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BronsiolitaAcuta

BronsiolitaAcuta

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Published by Dr Diana Enachescu

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Published by: Dr Diana Enachescu on Jan 17, 2009
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06/06/2015

Pediatrie curs 2

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2.10.2001

BRONŞIOLITA ACUTA
Definitie: E o afectiune respiratorie de etiologie virala a sugarului mai mic de 6 luni, caract. Clinic prin: • expir prelungit • wheezing • stetacustic – raluri sibilante si subcrepitante • rx.: emfizem Etiologie: • v. sincitial respirator (VSR) • adenovirusuri • v. gripale • rar v. rujeolic • • • • VSR→ cai respiratorii inf. → bronsiole terminale → distrugerea muc. respir., inlocuirea cel.ciliate cu cel cuboide fara cili bronsiole: ▪ edem al peretelui ▪ hipersecretie → obstructie → wheezing debut necaracteristic: ▪ coriza ▪ inapetent / apetit capricios 24-48h: ▪ tuse iritativa ▪ wheezing ▪ dispnee

Ex. clinic: ▪ agitat ▪ ± cianoza perioronazala ▪ tahipnee (υ>40/min.) ▪ tiraj i.c. ▪ expir prelungit ▪ wheezing ▪stetacustic: raluri sibilante / subcrepitante ▪ ficat la 3-4 cm sub rebord: ▪ coborarea marg. inf. a ficatului (emfizem) cu marg. sup in sp.VII i.c. stg. ▪ IC sec. afectarii pulmonare (marg. sup. in sp.VI i.c. stg.) ▪ rx: ▪ orizontalizarea coastelor ▪ hiperinflatia pulm. ▪ ocazional – zone de atelectazie segm. / lobara • teste biol. – necaracteristice bolii: ▪ hemoleucograma – limite normale pt. varsta (predomina Ly) ▪ leucocitoza cu devierea la stg. A formulei leucocitare ▪ PCR↑ ▪ nu face diferentierea infectiei cu adenovirusuri si suprainfectia bacteriana ▪ uneori ↑IgG ▪ sugarul are antecedente atopice in familie → IgE↑ • identificarea ag. etiol.:

Pediatrie curs 2

▪ VSR – identificat indirect: in sange Ac (test in dinamica): ziua 1 si 7 ⇒ dg. retrospectiv

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2.10.2001

Dg. diferential: ▪ pneumonii virale la pacienti cu handicapuri biol.: rahitism carential (wheezing, rx., biol. la fel) ▪ det. Ac anti-VSR in dinamica ⇒ dg. retrospectiv ▪ IC stg.← malformatie congenitala de cord ▪ sdr. de aspiratie de corp strain (sugar >4 luni) → sdr. de penetratie bronsica: cianoza, acces de tuse, dupa ore se amelioreaza starea gen., apoi wheezing ▪ rx.: zone de atelectazie decliv fata de corpul strain ▪ mucoviscidoza (fibroza chistica de pancreas) – secr. vascoase pulm. → obstructie, infectie → afectiuni pulm. → wheezing ▪ ileus meconial la nastere ▪ distrofic + infectii respir. repetate + diaree trenanta ▪ dg. – proba transpiratiei: Na si Cl >60mEq/l ▪ deficit de IgAs→ infectii respir repetate ▪ anomalii de arc aortic – wheezing ▪ RGE - infectii respir repetate ▪ astm bronsic(A.B.) – wheezing – prima criza ▪ <6 ani → foarte greu de diagnosticat A.B. ▪ in familie cu A.B., IgE↑ → poate avea A.B. cu debut la varsta mica Tratament: ▪ internat in spital sugarul <3 luni, prematuri, distrofici ▪VSR → bronsiolita acuta → primele ore – crize de apnee ▪ regim igieno-dietetic – fara complicatii(IC, I.Resp.Ac.) → alimentatia de dinaintea bolii ▪ nevoia de lichide: 150ml/kgC/24h, ≤1000ml ▪4 pranzuri pt. a nu da distensie gastrica, impingerea diafragmului ▪ IC, I.Resp.Ac.: 100, 80, 50 ▪ stare gen. grava → perfuzie: cantitatea totala de lichide picaturi/min nr. ore x 3 ▪ SO2↓→ masca / izoleta / cort de oxigen ▪ e contraindicata sedarea bolnavului, doar in cazuri extreme cu cloralhidrat, celelalte (diazepam)→ deprimarea centrului respir. ▪ fluidifierea secretiilor bronsice: ▪ hidratare corecta ▪ adm. de mucolitice: Fluimucil fiole ▪ bronhodilatator – discutabil: toate subst. Folosite in A.B. act. Pe bronhiile mari, cele mici nu au receptori ▪Teofilina (Miofilin):tb.100mg / fiole 240mg in 10ml ▪doza: 10-15 mg/kgC/24h, adm. la 6/8h, i.v./ per os ▪ i.v.- injectat lent pt. ca da agitatie, tahicardie, varsaturi ▪ familia: a mai primit la domiciliu? (intoxicatie) ▪ da relazarea cardiei → RGE la sugar = de rezerva ▪Salbutamol: tb. 2 / 4mg

Pediatrie curs 2

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2.10.2001

▪ doza: 0.1-0.2 mg/kgC/24h,la 8h interval ▪ ideal in aerosoli / aparat de nebulizari →efect local ▪Glucocorticoizi – efect discutabil ▪ justificat doar daca are semne clinice de edem cerebral acut → Metilprednison 10-20 mg/kgC/24h, la 6h interval HHC (ef. antiinflam.) –folosirea lui favorizeaza evolutia lunga a bolii / suprainfectia bacteriana ▪2 fiole(25mg): 5-subst. activa, 20-solvent ▪doza 10-15 mg/kgC/24h, la 6h interval Manitol – antiedematos cerebral + diuretic ▪20% concentratie ▪doza test 0.5g/kgC→ef. diuretic→1-2g/kgC/24h (doza terapeutica) ▪nu are ef. diuretice→Furosemid Furosemid:1-2 mg/kgC/24 ▪IC → digitalizarea pacientului: Digoxin tb. 0.25mg / fiole de 2ml cu 0.5mg SA ▪doza: 0.01-0.04mg/kgC/24h ▪1/2 initial i.v., apoi cate ¼ la 3 / 4 / 8h interval ▪toata lent i.v. ▪apoi doza de intretinere: ¼ din doza de atac(tb.) ▪ tratam. Etiol.: Ribavirin – prematuri, distrofici, pacienti cu deficite imune (costa mult) → spitalizare, perfuzie i.v. 12-18h / 24h, cel putin 7 zile ▪ antibiotice→ deficite imunologice, copii polispitalizati, copii tratati cu imunosupresive (boala Steel) ▪Ampicilina:flacoane de pulberi albe→solvite→incolore ▪250-500mg ▪doza 150mg/kgC/24h, la 6h interval ▪ Gentamicina – fiole ▪ ef. adverse: afectare renala si auditiva ▪ uree normala ▪ 4mg/kgC/24h, la 6h interval ▪ Penicilina: flacoane 400.000 / 1.000.000 UI ▪ potasica / sodica (de preferat) ▪ 100.000 UI/kgC/24h, la 6h interval ▪ Cefalosporine de gen. I / II ▪ sirop (se evita sub 1 an), tablete, injectabil ▪ 50 mg/kgC/24h, la 12h interval ▪ gen. III – Rocephin – 1 administrare pe zi Bronsiolita det. De adenovirusuri: =obliteranta ▪ muc. respir.→ distructie extinsa a epit. Respir. ▪ per. de stare→ tablou clinic de bronsiolita ac. ▪ reepitelizarea→ cicatrici→afectarea bronsiolelor: nu au epit. ciliat ⇒ dispnee, wheezing, agravare progresiva a dispneei→HHCin tratam. / cortizon per os (Prednison tb, 5mg, doza 1mg/kgC/24h, la 6h interval) ▪ A.B. – adrenalina 1 diviziune→revine din criza (fara wheezing)

J

Pediatrie curs 2

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2.10.2001

N.B.: Acest curs aparţine autorilor (12beri/pag.) se pedepseşte conform legii.

iar multiplicarea fără licenţă sau aprobare specială

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