PAEDIATRIC BREATHING DIFFICULTIES

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PAEDIATRIC BREATHING DIFFICULTIES

• LEE WALLIS

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OBJECTIVES

• BRONCHIOLITIS
• CROUP
• EPIGLOTTITIS
• FOREIGN BODY
• NASAL OBSTRUCTION

• ASPIRATION
• PERTUSSIS
• PNEUMONIA
• PERITONSILLAR ABSCESS
• RETRO-PHARYNGEAL ABSCESS
• ASTHMA

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BRONCHIOLITIS

• WHEEZING IN A LITTLE KID
• INFANTS
• 50 RSV
• RUNNY NOSE FROM HELL
• TINY BABIES MAY HAVE APNOEA (ALTE)
• HUGE VARIATION IN DURATION
• DAYS TO WEEKS

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BRONCHIOLITIS

• TESTS
• (RSV TITRE)
• FOR ISOLATION
• URINE DIPSTICK
• CXR BILATERAL AIR TRAPPING

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BRONCHIOLITIS

• NEBULISED ADRENALINE
• 11000, 4-5ml
• DOSE IRRELEVANT GENERATE OWN Vt
• STEROIDS
• NEBULISED NO HELP
• ORAL ?HELP

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BRONCHIOLITIS

• Schidler, 2002 Crit Care
• META ANALYSIS 12 STUDIES (n843)
• 75 ß AGONISTS NO HELP
• 5 (n223) ADRENALINE WORKED IN ALL
• STEROIDS MAY OR NOT HELP
• VARIED RESULTS. WHY? MIXED DISEASES MULTIPLE
  CAUSES
• RSV, RHINOVIRUS etc

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BRONCHIOLITIS

• Keenie, 2002 Arch Ped Adol Medicine
• Average LoS 3 days
• Either get better quickly or are sick!
• Obs ward not suitable

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CROUP

• Toddlers, Pre-schoolers
• Prodrome 2 days
• RHINORRHOEA, COUGH
• Then very bad night
• STRIDOR
• BARKING COUGH
• Often better when at EU

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CROUP

• Para-influenza, other virus
• Previously well, gt 4 months, immunised against
  diphtheria
• FB
• Diphtheria
• Candida
• Epiglottitis

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GRADING OF STRIDOR

• BECOMES SOFTER AS OBSTRUCTION GETS WORSE
• I Insp only
• II Insp Passive Exp
• III Insp Active Exp (pulsus paradoxus)
• IV As III recession, cyanosis, tired etc.

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CROUP

• COOL MIST
• cf BOILING WATER WHEN IN LABOUR.
• ADRENALINE NEBS
• Gd II stridor
• DEXAMETHASONE
• IM / PO 0.6 mg/kg
• NEBS 2-4mg
• PREDNISOLONE
• PROBABLY FINE TOO
• ? SINGLE OR MULTIPLE DOSES

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CROUP

• CXR
• To exclude something else (?FB)
• ADMISSION
• GD II STRIDOR
• Grade III-IV need ICU

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CROUP

• Luria, 2001 arch ped adol med
• RCT n264, 6/12 6 yrs
• Mild Croup
• Neb dex vs oral dex vs no dex
• Oral best by far

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EPIGLOTTITIS

• HiB
• GONE IN WEST
• TODDLERS, PRE-SCHOOL
• ABRUPT ONSET
• FEVER, SORE THROAT, DROOLING, MUFFLED VOICE, LEAN
  FORWARD
• No cough
• TOXIC

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EPIGLOTTITIS

• INTUBATE
• GAS INDUCTION, CALM, EXPERIENCED
• 3rd GENERATION CEPHALOSPORIN

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FOREIGN BODY

• 80 RADIO LUCENT
• PEANUTS
• COUGHING, CHOKING, BREATHLESS, UNILATERAL WHEEZE
• MOST ARE SMALL KIDS
• NEED BRONCHOSCOPY

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FOREIGN BODY

• IF UNSURE, CXR
• INSPIRATION EXPIRATION
• ALLOWS VISUALISATION OF BALL VALVE EFFECT. I
  FILMS LOOKS FINE, E FILM SHOWS AIR TRAPPING
• DECUBITUS
• SIDE WITH FB STAYS INFLATED WHEN SHOULD COLLAPSE

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FOREIGN BODY

• Silva , 1998 ann otol rhinol laryngol
• Retrospective review (n93)
• 88 history, 82 wheeze, 51 reduced BS
• CXR sens 63 spec 47
• 83, 50 after 24 hrs

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NASAL OBSTRUCTION

• WHY IS AN EMERGENCY?
• TINY BABIES CANT BREATHE
• OBLIGATE NASAL BREATHING SO MUCUS BECOMES AN
  EMERGENCY!
• NASAL SUCTION

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ASPIRATION PNEUMONIA

• (CHEMICAL PNEUMONITIS)
• KEROSENE, PARAFFIN
• COUGH, WHEEZE, LOW GCS
• DONT INDUCE VOMITING
• MICRO-ASPIRATION OF HYDROCARBONS
• NO ACTIVATED CHARCOAL
• ANTIBIOTICS WHEN INDICATED

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PERTUSSIS

• WHOOPING COUGH
• INFANTS
• UNIMMUNISED
• FEVER REPETITIVE COUGH
• SEIZURES, ENCEPHALOPATHY, PNEUMONIA
• ERYTHROMYCIN

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PNEUMONIA

• VERY WELL ---- SEPTIC SHOCK
• ACUTE ABDOMEN
• ONE SIDE DIFFERENT TO THE OTHER!
• WHEEZE, BRONCHIAL BREATHING
• NEONATES
• BETA HAEM STREP, CHLAMYDIA, G NEG
• OLDER
• PNEUMOCOCCUS, HIB, MYCOPLASMA

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PNEUMONIA

• ADMIT IF RECESSION, NOT FEEDING, SATS lt90
• AMOXYL
• MILD MODERATE
• AMPICILLIN GENTAMICIN
• SEVERE
• ?ERYTHROMYCIN

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PERITONSILLAR ABSCESS

• QUNISY
• OLDER KIDS
• TEENS? gt8?
• BAD SORE THROAT, UVULA DEVIATED
• ABSCESS DRAINAGE (OR ASPIRATION, 18G NEEDLE)

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RETROPHARYNGEAL ABSCESS

• SORE THROAT
• SUPPURATIVE CERVICAL ADENOPATHY
• OR PENETRATION
• FEVER
• STIFF NECK
• OFTEN MISTAKEN FOR MENINGITIS

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RETROPHARYNGEAL ABSCESS

• LATERAL NECK X RAY
• PREVERTEBRAL SOFT TISSUE SWELLING
• CT NECK
• EVALUATE UNDER ANAESTHESIA
• 3RD GENERATION CEPHALOSPORIN

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ASTHMA
Presenting features Presenting features
wheeze dry cough breathlessness noisy breathing
Detailed history and physical examination Detailed history and physical examination
pattern of illness severity/control differential clues
Is it asthma?
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DIFFERENTIAL
Clinical clue Possible diagnosis
Perinatal and family history Perinatal and family history
symptoms present from birth or perinatal lung problem family history of unusual chest disease severe upper respiratory tract disease cystic fibrosis chronic lung disease ciliary dyskinesia developmental anomaly cystic fibrosis developmental anomaly neuromuscular disorder defect of host defence
Symptoms and signs Symptoms and signs
persistent wet cough excessive vomiting dysphagia abnormal voice or cry focal signs in the chest inspiratory stridor as well as wheeze failure to thrive cystic fibrosis recurrent aspiration host defence disorder reflux (?aspiration) swallowing problems (?aspiration) laryngeal problem developmental disease postviral syndrome bronchiectasis tuberculosis central airway or laryngeal disorder cystic fibrosis host defence defect gastro-oesophageal reflux
Investigations Investigations
focal or persistent radiological changes developmental disorder postinfective disorder recurrent aspiration inhaled foreign body bronchiectasis tuberculosis
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Initial assessment of acute asthma in children
aged gt2 years in AE
Moderateexacerbation Severeexacerbation Life threateningasthma
SpO2 ?92 PEF ?50 best/ predicted (gt5 years) No clinical features of severe asthma Heart rate - ?130/min (2-5 years) - ?120/min (gt5 years) Respiratory rate - ?50/min (2-5 years) - ?30/min (gt5 years) SpO2 lt92 PEF lt50 best/ predicted (gt5 years) Too breathless to talkor eat Heart rate - gt130/min (2-5 years) - gt120/min (gt5 years) Respiratory rate - gt50/min (2-5 years) - gt30/min (gt5 years) Use of accessory neck muscles SpO2 lt92 PEF lt33 best/ predicted (gt5 years) Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis
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Management of acute asthmain children aged gt2
years in AE
Moderateexacerbation Severeexacerbation Life threateningexacerbation
ß2 agonist 2-10 puffs viaspacer facemask Reassess after 15 minutes Give nebulised ß2 agonistsalbutamol (2-5 years 2.5mg gt5 years 5mg) or terbutaline(2-5 years 5mg gt5 years 10mg) with oxygen as driving gas Continue oxygen via facemask/nasal prongs Give prednisolone (2-5 years 20mg gt5 years 30-40mg) orIV hydrocortisone (2-5 years 50mg gt5 years 100mg) Give nebulised ß2 agonistsalbutamol (2-5 years 2.5mg gt5 years 5mg) or terbutaline(2-5 years 5mg gt5 years 10mg) with oxygen as driving gas Continue oxygen via facemask/nasal prongs Give prednisolone (2-5 years 20mg gt5 years 30-40mg) orIV hydrocortisone (2-5 years 50mg gt5 years 100mg)
RESPONDING Continue inhaledß2 agonists1-4 hourly Add soluble oral prednisolone- 20mg (2-5 years)- 30-40mg (gt5 years) NOT RESPONDING Repeat inhaledß2 agonist every20-30 minutes Add soluble oral prednisolone- 20mg (2-5 years)- 30-40mg (gt5 years) IF LIFE THREATENING FEATURES PRESENT Discuss with senior clinician, PICU team or paediatrician. Consider Chest x-ray and blood gases Repeat nebulised ß2 agonists plus ipratropium bromide 0.25mg nebulised every 20-30 minutes Bolus IV salbutamol 15?g/kg of 200?g/ml solution over 10 minutes IV aminophylline
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Response to treatment in children aged gt2 years
in AE
Moderateexacerbation Severeexacerbation Life threatening exacerbation

RESPONDING TO TREATMENT NOT RESPONDING TO TREATMENT IF POOR RESPONSE TO TREATMENT
DISCHARGE PLAN Continue ß2 agonists 1-4 hourly prn Consider prednisolone20mg (2-5 years) 30-40mg(gt5 years) daily for up to 3 days Advise to contact GP if not controlled on above treatment Provide a written asthma action plan Review regular treatment Check inhaler technique Arrange GP follow up ARRANGE ADMISSION (lower threshold if concern over social circumstances) ARRANGE IMMEDIATE TRANSFER TO PICU/HDU
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Treatment of acute asthmain children aged gt2
years
D Use structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge
? Children with life threatening asthma or SpO2 lt92 should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations
A Inhaled ß2 agonists are first line treatment for acute asthma
A pMDI and spacer are preferred delivery system in mild to moderate asthma
B Individualise drug dosing according to severity and adjust according to response
B IV salbutamol (15mg/kg) is effective adjunct in severe cases
Dose can be repeated every 20-30 minutes
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Steroid therapy for acuteasthma in children aged
gt2 years
A Give prednisolone early in the treatment of acute asthma attacks
? Use prednisolone 20mg (2-5 years), 30-40mg (gt5 years) Those already receiving maintenance steroid tablets should receive 2 mg/kg oral prednisolone up to a maximum dose of 60 mg Repeat the dose of prednisolone in children who vomit and consider IV steroids Treatment up to 3 days is usually sufficient, but tailor to the number of days for recovery
? Do not initiate inhaled steroids in preference to steroid tablets to treat acute childhood asthma
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Other therapies for acuteasthma in children aged
gt2 years
A If poor response to ?2 agonist treatment, add nebulised ipratropium bromide (250mcg/dose mixed with ?2 agonist)
A Aminophylline is not recommended in children with mild to moderate acute asthma
C Consider aminophylline for children in high dependency/intensive care with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators and steroid tablets
? Do not give antibiotics routinely in the management of acute childhood asthma
? ECG monitoring is mandatory for all intravenous treatments
Dose can be repeated every 20-30 minutes
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Hospital admission for acuteasthma in children
aged gt2 years
? Children with acute asthma failing to improve after 10 puffs of ?2 agonist should be referred to hospital. Further doses of bronchodilator should be given as necessary whilst awaiting transfer
? Treat with oxygen and nebulised ?2 agonists during the journey to hospital
? Transfer children with severe or life threatening asthma urgently to hospital to receive frequent doses of nebulised ?2 agonists (2.5-5mg salbutamol or 5-10 mg terbutaline)
? Decisions about admission should be made by trained physicians after repeated assessment of the response to further bronchodilator treatment
B Consider intensive inpatient treatment for children with SpO2 lt92 on air after initial bronchodilator treatment
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Treatment of acute asthmain children aged lt2
years
B Oral ?2 agonists are not recommended for acute asthma in infants
A For mild to moderate acute asthma, a pMDI with spacer is the optimal drug delivery device
C Consider steroid tablets in infants early in the management of moderate to severe episodes of acute asthma in the hospital setting
? Steroid tablet therapy (10 mg of soluble prednisolone for up to3 days) is the preferred steroid preparation
B Consider inhaled ipratropium bromide in combination with an inhaled ?2 agonist for more severe symptoms
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