The child with breathing difficulties

• Primary Assessment
• Stridor
• Croup
• Epiglottitis
• Anaphylaxis
• Wheeze
• Asthma emergency treatment
• Bronchiolitis
• Pneumonia
• Heart failure
• Heart failure vs Bronchiolitis

Primary assessment

As before, but noting the following:

• Stridor suggests an upper airway pathology
• Sternal recession is particularly associated with upper airway obstruction
• Hypoventilation ie slow rate and/or shallow breaths suggests exhaustion
• Wheeze suggests lower airway pathology
• Tachycardia is expected; bradycardia is a sign of respiratory failure
• Cyanosis that does not improve with high flow oxygen suggests a congenital heart disease with a right to left shunt
• Signs of heart failure will differentiate cardiac causes for breathlessness
• Children in respiratory failure are usually hypotonic
• A fever suggests an infectious cause (although absence of fever does not exclude infection)
• Urticaria suggests anaphylaxis

Stridor

• Bubbly noises indicate secretions requiring clearance. They may also suggest fatigue or depressed conscious level (failure to clear by coughing)
• Snoring noises may indicate depressed conscious level
• Reassess breathing: What degree of effort is needed and what is its efficacy and effect?

Emergency airway treatment

In all cases avoid worsening the situation by upsetting the child. Crying and struggling may quickly convert a partially obstructed airway intoa n completely obstructed one. Parents' help should be enlisted for administration of oxygen and nebulised epinephrine, and for performing X-rays.

Depressed conscious level or extreme fatigue may precede complete obstruction. Support airway with chin lift or jaw thrust manoeuvre, call anaesthetist, consider an oropharyngeal or nasopharyngeal airway, consider intubation.

Croup

• nebulised epinephrine produces transient improvement (30-60 minutes) but does not improve blood gases, reduce duration of hospitalization or need for intubation. Close observation with continuous ECG and oxygen saturation monitoring is required. Best used to buy time to assemble an experienced team.
• Clinical signs correlate poorly with hypoxaemia (respiratory rate and sternal recession best), oxygen saturation in air should be checked intermittently.
• Inhalation of moist air is of unproven benefit.

Epiglottitis:

• lateral neck X rays have been used to make diagnosis but should be avoided as they disturb the child and have precipitated fatal total airway obstruction.
• no evidence for benefit of nebulised epinephrine or steroids
• gaseous induction of anaesthesia then intubation by experienced anaesthetist (will require smaller ETT than usual)

Anaphylaxis

Give IM epinephrine (10 mcg/kg) and nebulised adrenaline.

Wheeze

Bronchiolitis is confined to the under one year olds and asthma is more commonly diagnosed in the over ones. Often difficult to assess the severity of an acute exacerbation of asthma,esp young children. Those who have previously required IV therapy or ICU admission are at high risk. Use of accessory muscles, recession and pulse rate are the best clinical indicators. Pulsus paradoxus is usually associated with moderate to severe asthma but is no longer considered a reliable sign. Cyanosis, fatigue and drowsiness are late signs and are usually accompanied by a silent chest.

Other concerns include a poor response to repeated doses of bronchodilator at home.

Peak flows are reliable except in the under 5s and those who are very dyspnoeic. CXR is indicated only if there is severe dyspnoea, uncertainty about the diagnosis, asymmetry of chest signs or signs of severe infection.

Features of severe asthma

• Too breathless to feed or talk
• Recession, use of accessory muscles
• Respiratory rate >50 per min
• Pulse rate >140 per min
• Peak flow <50% expected/best

Features of life-threatening asthma

• Conscious level depressed/agitated
• Exhaustion
• Poor respiratory effort
• Oxygen sats <85% in="in" air="air" (cyanosis)
• Silent chest
• Peak flow <33% expected/best

Asthma emergency treatment

• High flow oxygen fiz face mask with reservoir bag
• Attach pulse oximeter and assess peak flow
• Give salbutamol (2.5 mg for <5 yrs,="yrs," 5 mg="mg" for="for" >5 yrs) and ipratropium (250 mcg for <5 yrs,="yrs," 500="500" mcg="mcg" >5 yrs) nebulised with oxygen if respiratory distress over 9 months of age
• If clearly in respiratory failure with poor respiratory effort, depressed conscious level and poor saturation despite maximum oxygen therapy, attempt bag-valve-mask; give an IV salbutamol infustion (loading dose 5 mcg/kg) and get help
• Nebulised salbutamol can be repeated every 1-2 hrs until improvement.
• Alternatively 10-20 puffs of a bronchodilator from a metered dose inhaler can be given (1 puff at a time) through a spacer but this can not be supplemented with oxygen.
• In severe asthma continous nebulised bronchodilator may be needed
• Prednisolone (2 mg/kg/d in 2 divided doses, max 60 mg/d, 3-5 days) expedites recovery from acute asthma. Unless the child is vomiting, there is no advantage in giving steroids IV
• IV salbutamol has an advantage over nebulised and has a place in severe episodes that do not respond promptly to nebulised. Important side effects include tachycardia and hypokalaemia (check potassium 12 hrly)
• IV aminophylline still has a role in the child who fails to respond adequately to nebulised therapy. Load 5 mg/kg over 15 minutes with ECG monitoring (omit if slow release theophylline has been given within 12 hrs) then continous infusion 1 mg/kg/hr. Seizures, vomiting and arrhythmias may follow rapid infusion
• If poor response to the above measures, a paediatric ICU team should be contacted
• IV fluids should be restricted to 2/3 normal
• Antibiotics only if clear signs of infection
• IV magnesium can be effective but little clinical experience
• No absolute criteria for ventilation but consider if:
• pCO2 > 8kPa
• pO2 <8 in FiO2 of 60%, or:
• increasing exhaustion

Bronchiolitis

There is no specific treatment. Humidified oxygen is delivered into a head box, IV/NG fluids are given if required. Antibiotics, bronchodilators and steroids are of no value. Ribavirin should be reserved for pre-existing lung disease, impaired immunity and congenital heart disease.

Pneumonia

In the absence of stridor and wheeze, fever with breathing difficulties are likely to be due to pneumonia. Airway and breathing support may be especially needed in children with neurological handicap. Caution should be excised with fluid administration. It is not possible to differentiate reliably between bacterial or viral infection on clinical or radiological grounds, so all children diagnosed as having pneumonia should receive antibiotics. Cefotaxime will be effective against most bacteria but flucloxacillin should be added if Staph aureus is suspected and erythromycin if Chlamydia or Mycoplasma suspected. A large pleural effusion on CXR should be tapped to relieve breathlessness.

Heart Failure

Causes of heart failure presenting as breathing difficulties:

• LV volume overload or excess Pulmonary flow: VSD, AVSD, PDA, truncus arteriosus
• Left heart obstruction: HOCM, AS, coarctation of aorta, hypoplastic left heart syndrome
• Pump failure: myocarditis, cardiomyopathy

Heart failure emergency treatment

• If signs of shock treat the child for cardiogenic shock
• If oxygen saturation is normal or improves significantly with oxygen, then the breathing difficulty is due to pulmonary congestion secondary to lart left to right shunt. A murmur will often be heard, a CXR will show a large, globular heart with pulmonary congestion. Give oxygen via mask with reservoir and diuretics (frusemide 1 mg/kg IV then 1-2 mg/kg/d in divided doses). Repeat IV bolus if no diuresis within 2 hours
• Babies in the first few days of life with unresponsive cyanosis are likely to have duct dependent disease eg tricuspid or pulmonary atresia. Infuse Alprostadil 0.05 mcg/kg/min, intubate and ventilate (side effect: apnoea), avoid excessive oxygen (promotes ductal closure)
• FBC, U+Es, Ca, glucose and ABG should be done. Infection screen is recommended esp in infants. 12 lead ECG and CXR are essential. Discuss with paediatric cardiologist

Differentiating infant with heart failure vs bronchiolitis

Greater degree of hepatomegaly, enlarged heart with displaced apex beat, gallop rhythm and/or murmur. CXR will show cardiomegaly and pulmonary congestion no hyperinflation.