RSV and Sepsis

REA LORRAINE FLORES STUDENT RT JAN.2010

Baby X
4 mo female Admitted in the PICU on Jan. 27th Diagnosed with sepsis and RSV pneumonia Intubated and ventilated, fluid-resuscitated Clinical course was complicated by difficulties to ventilate and oxygenate Conventional HFO (late Jan. 28th) NO (Jan.31st)

Objectives

Pathophysiology Normal physiology Pathology Treatment strategies

Pathophysiology

Pneumonia in Infants

Pneumonia, a leading cause of morbidity and mortality in the paediatric population Mostly affects children under 2 years of age Nearly 80% have a viral aetiology e.g. RSV (most common), parainfluenza 1, 2 and 3, and adenovirus RSV often causes bronchiolitis, but pneumonia can develop

RSV Infections
Rates of illness are highest among infants 1-6 mos of age Seasonal: winter (rarely in spring and summer) Attack rates approaches 100% in areas such as day-care centres By age 2, nearly all children will have been infected by RSV. RSV accounts for 20-25% of hospital admissions for pneumonia, while up to 75% for bronchiolitis Older children and adults can be infected by RSV, but milder (can progress to a severe illness if immunocompromised)

Mode of Transmission of RSV

Contact (direct and indirect) Droplet

*Incubation period: about 4-6 days *Viral shedding > 2 weeks

Pathogenesis of RSV
Cell-mediated immunity is a more important mechanism of host defence against RSV compared to antibody-mediated Infections can be severe even in infants who have moderate levels of serum antibody from their mothers Reinfections can occur

Pediatric A & P
Large upper airway structures Small-diameter airways High chest wall compliance Major muscle of breathing diaphragm High basal metabolic rate Less muscle glycogen stores fatigue Decreased elasticity air trapping High proportion of extracellular fluid prone to dehydration

Pathophysiology of RSV
Reaches the respiratory tract by cell-to-cell transfer Forms a syncytium (neighbouring cells merged together) Triggers the inflammatory processes In the bronchioles: (edema, mucus, cellular debris)

- partially obstructed (ball-valve-> air trapping) - completely obstructed (atelectasis)

Bronchiolitis

Increased WOB
Due to: A. Changes in mechanics of breathing Raw lung compliance B. Active infection Edema Consolidation O2 consumption

Sepsis
A systemic response to infection or tissue injury

Pro-inflammatory exceeds anti-inflammatory substances

Shock: imbalance between the supply of nutrients and O2

to the tissues and the metabolic demand of the tissues Compensatory mechanisms: cardiac output ( HR) Anaerobic metabolism ...Cardiorespiratory failure

Treatment Strategies

Intubation and ventilation Fluid resuscitation and inotropes Conventional and HFO NO therapy

Clinical Course

Pre-Admission
Clinic: presented with...
o 1-wk hx of cough/ URTI symptoms o diarrhea o poor feeding Nearby ER... o lethargic o decreased muscle tone

o unable to get a BP
o O2 saturation in the 40s Interventions: O2, intubate & ventilate, fluid resuscitation Transferred to HSC

PICU Admission
On arrival... Secured ETT in situ Persistent desaturations Poor perfusion Interventions: Sedation

Fluids (N/S, albumin)

Vasopressor (Dopamine) Antibiotics Diagnostics: blood and sputum cultures, CXR

 Re-intubated with a 3.5 ETT, nasally secured @ 15 cm ETT position (nasal)= [(Age + 2) + 12] + 3

Servoi
SIMV PC + PS

Vent Day 2
MODE

SIMV PC + PS

SIMV PC +PS

FiO2
RR set PIP PEEP PS Vt pH PCO2 PaO2 HCO3 BE RR total HR

0.70
25 28 10 15 41 7.31 52 76 26 0 35 110-130

0.70
18 25 10 15 28
7.26 61 62 26 0

34

BP
SpO2 Fluid Balance

86/44
92-95% -74.4

Vent Day 2
MODE FiO2 RR set PIP PEEP PS Vt pH PCO2 PaO2 HCO3 BE RR total HR

SIMV PC + PS 1.0 25 27 12 17 34 7.24 65 65 27 0 35 180 f P-P MAP Bias flow

HFO 1.0 12 60 20.6 30 7.41 51 51 32 +6

118

BP
SpO2 Fluid Balance

81/38
Mid 70-low 80s

99/40
92-96% +300.8

Vent Day 4
MODE
FiO2 RR set PIP PEEP PS Vt pH PCO2 PaO2 HCO3 BE RR total HR

HFO
1.0 f P-P MAP Bias flow 12 60 22 35

SIMV PC + PS
1.0 15 29 10 22 .85

6.87 207 61 36 -5 15 160-185

7.26 74 56 32 +4

118

BP
SpO2 Fluid Balance

120/52 (mean 94)

81-84% +275.7

83/42 (mean 58)

90-91%

Article 1
Curley M., Hibberd, P. & Fineman, L. (2005). Effect of Prone

Positioning on Clinical Outcomes in Children With Acute Lung Injury: A Randomized Controlled Trial. JAMA, 294 (2): 229-237.
Found no significant difference in duration of mech vent and

mortality, time to recovery and organ-failure free days Suggested an increase in oxygenation with no decrease in vent support days

Article 2
Duval, E. & van Vught A. (2000). Status asthmaticus treated by

high-frequency oscillatory ventilation. Pediatric Pulmonology, 30(4):350-3.

Case report on 2 yo girl with severe asthma
HFOV in obstructive disease:
Stent

open the airway by sufficient MAP Lower F Permissive hypercapnia Long Te

References
Czervinske, M. & Barnhart, S. Perinatal and Pediatric Respiratory Care. 2nd ed. Elsevier: 2003. 2. Des Jardins, T. & Burns, G. Clinical Manifestations and Assessment of Respiratory Disease. 5th ed. Mosby: 2006. 3. Fauci, A. Harrison's manual of medicine. McGraw-Hill: 2009. 4. Huether, S. Pathophysiology: the biologic basis for disease in adults & children. Mosby: 2002.
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