BY

: FAUZIAH RUSLI

DEFINITION

Inflammation of the bronchioles

Viral infection (RSV) >>

ETIOLOGY

 95% patients are < 2 years old 75 % patients are < 1 years old
EPIDEMIOLOGY

Viral infection inflammation obstruction bronchiolus (oedem, mucus secretion ext) lymfosit peribronchial disturb gas exchange in lung imbalance perfution ventilation hypoxemia tissue PATOFISIOLOGY hypoxia

Upper respiratory tract infection (runny nose, cough) Fever Increased work of breathing Wheezing Cyanosis Grunting Vomiting Irritability poor feeding or anorexia

Tachypnea, >50-60 breaths/m, nostril breathing Tachycardia, Fever, usually in the range of 38.5-39C Diffuse expiratory wheezing Ronkhi Intercostal retractions Cyanosis Apnea, especially in infants younger than 6 weeks Palpable liver and spleen from hyperinflation of the lungs and consequent depression of the diaphragm

Radiology

Normal Hyperinflation pulmo, flat diafragm,extrusion cavity of intercostal, infiltrate

Laboratorium

Leukositosis Blood gas analysis

Suportive

Supplemental Oxigen Restoration and/or maintenance of fluid balance Apnea monitoring if indicated by age or history Monitoring body temperature

Medical therapy

Bronchodilator , for repair gas circulation Dexamethasone 0,1-0,2 mg/kgBB/dose IV Ribavirin (viral infection) Antibiotic (bacterial infection), severe condition

RSV IG baby age <24 month, or premature baby (age < 35 weeks) Giving Palivizumab Minimal brings baby to public place Cleans hand if you contact baby Avoids smokes of cigaratte and air poluttion Avoids baby contact with person have upper respiratory infection

Asthma Bronchitis Congestive Heart Failure and Pulmonary Edema Pediatrics, Apnea Pediatrics, Foreign Body Ingestion Pediatrics, Pneumonia Pneumonia, Aspiration Pneumonia, Bacterial Pneumonia, Mycoplasma Pneumonia, Viral

Patient identity : Name : by. SS Age : 1 years 9 month Father/ Mother : Mr.JT/Mrs.N Address :Jl. Kulim Come in to hospital: Mei 24th 2011

ANAMNESE Given by

: alloanamnese : patients mother and father

Chief complain : breathless since 2 days before came to the hospital

2 days before came to the hospital, breathless(+), didnt depending activity, its first time, irritable(+), increased when didnt used pillow, difficult to breastfeeding, ronkhi (+), sianosis (-), pale(-), vomiting (-), fever (+), high, continously, treambles (+), sweating (-), nosebleeding (-), seizure (-), delirium (-)

4 days before came to the hospital, coughs (+), expectorates (+), but expectorates dificult to released. Patient always coughs and became fever, its first time coughs, he can breastfeeding, sweating at the night (-), loss weight (-), vomiting (-) 7 days before came to the hospital he got flu, mucus (+)

He had came to the hospital (RSUD Rokan Hulu, 2 days before came the hospital) and had given antipiretik for fever Because breathless didnt decrease he reffered to RSUD AA

Asthma (-) Alergy (-) Congenital heart failure (-)

Asthma (-) Alergy (-) Coughs (+) shes sister TB(-)

Patient's father: Farmer, elementary school graduate education, earning Rp.1.000.000/month, had habit for smoking Patient's mother: housewives, elementary school graduate education impression : low economy

During pregnancy, didnt regularly examined by the midwife, drink herbal (-), not smoking and not drinking alcohol. The patient was born by spontaneous, enough month

 Breastfeeding until now

porridge tim starts 4 month old

Family food starts 1 years old

Hepatitis B 2x BCG 1x DPT 3x Polio 2x Measles 1x Immunizations not complete

Sit 6 month Stands up 12 month Walking 1 years 3 month Speaking 1 years 9 month Impression physical and mental development little late

Patients living in permanent homes, one house containing 5 people, good ventilation, home environment dusty Impression: not good

General status : severe illness Conciousness : lethargy Vital sign : Pulse : 146x/minute, enough filling, reguler Breath : 50x/minute Temperature : 37,8 0C

 Nutrition

: W= 6,5 Kg, H= 146 cm

BB/U = 6,5/6,9x 100% = 94,2%

(Good) Calory = 6,9x 100%= 690 ccal

 Head

circumference: 45 cm (normosefaly, mongoloid facies, fontanel close Hair: black color, not easily removed Eyes: sclera icteric (-/-) konjungtiva anemis (-/-), isokor pupil, light reflex + / + Ears: normal form, symetry , tenderness aurikuler (-), serumen (-), discharge (-).

 Nose: norstil breathing (+) no deviation

of the septum, mucous (-), concha oedem (-) Mouth: lips moist, cyanosis (-), mucous membranes moist, wide tongue not hiperemis , pharyngeal mucosa not hyperemis , tonsils T1-T1 Neck: enlargement of the KGB (-), neck stiffness (-)

Lungs:

- Ins symetry form right=left, thorax wall movement rigth=left, intercostal retraction (+), tacycardi (50x/minute), long expiration - Pal fremitus right= left - Per sonor right= left - Aus vesicular right = left, rhonky (+/+), wheezing (+/+), strydor (+)

Heart:
Ins : ictus kordis (-) Palp : ictus kordis palpable at RIC V

LMCS Per : left heart border RIC V LMCS, right heart border liniaright parasternalis Aus : heart rhythm regular, BJ additional (-)

 ABDOMEN
Ins

: symmetry form, flat, venektasi (-

). Palp : supel, hepar not palpable, lien not palpable. Per : tympani Aus : bowel sound (+) normal
GENITALIA:

no deformity

 Extremity
Edema (-/-), warm acral, refilling

capiler 3, syanosis (-), clubbing finger (-)

Excitatory

Meningeal :

Stiff neck(-), Brudzinki I (-),

Brudzinki II (-), Kernig (-)

Blood :

Hb : 11,1gr% N=9,0-14,0 Leukosit : 15.000/mm3 N=6.000-17.500 Trombosit : 549.000/mm3 N=150.000-400.000 Ht : 32,3 vol% N=28-42 GDS: 114 mg/dl

Urine :

Color : yellow Clarity: clear Proteinuri : (-) Glukosa = (-) Micros : erytrocyt (+) 0/LP, leucocsyt : 2, Epitel : (-)

Feses

Makroskopik : yellow, mucus (-), blood(-),

amoeba (-), worm egg (-) leucocyt (-),erytrosyt (-)

Heart lungs

normal infiltrate at right and left pulmo

breathless (+) 2 days before came to the hospital increased when didnt used pillow, difficult to breastfeeding Fever (+), high, continous Coughs (+), 4 days before came to the hospital expectorates (+), but expectorates dificult to released. its first time coughs, 7 days before came to the hospital he got flue, mucus (+)

Irritable Asthma (-), Alergy (-),Congenital heart failure (-) history Sister had got coughs Father had smoking habit Home environment dusty

 General

status : severe illness conciousness : lethargy Noistril breathing HR : 146x/mnt, Breath: 50x/mnt Thorax rhonky (+/+), wheezing (+/+), strydor (+)

Trombosite 549.000/mm3 increase Na+ 130 mmol/l decrease Radiology lungs infiltrate at right and left lung

BRONCHIOLITIS

BRONCHOPNEUMONIA

BLOOD GAS ANALYSIS

Bedrest Oxygen 1-2l/mnt with nasal prongs IVFD with KA EN 1B 24 drip/mnt Parasetamol syrup 3x0,4cc Inj. Ceftriaxone 2x250 mg IV Inj.dexamethasone 3x0,6 mg IV Nebulizer with ventholin ampoule / 6 hours

 PROGNOSIS

Quo ad vitam

: Dubia ad

bonam Quo ad fungsionam: Dubia ad bonam

Assesme Therapy nt 25/5/ Fever (+), - Conciousness : bronchioliti -Bedrest 2011 coughs (+), severe illness -O2 1-2l/m s irretable,br - VS :T : 37,6oC, -IVFD KA eathless P:130x/mnt, RR: EN 1B 24 (+) 44X/mnt, w: 6,9kg drip/min appetite -Worm acral, RCT 2 -Ceftriaxone decrease second 2x250 mg -Eyes pupil 2/2, (I) light reflex +/+ dexamethas -Torgor good one 3x0,6 -Thorax ronkhy mg (+/+), wheezing (+/+), -Nebulizer intercostal retraction ventolin (+), /6 hours Parasetamo l syrup

Date Subjective

Objective

Assesme Therapy nt 26/5/ Fever (+), - Conciousness : bronchioliti -Bedrest 2011 coughs (+), severe illness -O2 1-2l/m s irretable, - VS :T : 37,6oC, -IVFD KA breathless P:130x/mnt, RR: EN 1B 24 (+), 44X/mnt, w: 6,9kg drip/min appetite -Worm acral, RCT 2 -Ceftriaxone decrease second 2x250 mg -Eyes pupil 2/2, (II) light reflex +/+ dexamethas -Torgor good one 3x0,6 -Thorax ronkhy mg (+/+), wheezing (+/+), -Nebulizer intercostal retraction ventolin (+), /6 hours Parasetamo l syrup

Date Subjective

Objective

Date Subjective 27/5/ Fever (+), 2011 coughs (+),breathl ess , irretable, appetite decrease, BAB (+)

Objective - Conciousness : moderate illness -VS :T : 38,3oC, P:133x/mnt, RR: 49X/mnt, -Thorax suprasternal retraction, epigastrium retraction, long expiration, vesiculer, ronkhy (+/+), wheezing (+/+),

Assesme Therapy nt bronchioliti -Bedrest -O2 1-2l/m s -IVFD KA EN 1B 24 drip/min -Ceftriaxone 2x250 mg (III) dexamethas one 3x0,6 mg -Nebulizer ventolin /6 hours Parasetamo l syrup

Date Subjective 27/5/ Fever (+), 2011 coughs (+),breathl ess (+), appetite decrease, BAB (+) , BAK (+)

Objective - Conciousness : moderate illness -VS :T : 38,9oC, P:130x/mnt, RR: 56X/mnt, -Thorax suprasternal retraction, epigastrium retraction, long expiration, vesiculer, ronkhy (+/+), wheezing (+/+),

Assesme Therapy nt bronchioliti -Bedrest -O2 1-2l/m s -IVFD KA EN 1B 24 drip/min -Ceftriaxone 2x250 mg (IV) dexamethas one 3x0,6 mg -Nebulizer ventolin /6 hours Parasetamo l syrup

Date

Subjective

Objective

Assesment

Therapy -Bedrest -O2 1-2l/m -IVFD KA EN 1B 24 drip/min -Ceftriaxone 2x250 mg (IV) dexamethason e 3x0,6 mg -Nebulizer ventolin /6 hours -Parasetamol syrup 3x0,4 cc -Aminofusin 50cc/day

28/5/2 Fever (+), 011 coughs (+),breathles s (+) , irretable, appetite decrease, BAB (+)

- Conciousness : bronchiolitis moderate illness -VS :T : 38,3oC, P:133x/mnt, RR: 49X/mnt, -Thorax suprasternal retraction, epigastrium retraction, long expiration, vesiculer, ronkhy (+/+), wheezing (+/+),

Date

Subjective

Objective

Assesment

Therapy -Bedrest -O2 1-2l/m -IVFD KA EN 1B 24 drip/min -Ceftriaxone 2x250 mg (V) dexamethason e 3x0,6 mg -Nebulizer ventolin /6 hours -Parasetamol syrup 3x0,4 cc

29/5/2 Fever (+), 011 coughs (+),breathles s (+) , appetite decrease, BAB (+)

- Conciousness : bronchiolitis moderate illness -VS :T : 38,3oC, P:129x/mnt, RR: 46X/mnt, -Thorax suprasternal retraction, epigastrium retraction, long expiration, vesiculer, ronkhy (+/+), wheezing (+/+),

Date

Subjective

Objective

Assesment

Therapy -Bedrest -O2 1-2l/m -IVFD KA EN 1B 24 drip/min -Ceftriaxone 2x250 mg (VI) dexamethason e 3x0,6 mg -Nebulizer ventolin /6 hours -Parasetamol syrup 3x0,4 cc

30/5/2 Fever (+), 011 coughs (+),breathles s(+) , appetite good, BAB (+)

- Conciousness : bronchiolitis moderate illness -VS :T : 36,8oC, P:100x/mnt, RR: 40X/mnt, -Thorax suprasternal retraction (-), epigastrium retraction(-), long expiration, vesiculer, ronkhy (-/-), wheezing (-/),

Date

Subjective

Objective - Conciousness : moderate illness -VS :T : 36,7oC, P:98x/mnt, RR: 40X/mnt, -Thorax suprasternal retraction (-), epigastrium retraction(-), long expiration, vesiculer, ronkhy (-/-), wheezing (-/),

Assesment bronchiolitis

Therapy -Bedrest -O2 1-2l/m -IVFD KA EN 1B 24 drip/min -Ceftriaxone 2x250 mg (VII) dexamethason e 3x0,6 mg -Nebulizer ventolin /6 hours -Parasetamol syrup 3x0,4 cc

31/5/2 Fever (-), 011 coughs (),breathless (+) , appetite good, BAB (+) , BAK (+)

Date

Subjective

Objective

Assesment

Therapy -Bedrest -IVFD KA EN 1B 24 drip/min -Ceftriaxone 2x250 mg (VII) dexamethason e 3x0,6 mg -Nebulizer ventolin /6 hours Patient home

1/6/20 Fever (-), 11 coughs (),breathless (-), appetite good, BAB (+) , BAK (+)

- Conciousness : bronchiolitis moderate illness -VS :T : 36,9oC, P:100x/mnt, RR: 38X/mnt, -Thorax suprasternal retraction (-), epigastrium retraction(-), long expiration, vesiculer, ronkhy (-/-), wheezing (-/),

Bronchiolitis anamnesa, pyhsical examination, laboratory finding and radiology Anamnesa age <2 years old,breathless, flue (+), fever (+),coughs (+), wheezing (+),sister had coughs, father had smoking habit, and environtment dusty

Pyhsical examination pulse 146x/mnt, breath 50x/mnt, wheezing, ronkhy, stridor, long expiration, noistril breathing But body temperatur little increase, flue (-), sianosis (-) Laboratory finding leucocyte normal Radiology finding infiltrate right and left lung

Therapy suportive give oxygen, dehidration, nutrition In this case had given oxygen 1-2l/mnt with nasal prongs, IVFD KA EN 1B 24 drip/mnt, parasetamol syrup 3x0,4cc, aminofusin 50cc/day Antibiotic had given in teory given if had got bacterial infection, and severe condition

Corticosteroid had given kontroversial but had got good respon Nebulizer (bronchodilator) had given kontroversial but had got good respon (3-5 days)