Chapter 4Cough or Difficult Breathing

Case II

Case study: Ratu

11 month old boy with 5 days of cough and fever, yesterday he became short of breath and unable to feed

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What are the stages in the management of any sick child?

Stages in the management of a sick child (Ref. Chart 1, p. xxii)

1. Triage

2. Emergency treatment

3. History and examination

4. Laboratory investigations, if required

5. Main diagnosis and other diagnoses

6. Treatment

7. Supportive care

8. Monitoring

9. Plan discharge

10. Follow-up

Have you noticed any emergency or priority signs?

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Temperature: 39.70C, pulse: 180/min, RR: 70/min, cyanosis visible suprasternal and subcostal

recession, grunting respiration

Triage

Emergency signs (Ref. p. 2, 6)

• Obstructed breathing• Severe respiratory distress• Central cyanosis• Signs of shock• Coma• Convulsions• Severe dehydration

Priority signs (Ref. p. 6)• Tiny baby• Temperature• Trauma• Pallor• Poisoning• Pain (severe)• Respiratory distress• Restless, irritable,

lethargic• Referral• Malnutrition• Oedema of both feet• Burns

Triage

Emergency signs (Ref. p. 2, 6)

• Obstructed breathing• Severe respiratory distress• Central cyanosis• Signs of shock• Coma• Convulsions• Severe dehydration

Priority signs (Ref. p. 6)• Tiny baby• Temperature• Trauma• Pallor• Poisoning• Pain (severe)• Respiratory distress• Restless, irritable,

lethargic• Referral• Malnutrition• Oedema of both feet• Burns

What emergency treatment does Ratu need?

Emergency treatment

• Airway management?

• Oxygen?

• Intravenous fluids?

• Anticonvulsants?

• Immediate investigations?

□ Check SpO2 and blood glucose

(Ref. Chart 2, p. 5-6)

• Place the prongs just inside the nostrils and secure with tape.

• Use an 8 F size tube • Measure the distance from

the side of the nostril to the inner eyebrow margin with the catheter

• Insert the catheter to this depth and secure it with tape

How to give oxygen

(Ref. Chart 5, p. 11 p.

312-315)Start oxygen flow at 1-2 litres/minute,

in young infants at 0.5 litre/minute

Emergency treatment (continued)

□ Blood glucose 1.8 mmol/l: How do you treat hypoglycaemia?

Give IV glucose (Ref. Chart 10, p. 16)

Give emergency treatment until the child is stable

History Ratu is a 11 month old boy with 5 days of cough and fever. Yesterday he became short of breath and was unable to feed.

He was apparently well 5 days ago. Then he developed fever with cough. He was taken to a local medical shop, where he was given two types of syrupy medicine. He deteriorated over two days with worsening fever, increased difficulties in breathing and today he is unable to feed.

• Past medical history: no significant past history.• Family history: Ratu's grandmother had tuberculosis, which was treated 3 years ago.• Social history: he lives with his parents and grandmother in a small semi-permanent house

ExaminationRatu was pale, ill-looking and cyanosed. He had fast breathing with visible suprasternal and subcostal recession and with grunting respiration.

Vital signs: temperature: 39.70C, pulse: 180/min, RR: 70/min

Oxygen saturation SpO2 : 82% on room air

Weight: 11 kgEar-Nose-Throat: dry mucus membranes, red pharynx, blue lips, slightly reddened eardrumsChest: bilateral course crepitations with suprasternal and subcostal recession, grunting and wheezeCardiovascular: three heart sounds were heard with gallop rhythm; the apex beat was displaced laterally to the anterior axillary lineAbdomen: liver was palpable 4 cm below the right costal marginNeurology: tired but alert; no neck stiffness

• List possible causes of the illness

• Main diagnosis

• Secondary diagnoses

• Use references to confirm (Ref. p. 77-79, p. 93)

Differential diagnoses

Differential diagnoses

• Pneumonia• Congenital heart disease• Tuberculosis• Foreign body• Effusion/empyema• Pneumothorax• Pneumocystis

pneumonia• Severe anaemia• Asthma• Bronchiolitis

(Ref. p. 77-79)

(Ref. p. 93)

Additional questions on history

• Prior illnesses

• Locally important illnesses

• Immunization history

• Nutritional history

• Tuberculosis in family

Additional questions on history

• Prior illnesses

• Locally important illnesses

• Immunization history

• Nutritional history– Breast fed for 3 months, now on

powdered cows milk, 2 meals a day, eats fruits (banana, papaya), rarely eats meat or vegetables, some cereals and biscuits

• Tuberculosis in family

Further examination based on differential diagnoses

• Palmar Pallor – indicating severe anaemia (Ref. p. 166). In any child with palmar pallor, determine the haemoglobin level

• Check also conjunctiva and mucous membranes

•Assess cause of respiratory distress:

- Pneumonia: crepitations, bronchial breathing, effusion, cyanosis

- Heart failure: tachycardia > 160/min (Ref. p. 120), gallop rhythm, enlarged liver, fast breathing, severe palmar pallor, no murmer

•Look for signs of anaemia-Palmer pallor (Ref. p. 121, 199, 307)

-If from a malaria area, Look for signs of malaria

- Fever, enlarged spleen, anaemia (Ref. p. 156-165)

Assess nutritional state

- Weight-for-length (or height) < 70% or < -3SD

- Look for oedema of feet (Ref. p. 198)

Further examination based on differential diagnoses (continued)

What investigations would you like to do to make your diagnosis?

Investigations

• Oxygen saturation (SpO2)

• Full Blood Examination and blood film

• Group and cross-match

• Malaria RDT, thick and thin blood film

• Chest x-ray

□ What are the indications for chest x-ray:

Severe pneumonia with complications (e.g. hypoxaemia)

Suspicion of effusion, empyema, pneumothorax

Unilateral changes on examination

Clinical signs of heart failure

If tuberculosis is suspected (Ref. p. 77, p. 85)

Full blood examination

• Haemoglobin 5.9 g/dl (105-135)

• Platelets 858 x 109/l (150-400)

• WCC 30.6 x 109/l (6.0-18.0)

• Neutrophils 17.4 x 109/l (1.0-8.5)

• Lymphocytes 3.4 x 109/l (4.0-10.0)

• Monocytes 1.2 x 109/l (0.1-1.0)

• Blood glucose 4.5 mmol/l (3.0 - 8.0), after IV glucose

Blood film: hypochromic microcytic anaemia

Hb 5.9g / dL

No malaria parasites, RDT negative

Chest x-ray

SpO2 : 82% on room air

Diagnosis

Summary of findings:• Examination: severe respiratory distress, central

cyanosis, palmar pallor, fever, bilateral course crepitations with suprasternal and subcostal recession, grunting and wheeze; three heart sounds were heard with gallop rhythm and tachycardia

• Chest x-ray shows enlarged heart and bilateral opacities

• SpO2 : 82% on room air• Hypoglycaemia (1.8 mmol/L)• Blood examination shows low haemoglobin,

neutrophilia with left shift, thrombocytosis • Blood film shows hypochromic microcytic anaemia

Diagnosis (continued)

Very severe pneumonia Heart failure

Severe anaemia

Severe iron deficiency

How would you treat Ratu?

Treatment

□ Very severe pneumonia

□ Heart failure

□ Severe anaemia (with heart failure) Blood transfusion Iron therapy (when improved) Diet change

Diuretics

Oxygen therapy Antibiotic therapy

(Ref. p. 307-308)

(Ref. p. 120-122)

(Ref. p. 82)(Ref. p. 82)

What supportive care and monitoring are required?

Supportive care

• Fever management (Ref. p. 305)

• Fluid management

– Avoid overhydration! Ratu has very severe pneumonia, heart failure, severe anaemia and he gets IV therapy and blood transfusion

– What type of fluid?

• Appropriate nutrition (Ref. p. 294-303)

– Insert a nasogastric tube and give appropriate feeds.

Monitoring• Use a Monitoring chart (Ref. p. 320, 413)

– Vital signs, fluid balance, treatments given

– Feeding / nutrition

– Blood glucose

– Oxygenation

– Response to blood transfusion

• The child should be checked by nurses frequently (at least every 3 hours) and by a doctor at least twice a day

• Further investigation

– Cardiac echo when possible (normal in this case)

Discharge planning and Follow up

• When is it OK for Ratu to be discharged?

• What follow-up is needed

Discharge planning and Follow up

• When is it OK for Ratu to be discharged?

– Respiratory distress resolved

– No hypoxaemia

– Completed course of parenteral antibiotics

– Able to take oral medications

– Check Hb shows improvement

– Started on iron

– Cardiac echo normal

– Parents understand the problems

• What follow-up is needed

– Anaemia

– Nutritional

Summary• Seriously ill children may present with one

symptom but may have multiple problems:

– Severe respiratory distress due to:

Pneumonia

Anaemia, due to iron deficiency

Heart failure due to anaemia and severe pneumonia

• Emergency treatment is life saving

• Need to identify and treat each problem if the child is to survive

• Monitoring and supportive care are vital

• Don’t forget follow-up