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 IInsp only IIInsp & Passive Exp IIIInsp & Active Exp (pulsus paradoxus) IVAs 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

Thorax 2003; 58 (Suppl I): i1-i92 Detailed history and physical examination pattern of illness severity/control differential clues Presenting features wheeze dry cough breathlessness noisy breathing Is it asthma? ASTHMA

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

Initial assessment of acute asthma in children aged >2 years in A&E Thorax 2003; 58 (Suppl I): i1-i92 Moderate exacerbation Severe exacerbation Life threatening asthma 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) SpO 2 <92% PEF 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 SpO 2 <92% PEF 5 years) Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis

Management of acute asthma in children aged >2 years in A&E Moderate exacerbation Severe exacerbation Life threatening exacerbation ß 2 agonist 2-10 puffs via spacer ± facemask Reassess after 15 minutes 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) mg (>5 years) NOT RESPONDING Repeat inhaled ß 2 agonist every minutes Add soluble oral prednisolone - 20mg (2-5 years) mg (>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 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 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 ARRANGE ADMISSION (lower threshold if concern over social circumstances) ARRANGE IMMEDIATE TRANSFER TO PICU/HDU

Treatment of acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92 D 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 A Inhaled ß 2 agonists are first line treatment for acute asthma * A pMDI and spacer are preferred delivery system in mild to moderate asthma B Individualise drug dosing according to severity and adjust according to response B IV salbutamol (15mg/kg) is effective adjunct in severe cases * Dose can be repeated every minutes

Steroid therapy for acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92 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

Other therapies for acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92 A If poor response to  2 agonist treatment, add nebulised ipratropium bromide (250mcg/dose mixed with  2 agonist) * A Aminophylline is not recommended in children with mild to moderate acute asthma C 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 minutes

Hospital admission for acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92  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 SpO 2 <92% on air after initial bronchodilator treatment

Treatment of acute asthma in children aged <2 years Thorax 2003; 58 (Suppl I): i1-i92 B Oral  2 agonists are not recommended for acute asthma in infants A For mild to moderate acute asthma, a pMDI with spacer is the optimal drug delivery device C 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 B Consider inhaled ipratropium bromide in combination with an inhaled  2 agonist for more severe symptoms