PAEDIATRIC BREATHING DIFFICULTIES

LEE WALLIS

OBJECTIVES

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

• ASPIRATION • PERTUSSIS• PNEUMONIA • PERITONSILLAR

ABSCESS• RETRO-PHARYNGEAL

ABSCESS

• ASTHMA

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

BRONCHIOLITIS

• TESTS– (RSV TITRE)

• FOR ISOLATION

– URINE DIPSTICK– CXR BILATERAL AIR TRAPPING

BRONCHIOLITIS

• NEBULISED ADRENALINE– 1:1000, 4-5ml– DOSE IRRELEVANT – GENERATE OWN Vt

• STEROIDS– NEBULISED NO HELP– ORAL ?HELP

BRONCHIOLITIS

• Schidler, 2002 Crit Care– META ANALYSIS 12 STUDIES (n=843)

• 75% β AGONISTS NO HELP• 5 (n=223) ADRENALINE: WORKED IN ALL• STEROIDS MAY OR NOT HELP

– VARIED RESULTS. WHY? MIXED DISEASES – MULTIPLE CAUSES

• RSV, RHINOVIRUS etc

BRONCHIOLITIS

• Keenie, 2002 Arch Ped & Adol Medicine

• Average LoS 3 days– Either get better quickly or are sick!– Obs ward not suitable

CROUP

• Toddlers, Pre-schoolers

• Prodrome 2 days– RHINORRHOEA, COUGH

• Then very bad night– STRIDOR ++– BARKING COUGH

• Often better when at EU

CROUP

• Para-influenza, other virus– Previously well, > 4 months, immunised

against diphtheria

• FB

• Diphtheria

• Candida

• Epiglottitis

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.

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

CROUP

• CXR – To exclude something else (?FB)

• ADMISSION – GD II+ STRIDOR

• Grade III-IV need ICU

CROUP

• Luria, 2001 arch ped adol med– RCT n=264, 6/12 – 6 yrs– Mild Croup– Neb dex vs oral dex vs no dex– Oral best by far

EPIGLOTTITIS

• HiB– GONE IN WEST

• TODDLERS, PRE-SCHOOL• ABRUPT ONSET

– FEVER, SORE THROAT, DROOLING, MUFFLED VOICE, LEAN FORWARD

• No cough

– TOXIC

EPIGLOTTITIS

• INTUBATE– GAS INDUCTION, CALM, EXPERIENCED

• 3rd GENERATION CEPHALOSPORIN

FOREIGN BODY

• 80% RADIO LUCENT– PEANUTS

• COUGHING, CHOKING, BREATHLESS, UNILATERAL WHEEZE

• MOST ARE SMALL KIDS

• NEED BRONCHOSCOPY

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

FOREIGN BODY

• Silva , 1998 ann otol rhinol laryngol – Retrospective review (n=93)– 88% history, 82% wheeze, 51% reduced BS– CXR sens 63% spec 47%

• 83%, 50% after 24 hrs

NASAL OBSTRUCTION

• WHY IS AN EMERGENCY?

• TINY BABIES CAN’T BREATHE

• OBLIGATE NASAL BREATHING SO MUCUS BECOMES AN EMERGENCY!

• NASAL SUCTION

ASPIRATION PNEUMONIA

• (CHEMICAL PNEUMONITIS)• KEROSENE, PARAFFIN• COUGH, WHEEZE, LOW GCS• DON’T INDUCE VOMITING

– MICRO-ASPIRATION OF HYDROCARBONS

• NO ACTIVATED CHARCOAL• ANTIBIOTICS WHEN INDICATED

PERTUSSIS

• WHOOPING COUGH

• INFANTS

• UNIMMUNISED

• FEVER & REPETITIVE COUGH

• SEIZURES, ENCEPHALOPATHY, PNEUMONIA

• ERYTHROMYCIN

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

PNEUMONIA

• ADMIT IF RECESSION, NOT FEEDING, SATS <90%

• AMOXYL – MILD & MODERATE

• AMPICILLIN & GENTAMICIN– SEVERE

• ?ERYTHROMYCIN

PERITONSILLAR ABSCESS

• QUNISY

• OLDER KIDS– TEENS? >8?

• BAD SORE THROAT, UVULA DEVIATED

• ABSCESS = DRAINAGE (OR ASPIRATION, 18G NEEDLE)

RETROPHARYNGEAL ABSCESS

• SORE THROAT

• SUPPURATIVE CERVICAL ADENOPATHY– OR PENETRATION

• FEVER

• STIFF NECK– OFTEN MISTAKEN FOR MENINGITIS

RETROPHARYNGEAL ABSCESS

• LATERAL NECK X RAY– PREVERTEBRAL SOFT TISSUE SWELLING

• CT NECK

• EVALUATE UNDER ANAESTHESIA

• 3RD GENERATION CEPHALOSPORIN

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Detailed history and physical examination• pattern of illness• severity/control

• differential clues

Presenting features• wheeze• dry cough

• breathlessness• noisy breathing

Is it asthma?

ASTHMA

DIFFERENTIALDIFFERENTIAL

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Clinical clue Possible diagnosis

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

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

focal or persistent radiological changes developmental disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; tuberculosis

Initial assessment of acute asthma Initial assessment of acute asthma in children aged >2 years in A&Ein children aged >2 years in A&E

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Moderateexacerbation

Severeexacerbation

Life threateningasthma

• SpO2 92%

• PEF 50% best/ predicted (>5 years)

• No clinical features of severe asthma

• Heart rate: - 130/min (2-5 years) - 120/min (>5 years)• Respiratory rate: - 50/min (2-5 years) - 30/min (>5 years)

• SpO2 <92%

• PEF <50% best/ predicted (>5 years)

• Too breathless to talkor eat

• Heart rate: - >130/min (2-5 years) - >120/min (>5 years)• Respiratory rate: - >50/min (2-5 years) - >30/min (>5 years)• Use of accessory neck

muscles

• SpO2 <92%

• PEF <33% best/ predicted (>5 years)

• Silent chest• Poor respiratory effort• Agitation• Altered consciousness• Cyanosis

Management of acute asthmaManagement of acute asthmain children aged >2 years in A&Ein children aged >2 years in A&E

Moderateexacerbation

Severeexacerbation

Life threateningexacerbation

• ß2 agonist 2-10 puffs viaspacer ± facemask

• Reassess after 15 minutes

• Give nebulised ß2 agonist:salbutamol (2-5 years: 2.5mg; >5 years: 5mg) or terbutaline(2-5 years: 5mg; >5 years: 10mg) with oxygen as driving gas

• Continue oxygen via facemask/nasal prongs• Give prednisolone (2-5 years: 20mg; >5 years 30-40mg) or

IV hydrocortisone (2-5 years: 50mg; >5 years: 100mg)

RESPONDING• Continue inhaled

ß2 agonists1-4 hourly

• Add soluble oral prednisolone- 20mg (2-5 years)- 30-40mg (>5 years)

NOT RESPONDING• Repeat inhaled

ß2 agonist every20-30 minutes

• Add soluble oral prednisolone- 20mg (2-5 years)- 30-40mg (>5 years)

IF LIFE THREATENING FEATURES PRESENTDiscuss 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 15g/kg of 200g/ml solution over 10 minutes• IV aminophylline

Response to treatment in children Response to treatment in children aged >2 years in A&Eaged >2 years in A&E

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 prednisolone

20mg (2-5 years) 30-40mg(>5 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

Treatment of acute asthmaTreatment of acute asthmain children aged >2 yearsin children aged >2 years

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DUse structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge

Children with life threatening asthma or SpO2 <92% 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 *

ApMDI 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

Steroid therapy for acuteSteroid therapy for acuteasthma in children aged >2 yearsasthma in children aged >2 years

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A Give prednisolone early in the treatment of acute asthma attacks

• Use prednisolone 20mg (2-5 years), 30-40mg (>5 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

Other therapies for acuteOther therapies for acuteasthma in children aged >2 yearsasthma in children aged >2 years

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AIf poor response to 2 agonist treatment, add nebulised ipratropium bromide (250mcg/dose mixed with 2 agonist) *

AAminophylline is not recommended in children with mild to moderate acute asthma

CConsider 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

Hospital admission for acuteHospital admission for acuteasthma in children aged >2 yearsasthma in children aged >2 years

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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

BConsider intensive inpatient treatment for children with SpO2 <92% on air after initial bronchodilator treatment

Treatment of acute asthmaTreatment of acute asthmain children aged <2 yearsin children aged <2 years

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B Oral 2 agonists are not recommended for acute asthma in infants

AFor mild to moderate acute asthma, a pMDI with spacer is the optimal drug delivery device

CConsider 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

BConsider inhaled ipratropium bromide in combination with an inhaled 2 agonist for more severe symptoms