Acute Respiratory Disorders in Children Dr Donna Traves Paediatric Consultant 3rd October 2012

Objectives Be able to: Discuss a range of childhood acute respiratory problems Understand when to refer in children with acute respiratory disease Understand the acute management of paediatric acute respiratory disease

Aims To discuss: Recognising Sick child with respiratory disease Infection – bronchiolitis, pneumonia, croup, Epiglottitis Inflammatory respiratory disease - Asthma, allergy

Recognising sick child - respiratory Effort of breathing Recession Resp rate - ? Slow/shallow Grunting – may indicate atelectasis Accessory muscle use Nasal flare

Recognising sick child - respiratory Efficacy of breathing Breath sounds -? Any added Wheeze – indicates lower airway narrowing Stridor – indicates upper airway narrowing Chest – expansion - +/- abdominal use O2 saturations – ensure correct probe

Recognising sick child - respiratory Feeding history Reduced, absent Eating v drinking Wet nappies etc General activity Happy playing – eg happy wheezer Lethargic flat

Examples of Increased Respiratory Distress APLS video

Infection

Bronchiolitis Viral illness Affects children <2 yrs Oedema and mucus of the bronchioles (lower airways), leading to over inflation and collapse Causes – RSV ( 70%), para influenza, adenovirus, influenza

Bronchiolitis - Symptoms Coryzal symptoms 2-3 days Dry, wheezy Cough Wheeze Difficulty in Breathing Cyanosis Apnoea (esp <6 weeks) Poor Feeding

Bronchiolitis - Signs Cyanosis/ ↓ O2 Sats Tachypnoea Hyperinflation (liver displaced↓) Recession/ tracheal tug Widespread fine inspiratory crackles Wheeze Fever >38ºC not usually a feature

When to Refer < 1 month age Significant work of breathing Concerns over cyanosis/ low sats (<92%) <50% feeds or Signs of dehydration Look unwell Persistent high temp >38 Concerns over above early in illness

Bronchiolitis - Investigations Oxygen sats NPA CXR

Bronchiolitis - Treatment Supportive – mostly at home Small frequent feeds Nasal saline drops Positioning Admission treatment Oxygen NG feeding Suction

Other Treatment?.... Inhalers – not generally recommended; not clinically proven to effect hospitalisation Evidence emerging for: Nebulised epinephrine with either oral dexamethasone (decrease risk of hospitalisation) Nebulised 3% hypertonic saline ( decrease length of hospital stay)

Pneumonia Infection of the lung parenchyma/tissue Bacterial or Viral Commonly: Strep pneumoniae Staphylococcus Haemophilus influenzae mycoplasma

Pneumonia Symptoms Signs Cough Temperature Lethargy, decreased eating/drinking vomiting Signs Temperature, increased resp rate, decreased oxygen sats Increased work of breathing, tachycardia Crackles heard

Pneumonia - Diagnosis Clinical CXR Blood tests – culture, serology Sputum sample

Pneumonia

Persistent CXR changes If no response to course of antibiotics needs further investigation/ referral Can be investigated with Immune Bronchoscopy Flexible – thin and more mobile Rigid – large, inflexible, good for removing foreign bodies BAL ( Broncho-alveolar- lavage) Samples of secretions taken during bronchoscopy Sent for culture and sensitivity

Pneumonia-Treatment Antibiotics Admission Eg amoxicillin, clarithromycin Usually 5 days Admission Oxygen Severe respiratory distress Very young Dehydrated – NG feeding or IV fluids

When to refer Significant work of breathing Look unwell Dehydration O2 Sats < 92% in air Failure to respond to oral antibiotics after 48 hours with worsening signs/symptoms ( may be viral!) Concern over effusion

Empyema Complication of pneumonia Collection of pus – usually in pleural cavity Signs Pneumonia - not improving on abx Cough, temperature Chest pain

Empyema - Diagnosis CXR – fluid seen USS – site of collection CT chest – if complicated

Empyema - CXR

Croup Infection of the upper airway Oedema, swelling and inflammation =laryngotracheobronchitis Usually viral adenovirus, parainfluenzae, RSV

Anatomy <------bronchus

Croup – Symptoms Barking cough Noisy breathing – inspiratory stridor Mild temperature Often cold/coryzal symptoms Often wake at night Not usually acutely unwell

Croup - Signs Cough = often diagnostic Temperature Stridor ( due to sub-glottic narrowing) Respiratory distress: mild – severe Decreased oxygen saturations – if severe

Croup - Treatment Minimal handling/ examination Oral steroids – Dexamethasone (0.15-0.3mg/kg) or prednisolone (1mg/kg) Nebulised budesonide Nebulised adrenaline If severe – intubate and ventilate Keep child calm to maintain airway

When to refer: Marked respiratory difficulty Marked stridor at rest Agitated Decreased O2 sats (if available) Trial of dexamethasone = no improvement after 1 hour

Epiglottitis Infection/ cellulitis of the epiglottis Caused by Haemophilus influenzae Commonest 2-5 years – but any age

Anatomy

Epiglottitis - Signs and Symptoms Very acute onset Fever, ill toxic looking child Very sore throat – drooling, not speaking Soft stridor, respiratory distress Child sits upright, protecting own airway

Epiglottitis - Diagnosis No investigations initially Clinical – appearance on intubation Throat swabs Blood cultures

Epiglottitis - Treatment Keep child calm, no cannulas/ IM injections etc Intubate -> ventilate ~ 24 – 48hrs IV antibiotics

Epiglottitis – when to refer Always!

Inflammatory conditions

Asthma Chronic inflammatory disorder, inflammation that is variable; with hyper-responsiveness and reversible airways disease. Treatment – acute and chronic Reliever and preventer inhalers

Asthma: Symptoms Wheeze Cough – day/ night Breathlessness Increased work of breathing

Diagnosis Age - > 2 years History Examination PEFR Allergy tests Acute – exacerbation Chronic – interval symptoms Examination Wheeze, hyperexpansion, chest deformity PEFR Not in exacerbation Allergy tests

Treatment Acute Chronic/ interval symptoms Salbutamol, Atrovent (always with spacer) Monteleukast Prednisolone – 3 days Chronic/ interval symptoms Inhaled steroids (beclomethasone, fluticasone) Long acting salmeterol = seretide

When to refer: Acute: Chronic: Using more than 10 puffs 3-4 hourly Significant respiratory distress Look unwell Sats < 92% in air Chronic: Failure to respond to inhaled steroids Persistent interval symptoms Unclear trigger

Allergens

Allergy Symptoms: Signs Wheeze, cough, upper airway obstruction, stridor, Angioedema, rash, collapse Signs Rash, swelling, increased work of breathing Increased respiratory rate, noisy breathing/stridor Tachycardia Decreased GCS

Diagnosis Acutely – identify trigger => history Investigations Skin prick testing Blood tests – RAST testing Food challenge

When to refer? Anaphylaxis/ severe reaction Unknown/unclear trigger Multiple allergy Dietician input needed Concurrent diagnosis Asthma/wheeze Need epipen

Skin prick testing

RAST Tests Blood test Levels if IgE to specific allergens Many different allergens tested Grade of response/IgE level given >4 significant

Allergy - Treatment Severe reaction – call for help, 999, hospital admission ABC, oxygen, Adrenaline – IM or IV Steroids – IV or oral Anti histamines eg piriton, clarityn (IV or oral)

That’s all!! Thanks – Any questions??