oral dexamethasone 150 mcg/kg or pred 0.5-1 mg/kg or inhaled budesonide (if not taking oral meds or vomiting)

Child with breathing difficulties Flashcards by Catherine Hunter

The thoracic cage of children is more compliant than that of adults. T or F?

What are the implications of this when there is airway obstruction?

True.

Increased compliance results in marked chest wall recession and a reduction in the efficacy of breathing

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Mechanisms causing upper airway obstruction in children?

Epiglottitis / croup

Foreign body

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Mechanisms causing lower airway obstruction in children?

Bronchiolitis
Asthma
Tracheitis

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Disorders around the lungs that cause breathing difficulties in children?

Pneumothorax
Pleural effusion or empyema
Rib fractures

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Disorders affecting the lungs that cause breathing difficulties in children?

Pneumonia

Pulmonary oedema

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Disorders below the diaphragm that cause breathing difficulties in children?

Abdominal distension

Peritionitis

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Disorders that cause increased respiratory drive in children?

DKA
Shock
Poisoning e.g. salicylates
Anxiety / hyperventilation

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Disorders that causes decreased respiratory drive in children?

Coma
Convulsions
Increased ICP
Poisoning

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With regards to lung volumes, why are infants more at risk of small airway closure and hypoxia?

The lung volume at end expiration is similar to the closing volume in infants

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What is the significance of the large presence of fetal haemoglobin in the first few months of life?

It shifts the oxygen dissociation curve to the left
Means oxygen gives off less readily to the tissues
So more prone to hypoxia and acidosis

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Clinical features that suggest cardiac cause of respiratory inadequacy?

Cyanosis not correcting with O2 therapy 
Tachycardiac out of proportion to resp difficulty 
Raised JVP 
Gallop rhythm/murmur 
Enlarged liver
Absent femoral pulses

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Commonest pathogen causing croup

Parainfluenza

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Presentation of croup

barking cough
harsh stridor
hoarseness

preceded by fever + coryza for 1-3 days

symps often worse at night

as obstruction progresses:

sternal & subcostal recession
tachycardia
tahcypnoea
hypoxia

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Commonest age group for croup

6 months - 5 years

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Rx of croup

oral dexamethasone 150 mcg/kg or pred 0.5-1 mg/kg

inhaled budesonide (if not taking oral meds or vomiting)

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Which children require emergency Rx of croup and what is the emergency Rx

Children in severe respiratory distress with harsh stridor and barking cough

Nebulised adrenaline 400 mcg/kg of 1:1000 with O2 with face mask
+
Oral steroids (dex or pred)

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Clinical signs in croup that suggest intubation is required

increasing tachycardia 
tachypnoea 
chest retraction 
cyanosis 
exhaustion 
confusion

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A foreign body in the trachea tends to lie in which plane on CXR?

sagittal

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A foreign body in the oesophagus tends to lie in which plane on CXR?

What % of foreign body inhalations have a normal CXR?

20%

Rx of foreign body inhalation?

If stable - remove the foreign body under controlled conditions - removal via bronchoscope under GA

If extreme life threatening case - direct laryngoscopy and removal with Magills forceps

Most common causative pathogen of epiglottitis

Haemophilus influenza B

Presentation of epiglottitis

Fever 
Lerthargy 
Soft inspiratory stridor 
Rapidly increasing respiratory difficulty over 3-6 hours 
Minimal or absent cough 
Drooling 
Pale/toxic appearance

Important movements NOT to do with children with suspected epiglottitis

Lie them down or open mouth to examine airway

Mx epiglottitis

``` Senior input ENT/anaesthetics Deeply anaesthetise - only lie flat after to intubate Secure airway Blood for culture IV cefotaxime or ceftriaxone ``` Most only need intubated for 24-36 hours and fully recover in 3-5 days.

Most common causative pathogen of bacterial tracheitis

staph aureus, streptococci or Hib

Presentation of bacterial tracheitis

``` Harsh cough Purulent secretions Toxic appearance Fever Signs of progressive upper airway obstruction ```

Rx of bacterial tracheitis

``` Intubation and ventilatory support IV Abx (cefotaxime or ceftriaxone + flucloxacillin) ```

Pathophysiology of bacterial tracheitis

aka pseudomembranous croup life threatening form of upper airway obstruction infection of the tracheal mucosa, resulting in copious, purulent secretions and mucosal necrosis

2 commonest causes of lower respiratory obstruction in children

Acute severe asthma or episodic viral wheeze (> 1 year olds) or Bronchiolitis (<1 year olds)

Signs of acute severe asthma

``` Too breathless to feed or talk High RR (>30 in over 5's or >50 in 2-5's) High HR (>120 in over 5's or >130 in 2-5's) ```

Signs of life threatening asthma

``` Exhaustion Poor respiratory effort Silent chest Hypotension Reduced conscious level ```

Criteria for 'mild' exacerbation of asthma

Sats > 92% AND No incr WOB or accessory muscle use No incr in HR or RR Normal mental state Able to talk normally

Criteria for 'moderate' exacerbation of asthma

Sats >92% AND Moderate incr WOB - chest recession/accessory muscle use Dyspnoea resulting in shortened sentences Normal mental state PEWS <2 for both HR and RR

Criteria for 'severe' exacerbation of asthma

Sats <92% AND ``` Agitated and distressed Marked dyspnoea Severe incr WOB Marked accessory muscle use HR and RR PEWS >2 ```

Rx for mild asthma

10 puffs salbutamol via spacer Assess response after 10 min Consider oral pred

Rx for moderate asthma

10 puffs salbutamol x3 over 1 hour + Oral pred Then assess response after 10 min If no response move to severe pathway If responding, stretch MDI dosing as able

Rx for severe asthma

'mega neb' x3 over 1 hour - salbutamol - ipratropium - Mag sulphate

Rx of asthma if not improving after 3x meganebs

PICU support IV salbutamol, mag sulf Loading dose of IV aminophylline (if not on oral theophylline) with ondansetron cover

Most common causative pathogen of bronchiolitis

RSV

Clinical presentation of bronchiolitis

fever nasal discharge then dry cough increasing breathlessness wheeze +/- crackles feeding difficulties

Risk factors for increased severity of bronchiolitis

``` Age < 6 weeks premature birth chronic lung disease congenital heart disease immunodeficiency ```

Bronchiolitis emergency Rx

Mainly supportive - fluid replacement, gentle suctioning of nasal secretions, prone position, O2 therapy + resp support if required ABC first (!)

How long do symps of bronchiolitis normally last for

3-7 days

Main causes of heart failure in 1. infants, 2. older chidlren

1. structural heart disease, congenital heart defects | 2. myocarditis, cardiomyopathy