difficulty of breathing

Question 1

common respiratory causes of admissinon in children

Answer 1

Viruses and bacteria:

• Strep pneumonia
• RSV
• Mycoplasma
• Human metapneumovirus
• Pertussis
• Influenza/parainfluenza

Asthma, bronchiolitis, pneumonia, croup

Question 2

asthma

Answer 2

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

Question 3

Croup

Answer 3

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)

Question 4

Bronchiolitis

Answer 4

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

Question 5

Pneumonia

Answer 5

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.

Question 6

History

Answer 6

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.

Question 7

General exam

Answer 7

Level of alertness

Interested in surroundings?

Posture

Ability to speak

Question 8

Resp Exam

Answer 8

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

Question 9

noisy breathing

Answer 9

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.

Question 10

resp rate

Answer 10

Rate increases as illness gets more severe – until decompensation when rate slows

Remember to adjust for age

Look out for prolonged expiration (asthma, bronchiolitis)

Question 11

work of breathing

Answer 11

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.

Question 12

accessory muscles

Answer 12

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

Question 13

Sa02 and HR

Answer 13

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

Question 14

auscultation

Answer 14

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

Question 15

peak flow

Answer 15

:

Best in children who have done it before and who are old enough to understand

Compare with personal best or predicted for height

Question 16

Chocking

Answer 16

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.

Question 17

apnoea

Answer 17

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.

Question 18

Status Asthmaticus

Answer 18

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.