Viral-induced wheeze

Question 1

A 3 year old girl has come to ED with a cough and running nose for 2 days. On exam she has wheezing on auscultation. Her respiratory rate is 39brpm and her temp is 38.2. How would you assess and manage this patient?

Answer 1

Impression
Given this stem I am mostly concerned about a bacterial /viral pneumonia. Would want to rule out other red flag causes of respiratory distress in young patients including bacterial tracheitis, epiglottitis, croup - more likely to cause stridor.

This presentation most likely secondary to viral infection given low-grade fever.
- COVID, RSV, Influenza, parainfluenza, adenovirus, etc

Cant be asthma

Goals
- Ensure HD stable, assess for toxicity.
- Delineate likely causative aetiology and institute appropriate acute and ongoing management

Question 2

Viral-induced wheeze - Assessment

Answer 2

Assessment
A - patent, maintaining. Auscultate for stridor - if present call for senior help, consider need for intubation
B - RR/SP02 monitoring. Assess for WOB. supplemental 02, avoid excessive examination in child with ?croup.
C / D / E / F / G

Question 3

Viral induced wheeze - History

Answer 3

History
- PC: confirm wheeze (rule out stridor). ask about sx: coryza, sore throat, hoarse voice, coughing, sneezing, production. chest tightness?, timing, progression, course of illness, any prodromal features before wheeze was induced?
- HPI: sick contacts, allergies/exposure to triggers. irritability, feeding, sleep, inputs vs outputs
- PMHx: asthma, fam history, immunocompromised,
- Paeds: Growth, developmental, vaccinations, birth and pregnancy details

Question 4

Viral induced wheeze - Examination

Answer 4

Examination
- General appearance + vitals
- respiratory: rule out stridor, assess location of wheeze, severity, RR, chest expansion and air entry, look for signs of WOB
- hydration status assessment

Question 5

Viral induced wheeze - Investigations

Answer 5

Investigations
Primarily clinical diagnosis.
- nasopharyngeal aspirate for COVID - PCR (or RAT test)
- CXR for ?pneumonia if suspicious.

Others guided by clinical suspicion;
- VBG - P02, lactate
- FBC, UEC, LFT, CRP/ESR
- cultures (sputum, blood, etc)

Question 6

Viral induced wheeze - Management

Answer 6

Management
Acute
- relive bronchospasm and wheeze
o SABA’s - follow asthma exacerbation guidelines
o +/- SAMA, mag sulphate, aminophylline
o steroids not indicated in paeds <5years presenting for first time
- RediPred if severe presentation

Otherwise is largely supportive;
- 02 therapy: target SP02 >94%
- analgesia: paracetamol
- antipyretics
- parent education and reassurance, provide appropriate information sheets, may have increased risk of developing asthma
- medications to take home and management plan (adhere to asthma management plan)
- GP follow-up for review and assessment/diagnosis of asthma if possible

Disposition
- outpatient if improvements with SABA and normalising RR/SP02
o discharge if SP02 >94 and SABA only every 3 hrs
- inpatient if poor feeding history, toxic-looking, not tolerating orals, needs salbutamol consistently, not improving/ongoing oxygen requirements.