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Chapter 4
Cough or difficult breathing
Case III
Case study:
Mary is an 8 year old girl with cough and weight loss for
some weeks
What are the stages in the management
in Mary’s case?
Stages in the management of a sick child
(Ref. Chart 1, p. xxii)
1.
Triage
2.
Emergency treatment
3.
History and examination
4.
Laboratory investigations, if required
5.
Main diagnosis and other diagnoses
6.
Treatment
7.
Supportive care
8.
Monitoring
9.
Plan discharge
10.
Follow-up
Have you noticed any emergency (danger)
or priority (important) signs?
Temperature: 37.8 0C, pulse: 136/min, RR: 50/min with
mild chest indrawing and use of accessory muscles to
breathe, thin looking. Speaks in short sentences, but
with a quiet voice
Triage
Emergency signs (Ref. p. 2, 6)
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
• Coma
• Convulsions
• Severe dehydration
Priority signs (Ref. p. 6)
• Tiny baby
• Temperature
• Trauma
• Pallor
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, irritable,
lethargic
• Referral
• Malnutrition
• Oedema of both feet
• Burns
History
Mary has had cough for months. She has difficult
breathing on exertion, and her mother said she had
not been playing as much as before, and had not
attended school for 3 weeks. She had received 2
courses of medicine, the last one 2 weeks ago, but
the cough persisted. She sometimes felt hot and
perspired a lot according to her mother. Mary’s
appetite had been poor in recent weeks, and she had
lost weight.
Mary’s grandmother had been treated for TB when
Mary was 4 years of age. Mary’s parents and
younger brother (age 4) and sister (age 2) are well
.
Examination
Mary had mild chest indrawing, but moderate use
of accessory muscles, which increased when she
moved to sit up on the bed. She had no cyanosis,
but had finger clubbing.
MUAC: 12.5 cm, Weight 20 kg
Chest: dullness to percussion and increased breath
sounds over right chest at the back, crackles
throughout
Cardiovascular: two heart sounds were heard, but
chest very crackly
Abdomen: palpable liver 4 cm below the RCM
Neurology: tired but alert; responds with a quiet
voice
Differential diagnoses
• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to confirm (Ref. p. 109-111)
Differential diagnoses (continued)
• TB
• Asthma
• Foreign body
• Pertussus
• HIV
• Bronchiectasis
• Lung abscess
(Ref. p. 110)
Additional questions on history
• Night sweats?
• Purulent sputum?
• History of choking or sudden onset of symptoms?
• Wheeze?
• Personal or family history of asthma?
• Paroxysms of cough?
• Any other symptoms of HIV (e.g. persistent
diarrhoea, mouth sores)
• Vaccinations (? BCG, ? DTP)
(Ref. p. 110)
What investigations would you like to do
to make your diagnosis ?
Investigations
• Pulse oximetry (SpO2 : 93% at rest, falls to 88%
on exertion)
• Chest x-ray:
(Ref. p. 116)
Investigations
• Mantoux test
• Sputum smear for acid fast bacilli
• In younger children, gastric aspirate or Induced
sputum
• for smear microscopy
• Xpert MTB / Rif if available and if MDR
suspected
• HIV testing should be offered
(Ref. p. 115-116)
Diagnosis
Summary of findings:
• Cough for months, unresponsive to antibiotics
• Family history of TB
• Chest crackles
• Clubbing
Pulmonary Tuberculosis (Ref. 4.7.2, p. 115)
How would you treat Mary?
Treatment
• How many drugs in intensive phase for Mary’s PTB,
and what does this depend on?
(check p. 117)
• Four if: high HIV prevalence or high H
resistance, or severe lung disease
• Rifampicin (R), Isoniazid (H), Pyrazinamide
(Z), Ethambutol (E)
• For 2 months, followed by RH for 4 months
What supportive care and monitoring are
required?
Supportive Care
• Oxygen
• Nutritional support
• Ready-to-use-therapeutic feeds (Plumpy-nut)
• Schooling, entertainment and privacy while in hospital
• Staff protection: p50 mask until sputum smear
negative (check weekly)
Monitoring treatment and complications
• Adherence: Direct observation of each dose
• Temperature
• SpO2
• Weight gain
(Ref. p. 117)
Public health measures
• Register every TB patient with National TB Program
and Disease Control Office
• Check all household contacts, and school contacts
if appropriate, for undetected TB
• Who should receive Isoniazid preventative therapy?
(Ref. p. 118)
• <5 years of age, household or close contacts
• No active TB
• 6 months Isoniazid preventative therapy
(Ref. p. 117)
Contact screening
• On further questioning Mary’s mother had cough,
and sputum smear was heavily positive for TB
• Mary’s sister and brother were clear of symptoms,
and were well nourished and active
• Mary’s father was well, normal chest xray
• Contact screening can be “symptom-based
screening” if x-ray and sputum microscopy not
available
• If no symptoms and child <5 years, start IPT
• If symptoms refer for CXR, Mantoux.
(Ref. p. 117)
Follow-up
When can Mary be discharged?
• Completed Intensive Phase (2 months)
• Nutrition improved
• Not hypoxic, with good exercise tolerance
• Family screening done
• Education
A program of “active follow-up”, where a health
worker visits Mary and her family at their home, can
reduce defaulting from TB treatment. During followup at home or in the hospital, health workers can do
the following things…(Ref. p. 118)
Summary
• Mary, 4 year old girl with weight loss and chronic
cough. Pulmonary TB. Severe lung disease (so 4
drugs in intensive phase), HIV negative.
• A missed opportunity for prevention, as Mary did not
have screening and IPT when her grandmother was
treated for TB
• Directly Observed Therapy. Registration with NTP
• Active case finding and follow-up needed for child
and family
• TB treatment for mother, also HIV negative
• ITP for sister and brother
(both <5 years and no evidence of active TB)