Transcript BREATHING DIFFICULTIES IN CHILDREN

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
ASTHMA
Presenting features
• wheeze
• dry cough
•
•
breathlessness
noisy breathing
Detailed history and physical examination
• pattern of illness
• differential clues
• severity/control
Is it asthma?
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DIFFERENTIAL
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
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Initial assessment of acute asthma
in children aged >2 years in A&E
Moderate
exacerbation
Severe
exacerbation
Life threatening
asthma
• SpO2 92%
• PEF 50% best/
• SpO2 <92%
• PEF <50% best/
• SpO2 <92%
• PEF <33% 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)
predicted (>5 years)
• Too breathless to talk
or 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
predicted (>5 years)
• Silent chest
• Poor respiratory effort
• Agitation
• Altered consciousness
• Cyanosis
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Management of acute asthma
in children aged >2 years in A&E
Moderate
exacerbation
• ß2 agonist 2-10 puffs via
•
spacer ± facemask
Reassess after 15 minutes
RESPONDING
• Continue inhaled
ß2 agonists
1-4 hourly
• Add soluble oral
prednisolone
- 20mg (2-5 years)
- 30-40mg
(>5 years)
Severe
exacerbation
Life threatening
exacerbation
• 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)
NOT RESPONDING
• Repeat inhaled
ß2 agonist every
20-30 minutes
• Add soluble oral
prednisolone
- 20mg (2-5 years)
- 30-40mg (>5 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
Response to treatment in children
aged >2 years in A&E
Moderate
exacerbation
Severe
exacerbation
Life threatening
exacerbation
RESPONDING TO
TREATMENT
NOT RESPONDING TO
TREATMENT
IF POOR RESPONSE TO
TREATMENT
ARRANGE ADMISSION
(lower threshold if concern
over social circumstances)
ARRANGE IMMEDIATE
TRANSFER TO PICU/HDU
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
Treatment of acute asthma
in children aged >2 years
D

A
A
B
B
Use 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
Inhaled ß2 agonists are first line treatment for acute asthma *
pMDI and spacer are preferred delivery system in mild to moderate
asthma
Individualise drug dosing according to severity and adjust according
to response
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 acute
asthma in children aged >2 years
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
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Other therapies for acute
asthma in children aged >2 years
A
A
C


If poor response to 2 agonist treatment, add nebulised ipratropium
bromide (250mcg/dose mixed with 2 agonist) *
Aminophylline is not recommended in children with mild to
moderate acute asthma
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 acute
asthma in children aged >2 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 <92% on
air after initial bronchodilator treatment
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Treatment of acute asthma
in children aged <2 years
B
A
C

B
Oral 2 agonists are not recommended for acute asthma in infants
For mild to moderate acute asthma, a pMDI with spacer is the
optimal drug delivery device
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 to
3 days) is the preferred steroid preparation
Consider inhaled ipratropium bromide in combination with an
inhaled 2 agonist for more severe symptoms
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