Child and Chest Health Care Delhi NCR

Salbutomol/Levosalbutamol is the main drug for rescue in acute exacerbation of asthma.

Most of the asthmatic patients respond very well when this drug is given through metered dose inhaler(MDI)

Very few patients require this drug to be given through nebuliser.

Some patients may not respond to salbutamol/levosalbutamol due to mutation of beta 2 receptor,making this drug partially responsive or non responsive.

Every patient with asthma, whether mild,moderate,or severe are prescribed salbutamol/levosalbutamol for use when they feel symptoms of asthma.

Patients on regular controller medications are advised to take salbutamol/levosalbutamol through MDI ,when they perceive the symptom of asthma.

Few patients complaint of getting their symptoms worse after taking salbutamol/levosalbutamol instead of getting better. In usual circumstances,these complaints are ignored by treating  physicians.This is a phenomenon of paradoxical bronchospasm.Here is a case report.

A 25 years old African American suffering from moderate asthma with allergic rhinitis came for assessment including Pulmonary function test(PFT) in the clinic.He was using salmetrol with fluticasone,monteleukast and salbutamol for last 4 weeks. He was complaining of increased shortness of breath after taking salbutamol hydrofluoroalkane(HFA) through metered dose inhaler(MDI).

In the clinic, PFT was performed before and after giving 4 puffs of levosalbutamol. FVC decreased from 4.17 L(76%Predicted) to 4.07L(74% predicted). FEV1 decreased from 2.19L(50%predicted) to 1.70(39%predicted).

Similarly the FVCdecreased from 4.99L(107%predicted) to 4.42L(95%predicted) and FEV1 decreased from 2.68(68%) to 2.25 (57%) after administration of 4 puffs of Salbutamol.

When the salbutamol was given through nebuliser in the dose of 2.5mg, there was an increase in FEV1,while no change in FVC  was noticed.

After seeing such response,in contrary to the expectation,the PFT was performed before and after giving 4 puffs of ipratorium bromide to asseess the efficacy of this drug in acute exacerbation of asthma. There was no change in FVC 4.85L (104%),while the FEV1 increased from 2.47L(62%) to 2.73L(69%).

After the assessment and PFTs in clinic ,the patient was prescribed Ipratropium bromide HFA,MDI for rescue therapy and the dose of fluticasone/salmetrol was increased. Salbutamol MDI was withdrawn from the treatment. The patient is not reporting symptoms after this transition was made.

As the patient was feeling uncomfortable after salbutamol MDI,while getting better with the same drug through nubuliser,it was suspected that the inactive ingredient in inlaher was responsible for the bronchospasm.

So the paradoxical bronchospasm should be kept in mind  as an adverse effect ,while prescribing salbutamol/levosalbutamol as a rscue medications to asthmatic patients.

REFERENCES:

Magee JS, Pittman LM, Jette-Kelly LA. Paraxdoxical bronchoconstriction with short-acting beta agonist. Am J Case Rep. 2018;19:1204-1207. doi:10.12659/AJCR.910888.

Influenza may be seasonal during cold weather or throughtout the year as in India.

In India the highest number of cases are usually seen during rainy season.

There are three types of influenza viruses,Influenza A,B and C.

Influenza C virus usually causes mild and sporadic disease.

The particular strain H1N1 is called swine flu.

A person suffering from influenza can infect others , 24 hours before the onset of symptoms to 5 days after disappearance of symptoms.

Young children can shed virus for a longer time than adults and elderly.

Immunocompromised individual can shed virus for weeks to months.

The symptoms can appear very fast within a day or may progress overs days.

The incubation period is 1-4 days.

Immunised persons can have mild symptoms even if they get infected.

In mostof the caese ,the disease gets resolved in 3-7 days.

In few cases ,the generalised malaise and cough persist for 2 weeks or more.

Children particularly below 5 years of age, have more complications,more rates of hospitalisations,and more rates of deaths in comparision to adults.

Immunocompromised individuals may have severe disease and high chance of death due to influenza ,so they are particularly advised to get immunised.

The disease spreads through droplets from person to person, formed during coughing or sneezing.

 SIGNS AND SYMPTOMS:

Running nose is less common in influenza.

Patients or Parents complaint of headache,fever which may range from 100.4dF to 104dF.

Generalised bodyache,malaise,fatigueness.

No interest in eating ,playing or working depending on age.

Pain in throat and limb pain which makes children unable to walk.

Child may suffer from diarrhoea.

Cough may be troublesome which is usually dry cough but sputum may be produced.

Nausea and vomoting are common in children.

Blocked nose may be a complaint

Chest pain may be a complaint due to pleuritis.

On examination:

child may be dull

Eyes may be red and watery

Throat may be red due to pharyngitis

There may be cervical lymphadenopathy

On chest auscultation,there may be bilateral diffuse wheezes and crackles. If the                                                                  finding  is localised, it indicates secondary bacterial infection.

In severe cases,there may be signs of respiratory failure.

There may be generalised muscular tenderness.

There may be signs of dehydration.

Investigations:The gold standard investigation for confirming the diagnosis is RT-PCR or culture of                                                            nasopharyngeal or Pharyngeal swab.

Chest X-Ray shows bilateral diffuse reticular opacities or bilateral diffuse patchy opacities.

If the opacity is in lobar pattern,it indicates secondary bacterial infection.

Chest X-Ray may be normal.

Complete blood count is usually normal.

TREATMENT:Treatment is usually symptomatic. Paracetamol is given for pain and fever.

Salicylate should not be given due to fear of Rye syndrome.

Neuraminidase inhibitor is the drug of choice when the disease is severe enough to be treated by antiviral.

It acts against both A and B influenza.OSELTAMIVIR is recommended for infants and children

IT SHOUD BE STARTED WITHIN 48 HOURS OF ONSET OF SYMPTOMS

DOSES: For preterm neonates-1mg/kg/dose bid ,oral

For full term neonates:

less than 14 days old 3mg/kg/dose, once daily for 5 days,oral

More than 14 days old 3mg/kg/dose, bid for 5 days,oral

INFANTS :

LESS THAN 3 MONTHS:12mg,po,bid for 5 days

3-5 months:20mg po bid for 5 days

6-11months:25 mg po bid for 5 days

CHILDREN:

Less than 5 kg weight-30mg,po,bid for 5 days

5-23 kg-45mg,po,bid for 5 days

23-40kg-60mg,po,bid for 5 days

more than 40 kg -75mg,po,bid for 5 days

ORAL SUSPENSION CONTAINS 6 mg/ml

IMMUNISATION: It is recommended for all children above 6 months of age.

Below 6 months of age they are protected by antibody from mother.

Individuals having chronic lung,liver,kidney disease and primary or secondary

immunodeficiencies are particularly advised for vaccination.

There are two types of vaccines-Live attenuated and inactivated.

Live attenuated is recommended above 2 years of age and it is given intranasally.

Inactivated vaccines are either trivalent or tetravalent.

Tetravalent have better protection for influenza B along with A.

The vaccine is updated every year as the virus changes itself rapidly due to antigenic shift and drift

property.

It should be given as early as it becomes availabe and definitely before the start of season.

It takes 10-14 days for the start of protection after vaccination.

The inactivated vaccine is given intramuscularly,0.25ml for children between 3-36 months and

0.5ml for children above 36 months.

For the first time recipient, it is given in two doses ,4 weeks apart and then single dose every year.

REFERENCES:

•                          Wong SS, Yuen KY. Avian influenza virus infections in humans. Chest. 2006 Jan. 129(1):156-68. [Medline].
• Swine Influenza (Flu). Centers for Disease Control and Prevention. Available at http://www.cdc.gov/swineflu/. Accessed: April 27, 2009.
• Dawood FS, Jain S, Finelli L, Shaw MW, Lindstrom S, Garten RJ, et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med. 2009 Jun 18. 360(25):2605-15. [Medline].
• Henderson, D. Influenza: Complications in 1 in 3 Previously Healthy Kids. Medscape Medical News. Available at http://www.medscape.com/viewarticle/829342. Accessed: August 4, 2014.
• Troy Brown, RN. FDA Committee Recommends 2018-2019 Influenza Vaccine. Medscape Medical News. 2018 Mar 01. Available at https://www.medscape.com/viewarticle/893314.
• Moscona A.Medical management of influenza infection.Annu Rev Med.2008;59:397-413
• Harriet Lane ,21e,2018

 

 

 

 

 

;

 

 

Air pollutin is a global emerging problem.

It affects all age groups but more affected age groups are children and elderly.

Bad air quality is known to exacerbate asthma in children and adults,and COPD in adults.

Now ,there is growing evidence that ,bad air quality may cause asthma in children and adults.

Particulate matters(PM) suspended in air may be inhaled and if the size is 2.5 micron or less(PM2.5),it may reach to the lower respiratory tract easily.

It may irritate the airways and cause asthma exacerbation.

If the airway is repeatedly irritated,it may become hyperreactive.

Other dangerous agent is ozone which adversly affects respiratory tract.

According to a study published in American Journal of Respiratory and Critical care medicine, people from areas of bad air quality depending on high ozone and PM2.5 level had high numbers of visits to the respiratory emergency department in comparision to the people from high air quality.

Data were analysed from 38.4 million visits to the department of respiratory emergency from 869 countries..Data represented 45% of US population including children,adults(18-65 years of age) and elderly beyond 65 years of age.Daily rates of respiratory emergency visits were 1.20 for all ages,1.90 for children,0.94 for adults and 1.37 for elderly over 65 years of age per 10000 population.The maximum 8 hour ozone per day varied from 8ppb to 34 ppb with a mean interquartile range of 16.54ppb.The level of PM2.5 ranged from 1.9mcg/m3 to 9.8mcg/m3 per day with an average of 5.3 mcg/m3. There was a positive association between respiratory emergency visits and ozone level.The rates of emergency visits were higher in children.

The study shows a causal relationship is likely between respiratory ailments and level of ozone and PM2.5 in ambient air

REFERENCES:

 

Strosnider H, Chang H, Darrow L, Liu Y, Vaidyanathan A, Strickland MJ. . Age-specific associations of ozone and PM2.5 with respiratory emergency department visits in the US [published October 2, 2018]. Am J Respir Crit Med. doi:10.1164/rccm.201806-1147OC