Cerebral Palsy - chest infection

  • See also

    Background

    • Chest infections are the commonest reason for children with cerebral palsy to require hospital admission
    • Predisposing factors include:
      • Pseudobulbar palsy - aspiration of saliva or food/fluid
      • Gastro-oesophageal reflux
      • Poor cough
      • Increased secretions (eg secondary to benzodiazepines)
      • Immobility
      • Severe scoliosis
    • Causative organisms:
      • The same as for other children (eg viral, Strep pneumoniae, mycoplasma), though may be at risk for anaerobes if aspiration is a contributing factor

    Assessment

    • Severity of respiratory distress (tachypnoea, intercostal/subcostal recession, accessory muscle use, grunting)
    • Oxygen requirement
    • Respiratory failure (conscious state, venous blood gas (pH, CO2))
    • Presence of bronchospasm (wheeze, response to salbutamol?)
    • Risk factors for severe respiratory illness
      • Previous ICU admissions
      • Pre-existing respiratory failure (previous blood gases?)
      • Severe scoliosis

    Children with cerebral palsy may develop hypothermia (rather than fever) in the presence of severe infection
    NB Chest X-rays may be difficult to interpret in children with scoliosis

    Management

    • See  Pneumonia  guideline
    • Antibiotics: as for other children
      • Have a lower threshold for starting antibiotics in children with severe cerebral palsy
      • Penicillin is thought to provide adequate anaerobic cover for aspiration pneumonia in children
      • If very unwell consider adding gram negative cover (especially if hospital-acquired), or metronidazole (especially if on maintenance ranitidine or omeprazole)
    • Discuss with senior doctor +/- ICU if:
      • Evidence of acute respiratory failure
      • Severe respiratory distress
      • Oxygen requirement >50%
      • Risk factors for severe respiratory illness (see above)
    • Salbutamol - use if there is evidence of bronchospasm (hyperinflation, wheeze, response to trial of salbutamol)
    • Secretions: 
      • nebulised saline may help to mobilise secretions (give 5mls normal saline via nebuliser)
      • oro-pharyngeal suctioning may be useful if the child is unable to clear oral secretions
      • chest physiotherapy is helpful if children have large airway secretions and a poor cough, or focal consolidation
    • Feeding:
      • For moderate or severe respiratory distress withhold feeds and give IV fluids at 75% maintenance.
    • Oxygen:
      • Give oxygen if the child's oxygen saturations are <90% in room air
      • Be careful with oxygen in children with chronic respiratory failure (known hypoventilation with elevated CO2 even when well) - in this case aim for saturations 90-95%

    Prevention

    • Children with severe cerebral palsy should receive annual influenza vaccine in addition to the usual vaccines on the schedule.
    • Consider pneumococcal vaccine (all children <4 years are eligible to receive on the schedule from January 2005)