EVIDENCE BASED GUIDELINE FOR MANAGEMENT OF CHILDREN PRESENTING WITH ACUTE BREATHING DIFFICULTY Produced by the Paediatric Accident and Emergency Research Group at Queens Medical Centre, Nottingham supported by Children Nationwide Next slide

ACUTE BREATHING DIFFICULTY Click here to begin. To run through the programme, click on: for further information, to return to the previous page to return to this page For grades of evidence used see

ACUTE BREATHING DIFFICULTY ASSESS: Respiration rate over 60 secs Work of breathing-degree of distress Wheeze,cough, stridor ? Signs of serious illness Age and / or complicating factors SaO 2 ABC Resuscitate if needed Next slide Previous page

This guide takes you through each of these points. It offers guidance on actions to take. At each stage you can access the level of evidence behind each step. For full discussion of the evidence please see the full report by Lakhanpaul M et al on The guideline has been appraised by the Quality of Practice Committee of the Royal College of Paediatrics and Child Health (2002) Next slide

ACUTE BREATHING DIFFICULTY INITIAL ASSESSMENT PROTOCOL Presence of pre-terminal signs or signs requiring urgent attention Click if NO Click if Click if YES

Start basic life support & Call appropriate team for advanced life support CHECK:AirwayBreathingCirculationCHECK:AirwayBreathingCirculation ADMIT to HDU/PICU Previous page

Measure respiratory rate for 60 seconds & oxygen saturation Previous page If O 2 sat <= 92% Give oxygen and admit No ? URTI Home with GP Follow up; Patient Education ? URTI Home with GP Follow up; Patient Education Yes D/W senior Dr Consider alternative diagnoses Arrange appropriate investigations Admit D/W senior Dr Consider alternative diagnoses Arrange appropriate investigations Admit ? Signs of increased work of breathing Stridor/stertor/ wheeze or cough? No ? Signs of serious illness/ complicating factors Yes Click if Yes ? Admit ? Admit

Mild/moderate distress Admit if complicating factors/serious illness Admit if severe distress Yes STRIDOR/STERTORSTRIDOR/STERTOR COUGHCOUGH WHEEZEWHEEZE Previous page

STRIDOR (limited airflow at larynx or trachea) or STERTOR (noise due to obstruction at pharyngeal level ) No Yes ? BARKING COUGH ? Agitated/ Drooling ? Toxic & High Fever Click if YES Click if YES Click if NO Click if NO Click if YES Click if YES Click if NO Click if NO Previous page

Secure Airway Call for senior assistance Consider ENT referral Admit to PICU/HDU Call for senior assistance Consider ENT referral Admit to PICU/HDU ? EpiglottisAgitated/Drooling Previous page

Refer urgently to ENT ? STERTOR Yes No ? Enlarged Tonsils ? Foreign body aspiration CXRCXR ? Normal If strong suspicion of aspiration Refer to appropriate doctor for bronchoscopy No Yes Previous page

Secure Airway Admit to PICU/HDU ? Bacterial tracheitis Toxic+ High Fever Previous page

? CROUP Treat with: Oral dexamethasone If vomiting: Use nebulised budesonide ? Signs of potential respiratory failure HOME with GP follow up, patient education and call back instructions 1.Give l-epinephrine (adrenaline) nebuliser 2.Admit for close observation 3.PICU/HDU 1.Give l-epinephrine (adrenaline) nebuliser 2.Admit for close observation 3.PICU/HDU 1.Signs of severe resp distress 2.Signs of serious illness 1.Signs of severe resp distress 2.Signs of serious illness No 1.Consider adrenaline nebuliser 2.ADMIT 1.Consider adrenaline nebuliser 2.ADMIT Yes Previous page

WHEEZE Yes History of choking or paroxysmal cough Assess severity Age >2 Age <2 Continue management as for other children presenting with wheeze BUT CXR if ?foreign body aspiration/other atypical features e.g. focal signs but no symptoms of bronchiolitis If high suspicion refer to appropriate surgical team Previous page

Age >2 Yes ? Mild/moderate symptoms 1. B 2 -agonist via spacer 1.HOME 2.Follow up instructions 1.HOME 2.Follow up instructions Moderate/severeModerate/severe Life threatening 1.B 2 -agonist (volumatic if not on 0 2 ) 2.Oral steroid 3.+/- 4-6hrly anticholinergic 1.B 2 -agonist (volumatic if not on 0 2 ) 2.Oral steroid 3.+/- 4-6hrly anticholinergic 1.Check ABC 2.Follow BTS guidelines, i.e. IV aminophyline + steroids + frequent B2-agonist 3. ADMIT TO HDU/PICU 4.X-RAY when stable 1.Check ABC 2.Follow BTS guidelines, i.e. IV aminophyline + steroids + frequent B2-agonist 3. ADMIT TO HDU/PICU 4.X-RAY when stable 1. ADMIT TO WARD 2.If no improvement, inc. frequency of B2-agonist up to ½ hourly or continuously 3.Follow BTS guidelines 4.Consider X-RAY 1. ADMIT TO WARD 2.If no improvement, inc. frequency of B2-agonist up to ½ hourly or continuously 3.Follow BTS guidelines 4.Consider X-RAY Yes No Previous page

Age <2 1.Dry wheezy cough 2.Fever 3.Nasal discharge 4.Fine insp crackles and/or high pitched exp wheeze 1.HOME 2.Follow up instructions 1.HOME 2.Follow up instructions Mild/moderateMild/moderate Moderate/Severe/Life threatening 1.TRIAL of B 2 -agonist/anticholinergic 2.Monitor 0 2 sats 3.Discontinue if no effect 4.X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion) 1.TRIAL of B 2 -agonist/anticholinergic 2.Monitor 0 2 sats 3.Discontinue if no effect 4.X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion) 1.ADMIT 2.Short course of oral steriods 3.?X-ray if no improvement 4.Follow BTS guidelines, i.e. inc frequency of bronchodilator 1.ADMIT 2.Short course of oral steriods 3.?X-ray if no improvement 4.Follow BTS guidelines, i.e. inc frequency of bronchodilator Yes ? Bronchiolitis See cough algorithm ? Bronchiolitis See cough algorithm No Previous page

Click if NO Click if NO COUGH Yes CXRCXR ? Referral to appropriate team for bronchoscopy If accompanied by whee ze or stridor see appropriate algorithm or stridor see appropriate algorithm If accompanied by whee ze or stridor see appropriate algorithm or stridor see appropriate algorithm ? Paroxysmal cough or high suspicion of foreign body 1.Dry wheezy cough and age under Fever +/ Nasal discharge 4. Fine insp crackles and/or high pitched exp rhonchi No Previous page Click if YES Click if YES

BronchiolitisBronchiolitis ADMIT if: 1. Signs of serious illness 2. Complicating factors 3. Inc risk of serious disease ADMIT if: 1. Signs of serious illness 2. Complicating factors 3. Inc risk of serious disease 1. Trial of bronchodilator 2. Stop if no clinical improvement 3. Monitor 0 2 sat 4. No steroids 5. No routine blood tests/X-rays 1. Trial of bronchodilator 2. Stop if no clinical improvement 3. Monitor 0 2 sat 4. No steroids 5. No routine blood tests/X-rays ? Severe distress 1. Discuss with senior clinician 2. Consider trial of nebulised adrenaline 3. ADMIT for close observation, e.g. HDU/PICU 1. Discuss with senior clinician 2. Consider trial of nebulised adrenaline 3. ADMIT for close observation, e.g. HDU/PICU No Yes Previous page

1.X-ray child under 2 months/if no response to antibiotics/recurrent pneumonia 2.No routine blood tests 3.Oral antibiotics if clinically suspected 4.HOME with follow up instructions. 1.X-ray child under 2 months/if no response to antibiotics/recurrent pneumonia 2.No routine blood tests 3.Oral antibiotics if clinically suspected 4.HOME with follow up instructions. PNEUMONIAPNEUMONIA Combination of cough & breathing difficulty and: 1.Fever 2. High resp rate 3. Grunting 4. Chest in-drawing No Re-assess child Mild/moderate distress Severe distress 1.CXR 2.Oral/IV antibiotics according to local protocol 3.FBC & B.culture if requires IV antibiotics 4.No routine blood tests if on oral rx 5.ADMIT 1.CXR 2.Oral/IV antibiotics according to local protocol 3.FBC & B.culture if requires IV antibiotics 4.No routine blood tests if on oral rx 5.ADMIT Yes Previous page CXR ? CXR ?

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Table 3 Signs of increased work of breathing Increased respiratory rate Chest in-drawing Nasal flaring Tracheal tug Use of accessory muscles Grunting Back More Information

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Table 6: Complicating Factors contributing to the clinician’s decision regarding admission or discharge Co-morbidity e. g prematurity, congenital heart disease, any chronic lung disease, neurological disorder Social problems e. g previous non-accidental injury, ill parents, parents having difficulty coping Infants younger than 2 months of age Back

Table 7: Severity of Asthma Based on BTS Guidelines AgeUnder 5 yearsOver 5 years Mild to ModerateWheeze and cough with tightness and mild dyspnoea, no distress, no speech or feeding difficulty Mild respiratory distress Respiratory rate <50 Pulse <140 bpm Saturations >92% in air Wheeze and cough with tightness Able to talk PEFR >50% predicted Pulse <120 Saturations >92% in air Moderate to SevereToo breathless to talk Too breathless to feed Respiratory rate >50/min Pulse >140/min Use of accessory muscles Too breathless to talk Too breathless to feed Respiratory rate >40 Pulse >120/min PEFR <50%predicted Life ThreateningCyanosis Silent chest Poor respiratory effort Fatigue or exhaustion Agitation or reduced level of consciousness Cyanosis Silent chest Poor respiratory effort Fatigue or exhaustion PEFR <33%predicted Agitation or reduced level of consciousness Back

Table 8: Infants at risk of developing severe bronchiolitis (adapted from Management of acute bronchiolitis by Rakshi and Couriel, Archives of Disease in Childhood, 1994; 71: ) Apnoea Preterm birth Underlying disorders Lung disease e.g. bronchopulmonary dysplasia,cystic fibrosis Congenital heart disease Immunodeficiency (congenital or acquired) Multiple congenital abnormalities Severe neurological disease Back

Toxic appearance Severe respiratory distress Vomiting Immunocompromised Dehydrated and requiring intravenous fluids Table 9: Indications for treatment with parenteral antibiotics in a child clinically suspected to have pneumonia Back

Table 10: Differential diagnosis of less obvious causes of respiratory distress (Adapted from Fleischer's Textbook of Emergency Medicine, Chapter 65) Metabolic Disorders Central Nervous System Dysfunction Neuromuscular Disorders Chest Wall Disorders Diabetes mellitusMeningitisSpinal cord injuryFlail chest DehydrationEncephalitisInfantile botulismCongenital anomalies SepsisTumourGuillain-Barre Liver/renal diseaseIntoxicationMyopathy IntoxicationStatus epilepticus Inborn errors of metabolism Trauma Hydrocephalus Back

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Statements in this algorithm are derived from a critical appraisal of literature and a subsequent two round Delphi consensus process. Thus the levels of evidence and recommendations made follow the grading system used by SIGN and the last column in the tables which follow refer to the degree of consensus reached in the Delphi panel process where 86% was accepted as an acceptable level of agreement. Based on development and studies by the Paediatric Accident and Emergency Research Group in Queens Medical Centre Nottingham Supported by Children Nationwide Full technical report is available at:

Parent advice When you take your child home: It is important that you: 1. encourage your child to drink plenty little and often 2. c heck their breathing and colour (see below) 3.give your child the medication prescribed by the doctor(list)

Parent return advice (2) You must call a doctor or go back to the hospital if: 1.your child is struggling to breathe and getting very tired 2. your child is too breathless to talk or your baby is grunting or unable to feed 3.your child changes colour and becomes pale grey, white or blue around the lips 4.you are worried that your child has got worse

Parent advice When you take your child home: It is important that you: 1. encourage your child to drink plenty little and often 2. c heck their breathing and colour (see below) 3.give your child the medication prescribed by the doctor(list)

Parent return advice (2) You must call a doctor or go back to the hospital if: 1.your child is struggling to breathe and getting very tired 2. your child is too breathless to talk or your baby is grunting or unable to feed 3.your child changes colour and becomes pale grey, white or blue around the lips 4.you are worried that your child has got worse

Parent advice When you take your child home: It is important that you: 1. encourage your child to drink plenty little and often 2. c heck their breathing and colour (see below) 3.give your child the medication prescribed by the doctor(list)

Parent return advice (2) You must call a doctor or go back to the hospital if: 1.your child is struggling to breathe and getting very tired 2. your child is too breathless to talk or your baby is grunting or unable to feed 3.your child changes colour and becomes pale grey, white or blue around the lips 4.you are worried that your child has got worse

Table 3 Signs of increased work of breathing Increased respiratory rate Chest in-drawing Nasal flaring Tracheal tug Use of accessory muscles Grunting Back More Information

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Table 3 Signs of increased work of breathing Increased respiratory rate Chest in-drawing Nasal flaring Tracheal tug Use of accessory muscles Grunting Back More Information

Table 3 Signs of increased work of breathing Increased respiratory rate Chest in-drawing Nasal flaring Tracheal tug Use of accessory muscles Grunting Back More Information

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