The Child with Cough, Respiratory Distress or Noisy Breathing

Question 1

A sick child needs inhaled salbutamol. What is the dosage?

Answer 1

• Salbutamol dosage - 6 puffs under 6, 12 over 6

Question 2

A sick child needs inhaled ipratropium. What is the dosage?

Answer 2

• Ipratropium dosage - 4 puffs under 6, 8 puffs over 6

Question 3

What are the signs that asthma is mild?

Answer 3

• Normal mental state
• Subtle WOB
• Talking normally
• No limitation of speech

Question 4

What is the management for mild asthma?

Answer 4

• Salbutamol, 1 dose (6 puffs under 6, 12 over 6) via spacer, reassess 20/60
• Oral prednisolone if no response

Question 5

What is the management for moderate asthma?

Answer 5

• Oxygen if < 92%
• Salbutamol, 1 dose (6 puffs under 6, 12 over 6) via spacer 20/60ly for 1 hour
• Oral prednisolone

Question 6

What are the signs of moderate asthma?

Answer 6

• Normal mental state
• Some WOB
• Tachycardia
• Some limitation of talking

Question 7

What are the signs of severe asthma?

Answer 7

• Agitated
• Mod-marked WOB
• Tachycardia
• Marked talking limitation

Question 8

What is the management for severe (not critical) asthma?

Answer 8

• Oxygen if < 92%
• Salbutamol, 1 dose (6 under 6, 12 over 6) via spacer 20/60ly for 1 hour
• Ipratropium, 1 dose (4 under 6, 8 over 6) via spacer 20/60ly for 1 hour
• MgSO4
• Oral prednisolone
• Consider aminophylline

Question 9

What are the signs of a child with critical asthma?

Answer 9

• Drowsy
• Maximal WOB
• Exhaustion
• Marked tachycardia
• Unable to talk
• Silent chest

Question 10

What is the management for critical asthma?

Answer 10

• Oxygen
• Continuous nebulised salbutamol
• Nebulised ipratropium
• Methylprednisolone IV
• Aminophylline
• MgSO4

Question 11

How might a child with bronchiolitis present?

Answer 11

• Prodrome: URTI with cough and fever - 1-3 days
• Symptoms: wheeze, cough (wet, non-productive), poor feeding, fever, peaking at 3-5 days
• Signs: wheeze, respiratory distress, tachypnoea, tachycardia, retractions, poor air entry

Question 12

How might you grade the severity of bronchiolitis in a child?

Answer 12

• Severe - increased WOB, SaO2 <92% on FiO2 > 0.5, apnoeic episode
• Moderate - Some increased WOB, SaO2 < 92% on room air, decreased feeding
• Mild - no increased WOB

Question 13

How is bronchiolitis managed?

Answer 13

• Severe - O2 to 92%, supportive fluids, ICU monitoring, CPAP or intubation
• Moderate - admit, O2 to 90%, supportive fluids
• Mild - home treatment, early review

Question 14

How does a child with croup present?

Answer 14

• Prodrome: coryzal
• Barking cough, inspiratory stridor, hoarse voice, worsens at night
• DDx: epiglottitis (acute, high fever, dysphagia, drooling, lymphadenopathy), foreign body (Hx, no prodrome)

Question 15

How might you decide the severity of croup in a child?

Answer 15

• Cough only: supportive at home, return if worsening
• Mild (minimal accessory muscle use and rest stridor)
• Moderate (accessory muscle use and recession/stridor at rest)
• Severe (hypoxia < 92%, distress, marked accessory muscle use)

Question 16

How might you manage croup in a child?

Answer 16

• Cough only: supportive at home, return if worsening
• Mild (minimal accessory muscle use and rest stridor): prednisolone, monitor 1-2 hours
• Moderate (accessory muscle use and recession/stridor at rest): prednisolone, nebulised adrenaline if no improvement by 30 minutes, monitor 3 hours
• Severe (hypoxia < 92%, distress, marked accessory muscle use): prednisolone, neb adrenaline, admit +/- ICU

Question 17

How might a child with epiglottitis present? What treatment do they urgently need?

Answer 17

• Presentation
  
  • Toxic child - fever, flushing, tachycardia
  • Stridor, drooling, increased work of breathing
• Treatment
  
  • ICU admission
  • IV cefuroxime

Question 18

How might you manage a child with croup?

Answer 18

• Antibiotics (do not improve clinical course but limit transmission)
  
  • Clarithromycin/azithromycin (GN bacteria) for child and contacts
• Continue with routine immunisations
• Admit if: systemically unwell, <6/12, severe respiratory distress, feeding poorly

Question 19

How might a child who has inhaled a foreign body present?

Answer 19

• Choking or coughing while eating solids or chewing on a toy
• Unwitnessed
• Persistent wheeze and cough, unilateral breath sounds and hyperinflation in unaffected side

Question 20

What are some of the complications associated with cystic fibrosis?

Answer 20

• Respiratory: bronchiectasis, pneumothorax, aspergillosis, pulmonary fibrosis/cor pulmonale
• Gastrointestinal: pancreatic insufficiency, chronic liver disease (CBD atresia), biliary disease, intussusception
• Cardiovascular: cor pulmonale (secondary to pulmonary fibrosis/HT)
• Misc: infertility (males), subfertility (females), diabetes mellitus, clubbing (hypertrophic osteoarthropathy)

Question 21

What are some of the issues that may arise in the management of a patient with cystic fibrosis?

Answer 21

• Genetic counselling
• Nutrition: high-fat, high calorie diet
• Pancreatic enzyme replacement
• Vitamin supplementation (A, E, D) and salt
• Pulmonary care
  
  • Chest physiotherapy (daily)
  • Bronchoalveolar lavage (after diagnosis and annually until expectoration occurs)
  • Antibiotic therapy based on colonisation
• Acute respiratory infection treatment
• Distal intestinal obstruction syndrome
• Infertility