1. Childhood Respiratory Conditions

2. Learning Outcomes By the end of the session you should be able to;
Recognise how common conditions present
Initiate management
Identify high risk groups
Answer questions on respiratory topics

3. Case 1 A 3 month old presents with; He has had a runny nose for 4 days
Increased WOB
Reduced feeding
Less wet nappies
He has had a runny nose for 4 days
Obs: HR 155, RR 48, T 37.4oC
What do you think about the observations?
Tachycardic, tachypnoeic and apyrexial.
It is important to be aware of the normal values for different age groups, as what may be normal for one child may be distinctly abnormal for another. In the above case the child is tachycardic and tachypnoeic.
Normal values
0-6 months – HR , RR 30-50
6-12 months – HR , RR 20-40
1-5 years – HR , RR 20-30

4. Case 1 On examination; What are the differentials?
Appears upset, crying
Signs of respiratory distress
Widespread inspiratory crackles bilaterally
Mild scattered wheeze
What are the differentials?
What investigations might be useful?
What are the signs of respiratory distress in children?
Tracheal tug
Intercostal recession (especially visible in the under 1’s)
Subcostal recession
Supraclavicular recession
Nasal flaring
Abdominal breathing
Differentials include;
Bronchiolitis (very common in this age group, following a viral URTI)
Viral induced wheeze
Inhaled foreign body (tends to have unilateral signs +/- stridor)
LRTI (likely to be pyrexial, more localised signs)
Investigations;
Oxygen saturations
Chest x-ray
NPA
Bloods (FBC and U+Es)
Cultures (blood and urine if temp >38)
Venous blood gas (if severely unwell)

5. Case 1 Investigations; Oxygen saturations 89% on room air Chest x-ray
What’s the diagnosis?
Is the CXR normal?
Hyperinflation, patchy infiltrates and a large thymus – the thymus gradually disappears between 2 and 8 years of age.
The likely diagnosis is bronchiolitis.
CXR findings in bronchiolitis include non-specific patchy infiltration and hyperinfiltration, focal atelectasis, air trapping and diaphragmatic flattening)

6. Case 1: Bronchiolitis Acute LRTI Most common between 2-6 months of age
Presents with breathing difficulties, cough, coryza and decreased feeding
Often follows a viral URTI
Usually due to RSV (50-90% of cases)
Bronchiolitis is the most common cause of hospitalisation and acute respiratory failure in infants in the UK. Peaks occur during the winter months.
About 80% of infants will be affected before the age of 2 years, though most just suffer a mild illness.
Risk factors include;
Prematurity
Chronic lung disease (e.g. CF)
Age <3 months
Older siblings attending nursery and school
Passive smoking
Over crowding
Neurological disease
Immunodeficiency
Breastfeeding is considered protective.
It presents with breathing difficulties, decreased feeding and irritability, usually following a viral URTI.
50-90% of cases are due to respiratory syncytial virus, other causes include human metapneumovirus, adenovirus and parainfluenza virus.

7. Case 1: Bronchiolitis Most infants managed at home Hospital if;
Feeding <50% of normal Grunting
Lethargy Cyanosis
Significant tachypnoea Sats <94%
Supportive hospital management;
Oxygen
Nasogastric feeds
Most infants with bronchiolitis have a mild, self-limiting illness that can be managed in the community with monitoring of fluid intake and temperature.
Infants should be referred to hospital if there is a history of;
- Poor feeding (<50% usual intake over previous 24 hours) which is inadequate to maintain hydration
- Lethargy
- Apnoea
- Respiratory rate >70 breaths/minute
- Nasal flaring or grunting
- Severe chest wall recession
- Cyanosis
- Saturations ≤94%
Even in hospital most children only require supportive management with oxygen and nasogastric feeds.
Other therapies which may be tried include bronchodilators, corticosteroids and adrenaline but there is little evidence of their benefit.
Why might these babies require NG feeds?
Their respiratory rate mean it is very difficult for them to feed orally. NG feeds allow mums to continue giving breast milk and feed is more physiological. The alternative is IV fluids which don’t contain calories, and IV access may be difficult.

8. Case 1: Bronchiolitis
Oxygen is often delivered via a head box for younger infants as it is better tolerated than face masks, and allows a higher percentage of oxygen delivery than nasal cannulae.

9. Case 1: Bronchiolitis Usually lasts 7-10 days
Most infants make a full recovery
Mortality is higher with underlying heart and lung disease
Immunoprophylaxis is available for certain groups
The usual course of bronchiolitis is for things to get worse, peaking around day 3, before getting better.
The majority of children recover within 7-10 days, though a small percentage will still have symptoms at 4 weeks.
Mortality is higher in under 6 months and in infants with underlying cardiac or pulmonary disease.
Palivizumab is a monoclonal antibody that provides passive immunity and significantly reduces RSV-related hospital and PICU admissions. It is offered to those at risk of severe RSV disease, including;
Children under 2 years with chronic lung disease who required 28 days of oxygen from birth or has home oxygen
Children under 2 years with severe congenital immunodeficiency
Children under 6 months with left-right shunt, significant congenital heart disease or pulmonary hypertension
It is given as a monthly IM injection during winter months.

10. Case 2 A 2 year old girl presents with;
3 day history of sore throat and coryza
Fever
Inspiratory noises at rest
Loud, barking cough for the last 20 hours
On examination there are signs of respiratory distress, tachypnoea and tachycardia
What are the inspiratory sounds?
Stridor
What do they signify?
Upper airway obstruction
What are the differentials?
Inhaled foreign body
Croup
Epiglottitis
Diptheria
Anaphylaxis
Laryngomalacia
Retropharyngeal abscess (quinsy)
Peritonsillor abscess

11. Case 2: Croup Upper respiratory tract inflammation
Usually secondary to viral URTI
Symptoms of URTI, barking cough and stridor
Parainfluenza viruses cause ~80%
Most common between 6 months – 3 years
Croup is inflammation of the upper respiratory tract, usually secondary to a viral upper respiratory tract infection. The inflammation and oedema of the nasopharynx, trachea and larynx is responsible for the stridor, whilst the impairment of the vocal cords causes the barking cough.
The main diagnoses to exclude in expected croup are inhaled foreign body and epiglottitis.
Parainfluenza viruses are responsible for around 80% of cases, with other organisms including RSV, adenovirus and rhinovirus.

12. Case 2: Croup Most managed at home after dexamethasone
Last around 3-7 days
Consider hospital admission if;
Aged <6 months Severe obstruction
Poor oral intake Immunocompromise
Keep upright, minimise distress, give O2 to keep sats >93%, steroids, nebulised adrenaline
The majority of cases are mild and self-limiting, lasting around 3-7 days, and can be managed at home following a stat dose of oral dexamethasone.
Hospital admission should be considered;
For children <6 months
Where there is inadequate oral intake
Underlying upper airway abnormalities
Immunocompromise
Management includes;
Keeping the child upright and comfortable
Giving oxygen to keep sats above 93%
Nebulised adrenaline if significant stridor or respiratory distress
Steroids (route dependent on severity)
Don’t give antibiotics unless you suspect superimposed bacterial infection.
The prognosis is excellent, less than 5% of infants require hospitalisation and less than 2% of those admitted require intubation and ventilation.

13. What diagnoses needs to be considered?
Case 3
A 4 year old is referred to clinic with FTT
6 admissions with LRTI in the last year
On examination;
Small for his age
Widespread bilateral crackles
Upper zone wheeze
What diagnoses needs to be considered?
What is the most likely diagnosis?
Cystic fibrosis
Immunodeficiency
Failure to thrive is a common presentation in paediatrics, but with a history of recurrent chest infections and the chest signs, cystic fibrosis is the likely diagnosis.

14. Case 3: Cystic Fibrosis Autosomal recessive disease
Mutation of the CFTR gene on Chr 7
Affects 1 in 2500 newborns
Usually identified on the newborn Guthrie test
Other investigations include sweat testing, genetic testing, CT head and thorax
CF is an autosomal recessive condition resulting in a mutation of the CFTR gene on chromosome 7. There are over 1500 mutations, with the most common being mutation in the Caucasian population being delta F508.
CFTR is an ATP-responsive chloride channel, affecting chloride transport across respiratory epithelium and composition of cell surface glycoproteins.
It is the most common inherited disease in white populations, affecting 1 in every 2500 newborns. The only risk factor is a positive family history.
In the UK CF is usually diagnosed on the Guthrie test on day 6 of life, though screening failures do occur.
Other investigations include;
Sweat testing: 98% sensitive, chloride >60 mmol/L on two separate occasions with lower sodium levels are diagnostic
Genetic testing for the CFTR gene
Sinus x-ray or head CT: opacification is present in almost all CF patients
CXR or chest CT

15. Case 3: Cystic Fibrosis Perinatal presentation;
Screening Prolonged jaundice
Meconium ileus Haemorrhagic disease
Infancy and childhood presentation;
Recurrent LRTI FTT
Diarrhoea Rectal prolapse
Nasal polyps Acute pancreatitis
Presentation and diagnosis of CF is dependent on age – their are certain condition that should always prompt investigation for CF, including meconium ileus in neonates and nasal polyps in children, which are almost always due to CF.

16. Case 3: Cystic Fibrosis Signs include; Clubbing Cough Purulent sputum
Crackles
Wheeze
Obstructive FEV1
Chest x-ray changes in cystic fibrosis include;
Hyperinflation
bronchiectasis
What is the device seen?
A portacath – a subcutaneous central venous catheter that allows both injection or intravenous infusion or withdrawal of bloods.
There are commonly used in CF patients due to the frequent need for IV antibiotics and blood tests. They decrease discomfort for patients compared to repeat venepuncture and cannulation.

17. Case 3: Cystic Fibrosis Best managed in a tertiary CF centre
Respiratory problems;
Chest physio Regular sputum samples
Saline nebs Prophylactic abx
Pancreatic insufficiency and nutrition;
Creon Vitamin supplements
Estimated survival is years
CF should be managed in a tertiary CF centre, by a multidisciplinary team.
The most common cause of morbidity and mortality in CF is secondary to respiratory disease – chronic inflammation leads to bronchiectasis, progressive airflow obstruction, cor pulmonale and death.
The aim is to prevent or reduce this initial inflammation by promoting good mucous clearance with chest physio and saline nebs, regular sputum cultures and prophylactic antibiotics to reduce the incidence of staph aureus and appropriate antibiotic choice in acute infections.
At least 85% of CF patients have pancreatic insufficiency, resulting in meconium ileus, FTT, steatorrhoea and malabsorption. Diagnosis of pancreatic insufficiency is with faecal elastase (the presence of unsplit fat globules in stool). Treatment is with pancreatic enzyme supplements, such as creon, and vitamin suppletmentation.
With improved treatment of the complications of CF has meant an increase in estimated survival from 30 years of age for children born in 1999 to years for children born today.

18. Case 4 A 5 year old girl presents to resus with;
Acute SOB
RR 42
HR 138
How should she be assessed?
ABCDE assessment

19. Case 4 Airway: speaking, but not in full sentences
Breathing: RR 42, sats 91% on RA, intercostal and subcostal recession, poor AE/wheeze bilaterally
Circulation: HR 138, systolic BP 100
Disability: GCS 15/15, CBG 6.2
Expose: no other sign of injury or illness
What is the most likely diagnosis?
Acute severe asthma
Parameters for diagnosis of acute severe asthma are;
Unable to speak in full sentences/feed
Heart rate >120pm if >5 years, or >130bpm if aged 2-5 years
Respiratory rate >30 if >5 years, or >40-50 if age 2-5 years
Are any other investigations needed at this point?
Probably not – CXR and blood gases are rarely required in children as they don’t add much information.
Continued sats monitoring and assessment of GCS is of course important.

20. Case 4: Asthma Most common respiratory illness in children
Characterised by;
Chronic airway inflammation
Bronchial hyper-reactivity
Reversibility with bronchodilators
Often a family history or history of atopy
Asthma affects around 10% of the population, and can present at any age, though approximately half present before 10 years of age.

21. Case 4: Asthma Symptoms; Acute exacerbation;
Dry cough Wheeze
Chest tightness Breathing difficulties
Acute exacerbation;
Tachypnoea Tachycardia
Low saturations Decreasing consciousness
Peak flows are useful >5 years of age
Symptoms of asthma tend to be worse early in the morning, on exertion and in cold weather.
Peak flows are used in children over 5 years of age. Normal values are based on the child's height and weight.

22. Case 4: Asthma
For all children with asthma non-drug management should include advice on;
Avoiding precipitants such as house dust mites and pets
Stopping smoking in the household
Clear asthma management plans
Chronic management for children under 5 years of age;
Step 1: short-acting beta 2 agonist PRN
Step 2: add inhaled steroid or leukotriene receptor antagonist
Step 3: short-acting beta 2 agonist, inhaled steroid and leukotriene receptor antagonist
Step 4: refer to respiratory specialist

23. Case 4: Asthma Chronic management for children 5 to 12 years of age;
Step 1: short-acting beta 2 agonist PRN
Step 2: add inhaled steroid
Step 3: add long-acting beta 2 agonist and monitor response – if poor response increase dose of inhaled steroid
Step 4: increased inhaled steroid up to 800mcg a day
Step 5: oral steroid and refer to respiratory specialist
Remember, if control is good for >3 months consider stepping down

24. Case 4: Asthma Acute management; High flow oxygen if SpO2 <92%
Inhaled/nebulised β2 agonists
Early steroids
Consider inhaled/nebulised ipratropium bromide
Consider nebulised MgSO4
If not improving IV salbutamol and aminophylline
Consider critical care review
Management of acute asthma involves;
High flow oxygen if sats less than 92% or life-threatening asthma on presentation
Inhaled β2 agonists via a spacer, up to 10 puffs – inhaler preferred to nebulisers in mild/mod asthma as less tahcycardia
If not improving with 10 puffs refer to hospital and give 2.5-5mg of nebulised salbutamol or 5-10mg of terbutaline
Early steroids – there is little difference in efficacy between oral and IV steroids, give IV if unable to swallow
20mg for children aged 2-5 years, 30-40mg for children > 5 years
A 3 day course is usually sufficient
If not responsing to oxygen, salbutamol and steroids consider adding ipratropium bromide and IV salbutamol – bolus or infusion.
IV aminophylline should be considered for acute severe and life threatening asthma who have not responded to other treatment. It should be delivered in a HDU/ICU setting.
There is little evidence showing the benefit of IV magnesium sulphate.

25. Practice Questions

26. Questions: MCQs A chloride concentration of _____ is diagnostic of CF.
a. >40mmol/L b. >60mmol/L
c. >80mmol/L d. >120mmol/L
Which of the following is a side effect of inhaled steroids?
a. Genital candidiasis b. Growth stunting
c. Immunosupression d. Gastric ulcers

27. Questions: MCQs
3. What is the next step for a 4 year old child with uncontrolled asthma already using PRN salbutamol and 200mcg of inhaled steroid? a. Regular salbutamol b. 400mcg steroids c. Montelukast d. Paeds referral 4. CF may present with... a. Early jaundice b. Recurrent URTI c. Female sterility d. Nasal polyps

28. Questions: MCQs
5. Risk factors for bronchiolitis include... a. Obesity b. Infants <6 months c. Passive smoking d. Only child 6. Most common cause of pneumonia <5 years a. Staph aureus b. E. coli c. Mycoplasma pneum. d. Strep pneumonia

29. Questions: EMQ 1 a. Bordetella pertussis b. Parainfluenza
c. Haemophilus influenza d. RSV
e. Adenovirus f. Rhinovirus
A 7 week old child presents with bouts of coughing, followed by a loud noise & vomiting. He has been unwell for the last 2 weeks.
An 6 month old ex-26 weeker presents with signs of respiratory distress & poor feeding. Temp 37.2, RR 47, HR 145.

30. Questions: EMQ 1 a. Bordetella pertussis b. Parainfluenza
c. Haemophilus influenza d. RSV
e. Adenovirus f. Rhinovirus
A 2 year old presents with a barking cough and coryza for 48 hours. Temp 36.4.
4. A 2 year old presents with 2 hours of fever and pyrexia. He is drooling and very still. Temp There was no prodrome.

31. Questions: EMQ 2 a. Inhaled salbutamol b. IV salbutamol
c. IV MgSO4 d. Prednisolone
e. Nebulised salbutamol e. Aminophylline
A 4 year old child presents with acute SOB, RR 34, sats 95%, HR 125.
A 7 year old with acute asthma is not responding to nebulisers and steroids.

32. Questions: EMQ 2 a. Inhaled salbutamol b. IV salbutamol
c. IV MgSO4 d. Prednisolone
e. Nebulised salbutamol e. Aminophylline
3. A 9 year old acute asthma is not responding to IV salbutamol or IV steroids.
4. A 4 year old is referred from her GP as she is not responding to 10 puffs of salbutamol.

33. Questions: Image 1 What drug is in this inhaler?
When should it be used?

34. Questions: Image 2 What type of device is shown?
What % of oxygen can it deliver?

35. Questions: Image 3
Child presents with 5 days of SOB, cough and fevers. Started on abx by GP 2 days ago, but no response.
What is the diagnosis?
Where are they most likely to occur?

36. Questions: Image 4
This 11 year old boy presents with acute SOB and RR 32.
What is the diagnosis?
What treatment is needed?

37. Answers

38. Answers: MCQs A chloride concentration of _____ is diagnostic of CF.
a. >40mmol/L b. >60mmol/L
c. >80mmol/L d. >120mmol/L
Which of the following is a side effect of inhaled steroids?
a. Genital candidiasis b. Growth stunting
c. Immunosupression d. Gastric ulcers
Inhaled steroids rarely cause systemic side effects as there is minimal absorption, however growth should be monitored if there is prolonged use at higher doses.
Local effects are more common, including oral candidiasis, so children should be advised to wash their mouths out or brush their teeth after administration.

39. Answers: MCQs
3. What is the next step for a 4 year old child with uncontrolled asthma already using PRN salbutamol and 200mcg of inhaled steroid? a. Regular salbutamol b. 400mcg steroids c. Montelukast d. Paeds referral 4. CF may present with... a. Early jaundice b. Recurrent URTI c. Female sterility d. Nasal polyps
Presentation of CF in the neonate includes;
Screening with the Guthrie card
Meconium ileus
Prolonged jaundice
Presentation of CF in the infant or child includes;
Nasal polyps
Recurrent LRTI
FTT
Diarrhoea
Acute pancreatitis

40. Answers : MCQs
5. Risk factors for bronchiolitis include... a. Obesity b. Infants <6 months c. Passive smoking d. Only child 6. Most common cause of pneumonia <5 years a. Staph aureus b. E. coli c. Mycoplasma pneum. d. Strep pneumonia

41. Answers : EMQ 1 a. Bordetella pertussis b. Parainfluenza
c. Haemophilus influenza d. RSV
e. Adenovirus f. Rhinovirus
A 7 week old child presents with bouts of coughing, followed by a loud noise & vomiting. He has been unwell for the last 2 weeks.
An 6 month old ex-26 weeker presents with signs of respiratory distress & poor feeding. Temp 37.2, RR 47, HR 145.
Bordetella pertussis infection causes whooping cough – an upper respiratory tract infection presenting with persistent cough, lasting >21 days, which come in paroxysms, ending in a whoop and often causing vomiting. It is extremely distressing for parents and is a notifiable disease.
The disease has 3 stages;
Catarrhal (1-2 weeks): mild symptoms or fever, cough and coryza
Paroxysmal (2-6 weeks): severe paroxysms followed by an inspiratory whoop and vomiting
Convalescent (2-4 weeks): improving symptoms

42. Answers : EMQ 1 a. Bordetella pertussis b. Parainfluenza
c. Haemophilus influenza d. RSV
e. Adenovirus f. Rhinovirus
A 7 week old child presents with bouts of coughing, followed by a loud noise & vomiting. He has been unwell for the last 2 weeks.
An 6 month old ex-26 weeker presents with signs of respiratory distress & poor feeding. Temp 37.2, RR 47, HR 145.

43. Answers : EMQ 1 a. Bordetella pertussis b. Parainfluenza
c. Haemophilus influenza d. RSV
e. Adenovirus f. Rhinovirus
A 2 year old presents with a barking cough and coryza for 48 hours. Temp 36.4.
4. A 2 year old presents with 2 hours of fever and pyrexia. He is drooling and very still. Temp There was no prodrome.
Viral laryngotracheobronchitis, a.k.a. Croup is caused by parainfluenza viruses in 80% of cases.

44. Answers : EMQ 1 a. Bordetella pertussis b. Parainfluenza
c. Haemophilus influenza d. RSV
e. Adenovirus f. Rhinovirus
A 2 year old presents with a barking cough and coryza for 48 hours. Temp 36.4.
4. A 2 year old presents with 2 hours of fever and pyrexia. He is drooling and very still. Temp There was no prodrome.
This describes a cause of epiglottitis, which is life-threatening swelling of the epiglottis most commonly caused by haemophilus influenza type B.
It most commonly presents in children aged 1-6 years and is one of the most important differential diagnoses for children presented with suspected croup.
The main differences between epiglottitis and croup are;
Epiglottitis occurs rapidly over hours, croup may day take days
There is no prodrome or warning in cases of epiglottitis
Children are unable to drink, and dribble as they cannot swallow their own saliva (children with croup can still feed though it may be reduced)
Children appear toxic with epiglottitis, with fevers >38.5
They have a very soft stridor and quiet or no voice (compared with the rasping stridor and hoarse voice in croup)

45. Answers : EMQ 2 a. Inhaled salbutamol b. IV salbutamol
c. IV MgSO4 d. Prednisolone
e. Nebulised salbutamol e. Aminophylline
A 4 year old child presents with acute SOB, RR 34, sats 95%, HR 125.
A 7 year old with acute asthma is not responding to salbutamol nebs and steroids.
Inhaled salbutamol is always first line in mild-moderate acute asthma.

46. Answers : EMQ 2 a. Inhaled salbutamol b. IV salbutamol
c. IV MgSO4 d. Prednisolone
e. Nebulised salbutamol e. Aminophylline
A 4 year old child presents with acute SOB, RR 34, HR 125.
A 7 year old with acute asthma is not responding to nebulisers and steroids.
The next step is to try nebulised ipratropium bromide and IV salbutamol (initially bolus, then infusion is required)

47. Answers : EMQ 2 a. Inhaled salbutamol b. IV salbutamol
c. IV MgSO4 d. Prednisolone
e. Nebulised salbutamol e. Aminophylline
3. A 9 year old acute asthma is not responding to IV salbutamol or IV steroids.
4. A 4 year old is referred from her GP as she is not responding to 10 puffs of salbutamol.
At this point if the child is not improving you should be getting a critical care review (PICU) and considering an aminophylline infusion. There is little evidence for the use of magnesium sulphate infusions in paediatrics.

48. Answers : EMQ 2 a. Inhaled salbutamol b. IV salbutamol
c. IV MgSO4 d. Prednisolone
e. Nebulised salbutamol e. Aminophylline
3. A 9 year old acute asthma is not responding to IV salbutamol or IV steroids.
4. A 4 year old is referred from her GP as she is not responding to 10 puffs of salbutamol.
For children not responding to inhaled salbutamol nebulised salbutamol is the next step – this is much more potent than inhalers and can be oxygen driven if required.
You may want to consider a trial of ipratropium as well – it works very well for some children.

49. Answers: Image 1 What drug is in this inhaler? Salbutamol
When should it be used?
When required to RELIEVE symptoms
Many parents know their child's salbutamol inhaler as the ‘blue inhaler’ or by its trade name ‘Ventolin’.
It is a short acting β2 agonist that causes bronchodilatation in acute shortness of breath. The usual dose is 2 puffs when required.
Parents should be advised to use up to 6 puffs at a time, and if that is not helping to seek medical attention. If a child is not responding to 10 puffs they should be referred to hospital.

50. Answers: Image 2 What type of device is shown?
Non-rebreathe or trauma mask
What % of oxygen can it deliver?
~80%
A face mask with a oxygen reservoir bag is called a non-rebreathe or trauma mask.
It is often used in emergency situations and can deliver around 80% oxygen when using a flow rate of 15L/min.

51. Answers: Image 3 What is the diagnosis? Inhaled foreign body (right)
Child presents with 5 days of SOB, cough and fevers. Started on abx by GP 2 days ago, but no response.
What is the diagnosis?
Inhaled foreign body (right)
b. Where are they most likely to occur?
Right main bronchus
Inhaled foreign body is a common presentation in paediatrics, and should be considered in any child with persistent SOB and cough that doesn’t respond to antibiotics. If left the child can become very unwell with LRTI and sepsis.
Treatment is bronchoscopy and removal.

52. Answers: Image 4
This 11 year old boy presents with acute SOB and RR 32.
What is the diagnosis?
Tension pneumothorax (right)
b. What treatment is needed?
Thoracocentesis
This shows a right sided pneumothorax under mild tension.
Emergency management involves insertion of a large-bore cannula (attached to a syringe filled with water) into the 2nd intercostal space, mid-clavicular line to release the air from the pleural space.
A chest drain will be needed following this.

53. Summary Respiratory conditions are common in infants
Early recognition and management decreases mortality
Good communication with parents helps to relieve distress and anxiety
Knowledge of causative organisms is important clinically, and also for exams!

54. Any questions?