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 • 3 rd 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 • 3 RD GENERATION CEPHALOSPORIN

ASTHMA

• •

Presenting features wheeze dry cough

• •

breathlessness noisy breathing

• •

Detailed history and physical examination pattern of illness severity/control

•

differential clues

Is it asthma?

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DIFFERENTIAL

Clinical clue

Perinatal and family history  symptoms present from birth or perinatal lung problem  family history of unusual chest disease  severe upper respiratory tract disease 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

Investigations

 focal or persistent radiological changes

Possible diagnosis

 cystic fibrosis; chronic lung disease; ciliary dyskinesia; developmental anomaly  cystic fibrosis; developmental anomaly; neuromuscular disorder  defect of host defence  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  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

• • • SpO 2  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)

Severe exacerbation

• • • • • • SpO 2 <92% PEF <50% best/ 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

Life threatening asthma

• • SpO 2 <92% PEF <33% best/ 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

• • ß 2 agonist 2-10 puffs via spacer ± facemask Reassess after 15 minutes

Severe exacerbation Life threatening exacerbation

• • • Give nebulised ß 2 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 ß 2 agonists 1-4 hourly Add soluble oral prednisolone - 20mg (2-5 years) - 30-40mg (>5 years) • •

NOT RESPONDING

Repeat inhaled ß 2 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 ß 2 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 RESPONDING TO TREATMENT

• • • • • • •

DISCHARGE PLAN

Continue ß 2 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

NOT RESPONDING TO TREATMENT ARRANGE ADMISSION

(lower threshold if concern over social circumstances)

Life threatening exacerbation IF POOR RESPONSE TO TREATMENT ARRANGE IMMEDIATE TRANSFER TO PICU/HDU

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 SpO 2 <92% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations Inhaled ß 2 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

   

B

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 hospital agonists during the journey to 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 Consider intensive inpatient treatment for children with SpO 2 air after initial bronchodilator treatment <92% on

Thorax 2003; 58 (Suppl I): i1-i92

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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