Child with breathing difficulties Flashcards
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
Mechanisms causing upper airway obstruction in children?
Epiglottitis / croup
Foreign body
Mechanisms causing lower airway obstruction in children?
Bronchiolitis
Asthma
Tracheitis
Disorders around the lungs that cause breathing difficulties in children?
Pneumothorax
Pleural effusion or empyema
Rib fractures
Disorders affecting the lungs that cause breathing difficulties in children?
Pneumonia
Pulmonary oedema
Disorders below the diaphragm that cause breathing difficulties in children?
Abdominal distension
Peritionitis
Disorders that cause increased respiratory drive in children?
DKA
Shock
Poisoning e.g. salicylates
Anxiety / hyperventilation
Disorders that causes decreased respiratory drive in children?
Coma
Convulsions
Increased ICP
Poisoning
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
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
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
Commonest pathogen causing croup
Parainfluenza
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
Commonest age group for croup
6 months - 5 years
Rx of croup
oral dexamethasone 150 mcg/kg or pred 0.5-1 mg/kg
or
inhaled budesonide (if not taking oral meds or vomiting)
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)
Clinical signs in croup that suggest intubation is required
increasing tachycardia tachypnoea chest retraction cyanosis exhaustion confusion
A foreign body in the trachea tends to lie in which plane on CXR?
sagittal
A foreign body in the oesophagus tends to lie in which plane on CXR?
anterior
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
- structural heart disease, congenital heart defects
2. myocarditis, cardiomyopathy
