evidence based guideline for management of children presenting with acute breathing difficulty...

EVIDENCE BASED GUIDELINEEVIDENCE BASED GUIDELINEFOR MANAGEMENT OF CHILDREN FOR MANAGEMENT OF CHILDREN

PRESENTING WITH ACUTE PRESENTING WITH ACUTE BREATHING DIFFICULTYBREATHING DIFFICULTY

Produced by the Paediatric Accident and Emergency Research Group at Queens Medical Centre , Nottingham supported by

Children Nationwide

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ACUTE BREATHING DIFFICULTYACUTE BREATHING DIFFICULTY

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For grades of For grades of evidence used evidence used

seesee


ASSESS:• Respiration rate over 60 secs• Work of breathing-degree of distress• Wheeze,cough, stridor ?• Signs of serious illness• Age and / or complicating factors• SaO2

ABCABC Resuscitate Resuscitate if neededif needed

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This guide takes you through each of these points.This guide takes you through each of these points.

It offers guidance on actions to take.It offers guidance on actions to take.

At each stage you can access the level of evidence At each stage you can access the level of evidence behind each step.behind each step.

For full discussion of the evidence please see the full For full discussion of the evidence please see the full report by Lakhanpaul M et al on www.cccccc report by Lakhanpaul M et al on www.cccccc

The guideline has been appraised by the Quality of The guideline has been appraised by the Quality of Practice Committee of the Royal College of Paediatrics Practice Committee of the Royal College of Paediatrics

and Child Health (2002)and Child Health (2002)

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INITIAL ASSESSMENT PROTOCOLINITIAL ASSESSMENT PROTOCOL

Presence of pre-terminal Presence of pre-terminal signs or signs requiring signs or signs requiring

urgent attentionurgent attention

ClickClick if NO

Click if Click if

YES

Start basic life supportStart basic life support&&

Call appropriate team Call appropriate team for advanced life for advanced life

supportsupport

Start basic life supportStart basic life support&&

Call appropriate team Call appropriate team for advanced life for advanced life

supportsupport

CHECK:CHECK:AirwayAirway

BreathingBreathingCirculationCirculation

CHECK:CHECK:AirwayAirway

BreathingBreathingCirculationCirculation

ADMITADMIT to to HDU/PICUHDU/PICUADMITADMIT to to HDU/PICUHDU/PICU

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Measure respiratory rate for 60 Measure respiratory rate for 60 seconds & oxygen saturationseconds & oxygen saturation

Measure respiratory rate for 60 Measure respiratory rate for 60 seconds & oxygen saturationseconds & oxygen saturation

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If OIf O22sat <= 92%sat <= 92%

Give oxygen and admitGive oxygen and admit

If OIf O22sat <= 92%sat <= 92%

Give oxygen and admitGive oxygen and admit

NoNo

? URTI ? URTI HomeHome with GP Follow up; with GP Follow up;

Patient EducationPatient Education

? URTI ? URTI HomeHome with GP Follow up; with GP Follow up;

Patient EducationPatient Education

YesYes

D/W senior DrD/W senior DrConsider alternative diagnosesConsider alternative diagnosesArrange appropriate investigationsArrange appropriate investigationsAdmitAdmit

D/W senior DrD/W senior DrConsider alternative diagnosesConsider alternative diagnosesArrange appropriate investigationsArrange appropriate investigationsAdmitAdmit

? Signs of increased work of breathing

Stridor/stertor/wheeze or cough?

NoNoNoNo

? Signs of serious illness/

complicating factors

YesYes

Click ifYes

Click ifYes

? ? Admit

Mild/moderate distressMild/moderate distressAdmit if complicating Admit if complicating factors/serious illnessfactors/serious illness

Mild/moderate distressMild/moderate distressAdmit if complicating Admit if complicating factors/serious illnessfactors/serious illness

Admit ifAdmit if

severe distresssevere distressAdmit ifAdmit if

severe distresssevere distress

YesYes

STRIDOR/STERTORSTRIDOR/STERTORSTRIDOR/STERTORSTRIDOR/STERTOR

COUGHCOUGHCOUGHCOUGH

WHEEZEWHEEZEWHEEZEWHEEZE

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STRIDOR (limited airflow at larynx or trachea) or STERTOR (noise due to obstruction at pharyngeal

level)

STRIDOR (limited airflow at larynx or trachea) or STERTOR (noise due to obstruction at pharyngeal

level)

NoNo YesYes

?BARKING COUGH

?Agitated/Drooling

?Toxic &

High Fever

Click if YES

Click if YESClick if

NOClick if

NOClick if

YESClick if

YESClick if

NOClick if

NO

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Secure Secure AirwayAirwaySecure Secure AirwayAirway

Call for senior assistanceCall for senior assistanceConsider ENT referralConsider ENT referral

Admit to PICU/HDUAdmit to PICU/HDU

Call for senior assistanceCall for senior assistanceConsider ENT referralConsider ENT referral

Admit to PICU/HDUAdmit to PICU/HDU

?Epiglottis

Agitated/DroolingAgitated/Drooling

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Refer urgently to Refer urgently to ENTENT

Refer urgently to Refer urgently to ENTENT

? STERTOR

YesYes NoNo

?Enlarged Tonsils ?

Foreign body aspiration

CXRCXRCXRCXR

?Normal

If strong suspicion If strong suspicion of aspirationof aspiration

If strong suspicion If strong suspicion of aspirationof aspiration

Refer to appropriate Refer to appropriate doctor for doctor for

bronchoscopybronchoscopy

Refer to appropriate Refer to appropriate doctor for doctor for


NoNoYesYes

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Secure Secure AirwayAirwaySecure Secure AirwayAirway

Admit to PICU/HDUAdmit to PICU/HDUAdmit to PICU/HDUAdmit to PICU/HDU

?Bacterial tracheitis

Toxic+ High FeverToxic+ High Fever

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? CROUP Treat with: Oral dexamethasoneIf vomiting: Use nebulised budesonide

?Signs of potential respiratory failure

HOME with GP follow up, HOME with GP follow up, patient education and call patient education and call

back instructionsback instructions

HOME with GP follow up, HOME with GP follow up, patient education and call patient education and call

back instructionsback instructions

1.1. Give l-epinephrine (adrenaline) Give l-epinephrine (adrenaline) nebulisernebuliser

2.2. Admit for close observationAdmit for close observation3.3. PICU/HDUPICU/HDU

1.1. Give l-epinephrine (adrenaline) Give l-epinephrine (adrenaline) nebulisernebuliser

2.2. Admit for close observationAdmit for close observation3.3. PICU/HDUPICU/HDU

1.1. Signs of severe resp distressSigns of severe resp distress2.2. Signs of serious illnessSigns of serious illness1.1. Signs of severe resp distressSigns of severe resp distress2.2. Signs of serious illnessSigns of serious illness

NoNo

NoNo

1.1. Consider adrenaline nebuliserConsider adrenaline nebuliser2.2. ADMITADMIT1.1. Consider adrenaline nebuliserConsider adrenaline nebuliser2.2. ADMITADMIT

YesYes

YesYes

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WHEEZEWHEEZE

YesYesHistory of choking or paroxysmal

cough

Assess severityAssess severityAssess severityAssess severity

Age >2Age >2Age >2Age >2 Age <2Age <2Age <2Age <2

Continue management as for Continue management as for other children presenting with other children presenting with wheeze wheeze BUTBUT CXR if ?foreign body CXR if ?foreign body aspiration/other atypical features aspiration/other atypical features e.g. focal signs but no symptoms e.g. focal signs but no symptoms of bronchiolitisof bronchiolitis

Continue management as for Continue management as for other children presenting with other children presenting with wheeze wheeze BUTBUT CXR if ?foreign body CXR if ?foreign body aspiration/other atypical features aspiration/other atypical features e.g. focal signs but no symptoms e.g. focal signs but no symptoms of bronchiolitisof bronchiolitis

If high suspicion refer If high suspicion refer to appropriate to appropriate surgical teamsurgical team

If high suspicion refer If high suspicion refer to appropriate to appropriate surgical teamsurgical team

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Age >2

YesYes

? Mild/moderate symptoms

1. B1. B22-agonist via spacer-agonist via spacer1. B1. B22-agonist via spacer-agonist via spacer

1.1. HOMEHOME2.2. Follow up Follow up

instructionsinstructions



Moderate/severeModerate/severeModerate/severeModerate/severe

Life threateningLife threateningLife threateningLife threatening 1.1. BB22-agonist (volumatic if not on 0-agonist (volumatic if not on 022))

2.2. Oral steroidOral steroid3.3. +/- 4-6hrly anticholinergic+/- 4-6hrly anticholinergic

1.1. BB22-agonist (volumatic if not on 0-agonist (volumatic if not on 022))

2.2. Oral steroidOral steroid3.3. +/- 4-6hrly anticholinergic+/- 4-6hrly anticholinergic

1.1. Check ABCCheck ABC2.2. Follow BTS guidelines, i.e. IV Follow BTS guidelines, i.e. IV

aminophyline + steroids + frequent aminophyline + steroids + frequent B2-agonistB2-agonist

3.3. ADMITADMIT TO HDU/PICU TO HDU/PICU4.4. X-RAY when stableX-RAY when stable

1.1. Check ABCCheck ABC2.2. Follow BTS guidelines, i.e. IV Follow BTS guidelines, i.e. IV

aminophyline + steroids + frequent aminophyline + steroids + frequent B2-agonistB2-agonist

3.3. ADMITADMIT TO HDU/PICU TO HDU/PICU4.4. X-RAY when stableX-RAY when stable

1.1. ADMIT TO WARDADMIT TO WARD2.2. If no improvement, inc. frequency of If no improvement, inc. frequency of

B2-agonist up to ½ hourly or B2-agonist up to ½ hourly or continuouslycontinuously

3.3. Follow BTS guidelinesFollow BTS guidelines4.4. Consider X-RAY Consider X-RAY

1.1. ADMIT TO WARDADMIT TO WARD2.2. If no improvement, inc. frequency of If no improvement, inc. frequency of

B2-agonist up to ½ hourly or B2-agonist up to ½ hourly or continuouslycontinuously

3.3. Follow BTS guidelinesFollow BTS guidelines4.4. Consider X-RAY Consider X-RAY

YesYes

NoNo

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Age <2

1. Dry wheezy cough2. Fever3. Nasal discharge4. Fine insp crackles and/or high pitched

exp wheeze





Mild/moderateMild/moderateMild/moderateMild/moderate Moderate/Severe/Life threateningModerate/Severe/Life threateningModerate/Severe/Life threateningModerate/Severe/Life threatening

1.1. TRIALTRIAL of B of B22-agonist/anticholinergic-agonist/anticholinergic

2.2. Monitor 0Monitor 022 sats sats

3.3. Discontinue if no effectDiscontinue if no effect4.4. X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion)X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion)

1.1. TRIALTRIAL of B of B22-agonist/anticholinergic-agonist/anticholinergic

2.2. Monitor 0Monitor 022 sats sats

3.3. Discontinue if no effectDiscontinue if no effect4.4. X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion)X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion)

1.1. ADMITADMIT2.2. Short course of oral steriodsShort course of oral steriods3.3. ?X-ray if no improvement?X-ray if no improvement4.4. Follow BTS guidelines, i.e. inc frequency of Follow BTS guidelines, i.e. inc frequency of

bronchodilatorbronchodilator

1.1. ADMITADMIT2.2. Short course of oral steriodsShort course of oral steriods3.3. ?X-ray if no improvement?X-ray if no improvement4.4. Follow BTS guidelines, i.e. inc frequency of Follow BTS guidelines, i.e. inc frequency of

bronchodilatorbronchodilator

YesYes

? Bronchiolitis? BronchiolitisSee cough algorithmSee cough algorithm? Bronchiolitis? BronchiolitisSee cough algorithmSee cough algorithmNoNo

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Click if

NOClick if

NO

COUGHCOUGH

YesYes CXRCXRCXRCXR

? Referral to ? Referral to appropriate team for appropriate team for


? Referral to ? Referral to appropriate team for appropriate team for


If accompanied by whee ze If accompanied by whee ze or stridor see appropriate algorithmor stridor see appropriate algorithm

If accompanied by whee ze If accompanied by whee ze or stridor see appropriate algorithmor stridor see appropriate algorithm

? Paroxysmal cough or high suspicion of

foreign body

1. Dry wheezy cough and age under 22. Fever +/-3. Nasal discharge4. Fine insp crackles and/or

high pitched exp rhonchi

NoNo

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Click ifYES

Click ifYES

BronchiolitisBronchiolitisBronchiolitisBronchiolitis

ADMIT if:ADMIT if:1. Signs of serious illness1. Signs of serious illness2. Complicating factors2. Complicating factors3. Inc risk of serious disease3. Inc risk of serious disease

ADMIT if:ADMIT if:1. Signs of serious illness1. Signs of serious illness2. Complicating factors2. Complicating factors3. Inc risk of serious disease3. Inc risk of serious disease

1. Trial of bronchodilator1. Trial of bronchodilator2. Stop if no clinical improvement2. Stop if no clinical improvement3. Monitor 03. Monitor 022 sat sat

4. No steroids4. No steroids5. No routine blood tests/X-rays5. No routine blood tests/X-rays

1. Trial of bronchodilator1. Trial of bronchodilator2. Stop if no clinical improvement2. Stop if no clinical improvement3. Monitor 03. Monitor 022 sat sat

4. No steroids4. No steroids5. No routine blood tests/X-rays5. No routine blood tests/X-rays

? Severe distress

1. Discuss with senior clinician1. Discuss with senior clinician2. Consider trial of nebulised adrenaline2. Consider trial of nebulised adrenaline3. ADMIT for close observation, e.g. HDU/PICU3. ADMIT for close observation, e.g. HDU/PICU

1. Discuss with senior clinician1. Discuss with senior clinician2. Consider trial of nebulised adrenaline2. Consider trial of nebulised adrenaline3. ADMIT for close observation, e.g. HDU/PICU3. ADMIT for close observation, e.g. HDU/PICU

NoNoYesYes

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1.1. X-ray child under 2 months/if no X-ray child under 2 months/if no response to antibiotics/recurrent response to antibiotics/recurrent pneumoniapneumonia

2.2. No routine blood testsNo routine blood tests3.3. Oral antibiotics if clinically suspectedOral antibiotics if clinically suspected4.4. HOME with follow up instructions.HOME with follow up instructions.

1.1. X-ray child under 2 months/if no X-ray child under 2 months/if no response to antibiotics/recurrent response to antibiotics/recurrent pneumoniapneumonia

2.2. No routine blood testsNo routine blood tests3.3. Oral antibiotics if clinically suspectedOral antibiotics if clinically suspected4.4. HOME with follow up instructions.HOME with follow up instructions.

PNEUMONIAPNEUMONIAPNEUMONIAPNEUMONIA

Combination of cough &breathing difficulty and:1. Fever2. High resp rate3. Grunting4. Chest in-drawing

NoNo

Re-assess childRe-assess childRe-assess childRe-assess child

Mild/moderate Mild/moderate distressdistressMild/moderate Mild/moderate distressdistress

Severe distressSevere distressSevere distressSevere distress

1.1. CXRCXR2.2. Oral/IV antibiotics according to Oral/IV antibiotics according to

local protocollocal protocol3.3. FBC & B.culture if requires IV FBC & B.culture if requires IV

antibioticsantibiotics4.4. No routine blood tests if on oral No routine blood tests if on oral

rxrx5.5. ADMITADMIT

1.1. CXRCXR2.2. Oral/IV antibiotics according to Oral/IV antibiotics according to

local protocollocal protocol3.3. FBC & B.culture if requires IV FBC & B.culture if requires IV

antibioticsantibiotics4.4. No routine blood tests if on oral No routine blood tests if on oral

rxrx5.5. ADMITADMIT

YesYes

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CXR ?CXR ?

Table 1 Pre-terminal signs

Exhaustion

Bradycardia

Silent chest

Significant apnoea

Table 2 Signs of severely ill child requiring urgent attention

Inappropriate drowsiness (difficult to rouse)

Agitation

Cyanosis in air

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Table 3 Signs of increased work of breathing

Increased respiratory rate

Chest in-drawing

Nasal flaring

Tracheal tug

Use of accessory muscles

Grunting


Table 4 Assessment of severity of breathing difficulty adapted from WHO management of acute repiratory infections in children. World Health Organisation, Geneva, 1995

Assessment of severity(breathing difficulty)

Mild Moderate Severe

Oxygen saturation in air 92-95% <92%

Chest wall in-drawing none/mild moderate severe

Nasal flaring absent may be present present

grunting absent absent present

Apnoea/pausing normal absent present

Feeding history normal Approximately half of normal intake

Quantity, half normal

Behavior normal irritable Lethargic Unresponsive Flaccid Decreased level of consciousness Inconsolable

Back

< 3 months 3 months - 3 years 4 years-adult

Responsiveness and activity Flaccid Cannot awaken or keep awake Weak cry or weak suck Inconsolable Refuse feedings

Responsiveness and activity Unresponsive Cannot awaken or keep awake Markedly decreased activity Inconsolable Weak suck or weak cry(if infant) Refuses feeding

Responsiveness and activity Decreased level of consciousness Markedly decreased activity Cannot awaken or keep awake

Dehydration and vomiting reduced wet nappies> 8 hrs

Dehydration and vomiting no urine> 6-8 hrs if < 1yr no urine> 12 hrs if > 1yr

Dehydration and vomiting no urine> 12 hrs

Meningeal signs stiff neck persistent vomiting

Meningeal signs stiff neck persistent vomiting severe headache

Other petechial and purpuric rash convulsions very high fever hypothermia capillary refill<3 sec

Other petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill<3sec

Other decreased urination with decreased intake petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill> 3 sec

Table 5: Symptoms of Serious Illness (adapted from Viral Upper Respiratory Tract Guideline by Institute for Clinical Systems Improvement and the WHO recommendations on the management of children with cough or breathing difficulty)

Table 6:Complicating Factors contributing to the clinician’s decision regarding admission or discharge

Co-morbidity e. g prematurity, congenital heart disease, any chronic lung disease, neurological disorder

Social problems e. g previous non-accidental injury, ill parents, parents having difficulty coping

Infants younger than 2 months of age

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Table 7: Severity of Asthma Based on BTS Guidelines

Age Under 5 years Over 5 years

Mild to Moderate Wheeze and cough with tightness and mild dyspnoea, no distress, no speech or feeding difficultyMild respiratory distressRespiratory rate <50Pulse <140 bpmSaturations >92% in air

Wheeze and cough with tightnessAble to talkPEFR >50% predictedPulse <120Saturations >92% in air

Moderate to Severe Too breathless to talkToo breathless to feedRespiratory rate >50/minPulse >140/minUse of accessory muscles

Too breathless to talkToo breathless to feedRespiratory rate >40Pulse >120/minPEFR <50%predicted

Life Threatening CyanosisSilent chestPoor respiratory effortFatigue or exhaustionAgitation or reduced level of consciousness

CyanosisSilent chestPoor respiratory effortFatigue or exhaustionPEFR <33%predictedAgitation or reduced level of consciousness

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Table 8: Infants at risk of developing severe bronchiolitis(adapted from Management of acute bronchiolitis by Rakshi and Couriel,

Archives of Disease in Childhood, 1994; 71:463-469)

Apnoea

Preterm birth

Underlying disorders Lung disease e.g. bronchopulmonary dysplasia,cystic fibrosis Congenital heart disease Immunodeficiency (congenital or acquired) Multiple congenital abnormalities Severe neurological disease

Back

Toxic appearance

Severe respiratory distress

Vomiting

Immunocompromised

Dehydrated and requiring intravenous fluids

Table 9: Indications for treatment with parenteral antibiotics in a child clinically suspected

to have pneumonia

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Table 10: Differential diagnosis of less obvious causes of respiratory distress(Adapted from Fleischer's Textbook of Emergency Medicine, Chapter 65)

Metabolic Disorders

Central Nervous System

Dysfunction

Neuromuscular Disorders

Chest Wall Disorders

Diabetes mellitus Meningitis Spinal cord injury Flail chest

Dehydration Encephalitis Infantile botulism Congenital anomalies

Sepsis Tumour Guillain-Barre

Liver/renal disease Intoxication Myopathy

Intoxication Status epilepticus

Inborn errors of metabolism

Trauma

Hydrocephalus

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Statement Strength ofevidence

Recommendation Consensus

A1 The most important pre-terminal signs of a childwith breathing difficulty are:a) Exhaustionb) Bradycardiac) silent chestd) significant apnoea(Listed in Table 1)

4 D More than 83%

A2 The following signs indicate that a child with abreathing difficulty is severely ill and requiresimmediate and urgent attention:a) Inappropriate drowsiness (difficult to rouse)b) Agitationc) Cyanosis in air(Listed in Table 2)

4 D More than 83%

A3 The child presenting with breathing difficulty andlife threatening or pre-terminal signs will requirefurther investigation and blood tests oncestabilized.

4 D 94%

Statement Strength of evidence


A4 All children presenting to hospital with an acute breathing difficulty should have their oxygen saturation measured.

4 C 96%

A5 A child's oxygen saturation should be maintained above 92%. If necessary, oxygen therapy should be given to achieve this.

4 D 88%

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A7 Signs of increased work of breathing include: (Listed in Table 3) Increased respiratory rate, chest in-drawing and nasal flaring:

2 C 92%, 98%, 88% respectively

A7 Signs of increased Tracheal tug, accessory muscles and grunting.

4 D 94%, 92%, and 92%

A8 In children under 6 months of age respiratory rate is not an accurate measurement of respiratory illness.

2 B

A9 No recommendation can be provided for respiratory rate indicating tachypnoea. Further research is required.

very difficult to find an evidence-based definition of tachypnoea

panel could not reach the required 83%

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Statemet Evidence Strength


A10 The following are recommendations of definitions to be used for children presenting with acute breathing difficulty:

Stridor indicates limitation of airflow in the upper airway at the larynx or tracheal level. It is a harsh or rasping respiratory noise reflecting upper airway obstruction, usually inspiratory but may be biphasic.

4 D 94% and 96%

Wheeze indicates limitation of airflow in the lower airway. It is a high pitched whistling noise heard on auscultation which is usually more pronounced in the expiratory phase indicating intrathoracic airway obstruction

4 D 92% and 100%

Stertor is an airway generated sound caused by obstruction at pharyngeal level e.g. due to large tonsils.

4 D

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Statement Evidence Recommendation ConsensusA11 The adapted table 4 can be used to identifythe severity of a child presenting with a breathingdifficulty

4 D 76%

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B1 In a child with stridor, epiglottitis must be considered if the child is agitated, or drooling or there is absence of a cough.

2 C 88%

B2 Bacterial tracheitis can cause severe airway obstruction and should be considered in a child with a croup-like illness (barking cough and stridor) if there is a combination of the following: a) Toxicity b) High fever c) No response to treatment for croup i.e. no improvement in respiratory distress following accepted treatment for croup

3 D 98%, 86%, 84%

respectively

In a child with inspiratory stridor and a barking cough and who is therefore unlikely to have epiglottitis or bacterial tracheitis and more likely to have croup:

B3a Nebulised budesonide or dexamethasone are effective in treating croup

1 A 96%

B3b In a child with suspected croup, oral dexamethasone is cheaper and as efficacious as budesonide. Until more evidence becomes available, oral dexamethasone should therefore be used in preference to nebulised budesonide except in those children who are vomiting or unable to tolerate oral treatment.

4 D 90%

B4a L-epinephrine (adrenaline) can be used in children with severe croup in addition to oral or nebulised steroids

1 B 96%

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Statement Evidence Recommendation ConsensusB4b If treated with L-epinephrine (adrenaline) achild with severe disease requires closeobservation. Admission to intensive care or highdependency for observation should be considered.

4 D 92% and 98%

The next section refers to a child presentingwith stridor or stertor but has no barking coughand no evidence of epiglotittis.B5 Enlarged tonsils should be considered in a childpresenting with breathing difficulty and stertor. Thechild should be referred to the ENT surgeons.

4 D ENT surgeon

B6 Aspiration of a foreign body should beconsidered in a child presenting with stridor. Thechild could also present with cough, wheeze, orbreathlessness.

2 C 84%, 90%, 92%,and 94%

B7 A child presenting with a history of choking,paroxysmal cough or any suspicion of foreign bodyshould have a chest x-ray.

4 D 96%

B8 A normal chest x-ray cannot rule out thediagnosis of foreign body aspiration.

2 C 100%

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C. Child presenting with wheeze. C1 The presence of a foreign body should be considered in a child presenting with acute breathing difficulty and wheeze.

2 C 66% consensus achieved when the word 'excluded' was used. More than 93% consensus would have been achieved if we had originally used the word 'considered'.

C2 During the acute management of a child with wheeze it is not possible to differentiate between those who will have transient symptoms and those who will later develop asthma. After consideration of diagnosis of a foreign body the acute management should focus on the relief of symptoms rather than the ultimate diagnosis

2 B 84%

C3 The criteria suggested by the British Thoracic Society regarding the differentiation between mild, moderate, severe and life threatening asthma or wheeze should be accepted . Table 7

4 D 88%

C4 In children under the age of 2, the limited evidence does not support the widespread indiscriminate use of anticholinergic agent i.e. anticholinergic agents should only be used on a trial basis on children under the age of 2 until further research is available

1 A 80%

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Statement Evidence Recommendation ConsensusC5 In a child under the age of 2 with wheeze, a trialof either an anticholinergic agent, beta-2 agonist orboth can be used to relieve symptoms. Oxygensaturation and response to treatment must bemonitored.

4 D 92%

C6 In children over the age of 2 with moderate tosevere asthma, the addition of 4-6 hrlyanticholinergics to the beta 2-agonists inhalationregimen is indicated if there has been poorresponse to beta 2 agonist alone.

1 A 92%

C7 In children over the age of 2, without life-threatening asthma (Table 7) and not requiringoxygen, holding chambers (spacers) could be usedinstead of nebulisers in most situations.

1 A 90%

C8 All children, regardless of their age, withmoderate-severe or life threatening wheeze shouldbe prescribed a short course of oral steroids.

4 D 84%

C9 Aminophylline should continue to be used forthe treatment of acute severe life threateningasthma when other treatments including salbutamoland corticosteroids have been unsuccessful

1 A 88%

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The next section will consider investigations for a child presenting with wheeze or asthma

C10 Chest x-rays do not routinely need to be performed on every child presenting with their first acute attack of wheeze. Consider if there are atypical clinical features (e.g. focal signs, suspicion of foreign body).

2 C 76%

C11 A child presenting with acute asthma/wheeze do not routinely require a chest x-ray

2 C 98%

C12 A child presenting with acute wheeze/asthma with the following unusual signs should have a chest x-ray when stable: a) Unilateral reduced air entry and hyperresonance

on percussion (signs of pneumothorax) b) no improvement after treatment of severe

symptoms

4 D 96% and 98%

C 13 A child presenting or admitted with acute wheeze does not routinely require blood tests.

4 D 92% and 94%

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D This section discusses a child under the ageof 2 who presents with wheeze.Statement Evidence Recommendation ConsensusD1. Bronchiolitis is a seasonal viral illnesscharacterised by fever, nasal discharge, and drywheezy cough. On examination there are fineinspiratory rackles and/or high pitched expiratorywheeze.

4 D 90%

D2 In a child clinically diagnosed with bronchiolitis,bronchodilators should not be routine practice. Atrial may be considered but stopped if found to beof no help.

1 A 86%

D3 During a trial of bronchodilator therapy the childshould be closely monitored for clinicaldeterioration and hypoxaemia and treatmentstopped if there is no clinical improvement.

1 A 86%

D4 Budesonide is not recommended in themanagement of a child with bronchiolitis.

1 A 100%

D5 Oral or intramuscular steroids are notrecommended in the routine treatment of a childwith bronchiolitis.

1 A 98%

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D6 In a child with bronchiolitis and severe respiratory distress, a trial therapy of nebulised adrenaline (L-epinephrine) may be considered after discussion with a senior clinician

1 B 60%

D7 If treated with adrenaline (L-epinephrine) the child requires close observation. Admission to intensive care or high dependency for observation should be considered

4 D 98% and 92%

D7 Blood tests are not routinely recommended in the management of a child with bronchiolitis.

4 D 96%

D8 Routine x-ray of a child with clinically diagnosed bronchiolitis is not recommended.

2 C 92%

D9 A child aged less than 2 months with clinical signs of bronchiolitis should be admitted if they are at risk of developing serious disease (see Table 8)

4 D 98%

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E Child presenting with a cough

E1 A child who has aspirated a foreign body can present with a cough

2 C 90%

E2 A child presenting with a breathing difficulty and a history of paroxysmal cough or any suspicion of foreign body aspiration should have a chest x-ray.

4 D 96%

E3 In a child with cough and breathing difficulty the probability of pneumonia is increased in the presence of any of the following: a) Tachypnoea b) Grunting c) Chest in-drawing d) Fever e) Nasal flaring f) Crepitations

2 C 88% and 93% consensus achieved respectively for a) and b) Consensus not achieved for c), d)(66% consensus), e)(68% consensus), f)(82% consensus) but based on level 2 evidence

E4(a)All children under the age of 2 months with clinically suspected pneumonia should have a chest x-ray

4 D 94%

E4(b)Children over the age of 2 months with signs suggesting pneumonia but who do not require admission to hospital do not routinely require a chest x-ray. An x-ray may be indicated if there has been no response to oral antibiotics or the patient is not presenting with the first episode of pneumonia

1 A 80%

E4( c)A child admitted to hospital with clinically suspected pneumonia i.e. with cough and severe respiratory distress should have a chest x-ray

4 D 89%

E5 Even when a chest x-ray is taken, this may not allow differentiation between viral and bacterial pneumonia.

2 C 96%

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Statement Evidence Recommendation

Consensus

E6 In children with clinically suspected pneumonia anormal chest x-ray cannot exclude pneumonia

2 C 88%

E7 (a) No laboratory tests should be routinely performedon children with clinically suspected pneumonia who arenot admitted to hospital

2 C 94%

E7 (b) It is not necessary to carry out blood tests in a childadmitted to hospital with clinically suspected pneumoniabut who is treated with oral antibiotics

2 C 82%

E7 (c) All children admitted to hospital with clinicallysuspected pneumonia and who will be treated withintravenous antibiotics should have a full blood count andblood culture. Acute phase reactants, urea, andelectrolytes are not required routinely.

2 C 76% consensus achievedoriginally butrecommendation wasreworded after re-appraising the evidence

E7 (d) Acute phase reactants such as ESR and CRP donot help distinguish between viral and bacterial infection.

2 C

E8 A child admitted to hospital with clinically suspectedpneumonia should be prescribed parenteral antibiotics ifthey have any of the following:

a) Toxic appearanceb) Severe respiratory distressc) Vomitingd) Immunocompromisede) dehydrated and requiring intravenous fluids

4 D 90%, 94%, 94%, 92%,and 94%

E9 The antibiotic used for the treatment of a child withcommunity acquired pneumonia should be chosenaccording to the local protocol

4 D 90%















Table 6: Complicating Factors contributing to the clinician’s decision regarding admission or discharge

















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Recommendation

Consensus

A12 A child with acute breathing difficulty should be admitted to hospital if they fall into any of the following category: a) Has signs indicating that a child with a

breathing difficulty is severely ill and requires immediate and urgent attention (Table 1 and 2).

b) Oxygen saturation less than 92% in air c) Has signs of severe respiratory distress

(Table 4) d) A child with mild to moderate breathing

difficulty who has other signs of serious illness (Table 5).

4 D 98%, 98%, 100%, 96%



C4 In children under the age of 2,the limited evidence does notsupport the widespreadindiscriminate use of anticholinergicagent i.e. anticholinergic agentsshould only be used on a trial basison children under the age of 2 untilfurther research is available

1 A 80%

C5 In a child under the age of 2 withwheeze, a trial of either ananticholinergic agent, beta-2 agonistor both can be used to relievesymptoms. Oxygen saturation andresponse to treatment must bemonitored.

4 D 92%



C10 Chest x-rays do not routinelyneed to be performed on every childpresenting with their first acuteattack of wheeze. Consider if thereare atypical clinical features (e.g.focal signs, suspicion of foreignbody).

2 C 76%

C11 A child presenting with acuteasthma/wheeze do not routinelyrequire a chest x-ray

2 C 98%

C12 A child presenting with acutewheeze/asthma with the followingunusual signs should have a chestx-ray when stable:a) Unilateral reduced air entry and

hyperresonance on percussion(signs of pneumothorax)

b)no improvement after treatment ofsevere symptoms

4 D 96% and 98%


Recommendation

Consensus

C7 In children over the age of 2,without life-threatening asthma(Table 7) and not requiringoxygen, holding chambers(spacers) could be used insteadof nebulisers in most situations.

1 A 90%

C8 All children, regardless oftheir age, with moderate-severeor life threatening wheeze shouldbe prescribed a short course oforal steroids.

4 D 84%


Recommendation

Consensus

E3 In a child with cough andbreathing difficulty the probabilityof pneumonia is increased in thepresence of any of the following:a) Tachypnoeab) Gruntingc) Chest in-drawingd) Fevere) Nasal flaringf) Crepitations

2 C 88% and 93%consensus achievedrespectively for a) andb)Consensus notachieved for c),d)(66% consensus),e)(68% consensus),f)(82% consensus)but based on level 2evidence

E4(a)All children under the age of2 months with clinicallysuspected pneumonia shouldhave a chest x-ray

4 D 94%


Recommendation

Consensus

E4(b)Children over the age of 2months with signs suggestingpneumonia but who do notrequire admission to hospital donot routinely require a chest x-ray. An x-ray may be indicated ifthere has been no response tooral antibiotics or the patient isnot presenting with the firstepisode of pneumonia

1 A 80%

E4( c)A child admitted to hospitalwith clinically suspectedpneumonia i.e. with cough andsevere respiratory distress shouldhave a chest x-ray

4 D 89%

E5 Even when a chest x-ray istaken, this may not allowdifferentiation between viral andbacterial pneumonia.

2 C 96%

E6 In children with clinicallysuspected pneumonia a normalchest x-ray cannot excludepneumonia

2 C 88%


Recommendation

Consensus

E7 (a) No laboratory tests shouldbe routinely performed onchildren with clinically suspectedpneumonia who are not admittedto hospital

2 C 94%

E7 (b) It is not necessary to carryout blood tests in a child admittedto hospital with clinicallysuspected pneumonia but who istreated with oral antibiotics

2 C 82%

E7 (c) All children admitted tohospital with clinically suspectedpneumonia and who will betreated with intravenousantibiotics should have a fullblood count and blood culture.Acute phase reactants, urea, andelectrolytes are not requiredroutinely.

2 C76% consensus

achieved originally but

recommendation was

reworded after re-

appraising the

evidence


Recommendation

Consensus

A12 A child with acute breathingdifficulty should be admitted tohospital if they fall into any of thefollowing category:a) Has signs indicating that a child

with a breathing difficulty isseverely ill and requiresimmediate and urgent attention(Table 1 and 2).

b) Oxygen saturation less than 92%in air

c) Has signs of severe respiratorydistress (Table 4)

d) A child with mild to moderatebreathing difficulty who has othersigns of serious illness (Table 5).

4 D 98%, 98%, 100%,96%

Statements in this algorithm are derived from a critical appraisal of literature Statements in this algorithm are derived from a critical appraisal of literature and a subsequent two round Delphi consensus process. Thus the levels of and a subsequent two round Delphi consensus process. Thus the levels of evidence and recommendations made follow the grading system used by evidence and recommendations made follow the grading system used by SIGN and the last column in the tables which follow refer to the degree of SIGN and the last column in the tables which follow refer to the degree of

consensus reached in the Delphi panel process where 86% was accepted as consensus reached in the Delphi panel process where 86% was accepted as an acceptable level of agreement.an acceptable level of agreement.

Based on development and studies by the Paediatric Accident and Emergency Based on development and studies by the Paediatric Accident and Emergency Research Group in Queens Medical Centre NottinghamResearch Group in Queens Medical Centre Nottingham

Supported by Children NationwideSupported by Children Nationwide

Full technical report is available at:Full technical report is available at:

www.nnnnnnnnwww.nnnnnnnn

Levels of evidence

Level Type of evidence (based on SIGN 2000)

1++

1+

1-

Evidence from high quality meta-analyses, systematic reviews of

RCTs, or RCTs with a very low risk bias

Evidence from well conducted meta-analyses, systematic reviews of

RCTs, or RCTs with a low risk of bias

Evidence from meta-analyses, systematic reviews of RCTSs, or RCTs

with a high risk of bias

2++

2+

2-

Evidence from high quality systematic reviews of case-control or

cohort studies or high quality case-control or cohort studies with a very

low risk confounding, bias, or change and a moderate probability that

the relationship is causal

Evidence from well conducted case-control or cohort studies with a

low risk of confounding, bias, or chance and a moderate probability

that the relationship is causal

Evidence from case-control or cohort studies with a high risk of

confounding, bias, or chance and a significant risk that the relationship

is not causal

3 Evidence from non-analytical studies eg case reports, case series

4 Evidence from expert opinion

Grading of recommendations

Grade Type of recommendation (based on SIGN 2000)

A Requires at least one meta-analyses, systematic review of RCT rated

as 1++, and directly applicable to the target population, and

demonstrating overall consistency or results

B Requires a body of evidence including studies rated as 2++, directly

applicable to the target population, and demonstrating overall

consistency of results; or extrapolated evidence from studies rated as

1++ or 1+

C Requires a body of evidence including studies rated as 2+, directly

applicable to the target population and demonstrating overall

consistency of results; or extrapolated evidence from studies rates as

2++

D Evidence level 3 or 4; or extrapolated evidence from studies rates as

2+

Parent advice

When you take your child home:• It is important that you:• 1. encourage your child to drink plenty

little and often• 2.check their breathing and colour (see

below)• 3.give your child the medication

prescribed by the doctor(list)•

Parent return advice (2)

You must call a doctor or go back to the hospital if:

• 1.your child is struggling to breathe and getting very tired

• 2. your child is too breathless to talk or your baby is grunting or unable to feed

• 3.your child changes colour and becomes pale grey, white or blue around the lips

• 4.you are worried that your child has got worse

Parent advice







Chest in-drawing

Nasal flaring

Tracheal tug


Grunting













Back

Back

The next section will consider investigations for a child presenting with wheeze or asthma

C10 Chest x-rays do not routinely need to be performed on every child presenting with their first acute attack of wheeze. Consider if there are atypical clinical features (e.g. focal signs, suspicion of foreign body).

2 C 76%

C11 A child presenting with acute asthma/wheeze do not routinely require a chest x-ray

2 C 98%

C12 A child presenting with acute wheeze/asthma with the following unusual signs should have a chest x-ray when stable: a) Unilateral reduced air entry and hyperresonance

on percussion (signs of pneumothorax) b) no improvement after treatment of severe

symptoms

4 D 96% and 98%

C 13 A child presenting or admitted with acute wheeze does not routinely require blood tests.

4 D 92% and 94%

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C10 Chest x-rays do not routinelyneed to be performed on every childpresenting with their first acuteattack of wheeze. Consider if thereare atypical clinical features (e.g.focal signs, suspicion of foreignbody).

2 C 76%

C11 A child presenting with acuteasthma/wheeze do not routinelyrequire a chest x-ray

2 C 98%

C12 A child presenting with acutewheeze/asthma with the followingunusual signs should have a chestx-ray when stable:a) Unilateral reduced air entry and

hyperresonance on percussion(signs of pneumothorax)

b)no improvement after treatment ofsevere symptoms

4 D 96% and 98%

Back

D This section discusses a child under the age of 2 who presents with wheeze.

Statement Evidence Recommendation Consensus D1. Bronchiolitis is a seasonal viral illness characterised by fever, nasal discharge, and dry wheezy cough. On examination there are fine inspiratory rackles and/or high pitched expiratory wheeze.

4 D 90%

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B1 In a child with stridor, epiglottitis must be considered if the child is agitated, or drooling or there is absence of a cough.

2 C 88%

B2 Bacterial tracheitis can cause severe airway obstruction and should be considered in a child with a croup-like illness (barking cough and stridor) if there is a combination of the following: a) Toxicity b) High fever c) No response to treatment for croup i.e. no improvement in respiratory distress following accepted treatment for croup

3 D 98%, 86%, 84%

respectively

In a child with inspiratory stridor and a barking cough and who is therefore unlikely to have epiglottitis or bacterial tracheitis and more likely to have croup:

B3a Nebulised budesonide or dexamethasone are effective in treating croup

1 A 96%

B3b In a child with suspected croup, oral dexamethasone is cheaper and as efficacious as budesonide. Until more evidence becomes available, oral dexamethasone should therefore be used in preference to nebulised budesonide except in those children who are vomiting or unable to tolerate oral treatment.

4 D 90%

B4a L-epinephrine (adrenaline) can be used in children with severe croup in addition to oral or nebulised steroids

1 B 96%

Table 1 Pre-terminal signs

Exhaustion

Bradycardia

Silent chest

Significant apnoea

Table 2 Signs of severely ill child requiring urgent attention

Inappropriate drowsiness (difficult to rouse)

Agitation

Cyanosis in air




Chest in-drawing

Nasal flaring

Tracheal tug


Grunting













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evidence based guideline for management of children presenting with acute breathing difficulty...

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