Respiratory illness in children Assessment and management of acute episodes Jeremy Hull, CHOX Oxford Children’s Hospital.

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Presentation transcript:

Respiratory illness in children Assessment and management of acute episodes Jeremy Hull, CHOX Oxford Children’s Hospital

What are acute episodes? Breathlessness Cough Noisy breathing Oxford Children’s Hospital

What are the likely causes? Asthma Croup Bronchiolitis Pneumonia Pertussis Inhaled foreign body Anaphylaxis Pneumothorax Not respiratory sepsis diabetic ketoacidosis heart failure likely rare Oxford Children’s Hospital

Assessment History! previously well, or previous episodes coryza onset of symptoms – sudden, gradual, precipitant any history of choking eating and drinking exercise / general activity levels usual medication Oxford Children’s Hospital

Assessment Examination Global assessment – well or ill? ABC Conscious level Respiratory rate – COUNT don’t guess Heart rate Work of breathing – recession plus use of accessory muscles Oxygen saturation – use paediatric probe for < 2yrs Breathing noises – stridor or audible wheeze Auscultate – wheeze and/or crackles Oxford Children’s Hospital

Breathing noises Stridor Wheeze Crackles (crepitations) Harsh noise coming from trachea Usually predominantly inspiratory Usually heard without a stethoscope Wheeze Turbulent airflow in small to medium sized airways Usually high-pitched and polyphonic Always loudest on expiration May be heard without a stethoscope Crackles (crepitations) Coarse or fine snapping noises heard on inspiration or expiration Only heard with a stethoscope Oxford Children’s Hospital

Heart rate and respiratory rate Will change with distress and anxiety Higher in febrile children Varies with age Respiratory rate May be the only abnormal sign Oxford Children’s Hospital

Heart rate and respiratory rate Adapted from APLS Age Respiratory Rate Heart Rate Systolic BP <4wk 40-60 120-160 >60 <1yr 30-40 110-160 70-90 1-2yrs 25-35 100-150 75-95 2-5 yrs 25-30 95-140 85-100 5-11 yrs 20-25 80-120 90-110 12-16 yrs 15-20 60-100 100-120 Oxford Children’s Hospital

Assessment – Asthma (Bucks) Green - Moderate Amber - Severe Red - Life Threatening Talking In sentences Not able to complete a sentence in one breath. Taking two breaths to talk or feed. Not able to talk / Not responding Confusion / Agitation Auscultation Good air entry, mild-moderate wheeze Decreased air entry with marked wheeze Silent chest Respiratory Rate Normal range: ≤ 40 breaths/min (2-5 yrs) ≤ 30 breaths/min (>5 yrs) Above normal range: > 40 breaths/min (2-5 yrs) > 30 breaths/min (>5yr) Cyanosis Poor respiratory effort Exhaustion Heart Rate ≤ 140bpm (2-5 yrs) ≤ 125 bpm (>5 yrs) > 140 bpm (2-5 yrs) > 125 bpm (>5 yrs) Tachycardia or bradycardic Hypotension Sp02 in air ≥ 92% < 92% < 92% plus anything else in this column PEFR (if possible) > 50% of predicted 33-50% of predicted < 33% of predicted Feeding Still feeding Struggling Unable to feed PEFR is often of limited use, especially in children who have not previously used a peak flow meter Oxford Children’s Hospital

Assessment – Asthma (BTS) PEFR is often of limited use, especially in children who have not previously used a peak flow meter https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/ Oxford Children’s Hospital

Assessment – bronchiolitis (Oxford CCG) Low risk Intermediate risk High risk Activity Alert Normal Irritable Not responding to social cues Decreased activity No smile Unable to rouse Wakes only with prolonged stimulation No response to social cues Weak, high pitched or continuous cry Appears ill to a health care professional Skin Capillary refill <2 secs Normal colour skin, lips and tongue Moist mucous membranes Capillary refill 2-3 secs Pale / mottled Pallor reported by parent / carer Cool peripheries Capillary refill >3 secs Pale / mottled / ashen / blue Cyanotic lips and tongue Respiratory Rate <12m: <50 breaths/min >12m: <40 breaths/min No respiratory distress <12m: 50-60 breaths/min >12m: 40-60 breaths/min Tachypnoea All ages: >60 breaths/min Significant respiratory distress Sp02 in air 95% or above 92-94% 92% or less Chest recession None Moderate Severe Nasal flaring Absent May be present Present Grunting Apnoeas Yes – 10-15 secs or shorter if with sudden decrease in sats, breadycardia or central cyanosis Feeding/ Hydration Tolerating 75% of fluid Occasional cough induced vomit 50-75% fluid intake over 3-4 feeds Cough induced vomiting Reduced urine output <50% fluid intake over 2-3 feeds Cough induced vomiting frequently Significantly reduced urine output PEFR is often of limited use, especially in children who have not previously used a peak flow meter Over 12 months – not likely to be bronchiolitis

Generic Assessment – my suggestions Mild - Moderate manage in community Severe ?send to hospital Life Threatening call an ambulance Talking Activity Normal Impeded Not talking, confused, agitated Resp effort Increased Either severe or decreased Resp Rate Normal or slightly elevated Elevated Either very high or low Heart Rate Sp02 in air 95% or above 92-94% Less than 92% Skin and perfusion May be cool peripheries Cool, cyanosed, poor perfusion Feeding At least 75% of normal 50-75% of normal <50% or not feeding PEFR (asthma) >50% predicted 33-50% <33% PEFR is often of limited use, especially in children who have not previously used a peak flow meter Sats for asthma apply to those after treatment and need to be taken in the context of the other aspects of assessment Amber - Send to hospital if no improvement – either after observation or treatment. Oxford Children’s Hospital

What to do - options Get help, call an ambulance Oxygen Inhaled beta-agonists nebulised via spacer Antibiotics Oral steroids Intra-muscular adrenaline Nebulised adrenaline Give advice – feeding, illness duration, safety net, follow-up Oxford Children’s Hospital

Wheeze – mild to severe Treat with beta-2 agonist – salbutamol (think twice if <1 year) Spacer if normal saturations Slow deep inhalations are most effective Nebuliser if de-saturated or will not tolerate spacer Give oral steroids (20-40mg); 3 days is usually enough. NB: steroids don’t work for viral wheeze Chamber volume is 150ml. Average 5 year old has inspiratory capacity when well of ~1000ml Oxford Children’s Hospital

Wheeze Mild to moderate wheeze can be treated at home Can safely use upto 10 puffs (<5yrs) or 20 puffs (<5 years) every 4 hours Reduce frequency according to symptoms Need to check on the child at least once during the night Need to seek further help if wheeze worsens Need review if not better in 3 days Oxford Children’s Hospital

Life-threatening wheeze Give oxygen Call an ambulance Give salbutamol (2.5 – 5mg) nebuliser driven by oxygen Continuous nebulisers if necessary (top-up every 10 minutes) If you have it, add nebulised ipratropium (250mcg) for 2 nebs If the child can swallow, give a dose of prednisolone (20-40mg) Oxford Children’s Hospital

Croup Symptoms and signs If intermittent stridor, give oral steroid <5 years coryza for 24 hours barking cough, stridor low grade fever, not toxic If intermittent stridor, give oral steroid dexamethasone 0.15mg/kg or prednisolone 1mg/kg 2 doses 12 hours apart Need planned review if stridor present Hospital review if stridor at rest recession at rest If desaturated, severe stridor and recession Give oxygen, call an ambulance, give nebulised adrenaline 5ml of 1 in 1000 Plain (not enteric coated) prednisolone can be crushed. 1mg/kg, 2 doses 12 hours apart is cheaper than dexamethasone 0.15mg/kg Oxford Children’s Hospital

Bronchiolitis Symptoms and signs Supportive treatment infants coryza, breathlessness, poor feeding cough, low grade fever tachypnoea, recession, crackles +/- wheeze Supportive treatment frequent, smaller volume feeds paracetamol Hospital review if recession at rest desaturated, taking <50% of feeds, history of apnoea low threshold for infants < 6 weeks old and ex-preterm infants. Oxford Children’s Hospital

Pneumonia Symptoms and signs Give amoxycillin Hospital review if lethargy and fever cough, breathlessness, chest pain crackles or bronchial breathing not bilateral wheeze! Give amoxycillin Hospital review if significant respiratory distress (see slide 11) gets less well or remains febrile after 72 hours despite amoxycillin Oxford Children’s Hospital

Anaphylaxis Symptoms and signs If respiratory distress, give puffy face / lips/ tongue urticarial rash stridor and/or wheeze known history of severe allergy hypotension and collapse If respiratory distress, give oxygen IM 1 in 1,000 adrenaline 0.5ml (adult / large child) 0.125ml - 0.25ml for smaller children Adrenaline given IM is safe and a good treatment for asthma Oxford Children’s Hospital

Be suspicious if Very young infant (< 4 weeks) Increases possibility of a congenital problem (heart or lungs) There is tachypnoea but no recession, consider sepsis acidosis fever anxiety The child has not been previously well Oxford Children’s Hospital

Follow-up after exacerbations Follow up within 48 hours (NICE) or at the longest 7 days of discharge – certainly by phone, preferably face – to – face Identify any avoidable factors and review PAAP – or provide if not already given Review inhaler technique and adherence Adjust management if necessary Oxford Children’s Hospital

Duncan’s slides on coding Oxford Children’s Hospital

Follow up after asthma exacerbations Code and capture asthma admissions and ED attendances – key outcome measure of practice asthma care

Read Coding Asthma Exacerbations Event Suggested Code Acute Exacerbation of Asthma H333 Emergency Admission Asthma 8H2P ED Attendance Asthma No Code Follow-up Respiratory Assessment 6632 Last code could be used for follow up after admission or ED visit

High Risk Asthma Register Consider establishing a register for patients On BTS Step 4 or Step 5 Frequent admissions or ED attendances Post any ITU / HDU admission Psychosocial problems or known non-adherence causing poor control High beta agonist use >8 blue inhalers per year

Possible Coding for High Risk Asthma 13Zu “At Risk of Emergency Hospital Admission” Makes health professionals aware of their risk status, prompts rapid response to calls, notification of OOH service via special patient notes etc. This code is used for the avoiding unplanned admissions DES and would involve provision of a care plan