difficulty of breathing Flashcards
common respiratory causes of admissinon in children
Viruses and bacteria:
- Strep pneumonia
- RSV
- Mycoplasma
- Human metapneumovirus
- Pertussis
- Influenza/parainfluenza
Asthma, bronchiolitis, pneumonia, croup
asthma
Hyper-reactive airways causing coughing and wheezing
“Viral-induced wheeze” in pre-schoolers – not necessarily asthma
Asthma triggers: smoke, exercise, excitement, dust, pollen, allergies
Inhaler via spacer +/- mask
Croup
Virus causing airway inflammation/obstruction in toddlers
Barking cough, hoarse voice +/- stridor (turbulent airflow through narrowed airways) and shortness of breath
Try not to distress a child with croup as this can worsen obstruction
Steroids +/- adrenaline nebuliser (will shrink inflamred airways until steroids work)
Bronchiolitis
Mainly infants < 1 yr
Shortness of breath, wheezy cough, mild fever, runny nose
Winter months
Manage at home or admit for feeding support, oxygen, suction
It is caused by a few viruses, the main one being respiratory syncitial virus. The virus infects the lower airways causing secretions. The infant will therefore have a wet sounding cough and will sound wheezy
Pneumonia
Clinical signs often subtle in children
Generally unwell, febrile, tachypnoiec
May not have a cough
Check O2 saturations and look for signs of respiratory distress
In children under 3 years old with signs of sepsis, hospital specialists often perform a chest X-ray to detect pneumonia, because the clinical signs are notoriously subtle. Children with bacterial pneumonia will appear more unwell and lethargic than with common viral respiratory infections, with a temperature typically above 38.5 degrees centigrade, and they often refuse food and drink. TTo diagnose pneumonia in children, you therefore have to rely on the general signs of severe infection, as picked up in the 3 minute toolkit, such as lethargy, fever and a high heart rate, particularly if the heart rate is out of proportion to the degree of fever. When examining the respiratory system, the most important discriminating sign is a raised respiratory rate. Low oxygen saturations give another important clue to the presence of pneumonia.
History
Age:
different illnesses at different ages
small babies get more ill more quickly
Past medical history:
Prematurity
Cardiac/respiratory disease
Fast/noisy breathing?
Eating and drinking?
Level of activity?
Fever?
Apnoea? Admit urgently
Characteristic stories:
Baby with snuffly nose, wet cough, wheeze – Bronchiolitis
Pre-schooler with runny nose then dry cough and wheeze – Viral induced wheeze
Older child with recurrent wheezy episodes, atopy in family - Asthma
Healthy small infants often have noisy breathing simply because the airways are so small. If the parents say the baby has always been like this you don’t need to worry. The baby will grow out of it by around 6 months of age, often with respiratory disease, the child will have a cough, and may sometimes be coughing so much they make themselves vomit.
General exam
Level of alertness
Interested in surroundings?
Posture
Ability to speak
Resp Exam
Respiratory Examination
In this section, you should think about the following:
Do as much as possible from a distance to keep child calm
Noisy breathing?
Respiratory rate?
Work of breathing?
Accessory muscles?
Oxygen saturations and heart rate
Auscultation
Peak flow
Beware children who have little work of breathing may be tired and about to decompensate
noisy breathing
Coryza (runny nose) – common in URTIs, bronchiolitis and well infants!
Wheeze – lower airway narrowing or secretions – asthma, bronchiolitis, viral-induced wheeze. can hear across room.
Stridor – upper airway narrowing – croup, other rarer infections, epiglotitis, anaphylaxis, foreign body, bacterial tracheitits
Grunting – infants with severe respiratory distress
infants close their glottis to generate end expiratory pressure, to keep their alveoli open when they have lots of secretion.
resp rate
Rate increases as illness gets more severe – until decompensation when rate slows
Remember to adjust for age
Look out for prolonged expiration (asthma, bronchiolitis)
work of breathing
Recession (mild-moderate-severe)
Tracheal tug
Supraclavicular
Sternal
Intercostal
Subcostal
Younger children show recession more frequently, due to their softer chest walls
Sternal recession indicates more severe respiratory distress - this is because the sternum is a large bone, and to draw it in means that severe effort is being put in.
accessory muscles
Abdominal breathing
Head bobbing
Nasal flaring
When a child has respiratory difficulty, they can recruit other muscles to help inflate the chest. These are called accessory muscles, in this context. Forced diaphragm movement causes abdominal breathing and pulling on the sternomastoid muscles in the neck causes something called head bobbing in babies
Sa02 and HR
Detects hypoxia well before the naked eye can see cyanosis
Give supplemental oxygen if O2 saturations <94%
Children whose saturations are still low despite oxygen are very unwell
Tachycardia (adjust for age) = ill child
Bradycardia (adjust for age) = pre-arrest
auscultation
Limitations:
Often hear noisy breathing without stethoscope
Sounds do not always relate to how ill the child is
Small chests transmit sounds all over
Children cry!
Wheeze
Crackles/crepitations, bronchial breathing – pneumonia?
Beware a “silent chest” – could be life-threatening asthma
peak flow
:
Best in children who have done it before and who are old enough to understand
Compare with personal best or predicted for height
Chocking
Choking
In this section, you should think about the following:
Foreign bodies
Upper airway (larynx) – life-threatening
Bronchi – wheeze, chest infection
Oesophagus – discomfort, drooling
Stuck in larynx:
Spontaneous cough? – encourage coughing
No/ineffective cough? – back blows, abdominal thrust (>1 yr) or chest thrusts (<1 yr)
Unconscious? – standard CPR
In hospital – contact ENT and anaesthetics urgently
Stuck in main bronchus:
Wheezing or chest infection some time after the event which may not be recalled
Chest X-ray may be helpful
May need bronchoscopy to remove
Stuck in oesophagus:
No respiratory compromise
Drooling
Refer to surgery/anaesthetics
in this semi-stable situation, the child can be given a short acting, light, anaesthetic by inhalation, and the foreign body removed with Magill’s forceps. If the child has already lost consciousness, you have to act. Use a laryngoscope and retrieve the foreign body with Magill’s forceps without wating for further help. In rare circumstances the foreign body will be difficult to retrieve and a cricothyrotomy may be needed. The more common acute situation is the child who has in fact ingested the foreign body. They will look very uncomfortable, just like this child, but will not be hypoxic or showing signs of respiratory distress
If you see a child in the acute phase, listen carefully for localised wheezing and get a chest x-ray, which may show a ball-valve effect where air gets in past the foreign body, but can’t escape as the child breathes out, and the lung becomes progressively hyperinflated. The child will need to be referred for bronchoscopy to retrieve the foreign body.
apnoea
In this section, you should think about the following:
Pause in breathing/stopping breathing
Occur in infants with bronchiolitis, Pertussis, sepsis, meningitis, fits
Apparent life-threatening event (ALTE)
Floppiness, cyanosis, and/or apnoea
Many possible causes
Apnoeas happen in various conditions such as bronchiolitis, whooping cough (which is due to Pertussis infection), sepsis, meningitis and fits. Apnoea can be hard to diagnose from the parents’ account, and should be regarded as having happened during any event which includes floppiness or cyanosis.
Whooping cough tends to present with apnoeas at this age. It is only in older children that Pertussis causes coughing bouts followed by a big intake of breath which sounds like a whoop.
Status Asthmaticus
Status Asthmaticus or Acute Severe Asthma
Classify attack as moderate, severe or life-threatening
Acute severe: requires repeated nebulisers +/- IV treatment
In the featured cases, look out for:
History of severe attacks in the past
Increased work or breathing
Fatigue
Hypoxia
Tachycardia
PICU involvement
Marked improvement after treatment
Status asthmaticus is a term used to describe an acute severe asthma attack, which does not respond to the normal treatment of 2 or 3 nebulizers or repeated doses of an inhaler. When an asthma attack is severe and prolonged, children can become very tired and go into respiratory failure and require intubation and ventilation to take over the work of breathing.
