Acute Respiratory Diseases in the Tropics: diagnosis and treatment protocols for resource poor areas of sub-Saharan Africa Taste of Tropical Medicine

Bill Stauffer University of Minnesota Departments of Medicine and Pediatrics, Infectious Diseases

Introduction



Acute respiratory illness is the leading cause of mortality of children worldwide.



Resources will vary, these protocols will be most useful in resource limited settings and must be adapted to each new clinical setting depending on:

  

Disease epidemiology (i.e. malaria endemic) Diagnostics available Medications available

Unwell child or infant older than 2 months Exclude malaria Take a full history and perform an examination using unwell child and infant history and examination form What is the child’s main complaint/symptom?

Difficulty in breathing and cough Acute Respiratory Distress Protocol Diarrhoea Gastroenteritis Treatment Protocol Fever (not malaria) Septic Child Protocol Irritability, neck stiffness or bulging fontanelle Meningitis Treatment Protocol

Acute Respiratory Distress Protocol

Count respiratory rate over 1 minute >50 breaths and child 2 – 11 months >40 breaths and child 1-5 years

Yes

Take oxygen saturations If < 90% start oxygen

No

Go to septic child protocol If the child is less than 2 years and has wet sounding crepitations on auscultation and no increase in RR consider Bronchioloitis as a diagnosis

Bronchiolitis Protocol*

Gallop rhythm Heart murmur Enlarged palpable liver Possible

Cardiac Failure frequently aneamic

Consider furosemide 1mg/kg Blood transfusion if tachycardia and hgb less then 5** Call the doctor Does the child have any of the following?

Sudden onset of symptoms Barking cough Stridor Hoarse voice Consider

Foreign Body Aspiration (inspiratory/expiratory chest x-ray, in babies left and right lateral x-rays) Upper Airway Obstruction

Go to

Stridor Treatment Protocol

On auscultation of the chest the predominant feature is wheeze?

Child > 2- 3 years previous wheeze or diagnosis of asthma: follow

Acute Asthma Protocol If no to all of the above move to the Pneumonia Protocol

*if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

**discuss with physician if signs of heart failure but aneamia with a Hgb. more than 5.

Pneumonia Protocol: Infants and Children > 2 months

Does the infant have indrawing of the chest wall?

Yes No Yes

Does the infant have any of the following?

Central cyanosis off oxygen Severe respiratory distress Inability to drink

No Very Severe Pneumonia Severe Pneumonia Pneumonia

Ceftriaxone Ampicillin plus Chloramphenicol Worsens or fails to respond in 48-72 hours Amoxicillin or Ampicillin

Pneumonia Protocol: Infants and Children > 2 months Very Severe Pneumonia Severe Pneumonia Pneumonia

Ceftriaxone (50-100 mg/kg IV divided Bid (may give IM if no IV access) Give ampicillin (100 mg/kg IV/IM every 6 hours) and chloramphenical (50 mg/kg every 8 hours) for at least 48 hours

The child MUST be discussed with a doctor and reviewed as soon as possible

Obtain a chest x-ray Monitor and ensure oxygen saturations >90% Child should be checked by a nurse every 6 hours and by a doctor or medic every day Ensure that the child is receiving adequate fluid Encourage breastfeeding and oral fluids If child cannot drink: For For Severe Pneumonia: pass a nasogastric tube and give maintenance fluid in one hourly amounts, or, Very Severe Pneumonia give IV flush* if dehydrated and start on D5NS maintenance, the doctor and all medics on duty must be aware of this child, especially overnight Give paracetamol (15mg/kg as needed up to 4 times a day) for fever Give oral amoxicillin (or IV ampicillin) Give the first dose in the clinic

*IV flush

10-20 mls/kg of NS

**Maintenance fluid (D5NS)

Weight 2kg 4kg 6kg 8kg 10kg 12kg 14kg 16kg 18kg 20kg 22kg 24kg 26kg 65 67 69 46 50 54 58 63 Fluid ml/hour 8 16 25 33 42

Pneumonia Protocol: Infants and Children > 2 months Very Severe Pneumonia Severe Pneumonia

Look for complications Improvement after 48 hours?

No Yes

Consider cloxacillin (50mg/kg IV QID) If the child improves on cloxacillin continue cloxacillin orally 4 times a day for a total course of 3 weeks Improvement after 48 hours?

Yes No

Look for complications like Effusion/empysema After 5 days if the child has responded well change to oral amoxicillin and oral chloramphenical for a further 5 days Oral amoxicillin for 5 days Change to ceftriaxone 50-100mg/kg BID for 10 days

Treat complications if found Complications include: Empyaema* Pleural effusion* Lung abscess* *May need surgical intervention Antibiotic treatment can be changed by a doctor when blood culture results are available

Asthma Treatment Protocol Assess Severity Peak flow if child older than 7 years Mild / Moderate

No respiratory distress RR normal No / minimal chest indrawing Peak flow >70% predicted Saturations >92% in air

Severe

Unable to talk in sentences Fast respiratory rate Chest indrawing Nasal flaring Peak flow 33-50% predicted Saturations <92% in air

Life Threatening

Pale or cyanosis Poor respiratory effort Exhausted Confusion Silent chest Peak flow <33% 5-10 puffs salbutamol via spacer (infants with facemask) Reassess after one hour

No

Improvement

Yes Discharge

Ask to return if becomes worse Ensure good inhaler technique and adequate drug supply

Consider Antibiotics (as per ARI protocol) only if the child has a fever

Nebulized salbutamol 5mg every 20 minutes for 1 hour Prednisolone 1mg/kg (max 40mg) Oxygen to keep O >92% 2 Saturations Improvement

Yes Admit

1 hourly observations until improvement maintained Salbutamol nebulizer every 2-4 hours Prednisolone for 3 days

No

Nebulized salbutamol 5mg every 20 minutes for 1 hour Prednisolone 1mg/kg (max 40mg) or IV hydrocortisone (see emergency drug chart for dose) Oxygen to keep O 2 Saturations >92%

Call the Doctor

Start IV aminophylline 5mg/kg (max 500mg) over 1 hour every 6 hours STOP if the child starts to vomit, PR> 180, develops a headache or has a convulsion Chest X-ray (rule out pneumothorax) Close observation Salbutamol nebulizer every hour Prednisolone for 3 days

Bronchiolitis Treatment Protocol

Mild

Infant feeding well No signs of respiratory distress

Discharge home Symptomatic treatment

Ask the mother to return if the baby develops respiratory distress or cannot feed Common cold Runny nose Blocked nose Wet sounding cough Bilateral crepitations Wheeze

Moderate

Feeding for shorter time Mild chest indrawing No cyanosis RR not increased

No

Feeding compromised < 3 months Born premature Other medical conditions Mother not coping

Yes Admit for observation of feeding (child might need NGT fluids) and respiratory rate If wheeze is present give 5 puffs of salbutamol via a spacer, if there is an improvement in the child’s condition give 5 puffs via a spacer QID Severe

Not feeding well RR increased Signs of respiratory distress Nebulized salbutamol 5mg every 20 minutes for 1 hour, if Improvement every 1 hour prn. If No improvement can d/c.

if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

Treat using the Pneumonia Protocol

Stridor Treatment Protocol

Croup

Symptoms

Coryzal onset No drooling Barking cough Able to drink Harsh stridor Hoarse voice

Treatment

Moderate respiratory distress – prednisolone 2mg/kg (max 40mg) Severe respiratory distress – Prednisolone and 5ml 1:1000

adrenaline (epinephrine)

nebulized

Stridor

Definition: harsh breathing noise (DURING INSPIRATION) produced by obstruction to breathing in the larynx or trachea.

It is one of the common features of upper airway obstruction with hoarseness and barking cough Leave the child in a comfortable position DO NOT distress the child Epiglottitis Foreign body inhalation 40mg)

Symptoms

Rapid onset Toxic appearance Drooling Temp >38.5

° c

Treatment Contact Surgery

Prednisolone 2mg/kg (max 5ml 1:1000 adrenaline nebulized Ceftriaxone 50mg/kg IM Anaphylaxis

Symptoms

Choking Sudden onset

Treatment Choking Child Protocol Symptoms

Skin rash (urticaria) Itching Oedema

Treatment

IM adrenaline/epinephrine: 0.05ml <6months 0.012ml 6 mths – 5 years 0.25ml 6 years – 11 years 0.5ml 12 years+

Hydrocortisone

25mg TID <1year 50mg TID 1yr – 5 years 100mg TID 6 years – 11 years 250mg TID 12 years+ If wheeze 5mg nebulized salbutamol

Chlorpheniramine

2.5mg QID <1year 5mg QID 1yr – 5 years 10mg QID 6 years – 11 years 20mg QID 12 years+

Case 1



4 year old with cc of cough, shortness of breath two days



No fevers



Examination



RR 72, O

2

sats 88%, chest in-drawing

 

Bilateral wheezes throughout Able to talk only in 1 and 2 word sentences



What do you want to do?

Unwell child or infant older than 2 months Exclude malaria Take a full history and perform an examination using unwell child and infant history and examination form What is the child’s main complaint/symptom?

Difficulty in breathing and cough Acute Respiratory Distress Protocol Diarrhoea Gastroenteritis Treatment Protocol Fever (not malaria) Septic Child Protocol Irritability, neck stiffness or bulging fontanelle Meningitis Treatment Protocol

Acute Respiratory Distress Protocol

Count respiratory rate over 1 minute >50 breaths and child 2 – 11 months >40 breaths and child 1-5 years

Yes

Take oxygen saturations If < 90% start oxygen

No

Go to septic child protocol If the child is less than 2 years and has wet sounding crepitations on auscultation and no increase in RR consider Bronchioloitis as a diagnosis

Bronchiolitis Protocol*

Gallop rhythm Heart murmur Enlarged palpable liver Possible

Cardiac Failure frequently aneamic

Consider furosemide 1mg/kg Blood transfusion if tachycardia and hgb less then 5** Call the doctor Does the child have any of the following?

Sudden onset of symptoms Barking cough Stridor Hoarse voice Consider

Foreign Body Aspiration (inspiratory/expiratory chest x-ray, in babies left and right lateral x-rays) Upper Airway Obstruction

Go to

Stridor Treatment Protocol

On auscultation of the chest the predominant feature is wheeze?

Child > 2- 3 years previous wheeze or diagnosis of asthma: follow

Acute Asthma Protocol If no to all of the above move to the Pneumonia Protocol

*if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

**discuss with physician if signs of heart failure but aneamia with a Hgb. more than 5.

Acute Respiratory Distress Protocol

Count respiratory rate over 1 minute >50 breaths and child 2 – 11 months >40 breaths and child 1-5 years

Yes

Take oxygen saturations If < 90% start oxygen

No

Go to septic child protocol If the child is less than 2 years and has wet sounding crepitations on auscultation and no increase in RR consider Bronchioloitis as a diagnosis

Bronchiolitis Protocol*

Gallop rhythm Heart murmur Enlarged palpable liver Possible

Cardiac Failure frequently aneamic

Consider furosemide 1mg/kg Blood transfusion if tachycardia and hgb less then 5** Call the doctor Does the child have any of the following?

Sudden onset of symptoms Barking cough Stridor Hoarse voice Consider

Foreign Body Aspiration (inspiratory/expiratory chest x-ray, in babies left and right lateral x-rays) Upper Airway Obstruction

Go to

Stridor Treatment Protocol

On auscultation of the chest the predominant feature is wheeze?

Child > 2- 3 years previous wheeze or diagnosis of asthma: follow

Acute Asthma Protocol If no to all of the above move to the Pneumonia Protocol

*if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

**discuss with physician if signs of heart failure but aneamia with a Hgb. more than 5.

Asthma Treatment Protocol Mild / Moderate

No respiratory distress RR normal No / minimal chest indrawing Peak flow >70% predicted Saturations >92% in air

Assess Severity Severe

Unable to talk in sentences Fast respiratory rate Chest indrawing Nasal flaring Peak flow 33-50% predicted Saturations <92% in air Nebulized salbutamol 5mg every 20 minutes for 1 hour Prednisolone 1mg/kg (max 40mg) Oxygen to keep O 2 Saturations >92%

Consider Antibiotics (as per ARI protocol) only if the child has a fever

Improvement

Yes Admit

1 hourly observations until improvement maintained Salbutamol nebulizer every 2-4 hours Prednisolone for 3 days

Peak flow if child older than 7 years Life Threatening

Pale or cyanosis Poor respiratory effort Exhausted Confusion Silent chest Peak flow <33%

Case 2



22 month old, health, sudden onset of cough 10 days ago, fever 5 days ago, on antibiotics for 4 days, still fever.



Temp 38.8C, RR 72, O2 sats 91%



General: tachypnic, mild chest in-drawing



Resp: reduced air entry on L hemithorax, no other abnormalities

Unwell child or infant older than 2 months Exclude malaria Take a full history and perform an examination using unwell child and infant history and examination form What is the child’s main complaint/symptom?

Difficulty in breathing and cough Acute Respiratory Distress Protocol Diarrhoea Gastroenteritis Treatment Protocol Fever (not malaria) Septic Child Protocol Irritability, neck stiffness or bulging fontanelle Meningitis Treatment Protocol

Acute Respiratory Distress Protocol

Count respiratory rate over 1 minute >50 breaths and child 2 – 11 months >40 breaths and child 1-5 years

Yes

Take oxygen saturations If < 90% start oxygen

No

Go to septic child protocol If the child is less than 2 years and has wet sounding crepitations on auscultation and no increase in RR consider Bronchioloitis as a diagnosis

Bronchiolitis Protocol*

Gallop rhythm Heart murmur Enlarged palpable liver Possible

Cardiac Failure frequently aneamic

Consider furosemide 1mg/kg Blood transfusion if tachycardic and hgb less then 5** Call the doctor Does the child have any of the following?

Sudden onset of symptoms Barking cough Stridor Hoarse voice Consider

Foreign Body Aspiration (inspiratory/expiratory chest x-ray, in babies left and right lateral x-rays) Upper Airway Obstruction

Go to

Stridor Treatment Protocol

On auscultation of the chest the predominant feature is wheeze?

Child > 2- 3 years previous wheeze or diagnosis of asthma: follow

Acute Asthma Protocol If no to all of the above move to the Pneumonia Protocol

*if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

**discuss with physician if signs of heart failure but aneamia with a Hgb. more than 5.

Case 3



13 month old with cough, runny nose, wet cough for 2 days. Not eating or drinking well.



Examination

   

T 38.1 C, RR 87, O2 sats 83%, weight 12 Kg.

General: lethargic HEENT: coryza Resp: nasal flaring, super-clavicular and chest in drawing, abdominal breathing, bilateral wheeze/rhonchi throughout with some scattered crepitations.

Unwell child or infant older than 2 months Exclude malaria Take a full history and perform an examination using unwell child and infant history and examination form What is the child’s main complaint/symptom?

Difficulty in breathing and cough Acute Respiratory Distress Protocol Diarrhoea Gastroenteritis Treatment Protocol Fever (not malaria) Septic Child Protocol Irritability, neck stiffness or bulging fontanelle Meningitis Treatment Protocol

Acute Respiratory Distress Protocol

Count respiratory rate over 1 minute >50 breaths and child 2 – 11 months >40 breaths and child 1-5 years

Yes

Take oxygen saturations If < 90% start oxygen

No

Go to septic child protocol If the child is less than 2 years and has wet sounding crepitations on auscultation and no increase in RR consider Bronchioloitis as a diagnosis

Bronchiolitis Protocol*

Gallop rhythm Heart murmur Enlarged palpable liver Possible

Cardiac Failure frequently aneamic

Consider furosemide 1mg/kg Blood transfusion if tachycardic and hgb less then 5** Call the doctor Does the child have any of the following?

Sudden onset of symptoms Barking cough Stridor Hoarse voice Consider

Foreign Body Aspiration (inspiratory/expiratory chest x-ray, in babies left and right lateral x-rays) Upper Airway Obstruction

Go to

Stridor Treatment Protocol

On auscultation of the chest the predominant feature is wheeze?

Child > 2- 3 years previous wheeze or diagnosis of asthma: follow

Acute Asthma Protocol If no to all of the above move to the Pneumonia Protocol

*if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

**discuss with physician if signs of heart failure but aneamia with a Hgb. more than 5.

Bronchiolitis Treatment Protocol

Mild

Infant feeding well No signs of respiratory distress Common cold Runny nose Blocked nose Wet sounding cough Bilateral crepitations Wheeze

Moderate

Feeding for shorter time Mild chest indrawing No cyanosis RR not increased

Severe

Not feeding well RR increased Signs of respiratory distress Nebulized salbutamol 5mg every 20 minutes for 1 hour, if Improvement every 1 hour prn. If No improvement can d/c.

if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

Treat using the Pneumonia Protocol

Pneumonia Protocol: Infants and Children > 2 months

Does the infant have indrawing of the chest wall?

Yes No Yes

Does the infant have any of the following?

Central cyanosis off oxygen Severe respiratory distress Inability to drink

No Very Severe Pneumonia Severe Pneumonia Pneumonia

Ceftriaxone Ampicillin plus Chloramphenicol Worsens or fails to respond in 48-72 hours Amoxicillin or Ampicillin

Pneumonia Protocol: Infants and Children > 2 months Very Severe Pneumonia Severe Pneumonia Pneumonia

Ceftriaxone (50-100 mg/kg IV divided Bid (may give IM if no IV access) Give ampicillin (100 mg/kg IV/IM every 6 hours) and chloramphenical (50 mg/kg every 8 hours) for at least 48 hours

The child MUST be discussed with a doctor and reviewed as soon as possible

Obtain a chest x-ray Monitor and ensure oxygen saturations >90% Child should be checked by a nurse every 6 hours and by a doctor or medic every day Ensure that the child is receiving adequate fluid Encourage breastfeeding and oral fluids If child cannot drink: For For Severe Pneumonia: pass a nasogastric tube and give maintenance fluid in one hourly amounts, or, Very Severe Pneumonia give IV flush* if dehydrated and start on D5NS maintenance, the doctor and all medics on duty must be aware of this child, especially overnight Give paracetamol (15mg/kg as needed up to 4 times a day) for fever Give oral amoxicillin (or IV ampicillin) Give the first dose in the clinic

*IV flush

10-20 mls/kg of NS

**Maintenance fluid (D5NS)

Weight 2kg 4kg 6kg 8kg 10kg 12kg 14kg 16kg 18kg 20kg 22kg 24kg 26kg 65 67 69 46 50 54 58 63 Fluid ml/hour 8 16 25 33 42

Case 3



You give three salbutamol nebs over one hour, no improvement.



Started on oxygen and Ceftriaxone.



Chest x-ray pending



You need to give fluids, what are you going to give?

Pneumonia Protocol: Infants and Children > 2 months Very Severe Pneumonia Severe Pneumonia Pneumonia

Ceftriaxone (50-100 mg/kg IV divided Bid (may give IM if no IV access) Give ampicillin (100 mg/kg IV/IM every 6 hours) and chloramphenical (50 mg/kg every 8 hours) for at least 48 hours

The child MUST be discussed with a doctor and reviewed as soon as possible

Obtain a chest x-ray Monitor and ensure oxygen saturations >90% Child should be checked by a nurse every 6 hours and by a doctor or medic every day Ensure that the child is receiving adequate fluid Encourage breastfeeding and oral fluids If child cannot drink: For For Severe Pneumonia: pass a nasogastric tube and give maintenance fluid in one hourly amounts, or, Very Severe Pneumonia give IV flush* if dehydrated and start on D5NS maintenance, the doctor and all medics on duty must be aware of this child, especially overnight Give paracetamol (15mg/kg as needed up to 4 times a day) for fever Give oral amoxicillin (or IV ampicillin) Give the first dose in the clinic

*IV flush

10-20 mls/kg of NS

**Maintenance fluid (D5NS)

Weight 2kg 4kg 6kg 8kg 10kg 12kg 14kg 16kg 18kg 20kg 22kg 24kg 26kg 65 67 69 46 50 54 58 63 Fluid ml/hour 8 16 25 33 42

Weight was 12 Kilograms: Flush: 12 X 20 ml/kg = 240 mls. NS Maintenance: 12 Kg. = 46 D5NS

*IV flush

10-20 mls/kg of NS

**Maintenance fluid (D5NS)

Weight 2kg 4kg 6kg 8kg 10kg 12kg 14kg 16kg 18kg 20kg 22kg 24kg 26kg 65 67 69 46 50 54 58 63 Fluid ml/hour 8 16 25 33 42

Case 3



Respiratory rate increases to 90 over the next 12 hours despite previous therapy. Oxygen sats, originally over 92% on oxygen now 78%. Child has increased nasal flaring, chest in-drawing, and poor capillary refill.



What do you want to do?

Bronchiolitis Treatment Protocol

Mild

Infant feeding well No signs of respiratory distress Common cold Runny nose Blocked nose Wet sounding cough Bilateral crepitations Wheeze

Moderate

Feeding for shorter time Mild chest indrawing No cyanosis RR not increased

Severe

Not feeding well RR increased Signs of respiratory distress Nebulized salbutamol 5mg every 20 minutes for 1 hour, if Improvement every 1 hour prn. If No improvement can d/c.

if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

Treat using the Pneumonia Protocol

Case 4



4 y.o. with cc of fever and cough for two days



Worse at night



Examination



T 39 C, rr 25, o2 sats 95%



General: Barky cough



Resp: CTA B except upper airways sounds.

Unwell child or infant older than 2 months Exclude malaria--POSITIVE Take a full history and perform an examination using unwell child and infant history and examination form What is the child’s main complaint/symptom?

Difficulty in breathing and cough Acute Respiratory Distress Protocol Diarrhoea Gastroenteritis Treatment Protocol Fever (not malaria) Septic Child Protocol Irritability, neck stiffness or bulging fontanelle Meningitis Treatment Protocol

Acute Respiratory Distress Protocol

Count respiratory rate over 1 minute >50 breaths and child 2 – 11 months >40 breaths and child 1-5 years

Yes

Take oxygen saturations If < 90% start oxygen

No

Go to septic child protocol If the child is less than 2 years and has wet sounding crepitations on auscultation and no increase in RR consider Bronchioloitis as a diagnosis

Bronchiolitis Protocol*

Gallop rhythm Heart murmur Enlarged palpable liver Possible

Cardiac Failure frequently aneamic

Consider furosemide 1mg/kg Blood transfusion if tachycardic and hgb less then 5** Call the doctor Does the child have any of the following?

Sudden onset of symptoms Barking cough Stridor Hoarse voice Consider

Foreign Body Aspiration (inspiratory/expiratory chest x-ray, in babies left and right lateral x-rays) Upper Airway Obstruction

Go to

Stridor Treatment Protocol

On auscultation of the chest the predominant feature is wheeze?

Child > 2- 3 years previous wheeze or diagnosis of asthma: follow

Acute Asthma Protocol If no to all of the above move to the Pneumonia Protocol

*if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

**discuss with physician if signs of heart failure but aneamia with a Hgb. more than 5.

Stridor Treatment Protocol

Croup

Symptoms

Coryzal onset No drooling Barking cough Able to drink Harsh stridor Hoarse voice

Treatment

Moderate respiratory distress – prednisolone 2mg/kg (max 40mg) Severe respiratory distress – Prednisolone and 5ml 1:1000

adrenaline (epinephrine)

nebulized

Stridor

Definition: harsh breathing noise (DURING INSPIRATION) produced by obstruction to breathing in the larynx or trachea.

It is one of the common features of upper airway obstruction with hoarseness and barking cough Leave the child in a comfortable position DO NOT distress the child Epiglottitis Foreign body inhalation 40mg)

Symptoms

Rapid onset Toxic appearance Drooling Temp >38.5

° c

Treatment Contact Surgery

Prednisolone 2mg/kg (max 5ml 1:1000 adrenaline nebulized Ceftriaxone 50mg/kg IM Anaphylaxis

Symptoms

Choking Sudden onset

Treatment Choking Child Protocol Symptoms

Skin rash (urticaria) Itching Oedema

Treatment

IM adrenaline/epinephrine: 0.05ml <6months 0.012ml 6 mths – 5 years 0.25ml 6 years – 11 years 0.5ml 12 years+

Hydrocortisone

25mg TID <1year 50mg TID 1yr – 5 years 100mg TID 6 years – 11 years 250mg TID 12 years+ If wheeze 5mg nebulized salbutamol

Chlorpheniramine

2.5mg QID <1year 5mg QID 1yr – 5 years 10mg QID 6 years – 11 years 20mg QID 12 years+

Stridor Treatment Protocol

Stridor

Definition: harsh breathing noise (DURING INSPIRATION) produced by obstruction to breathing in the larynx or trachea.

It is one of the common features of upper airway obstruction with hoarseness and barking cough Leave the child in a comfortable position DO NOT distress the child Epiglottitis Foreign body inhalation Croup

Symptoms

Coryzal onset No drooling Barking cough Able to drink Harsh stridor Hoarse voice

Treatment

Moderate respiratory distress – prednisolone 2mg/kg (max 40mg) Severe respiratory distress – Prednisolone and 5ml 1:1000

adrenaline (epinephrine)

nebulized Anaphylaxis

Case 5



8 year old with known asthma, with cough for 3 days now acutely short of breath.



Examination

    T 38 C, rr 48, 02 sats 91% Gen: tachypnic, unable to speak in full sentences Skin: crepitations in neck and supra-clavicular Resp: Bilateral wheezes throughout

Unwell child or infant older than 2 months Exclude malaria Take a full history and perform an examination using unwell child and infant history and examination form What is the child’s main complaint/symptom?

Difficulty in breathing and cough Acute Respiratory Distress Protocol Diarrhoea Gastroenteritis Treatment Protocol Fever (not malaria) Septic Child Protocol Irritability, neck stiffness or bulging fontanelle Meningitis Treatment Protocol

Acute Respiratory Distress Protocol

Count respiratory rate over 1 minute >50 breaths and child 2 – 11 months >40 breaths and child 1-5 years

Yes

Take oxygen saturations If < 90% start oxygen

No

Go to septic child protocol If the child is less than 2 years and has wet sounding crepitations on auscultation and no increase in RR consider Bronchioloitis as a diagnosis

Bronchiolitis Protocol*

Gallop rhythm Heart murmur Enlarged palpable liver Possible

Cardiac Failure frequently aneamic

Consider furosemide 1mg/kg Blood transfusion if tachycardic and hgb less then 5** Call the doctor Does the child have any of the following?

Sudden onset of symptoms Barking cough Stridor Hoarse voice Consider

Foreign Body Aspiration (inspiratory/expiratory chest x-ray, in babies left and right lateral x-rays) Upper Airway Obstruction

Go to

Stridor Treatment Protocol

On auscultation of the chest the predominant feature is wheeze?

Child > 2- 3 years previous wheeze or diagnosis of asthma: follow

Acute Asthma Protocol If no to all of the above move to the Pneumonia Protocol

*if severe, may attempt 5ml 1:1000

adrenaline (epinephrine)

nebulized.

**discuss with physician if signs of heart failure but aneamia with a Hgb. more than 5.

Asthma Treatment Protocol Mild / Moderate

No respiratory distress RR normal No / minimal chest indrawing Peak flow >70% predicted Saturations >92% in air

Assess Severity Severe

Unable to talk in sentences Fast respiratory rate Chest indrawing Nasal flaring Peak flow 33-50% predicted Saturations <92% in air Nebulized salbutamol 5mg every 20 minutes for 1 hour Prednisolone 1mg/kg (max 40mg) Oxygen to keep O 2 Saturations >92%

Consider Antibiotics (as per ARI protocol) only if the child has a fever

Improvement

Yes Admit

1 hourly observations until improvement maintained Salbutamol nebulizer every 2-4 hours Prednisolone for 3 days

Peak flow if child older than 7 years Life Threatening

Pale or cyanosis Poor respiratory effort Exhausted Confusion Silent chest Peak flow <33%

Case 5



No improvement with therapy, now what?

Case 6



3 year old with cough for three days, drooling. No other symptoms.



Examination:



T 37.8 C, rr 21, O2 sats 98%



General NAD



Respiratory: CTA B

...with a vision

for the children of the world: that every one of them - without exception - lives a full and healthy life, with rights secured and protected, freed from poverty, violence and discrimination --UNICEF State of the World’s Children, 2000