Causes of chestiness in children

Question 1

What are respiratory symptoms that comprise chestiness?

Answer 1

SOB, wheeze, tachypnoeic, cough

Question 2

What are the causes of chestiness in children?

Answer 2

Upper resp tract

• URTI
• inhaled foreign body
• epiglottitis
• croup (Acute laryngotracheobronchitis)
• whooping cough (pertussis)

Lower respiratory tract

• pneumonia
• asthma/ viral induced wheeze/ multi-trigger wheeze
• bronchiolitis
• cystic fibrosis
• TB

Heart
- heart failure

Question 3

What are the clinical features of inhaled foreign body?

Answer 3

Common in toddlers.

History of choking.

Stridor

Question 4

Croup (acute laryngotracheobronchitis)

Answer 4

Age 6 months to 6 years

Caused by parainfluenza, influenza or RSV

Stridor, barking cough, coryzal prodrome (develops over days), temp < 38.5 degrees, able to drink

Tx - do not upset child by examining throat, moist/ humidifed air, oral pred/dexa/neb budenoside, neb adrenaline

Question 5

Epiglottitis

Answer 5

Children from 1-6 years of age

Caused by Hib

Stridor, drooling child, can’t drink, temp > 38.5 degrees, no prodrome (develops over hours)

Management - do not examine throat!, anaesthetic intervention, IV Abx and contact prophylaxis

Question 6

Whooping cough/ bordatella pertussis

Answer 6

3 stages to illness

• coryzal (1-2 weeks) - fever, cough, runny nose, sneezing
• paroxysmal (2-6weeks) - severe paroxysmal coughing episodes, followed by inspiratory whoop and vomiting
• convalescent (2-4 weeks) - lessening and resolving symptoms

May present as apnoeic episodes in infants

Investigations: pernasal swab

Management - infants with apnoeic episodes, severe paroxysms or cyanosis should be hospitalised due to risk of seizures and death, erythromycin for 14 days, isolation for 5 days and immunisation and prophylactic antibiotics to be given to close contacts

Question 7

Bronchiolitis

Answer 7

Infants under 2 years of age, typically first winter

Caused by RSV

History of coryza, followed by dry cough and increasing breathlessness, wheeze, feeding difficulty, apnoea

On examination - widespread wheeze and crackles

Investigations - nasopharyngeal swab, CXR (hyperinflation, atelectasis)

Management - send to hospital if not feeding, low sats, cyanosis, respiratory distress, apnoea - mainly supportive (oxygen, feeding, bronchodilators, ribavirin for immunodeficient or heart/lung disease)

Palivizumab - prophylactic in preterm babaies or oxygen dependent infants

Question 8

What are the differences between episodic wheeze (viral induced wheeze) and multi-trigger wheeze in pre-school children?

Answer 8

Viral induced wheeze is characterised by wheeze and breathing problems only when child has a cold and symptom-free in between colds - treated with intermittent bronchodilator +- montelukast +- inhaled corticosteroids

Multi-trigger wheeze is characterized by wheeze in between colds due to triggers such as cold air, exercise, pets etc and there may be a family history of atopy - treated with bronchodilator + preventative montelukast or inhaled corticosteroids

Question 9

What is management of asthma in children

Answer 9

Under 5s
Step 1: Inhaled SABA PRN
Step 2: (symptomatic or using reliever 3 times a week, one serious exacerbation in last two years, night symptoms): Inhaled very low dose ICS or LTRA
Step 3: (2-5 years) combine very low dose ICS and LTRA, ( < 2 years) refer to paediatrician

5 and older (Same as adult)
Step 1: Inhaled SABA PRN
Step 2: Inhaled standard dose corticosteroid
Step 3: LABA - if benefit, keep LABA + increase dose of corticosteroid to top end of standard dose, if no benefit stop LABA + increase dose of corticosteroid, if still no benefit consider LTRA/MR theophylline
Step 4: Increase inhaled corticosteroid/ add LTRA/MR theophylline/ MR oral B2 agonist
Step 5: refer +- oral steroids