1. Paediatric respiratory distress
EMC SDMH 2015

2. Objectives Identify paediatric respiratory distress
Become familiar with common causes
Understand management protocols and disposition
Objectives

3. Recognition History from parents ‘Grumpy’, poor feeding, unwell, cough
Tachypnoea
Increased Work of Breathing
Need to undress the chest!
Pallor, Diaphoresis, Drowsy  Danger signs of respiratory exhaustion
Recognition

4. Common syndromes Respiratory distress with stridor
Respiratory distress with wheeze
Think – Bronchiolitis
Asthma
Consider – Foreign body
Reflux
Cardiac Failure
Tachypnoea with fever +/- Distress
Think – Pneumonia/-itis
Sepsis
Consider - Bronchiolitis
Asthma (with URTI)
Croup (early)
Respiratory distress with stridor
Think – Croup
Foreign body
Epiglottitis/RP abscess
Consider – Tracheitis
Laryngomalacia
Subglottic stenosis
Common syndromes

5. Bronchiolitis Predominantly follows RSV infection (90%)
Seasonal presentation – autumn/winter. 0-2 yr peak age group
Typically URTI symptoms (snuffles) followed by LRT symptoms
Stereotypical illness lasting days. Symptoms peak day 2-3
Auscultation - mixed crackles and wheezes
Bronchiolitis

6. Bronchiolitis MANAGEMENT RISK FACTORS Supportive NG/IV hydration; O2
Titrate to WoB not Sats (92-93% okay if well)
Antibiotics, Hypertonic saline, Steroids no benefit
Trial salbutamol in older infants may be beneficial
ADMIT- At risk children; Marked WoB; Sats <95%; >50% drop input/output
Prematurity (<37 wk gestational age)
Age <12 wk
Postconception age <48 wk
Witnessed episode of apnea
Underlying cardiopulmonary disease
Immunodeficiency
Chronic lung disease
THESE CHILDREN AT RISK OF SEVERE DISEASE AND MAY REQUIRE SUPPORT
Bronchiolitis

7. URTI, primarily parainfluenza virus
URTI, primarily parainfluenza virus. Affects 0-5 yr , 6mth-3yr commonest
Commences with URTI; vocal changes follow with subsequent typical cough/distress D2-3
Majority mild illness – 1.7% intubation rate however
Diagnosis clinical based on clinical signs
Croup

8. Score <2 – mild, Score 3-7 moderate, Score >8 Severe
Croup Severity

9. Croup Management PREDICTORS OF SEVERE COURSE Age <6 mths
Steroids mainstay of therapy
Dexamethasone mg/kg PO or Prednisone 1mg/kg (2-3day course)
Adrenaline 0.5mg/kg up to 5mg nebulised for severe croup – observe 4 hrs
ADMIT
Severe croup;
If late at night for mod. croup;
Parental concern/representation
Age <6 mths
Hx of subglottic obstruction
Previous severe croup
Severe croup on arrival
Recurrent dose adrenaline needed
Croup

10. Pneumonia Variable presentation to ED. Can occur in any age group.
Cardinal features of pneumonia = fever+cough+tachypnoea+WoB
Nausea/vomiting/abdominal pain/diarrhoea can also be present, and may be presenting complaint
Older child = more typical presentation
Exam features variably present
Illness variable in severity
Pneumonia

11. Pneumonia – Severity assessment
State Guideline suggests use of SPOC for severity assessment
Age <3mths,
Marked dehydration,
Toxic appearance should guide management toward admission
Pneumonia – Severity assessment

12. Pneumonia - Investigations
CXR – not always indicated! Consider if -
diagnosis unclear or
pneumonia classed as moderate/severe or
pleural effusion suspected or
unresponsive to first line treatment
Pathology – likewise limited utility in mild disease. Reserve for Mod-severe
Blood culture % yield rate in mod-severe. Unlikely to change management, but may assist if Staph. Pneumonia
Sputum culture – Younger children highly unlikely to have productive cough; however, older children may co-operate, but require good quality specimen
NPA/Swabs – viral studies. May be some use in limiting therapy if positive for viral infection
Pneumonia - Investigations

13. Pneumonia - Management
Emphasis upon use of amoxicillin/penicillin for uncomplicated pneumonia
Oral amoxicillin for oupatient management, or macrolide
<1 mths old, admitted for IV treatment, IV penicillin +/- gentamicin
1-3 mths old, admit IV penicillin for mild/moderate disease, or Cefotaxime + Lincomycin for severe disease
Attention to pain management, hydration and oxygenation also required.
Pneumonia - Management

14. Extremely common presentation to Australasian ED’s
Extremely common presentation to Australasian ED’s. Winter/Spring peak season
Occurs at any age 2-16 yrs
Due to inflammation + bronchospasm of bronchioles
Several different patterns of asthma in children
Asthma

15. Asthma Infrequent intermittent asthma – 70%:
Attacks of asthma, virtually all URTI related. Symptom free between attacks(>6 weeks apart). Doesn’t require preventer
Frequent intermittent asthma 20%:
Asthma attacks more commonly than 6 weeks.
Usually URTI related. Symptom free between attacks.
‘Seasonal asthma’. May benefit from low dose preventer
Persistent asthma – 10%:
Frequent asthma attacks with interval ongoing symptoms – nocturnal cough, wheeze etc. Benefit from asthma preventer and action plan, and regular paediatric management
Asthma

16. History usually suggestive – previous history common, OR marked family history of atopy
Triad - Cough, SOB and wheeze
Fever often related to triggering URTI, BUT consider differentials
Should NOT make 1st diagnosis in under 1 yr old esp. with fever
Differentials –
Bronchiolitis
Pneumonia
Inhaled foreign body
Laryngomalacia
Cystic fibrosis/Bronchiectasis
Cardiac failure
Asthma

17. Asthma Severity Symptom Mild Moderate Severe/Life-threatening
Oximetry (Air)
>94%
90-94%
<90% HR
Normal
Mildly tachycardic
Marked tachycardia
Talk/Cry
Phrases/Short cry
Words/Weak cry OR None
Work of Breathing
Normal/Mild
Mild/Moderate
Moderate /Severe
Conscious level
Easily distractable
Agitated/ Drowsy
Cyanosis
Cyanosis of any type
Asthma Severity

18. Asthma – High Risk features
History of brittle asthma
Previous Paediatric Intensive Care Unit (PICU) admission due to asthma OR a previous need for intravenous asthma treatment
Re-presentation very soon after discharge from hospital
Recurrent admissions
Co-existent:
Congenital heart disease
Chronic lung disease
Prematurity
Already on maximal treatment at home(e.g. steroids)
Asthma – High Risk features

19. Treatment Treatment Mild Moderate Severe/Life-threatening Oxygen
Not required
To maintain Sats. > 94%
To maintain Sats >94%. Consider HFNP
Steroids
Consider Prednisone 1mg/kg
Prednisone 1-2 mg/kg
Hydrocortisone 4mg/kg IV
Salbutamol
Spacer : Dose
<6 yrs - 6 puffs
>6 yrs - 12 puffs
Spacer : x 3 doses over 60 mins
Either spacer as per moderate OR Nebuliser
5 mg/ml nebs continuous 1 hr if life threatening
Ipratropium
Not recommended
Spacer : x 3 doses over 60 mins: Dose
<6 yrs – 4 puffs
>6 yrs – 8 puffs
Either spacer as per moderate OR Nebuliser x 3 doses: Dose -
<6 yrs - 250mcg
>6 yrs – 500mcg
Investigations
Nil recommended
Consider CXR if abnormal exam
CXR, UEC and ABG recommended
Observation/ED management
3 hrs observation. Treat as required
Observe 30 then 60 minutely. If stretch to 3 hrs, may discharge with clear plan; otherwise admit
Continuous obs.
Paediatric input.
Admission to site if settling.
Escalation
Check diagnosis -Move to moderate plan
Check diagnosis – move to severe
Senior ED/ICU/
NETS consultation
Treatment

20. Asthma - Discharge Requires stable child, salbutamol free for 3 hrs
Parents understand diagnosis and how to manage it (can work the spacer!)
Have medication (give them salbutamol if afterhours)
Easy and available transport back to ED and understanding of when to do so.
Clear discharge follow up with GP
Ideally, outpatient asthma education organised
Asthma - Discharge

21. Questions?

22. Summary Always undress upper half of child in respiratory distress
Beware the pale, sweaty, drowsy child with increased WoB
Look at the child, not the sats. Probe
Bronchiolitis gets worse before it gets better - take care with the young bronchiolitis
Croup normally gets better – but 1.7% still need to be intubated.
Mild pneumonia may not need a CXR (or many tests!) and can have amoxicillin. Low threshold for admission however.
Get used to assessing asthma severity and treat accordingly. Steroids early. Escalate early if not settling
Summary

23. Thank you.