drawing on his hands.

              Respiratory failure more evident than the younger the child, but usually it is not more than II degree. On physical examination, in addition to scattered wheezes and hard breathing, there are the signs of lung swelling: narrowing boundaries of relative cardiac dullness, boxed shade percussion tone. The inflation of the lungs is a result of consequence wears small bronchial branches during expiration, which leads to the so-called ventilation emphysema. The volume of the lungs increases. The rib cage is constantly in a state of inspiration, which increases the anteroposterior size.

            Changes in peripheral blood correspond to the nature of viral infection. Bacterial flora is rarely overlapped - not more than 5%.

            Radiologically, in addition to strengthening bilateral lung pattern and expansion of the roots of the lungs there are revealed: lowness flattened dome of the diaphragm, increasing the transparency of lung fields, lengthening the lung fields, a horizontal arrangement of ribs on the radiograph, which mean the signs of swelling of the lungs.

                             Diseases accompanied by BOS

              There are the following groups of diseases accompanied by BOS:

• Diseases of the respiratory system – Infectious-inflammatory diseases (acute constrictive laryngotracheitis, bronchitis, bronchiolitis, pneumonia), allergic diseases (obstructive bronchitis, bronchial asthma), bronchopulmonary dysplasia, malformation of bronchopulmonary system, tumors of the trachea and bronchi.

• Foreign bodies of trachea, bronchus, esophagus.

• Diseases of the aspiration genesis (aspiration or obstructive bronchitis) – gastroesophageal reflux, tracheoesophageal fistula, malformations of the gastrointestinal tract and diaphragmatic hernia.

• Diseases of the cardiovascular system – Congenital and acquired (congenital heart disease with hypertension, pulmonary circulation, vascular anomalies, congenital Non-rheumatic carditis, etc.).

• Diseases of the central and peripheral nervous system (birth injury, myopathy, etc.).

• Hereditary anomalies of metabolism (cystic fibrosis, α1-antitrypsin deficiency, mucopolysaccharidosis).

• Congenital and acquired immunodeficiency states.

• Rare hereditary diseases.

• Other states – Injuries and burns, poisoning, the effects of various physical and chemical environmental factors, pressure on the trachea and bronchi of extrapulmonary origin (tumor, venereal disease).

                       Diseases of the bronchopulmonary system

             The most frequently differential diagnosis of bronchial obstruction syndrome in children is made among the diseases of the bronchopulmonary system.

 

BRONCOOBSTRUCTIVE SYNDROME AT PNEUMONIA

 

The edema of mucus membrane of bronchial tubes lies in the basis of syndrome, hyperproductions of phlegm and, in a less measure, bronchospasm, more frequent on a background of congenital or acquired hyperreactivity of bronchial tubes are also important factor. This syndrome is identified at acute bronchopneumonia and is the reason of respiratory insufficiency on a bronchoobstructive type, which quite often determines severity of the state and needs adequate oxygent therapy.

Clinic. Increase of temperature of body, trouble or oppression, crabbiness, pallor of skin with perioral and acrocyanosis, unproductive cough, controlled from distance wheezes, oral crepitation, shortness of breath, with prolonged one and hard exhalation, drowning in chest of intervals between ribs, another areas of chest.

Percussion reveals the tympanic sound with areas of short sound.

Auscultation: hard breathing with the prolonged exhalation, dissipated dry and moist wheezes, the locally loosened breathing with the isolated proof moist wheezes.

 

Help on prehospital stage

1.             To provide access of fresh air.

2.             To release from squeezing clothes.

3.             Clean oral cavity and larynx from mucus and  phlegma

4.             Oxygentherapy with clean moistened oxygen through a mask or oxygen

                      pillow.

5.             Inhalation of dosed aerosol of Atroventi (ipratromium-bromide) 1-2

                      through spenser.

           6.     Inhalation of dosed aerosol b2-antagonists of quick actions (Salbutamoli,

        Ventolini, Berotec) 1-2 doses through spenser 20 minutes during hour.

        When it is impossible to make inhalations- syrup, tablets of Salbutamoli

        or Terbutalini (Bricaniliу)  to children upto 1 year - 1 mg 3 times, 3-6

        years – 2 mg 3 times, 7-15 years – 2-3 mg 3 times; Clentuberoli

        (Spiropent) – 0,005-0,02  3 times; Broncholitini to  children upto 3 years–

        half tea-spoon, 3-10 years  1 tea-spoon, elder 10 years is a 1 dessert-spoon

       3 times per days.

          7. Euphyllini 3-5 mg/kg  - 2,4 % solution of Euphyllini in that  dose 

                   intravenously streamly on 10 ml of 10 %  glucose solution .

           8. 3 % solution of Prednisoloni 1-2 mg/kg  intramuscular.

           9. Hospitalization.

 

Help on a hospital stage

1. To provide access of fresh air.

2. To release from squeezing clothes.

3. Sucking with electrosucker mucus and phlegma from upper respiratory tracts.

4. Oxygenation therapy through a nasal catheter is the clean moistened oxygen during 20 minutes every 2 hours or 40 % oxygen constantly.

5. Inhalation of dosed to the aerosol of Atroventi (ipratromium-bromide) 1-2 dose through spenser.

6. Inhalation of dosed  aerosol b2-antagonists of quick actions (Salbutamoli (Ventolini, Berotec) 1-2 doses through spenser 20 minutes during hour. When it is impossible to make inhalations- syrup, tablets of Salbutamoli or Terbutalini (Bricaniliу) children upto 1 year - 1 mg 3 times, 3-6 years – 2 mg 3 times, 7-15 years – 2-3 mg 3 times; Clentuberoli (Spiropent) – 0,005-0,02   3 times; Broncholitini to  children upto 3 years– half tea-spoon, 3-10 years- 1 tea-spoon, elder 10 years is a 1 dessert-spoon 3 times per days.

                                 

7.  3 % solution of Prednisoloni 1-2 mg/kg of  masses  intravenously  streamly.

 8. 2,4 % solution of Euphyllini 0,15 ml/kg of mass of  intravenously  in drops on

       10 % glucose solution  10–15 ml/kg.

 9. Cocarboxilazae of a 5–10 mg/kg of mass on 5,0 ml of 10 % Glucose solution

      intravenously  streamly.

 10. 5 % solution of sodium ascorbinati 2 ml/kg of masses of   intravenously  streamly

        on 5,0 ml of  10 % glucose solution .

 11. Panangini 0,1 ml/kgh of masses on 5,0 ml of 10 % Glucose solution

       intravenously  streamly.

 12.  In default of effect  drops intravenously introduction of Prednisoloni 2 – 3 mg/kg of  the masses (Hydrocortisoni 10 – 15 mg/kg) on 10 % Glucose solution  a 10 – 15 ml/kg of  mass.

 13. Mucolytic drugs: salt–alkaline inhalations; Lasolvani,Acetylcycteini  in inhalations, syrup, tablets; Bromhexini  in syrup, tablets; Mucaltini in tablets. 

Mucolytic inhalations

 14. Vibromassage of thorax in drainage position with next active aspiration of

       phlegm.

15. Alkaline drink: solution 1 % sodium bycarbonati per day to drink 10 – 12 ml/kg of mass slightly.                  

VIRAL CROUP

Acute narrowing of larynx, conditioned by the inflammatory edema of vocal cords and membranous space, hypersecretion of glands, viral etiology, that is accompanied by the hard breathing (croup).

Etiology: paraenfluenza I, ІІ type, flu I, rarely RS-, adenovirus infection.

Children are ill from 6 months till 3 years old.

 

It is acute widespread infection-inflammatory disease with the phenomena of stenosis. In most cases it arises up under action of different respiratory viruses, mainly paraenfluenza, more frequent in age from 6 months to 3 years.

The most common pathogens are influenza viruses (56.8%), second in frequency space occupied by parainfluenza viruses (20,1%), third - adenovirus (16,7%),  at 6.4% of patients with acute laryngotracheitis there is a manifestation of a mixed viral infection.         

Mostly in the development of acute laryngotracheitis a bacterial process is joined and may change the clinical picture.

Laryngoscopic picture with stenosing laryngotracheitis is characterized by the formation of rollers under the vocal ligaments and the presence of mucous-purulent discharge in the tracheobronchial tree. Some authors, except edematous form of stenotic laryngotracheitis, allocate purulent, fibrinous, necrotic, and other forms. After the obstruction at the level of the larynx there is a violation of drainage function of tracheobronchial tree, resulting in the appearance of inflammation in the lower respiratory tract, including lung tissue. 

Stenosis is a result of mucus and submucous tissue edema of larynx below vocal ligaments, accumulation of mucus, reflex spasm of muscles.

Schematic stages of the introduction of a laryngoscope with the direct laryngoscopy and the corresponding laryngoscopic picture – the end of a laryngoscope blade presses the epiglottis to the root of the tongue: 1 - aryepiglottic cartilage, 2 - interaryepiglottic hollow, 3 - vocal cords, 4 - folds of the laryngeal vestibule.    

Endoscopy image of larynx

Aquied undercord stenosis

(narrowing of respiratory tract)

The thickness of respiratory tracts is decreased, resistance of air grows. Inflammation, edema, spasm, presence of inflammatory exudation of respiratory tracts are the basic links of pathogenesis, which result in violation of breathing, hypoxia, hypercapnia. An inflammatory process can spread on a trachea, bronchial tubes.

Clinical classification of acute laryngotracheitis:

I. Type of respiratory viral infection: 1) influenza, parainfluenza, adenovirus infection, etc., and 2) ARVI (is specified in the impossibility of clinical interpretation and the absence of express-diagnostics).

II. Degrees of laryngeal stenosis: 1) compensation, 2) incomplete compensation, 3) decompensation, 4) terminal.

Clinic. The characteristic is triad of symptoms: the change of voice, rough, “barking” cough, stenotic breathing. More frequent stenosis laryngitis develops suddenly among night. There are 4 degrees of larynx stenosis.

I degree (compensated stenosis): hoarse of voice, rough “barking” cough, compensated hyperventilation of lungs, рО2 – within the limits of norm.

The ІІ degree (subcompensated stenosis): the child is excited, voice getting hoarse, rough, cough increases, the inciter shortness of breath appears. A skin is  moist, pallor, cyanosis of perioral triangle. Breathing is with participation of auxiliary muscles. Hyperventilation of lungs gradually changes on hypoventilation. Considerable tachycardia, рО2 is not reduced. Metabolic acidosis develops.

The ІІІ degree (decompensated form of stenosis) is the severe state. A child is excited. There are loosened voice, expressed inciter shortness of breath (inspiration is prolonged with stenotic noise). Breathing with participation of all auxiliary muscles. Frequent “barking” unproductive cough. A skin is pale, covered by a cold sweat, considerable cyanosis of nasooral triangle, lips, tongue, nail phalanges. Tones of heart are deaf, tachycardia, decreased arterial preassure, a pulse is frequent, weak. In lungs there is decreased breathing, superficial, is badly listened, sternum is down in. рО2 of arterial blood is reduced, рСО2 is promoted, mixed acidosis develops (metabolic and respiratory).

The ІV degree (asphyxia): a child is in the extraordinarily severe condition, without consciousness. Cyanosis of skin, a pallor develops later. Breathing is superficial, frequent, with the quick stops with next deep inspiration. At auscultation the breathing is not  listened. Tones of heart are deaf, decreased arterial preassure, a pulse is threadlike, later bradycardia, arrhythmia develop, which  precede to the stop of heart. In a blood рСО2considerably grows (to 100 ml Hg and higher) and рО2 considerably goes down (to 40 ml Hg.). The child dies from the asphyxia.

                 Differential diagnosis of real and false croup

                Real croup

              False croup

Acute start

Permanent start

Febril high t°

Subfebril t°

Catarrhal sings are expressed

Catarrhal sings are absent

Skin is moist, cyanotic

Skin is “toxic”, pale

Hyperemia, edema of pharynx

Grey-dirty tapes on tonsils after their scopes

Voice is hoarse

Aphonia

Edema of  subcutaneous tissue is absent

Edema of  subcutaneous tissue of neck

Absence of signs of palate paresis   

Effluence of liquid through a nose  

Primary aim of treatment is to pick up thread passage of respiratory tracts and remove hypoxia.

                   Help on prehospital stage

The volume of medical manipulations depends on the degree of stenosis

severity.

I degree:

1.             Distracting procedures:

       –warm tender baths, it is possible with mustard

             –mustard plasters on a thorax, on an area of laryngs

             –at allergy to mustard semialcoholic hot compress on a thorax,

              on the area of neck

              –warm alkaline drink: mineral water, tea with 2 %  solution of soda,

                 warm milk

2.             Oxygentherapy:

                     –warm, moistened air

   –soda inhalations.

3.             In children with the allergic reactions – Suprastin orally, in a dose 2 mg

                      per the kg of mass; from 2 years 1 tea-spoon of Claritini in syrup.

4.             Hospitalization in the diagnostic or infectious unit.

 

ІІ degree.

1.             Intramuscular 2 % solution of Suprastini 2 mg per the kg of mass.

2.             In excitation – 0,5 % solution of Seduxeni (Sibasoni, Relanium) in a

                     dose 0,3-0,5 mg per the kg of mass intramuscular, or 20 % solution

                     of  Oxybutirati sodium in a dose 50 mg per the kg of mass

                      intramuscular.

3.             Distracting procedures:

        – warm tender baths, it is possible with mustard;

        – mustard plasters on a thorax, on an area of laryngs;

              – at allergy to mustard semialcoholic hot compress on a thorax, on the

                   area of neck.

4.                Warm alkaline drink: mineral water, tea with 2 % soda solution, warm

                     milk.

5.                Oxygentherapy:

                    – warm, moistened air;

  – soda inhalations.

6.             Hospitalization in the intensive unit or chamber of intensive therapy for diagnostic or infectious separation.

 

ІІІ degree.

1.             Sucking of mucus from a mouth cavity, respiratory tracts;

2.             Oxygentherapy: warm, moistened air through a mask;

3.             0,5 % solution of Seduxeni (Sibasoni, Relanium) in a dose 0,3-0,5 mg

                     per the kg of mass intramuscular, or 20 % solution of Oxybutirati

                     sodium in a dose 50 mg per the kg of mass intramuscular;

4.             Hydrocortisoni intramuscular in a dose 5 mg per the kg of mass or 3 %

                     solution of Prednisoloni intravenously in a dose 1 mg/kg of mass.

5.             Distracting procedures:

           – mustard plasters on a thorax, on an area of laryngs;

           – at allergy to mustard semialcoholic hot compress on a thorax,

              on the area of neck.

6.             Oxygentherapy through a mask.

7.             Hospitalization in the intensive unit of child's hospital. 

ІV degree.

1.             Sucking of mucus from the cavity of mouth, respiratory tracts.

2.             Oxygentherapy through a mask, aerotherapy with the warm moistened

                     air.

3.             Intravenously streamly 3 % solution of Prednisoloni in a dose 1-2 mg

                     per the kg of mass of body.

4.             Intravenously streamly 10 % solution of Calcium gluconatis in a dose 1

                    ml per the year of life.

5.             At departure on the call of the specialized brigade and equipped

                       ambulance the intubation of patient.

6.             Hospitalization in the intensive unit of child's hospital.

                             Help on a hospital stage

Permanent observation of a patient who is hospitalized, the unit must be equipped by the inhalators of the «fog» type, ІP-2 and others, by oxygen tents, in which the proper microclimate is created (temperature 30 0C, moisture 100 %, 40-50 % oxygen).

I degree.

1.         Inhalations by the moistened 40 % oxygen, oxygen is possible to skip

                    through Bobrov apparatus, through the water extract of camomile, clary,

                    infusion of  eucalyptus, 2 % alkaline solution. Treatment in a oxygen tent

                    2-3 times per day.

Oxygen tent for babies and young children (up to 3 years) is used in maternity hospitals and children's hospitals for oxygen therapy procedures.

 

  Salt-alkaline inhalations or inhalations of such composition:

           – 5 % solution of ascorbic acid – 5,0;

           – 5 % solution of Ephedrine  – 1,0;

                 –0,1 % solution of Adrenalin  – 1,0;

                 –Hydrocortisoni 25 mg;

                 –3% solution of sodium hydrocarbonatis 6,0.

On inhalation - 4 ml of solution. In the first 2 days inhalations are done 4

times per day, on 3th day – 3 times, on 4-6th days – 1-2 times per day.

2.         Distracting therapy: mustard plasters on a thorax, tender baths, ozocerite

                    or paraphine “knee-boots”, warm drink.

3.         Sucking of mucus.

 

ІІ degree.

1.             At the protracted stenosis there is direct laryngoscopy for diagnostics of

                       inflammatory process, sucking of mucus (clearning of tracheobronchial

                       tree and larynx);

2.             Protracted inhalations of warm, moistened air, stream through mask or

                      under framework which covers a bed, in which a patient is (moisture to

                       90-100 %, temperature to 26-30 0С)  for 3-4 hours; oxygen tent 

Oxygen therapy through a mask.

3.             Inhalations with the medicine mixture:

1)            5 % solution of Ephedrine – 0,5 (1) ml,   Hydrocortisone 12,5 (25) mg,

                 1 % Dimedroli solution – 0,5 (1) ml, 0,5 % solution of sodium  chloride

                 – 3-4 ml (in handles there are  the indicated doses for children more

                    senior than 1 year old),

2)             antiedema mixture: 5 % solution of Ephedrine  1,0; 0,1 % solution of

                   Adrenalini 1,0; 0,1 % solution of sulfate Atropine  – 0,5; 1 % solution

                   of Dimedroli - 1,0; 2,5 % solution of Pipolpheni 1,0; Hydrocortisoni

                  25 mg; Hymotripsini 2 mg in 1 ml of liquids; 5 % solution of ascorbic

                  acid – 5,0. On one inhalation 4 ml of mixtures are used.

Stream inhalator

4.             At the excitation 20 % solution of  Oxybutiratis sodium  intravenously

                      streamly slowly in a dose 50 mg per the kg of mass.

5.             2,4 % solution of Euphyllini intravenously streamly slowly in a dose

                   1 ml per the year of life on 10 % glucose solution.

6.             Intravenously in drops 10 % Glucose solution , 0,9 % solution of sodium

                     chloride (in the ratio 3:1) + 5 % solution of ascorbic acid – 1-2 ml,

                    Cocarboxilazae 5 mg per the kg of mass; 15-20 drops in 1 minute.

7.             Distracting therapy: mustard plasters on a thorax, tender baths, ozocerite

                      or paraphine “knee-boots”

ІІІ degree.

            1.  Hospitalization in intensive unit.

            2.   Inhalation therapy in oxygen tent, 4-6 inhalations per day.

            3. 20 % solution of Oxybutiratis sodium  intravenously streamly slowly in a

            dose 50 mg per   the kg of mass; in 3-4 hours – 0,25 % solution of

            Droperidoli 0,3-0,5 ml/kg of mass.

           4. Direct laryngoscopy for diagnostics of inflammatory process, clearning

             of larynx, respiratory tract.

           5. 3 % solution of Prednisoloni intravenously streamly in a dose 2-3 mg per

              the kg of mass.

           6. Inhalations to the aerosol: 0,1 % solution of Adrenalini 0,5-1 ml per

             3 ml of isotonic solution of sodium chloride together with oxygen

             during 5-10 minutes; with a antiedema mixture

Dummy- inhalator that is compatible with standard sockets inhalator supply gas or mixed medication to the nose of the child. Dummy is reusable, capable of being sterilized by standard autoclaving or disinfectants.

 

          8. 2,4 % solution of Euphyllini intravenously streamly slowly in a dose 1 ml per the year of life on 5-10 ml of  0,9 % isotonic solution.

           9. Intravenously in  drops (20-25 drops for a minute) 10 % solution of Glucose, 10-20 % solution of Albumini or similar group Plasma in a dose 5-10 ml on the kg of mass of body; Reopoliglucini in a dose 10 ml on the kg of mass of body, correlation of glucose to the salt and colloid solutions 2:1. Common amount of liquid is a 30-50 ml/kg of mass daily.

           10. 4 % solution of Hydrocortisoni 4-8 ml per the kg of mass intravenously in  drops, in 2 injections under the control of acid- alkaloid balance.

            11. 10 % solution of Calcium gluconatis intravenously streamly slowly in a dose 1 ml per the year of life.

            12. Antibiotics:

1)    Cephalosporins: Duracef (Cefadroxil), suspensia 50 mg per the kg of mass per  day for 2 receptions in interval 12 hours; Kefsoli 75-100 mg/kg of  the masses per day for 2 receptions intramuscular;

2)    Macrolides: suspensia of Macropeni  a 50 mg/kg of  mass per day in 2 receptions, summamed a 10 mg/kg of  mass per  day.

3)                13. Indication to intubation: hypoxemia (рО2 below 50 mm Hg) with concentration of oxygen during inspiration higher 50 %; hypercapnia, acidosis( рСО2 higher than  55 mm Hg, рН less than 7,35); encreasing of  languor, somnolence.

IV degree.

1.             Intubation with soon artificial breathing. Advantage it to give nasotracheal intubation, as to more sparing and simple method.

2.             Clearning of respiratory tract with the use of warm isotonic solution with hydrocortisoni, euphyllini; 1 % by solution of hydrocarbonatis,

                       antibiotics of wide-spread action (a few times per days);

3.             Oxygentherapy with moistened oxygen.

  

Ventilator Vent201, created by the most modern technologies, provides high quality ventilation and provides an easy transition from noninvasive to invasive ventilation.

Ventilation, neuro-controlled respiratory support (NAVA) Servo-I (Maquet). Allows you to maintain respiratory activity of the patient using his own neuro impulses.

4.             3 % solution of prednisoloni intravenously streamly in a dose of  3-5 mg

                      per the kg of mass or hydrocortisoni intravenously in drops (15-30

                      drops in 1 minute) in a dose 15-20 mg per the kg of mass on 100-150

                      ml 0,9 % sodium chloride solution.

5.             Intravenously in drops 10 % solution of glucose, 0,9 % sodium chloride

                      solution, Reopoliglucini in a dose of 10 ml per  the kg of mass.

                     Correlation of glucose and salt solutions to the children upto 1 year old

                     is 3:1 or 4:1, from 1 to 2 - 1:1. Fresh-frozen plasma in a dose 10 ml per

                     the kg of mass. Common amount of liquid is 40-50 ml per kg of mass

                     daily. To conduct infusion therapy 2 times per day.

6.             With   infusion solutions intravenously enter 5 % solution of ascorbic

                     acid 1-2 ml, 10 % solution of chloride calcium  1 ml per the year of life,

                     Cocarboxilazae in a dose of  5 ml per  the kg of mass.

7.             Symptomatic therapy.

8.             Dynamic observation of paediatrician, reanimatologist, otolaryngologist.

9.      Determination of рО2, рСО2, ЕCG.

 

In all stages of stenosis must be indicated:

1.             Antienfluenza gamma-globulini in 1 dose till 1 year; 2 doses till 3 years,                                               3 doses to the children more senior then 3 years.

2.             Observation for the exception of diphtheria (stroke from a nose and                  pharynx).

3.             Consultation of otolaryngologist.

4.             At saving of swallowing- warm alkaline drink (mineral water, flora tea               with 2 % soda solution ), milk. 

ACUTE OBSTRUCTIVE BRONCHITIS

In the basis of syndrome is violation of the bronchial passage, conditioned by the diffuse inflammatory edema of mucus, hypersecretion and accumulation of mucous and purulent phegma in bronchial tubes, transitory reflex spasm of smooth musculature.

 

                 Until the 70's, the last century, the term "obstructive bronchitis and its analogs (asthmatic bronchitis, spastic bronchitis, etc.) were widely used by pediatricians. However, in the early 70's a series of epidemiological studies were performed, which showed that distinguish obstructive bronchitis and asthma in the general pediatric practice is almost impossible. Thus, equal sign between these states was put. This approach in older children has largely justified itself, as would save many patients from antibiotic therapy. But in younger children the problem is more complicated. It was established that cromoglycate in these patients is not effective enough or not effective at all. Inhaled bronchodilators such as salbutamol, are ineffective enough or not effective at all at wheezing in children of the first three years of life. Information regarding the effectiveness of inhaled steroids for acute or chronic bronchiolitis was contradictory.

               In addition, numerous studies in our country and abroad have shown that the outcomes of obstructive bronchitis in general are favourable. 54% of children with repeated episodes of obstructive bronchitis stopped hurting after four years, and another 37% of - at a later age, thus recovering is more than 90% of patients. In addition, the presence of obstructive syndrome in the first three years of life can not be considered as a factor predisposing to the appearance of asthma in the future. That is, it became clear that the mechanism of development of wheezing in infants, other than for the older children, and the main role is played not hyper reactivity in bronchial mucosa and muscle spasm and tone of the bronchial wall and edema of bronchial mucosa. This reflects the fact that "wheezing" in young children is a consequence of various causes, including abnormalities of the respiratory system and inflammatory processes of other etiologies.

 

Clinics: subfebril temperature, trouble, crabbiness of child, cyanosis of lips, nasolips triangle, acrocyanosis. Dyspnea, noisy, with the prolonged inspiration and  distance wheezes. Downing in of interrib intervals, supraclavia areas, jugular pit.  Unproductive coughing. A thorax is emphysematous, at percussion above lungs -box sound, аt auscultation- breathing is hard, with the prolonged inspiration and dry and different moist wheezes, character of which is changed after a cough. Таchycardia. A liver is often enlarged. In the general blood analysis there is not substantial changes or insignificant neutrophyls leucocytosis.             

                                           Barrel thorax

Diagnostic criteria of acute obstructive bronchitis in children

  - Long whistling breath, which is audible at a distance                        

- Inflated thorax when viewed from (horizontal placement

    ribs) participated in the act of breathing support muscles,

   retraction of the intercostal spaces, signs of respiratory

    failure

- Dry cough, paroxysmal, prolonged and at the end of the first

   week passes in the moist

- Percussion determined bandbox pulmonary sound

- Auscultation: hard breathing, exhaling is prolonged,

   large amount of dry whistling rales. There may be coarse

   bubbling low sound rales

- On the chest radiograph is observed decreased lung

   pattern in the lateral regions of the lungs, and increased in the medial

  (hidden emphysema) 

On the X-ray of thorax organs - the strengthening of pulmonary pattern, areas of promoted pneumatization without of infiltration changes in lungs.

Radiographs of the chest in front projection with AOB: total marked bilateral increase the transparency of lung fields, depletion of vascular pattern on the periphery with its increasing in the central parts, the expansion of the roots of the lungs and flattening of the diaphragm.

              Differential diagnosis of obstructive bronchitis and pneumonia

Symptoms

Obstructive bronchitis

Pneumonia

Temperature

Subfebril

Hyperthermia

Intoxication

Absent or slight

Expressed

Dyspnea

Dry whistling rales

Local moist rales

Percussion sound

Bandbox

Dull

X-ray

The strengthening of pulmonary pattern

Local (segmental, lobe, focal) infiltrates

    Differential diagnosis of bronchial asthma and obstructive bronchitis 

Symptoms

Bronchial asthma

Obstructive bronchitis

Allergologic anamnesis

Positive

Sometimes positive

Start of illness

Catarrhal sings of ARVI

Attack of dyspnea with or

without ARVI

Gradual increasing of symptoms

Temperature

Normal, sometimes increased

Everytimes increased

Course of disease

Repeating attack of dyspnea

Frequency of obstructive episodes decreases, recovery is possible

Ig E

Increased

Normal

Eosynophylia in blood

Present

Absent 

Help on prehospital stage.

1.             To provide access of fresh air.

2.             To release from squeezing clothes.

3.             Succing with electrosuccer mucus and phlegma from upper

                     respiratory tracts.

4.             Oxygentherapy with  clean moistened oxygen through a mask.

5.             Broncholytin for  children upto 3 years– harf of  tea-spoon, 3-10 years

                    a 1 tea-spoon, more senior than 10 years  a 1 dessert-spoon 3 times per

                   day or Solutani 5-10 drops 3 times per  day.

6.             Euphyllini in  dose of a 3-5 mg per kg of  mass orally or 24 % Euphyllini

                             solution intramuscular.          

7.             Salt-alkaline inhalation.

8.             In default of effect - hospitalization.

 

Help on  hospital stage.

            1. Succing with electrosuccer mucus and phlegma from upper respiratory

               tracts.

            2. Oxygentherapy through the nasal catheter with 40 % moistened oxygen

               constantly.      

Nasal catheters for oxygenotherapy

            3. Inhalations of broncholitic mixture: Euphyllini - 0,3, ephedrine  – 0,2,

               novocaine – 0,25, water – 50,0 мл. On inhalation 3–5 ml, before inhalation

               to add 1,0 ml of  5 % sodium ascorbinati solution .

            4. Mucolytic drugs: salt-alkaline inhalations; Acetylcysteini or Lasolvani in

               inhalations, syrup, tablets; Mucaltini in tablets, extract of altey.        

            5. Vibromassage of  thorax in drainage position with next active aspiration

                of phlegma.

           6.  2,4 % solution of Euphyllini 3-5 mg/kg of  mass of intravenously

                 in drops on isotonic solution of chloride sodium  10-15 ml/kg of mass.

          7. 5 % solution of sodium ascorbinati 0,2 mg/kg of the masses intravenously

               streamly on 5 ml of  10 % glucose solution .

          8. Cocarboxylazae 5-8 mg/kg of mass of intravenously streamly on 5 ml of 

              10 % glucose solution.

          9. In default of effect from previous therapy Prednisoloni 1–2 mg/kg of the

              masses (or Hydrocortisoni 5 mg/kg of  mass) intravenously streamly on

             5 ml of  10 % glucose solution.

          10. Alkaline drink: 1 % solution of sodium bicarbonates 10-15 ml/kg of 

              mass  per day.

ACUTE BRONCHIOLITI

Development of total obstruction of respiratory tracts lies in basis of syndrome, which is  conditioned with the expressed hypersecretion of phlegma, with the edema and swelling of mucus of  bronchial tubes and bronchiols and, in a less measure, bronchospasm in  the children of the first year of life on a background of viral, more frequent respiratory-syncitial infections.

Criteria of diagnosis of bronchiolitis:

1. Presence of the catarrhal phenomena (rhynopharyngitis, cough).

2. Temperature of body – subfebrile, rarely 38oС.

3. Expressed signs of respiratory insufficiency:  shortness of breathing, blowing nostrils, cyanosis of nasolabial triangle, participation of auxiliary musculature.

4. Violation of the bronchial passage: thorax is emphysematosis; horizontal position of ribs, flat position of diaphragm.

5.Bandbox sound at percussion.

6. Auscultation: hard  breathing  with prolonged inspiration, moist wheezes, on outbreathing - dry, whistling.

7. Cardiovascular syndrome – tachycardia, weakening of tones.

8. X-ray- sharp swelling of lungs tissue, increased broncho-vascular pattern, without infiltrative shades; sometimes atelectasis.

Clinic. Syndrome of airway obstruction lies at the basis of acute bronchiolitis, which is more typical for children of the first six months of life. In acute bronchiolitis body temperature is subfebrile or normal, respiratory failure progresses gradually. Signs of intoxication are insignificant. Characteristic features are perioral or acrocyanosis, dry cough, a large number of small moist rales on both sides - "wet" lung and a small number of dry wheezes. 

In severe cases dyspnea has predominantly expiratory character, groaning breath, tension and swelling of nostrils, participation in the act of breathing supporting muscles, general cyanosis of the skin. Nonproductive cough, frequently emphysematous swelling of the chest are present. Above the lungs percussion sounds are bandbox, throughout the lungs a large number of small bubbling and wet crepitative wheezing. There are tachycardia, increased liver,  may be attacks of apnea, hypoxic seizures, dehydration.

X-ray examination shows the symmetric strengthening of pulmonary pattern of  both sides, increase of transparency of pulmonary tissue, absence of infiltratative shades. In the blood test the appropriate changes are absent.

 

Help on prehospital stage.

1.             To release from clothes.

2.             To give the promoted position of body to the child.

3.             By a rubber bulb or gauze clean the  nasal cavity, mouth and pharynx

                     from mucus and phlegma.

4.             To provide access of fresh air.

5.             Oxygenation with clean moistened oxygen through a mask.

6.             Euphyllini in dose of 3-5 mg/kg of mass -24 % solution intramuscular.

7.             3 % solution of Prednisoloni 1-2 mg/kg of  the masses  for 

                     dose intramuscular

8.             Salt-alkaline inhalation.

9.             Urgent hospitalization.

 

Help on  hospital stage.

1.             To release respiratory tracts from mucus and phlegma with the help

                       of electrosuccer                       

2.             Oxygentherapy with  moistened warm 40 %  oxygen through a nasal

                    catheter or mask 3-5 litres per 1 minute.

3.             Inhalation of broncholytic mixture: Euphillini – 0,3, ephedrine – 0,2,

                     novocaine – 0,25, water – 50,0 ml. On inhalation 3-5 ml, before

                    inhalation to add 1,0 ml of  5 % solution of sodium ascorbinati.

4.             Inhalations of mucolytic drugs – 2 % solution of sodium hydrocarbonatis

                     3-5 ml, Acetylcysteini, Bisolvoni, Lasolvani  2-3 ml on inhalation with

                    next aspiration of phlegma.

5.             2,4 % solution of Euphyllin 3-5 mg/kg of mass on 10 % glucose solution

                      10 ml/kg of mass of intravenously slowly.

6.             3 % solution of Prednisoloni 1-2 mg/kg of the masses, one dose

                        intravenously streamly on 10 %  glucose solution 10 ml.

7.             5 % solution of sodium ascorbinati 0,2 ml/kg of the masses

                    of intravenously streamly on 5 ml of  10 % glucose solution .

8.             Cocarboxylazae 5-8 mg/kg of  mass of intravenously streamly

                     on 5 ml of  10 % glucose solution .

9.             Alkaline drink: 1 % solution of sodium hydrocarbonatis  10-15 ml/kg

                     of mass per day.

10.        Vibration massage of thorax in drainage position.

11.        In default of effect and enlargement of respiratory insufficiency – 

                     clearing of bronchial tree by bronchoscope,  artificial ventilation.

                          Sonotherapy at bronchiolitis

                              BRONCHOPULMONARY DYSPLASIA(BPD)

                   In recent years increasingly relevant bronchopulmonary dysplasia (BPD).

              BPD is acquired chronic obstructive pulmonary disease that develops as a result of respiratory distress syndrome of neonates and / or artificial ventilation (AVL) with high concentrations of oxygen, accompanied by hypoxemia, altered reactivity of the bronchi with hypersensitivity of airways, and typical radiological changes.

              In the etiology of BPD there are many factors: the impact of oxygen in high concentrations, mechanical ventilation, pulmonary edema, left to right shunt at patent ductus arteriosus, recurrent bacterial pneumonia, hereditary predisposition, hypovitaminosis A and E.

                             Pathological Anatomy and Physiology

                    According to the results of postmortem studies, there are 4 stages of BPD, which are similar to roengenologic findings. In the first three days of life (I stage), there is a typical respiratory distress syndrome. In the following days the first week of life (II stage) there are destruction of cells of the alveolar epithelium and capillary endothelium, interstitial edema and perivascular space, necrosis of the bronchioles, squamous metaplasia, hypertrophy of smooth muscle cells of the disappearance of ciliated epithelium. In the II-III week (III stage) there is increasing of the number of macrophages and plasma cells and fibroblasts. Process damage the bronchial tubes of different orders, which in severe cases leads to obliterative  bronchiolitis. In the following week atelectasis zones with interstitial and peribronchial fibrosis in conjunction with areas of emphysema (IV stage) are revealed. In the walls of the alveoli there is increasing of the number of reticular, collagen, elastic fibers, which structure is disrupted.

                 Naturally pulmonary emphysema develops caused by three mechanisms: 1) scars that appear due to hyperextension of nonfibroid lung; 2) violation of the multiplication of alveoli in some areas (atrophic form of emphysema); 3) destruction as a result of the inflammation and destruction of the walls of the alveoli and capillaries. Structural changes of the pulmonary arteries include intimal proliferation, smooth muscle hypertrophy, the proliferation of smooth muscle on the distal parts of vessels, thickening and fibrosis of the adventitia, the decreasing of diameter of the arteries