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

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

3. What are the likely causes?
Asthma
Croup
Bronchiolitis
Pneumonia
Pertussis
Inhaled foreign body
Anaphylaxis
Pneumothorax
Not respiratory
sepsis
diabetic ketoacidosis
heart failure
likely
rare
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4. 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
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5. 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
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6. 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
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7. 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
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8. Heart rate and respiratory rate
Adapted from APLS
Age
Respiratory Rate
Heart Rate
Systolic BP
<4wk
40-60
>60
<1yr
30-40
70-90
1-2yrs
25-35
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
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9. 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
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10. Assessment – Asthma (BTS)
PEFR is often of limited use, especially in children who have not previously used a peak flow meter
Oxford Children’s Hospital

11. 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: breaths/min
>12m: 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 – 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

12. 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.
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13. 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
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14. 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
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15. 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

16. 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)
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17. 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
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18. 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

19. 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
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20. 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 ml for smaller children
Adrenaline given IM is safe and a good treatment for asthma
Oxford Children’s Hospital

21. 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

22. 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
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23. Duncan’s slides on coding
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24. Follow up after asthma exacerbations
Code and capture asthma admissions and ED attendances – key outcome measure of practice asthma care

25. 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

26. 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

27. 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