Breathless and Noisy Breathing Flashcards
What is the significance of RR in paediatrics?
Differences in age groups, elevation in RR may arise as part of compensatory mechanisms for pathology in other systems.
How is CRT measured in paediatrics?
Checked centrally on sternum, should always be <2 secs, if prolonged indicates poor perfusion and impending circulatory failure.
What is the significance of O2 sats in paediatrics?
<92% indicate greater degree of severity in the absence of known pre-existing condition, cyanosis is a late pre-terminal sign.
What is the significance of BP in paediatrics?
Abnormalities of BP occur very late in childhood due to compensatory mechanisms in young people and are therefore a red flag sign of impending CV collapse.
What is the significance of HR in paediatrics?
180/min tachycardia; may indicate fear/distress, and CV compensation for respiratory distress, persistent tachycardia may be a sign of serious underlying sepsis or CV compromise.
How is level of consciousness assessed in paediatrics?
AVPU score used, children will often become agitated during acute illness prior to depression of conscious level.
What are the signs of respiratory distress?
- Tracheal tug (retraction at suprasternal notch, as baby is breathing in very strongly, intercostals and subcostals contract, so get pulled in) indicates further signs of increased respiratory effort, posture is also very important as children in severe respiratory distress; the child may hold themselves in a particular position)
- Remember: children with neurological/muscular disease may be unable to exhibit signs of respiratory distress
- Those with impending respiratory failure and exhaustion will develop a low RR (for their age) and diminished breath sounds; these are pre-arrest findings due to failure of compensatory mechanisms and require immediate treatment
- If stridor goes quiet - could be imminent respiratory failure or epiglottitis
How would a baby with croup present?
- Look unwell
- Inspiratory/expiratory stridor at rest
- Dry barking cough is observed
- Tachypnoea, nasal flaring, moderate to tracheal tug, intercostal and subcostal recession
- Appears pink
What do you do if there is a suspected airway obstruction in a child?
Don’t examine upper airway (may increase distress and breathlessness in epiglottits, can cause acute sudden airway obstruction). Ideally try not to do anything that may distress the child due to risk of further airway obstruction.
What are the signs and symptoms of croup?
- URTI usually at 6 months to 3yrs
- Stridor - inspiratory +/or expiratory
- Barking cough (worse at night, sounds like a seal)
- Fever
- Coryzal symptoms
- Severe: decreased air entry, increased work of breathing, pallor, cyanosis, decreased conscious level
What are the investigations for croup?
Usually clinical diagnosis, CXR can show subglottic narrowing (‘steeple sign’)
What is the management for croup?
- Single dose oral dexamethasone (0.15mg/kg) to all children, regardless of severity
- Emergency: high flow O2, nebulised adrenaline (5ml, 1:1000) - if giving adrenaline, continue monitoring as adrenaline has a short half life and symptoms may rebound)
What is the presentation of acute epiglottitis?
- Rare but serious: caused by haemophilus influenza type B (rare due to vaccine)
- Symptoms: rapid onset, fever, stridor, drooling of saliva, very ill
What are the investigations and treatment for acute epiglottitis?
- Investigations: CXR, lateral view shows swelling of epiglottis (‘thumb sign’)
- Treatment: IV fluids, IV broad spectrum abx, corticosteroids for inflammation
Describe foreign body aspiration in children
- Sudden onset: coughing, choking, vomiting, stridor
- If child is choking and can’t get it out on their own - perform Heimlich manoeuvre
Describe laryngomalacia (floppy larynx) in children
- Congenital abnormality
- Infants typically present at 4 weeks of age with stridor
- 90% may resolve on their own, but the rest may need surgery
Describe anaphylaxis
- Definition: hypotension, bronchoconstriction/airway compromise in an allergic reaction
- Symptoms: stridor, wheeze, pallor and sweating
- Other symptoms that can occur but don’t indicate a life-threatening allergic reaction: erythema, urticaria, facial swelling (tongue swelling can obstruct airway), itching
What is the treatment for anaphylaxis?
500 micrograms (0.5ml, 1 in 1000). Can repeat adrenaline every 5 mins if needed. Ideally IM injection in anterolateral aspect of middle third of the thigh, also give 200mg IV hydrocortisone and 10mg IV chlorphenamine - Inquire about allergies and allergy related conditions like asthma.
What are the questions to ask in a history of croup?
- Can they swallow?
- Any other symptoms e.g. rashes, in particular urticarial or swelling, may indicate allergy and anaphylaxis which requires specific emergency treatment
- What is the pattern of the cough? e.g. barking, seal cough
- Did they ingest a possible allergen?
- What happened before the onset of symptoms e.g. choking or playing with small objects
- Is fever present?
What is the management of croup?
- Reassure parents - important to maintain a calm atmosphere and handle the child as little as possible
- Call for paediatric, ENT and anaesthetic team - in severe croup, senior clinician/consultants are needed as airway management is difficult and in rare cases tracheostomy may be required.
- Monitor temperature. give paracetamol and fluids
- Always give single dose oral dexamethasone 0.15mg/kg (can be repeated 12hrs later)
- If croup moderate/severe - nebulised adrenaline 5ml 1:1000 (child requires close monitoring as adrenaline has a short half life and symptoms may rebound) - this is a high concentration adrenaline in contrast to the 1:10,000 usually used for cardiac arrest in children
How do you assess a child for risk of anaphylactic reaction?
- Do they have asthma?
- If they have asthma what treatment do they take?
- Do they take a regular preventer inhaler?
- When they had the initial reaction how much of the food stuff or allergen had they been in contact with?
- Need to assess severity of previous reactions and risk of future anaphylaxis. Also consider how easily avoidable an allergen is and amount of allergen ingested to cause reaction.
What type of reaction is a food allergy?
Type 1 hypersensitivity reaction:
Histamine is released immediately from activated mast cells causing:
- Bronchoconstriction (wheeze)
- Localised irritation (itching)
- Vasodilation (hypotension)
- Endothelial cell separation (urticaria)
