Acute Respiratory Acute Respiratory Disorders in ChildrenDisorders in Children

Dr Donna TravesDr Donna Traves

Paediatric ConsultantPaediatric Consultant

33rdrd October 2012 October 2012

Objectives Objectives

Be able to:Be able to: Discuss a range of childhood acute Discuss a range of childhood acute

respiratory problemsrespiratory problems Understand when to refer in children Understand when to refer in children

with acute respiratory diseasewith acute respiratory disease Understand the acute management of Understand the acute management of

paediatric acute respiratory diseasepaediatric acute respiratory disease

AimsAims

To discuss:To discuss: Recognising Sick child with respiratory Recognising Sick child with respiratory

diseasedisease Infection Infection

– – bronchiolitis, pneumonia, croup, bronchiolitis, pneumonia, croup, EpiglottitisEpiglottitis

Inflammatory respiratory disease Inflammatory respiratory disease

- Asthma, allergy- 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

InfectionInfection

BronchiolitisBronchiolitis

Viral illnessViral illness Affects children <2 yrsAffects children <2 yrs Oedema and mucus of the Oedema and mucus of the

bronchioles (lower airways), leading bronchioles (lower airways), leading to over inflation and collapseto over inflation and collapse

Causes – RSV ( 70%), para influenza, Causes – RSV ( 70%), para influenza, adenovirus, influenzaadenovirus, influenza

Bronchiolitis - SymptomsBronchiolitis - Symptoms

Coryzal symptoms 2-3 daysCoryzal symptoms 2-3 days Dry, wheezy CoughDry, wheezy Cough WheezeWheeze Difficulty in BreathingDifficulty in Breathing CyanosisCyanosis Apnoea (esp <6 weeks)Apnoea (esp <6 weeks) Poor Feeding Poor Feeding

Bronchiolitis - SignsBronchiolitis - Signs

Cyanosis/ ↓ O2 SatsCyanosis/ ↓ O2 Sats TachypnoeaTachypnoea Hyperinflation (liver displaced↓)Hyperinflation (liver displaced↓) Recession/ tracheal tugRecession/ tracheal tug Widespread fine inspiratory cracklesWidespread fine inspiratory crackles WheezeWheeze Fever >38ºC Fever >38ºC not usuallynot usually a feature 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 - InvestigationsBronchiolitis - Investigations

Oxygen satsOxygen sats NPANPA CXRCXR

Bronchiolitis - TreatmentBronchiolitis - Treatment

Supportive – mostly at homeSupportive – mostly at home Small frequent feedsSmall frequent feeds Nasal saline dropsNasal saline drops PositioningPositioning

Admission treatmentAdmission treatment OxygenOxygen NG feedingNG feeding SuctionSuction

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)

PneumoniaPneumonia

Infection of the lung Infection of the lung parenchyma/tissueparenchyma/tissue

Bacterial or ViralBacterial or Viral Commonly:Commonly:

Strep pneumoniaeStrep pneumoniae StaphylococcusStaphylococcus Haemophilus influenzaeHaemophilus influenzae mycoplasmamycoplasma

PneumoniaPneumonia

SymptomsSymptoms CoughCough TemperatureTemperature Lethargy, decreased eating/drinkingLethargy, decreased eating/drinking vomitingvomiting

SignsSigns Temperature, increased resp rate, decreased Temperature, increased resp rate, decreased

oxygen satsoxygen sats Increased work of breathing, tachycardiaIncreased work of breathing, tachycardia Crackles heardCrackles heard

Pneumonia - DiagnosisPneumonia - Diagnosis

ClinicalClinical CXRCXR Blood tests – culture, serologyBlood tests – culture, serology Sputum sampleSputum sample

PneumoniaPneumonia

Persistent CXR changesPersistent CXR changes

If no response to course of antibiotics If no response to course of antibiotics needs further investigation/ referralneeds further investigation/ referral

Can be investigated with Can be investigated with Immune Immune Bronchoscopy Bronchoscopy

Flexible – thin and more mobileFlexible – thin and more mobile Rigid – large, inflexible, good for removing foreign Rigid – large, inflexible, good for removing foreign

bodiesbodies BAL ( Broncho-alveolar- lavage) BAL ( Broncho-alveolar- lavage)

Samples of secretions taken during bronchoscopySamples of secretions taken during bronchoscopy Sent for culture and sensitivitySent for culture and sensitivity

Pneumonia-TreatmentPneumonia-Treatment

AntibioticsAntibiotics Eg amoxicillin, clarithromycinEg amoxicillin, clarithromycin Usually 5 daysUsually 5 days

AdmissionAdmission OxygenOxygen Severe respiratory distressSevere respiratory distress Very youngVery young Dehydrated – NG feeding or IV fluidsDehydrated – 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

EmpyemaEmpyema

Complication of pneumoniaComplication of pneumonia Collection of pus – usually in pleural Collection of pus – usually in pleural

cavitycavity SignsSigns

Pneumonia - not improving on abxPneumonia - not improving on abx Cough, temperatureCough, temperature Chest painChest pain

Empyema - DiagnosisEmpyema - Diagnosis

CXR – fluid seenCXR – fluid seen USS – site of collectionUSS – site of collection CT chest – if complicatedCT chest – if complicated

Empyema - CXREmpyema - CXR

CroupCroup

Infection of the upper airwayInfection of the upper airway Oedema, swelling and inflammationOedema, swelling and inflammation =laryngotracheobronchitis=laryngotracheobronchitis

Usually viral Usually viral adenovirus, parainfluenzae, RSVadenovirus, parainfluenzae, RSV

AnatomyAnatomy

<------bronchus

Croup – SymptomsCroup – Symptoms

Barking coughBarking cough Noisy breathing – inspiratory stridorNoisy breathing – inspiratory stridor Mild temperatureMild temperature Often cold/coryzal symptomsOften cold/coryzal symptoms Often wake at nightOften wake at night Not usually acutely unwellNot usually acutely unwell

Croup - SignsCroup - Signs

Cough = often diagnosticCough = often diagnostic TemperatureTemperature Stridor ( due to sub-glottic Stridor ( due to sub-glottic

narrowing)narrowing) Respiratory distress: mild – severeRespiratory distress: mild – severe Decreased oxygen saturations – if Decreased oxygen saturations – if

severesevere

Croup - TreatmentCroup - Treatment

Minimal handling/ examinationMinimal handling/ examination Oral steroids – Dexamethasone (0.15-Oral steroids – Dexamethasone (0.15-

0.3mg/kg) or prednisolone (1mg/kg)0.3mg/kg) or prednisolone (1mg/kg) Nebulised budesonideNebulised budesonide Nebulised adrenalineNebulised adrenaline If severe – intubate and ventilateIf severe – intubate and ventilate

Keep child calm to maintain airwayKeep 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

EpiglottitisEpiglottitis

Infection/ cellulitis of the epiglottisInfection/ cellulitis of the epiglottis

Caused by Haemophilus influenzaeCaused by Haemophilus influenzae

Commonest 2-5 years – but any ageCommonest 2-5 years – but any age

AnatomyAnatomy

Epiglottitis - Signs and Epiglottitis - Signs and SymptomsSymptoms

Very acute onsetVery acute onset Fever, ill toxic looking childFever, ill toxic looking child Very sore throat – drooling, not Very sore throat – drooling, not

speakingspeaking Soft stridor, respiratory distressSoft stridor, respiratory distress Child sits upright, protecting own Child sits upright, protecting own

airwayairway

Epiglottitis - DiagnosisEpiglottitis - Diagnosis

No investigations initiallyNo investigations initially Clinical – appearance on intubationClinical – appearance on intubation Throat swabsThroat swabs Blood culturesBlood cultures

Epiglottitis - TreatmentEpiglottitis - Treatment

Keep child calm, no cannulas/ IM Keep child calm, no cannulas/ IM injections etcinjections etc

Intubate -> ventilate ~ 24 – 48hrsIntubate -> ventilate ~ 24 – 48hrs IV antibioticsIV antibiotics

Epiglottitis – when to refer

Always!

Inflammatory conditionsInflammatory conditions

AsthmaAsthma

Chronic inflammatory disorder, Chronic inflammatory disorder, inflammation that is variable; with inflammation that is variable; with hyper-responsiveness and reversible hyper-responsiveness and reversible airways disease.airways disease.

Treatment – acute and chronicTreatment – acute and chronic Reliever and preventer inhalersReliever and preventer inhalers

Asthma: Symptoms Asthma: Symptoms

WheezeWheeze Cough – day/ nightCough – day/ night BreathlessnessBreathlessness Increased work of breathingIncreased work of breathing

DiagnosisDiagnosis

Age - > 2 yearsAge - > 2 years HistoryHistory

Acute – exacerbationAcute – exacerbation Chronic – interval symptomsChronic – interval symptoms

ExaminationExamination Wheeze, hyperexpansion, chest deformityWheeze, hyperexpansion, chest deformity

PEFRPEFR Not in exacerbationNot in exacerbation

Allergy testsAllergy tests

TreatmentTreatment

Acute Acute Salbutamol, Atrovent (always with spacer)Salbutamol, Atrovent (always with spacer) MonteleukastMonteleukast Prednisolone – 3 daysPrednisolone – 3 days

Chronic/ interval symptomsChronic/ interval symptoms Inhaled steroids (beclomethasone, fluticasone)Inhaled steroids (beclomethasone, fluticasone) MonteleukastMonteleukast Long acting salmeterol = seretideLong acting salmeterol = seretide

When to refer:

Acute: 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

AllergensAllergens

AllergyAllergy

Symptoms:Symptoms: Wheeze, cough, upper airway obstruction, stridor,Wheeze, cough, upper airway obstruction, stridor, Angioedema, rash, collapseAngioedema, rash, collapse

SignsSigns Rash, swelling, increased work of breathingRash, swelling, increased work of breathing Increased respiratory rate, noisy breathing/stridorIncreased respiratory rate, noisy breathing/stridor TachycardiaTachycardia Decreased GCSDecreased GCS

DiagnosisDiagnosis

Acutely – identify trigger => historyAcutely – identify trigger => history Investigations Investigations

Skin prick testingSkin prick testing Blood tests – RAST testingBlood tests – RAST testing Food challengeFood challenge

When to refer?

Anaphylaxis/ severe reaction Unknown/unclear trigger Multiple allergy Dietician input needed Concurrent diagnosis Asthma/wheeze

Need epipen

Skin prick testingSkin prick testing

RAST TestsRAST Tests

Blood testBlood test Levels if IgE to specific allergensLevels if IgE to specific allergens Many different allergens testedMany different allergens tested Grade of response/IgE level givenGrade of response/IgE level given >4 significant>4 significant

Allergy - TreatmentAllergy - Treatment

Severe reaction – call for help, 999, Severe reaction – call for help, 999, hospital admissionhospital admission

ABC, oxygen,ABC, oxygen, Adrenaline – IM or IVAdrenaline – IM or IV Steroids – IV or oralSteroids – IV or oral Anti histaminesAnti histamines eg piriton, clarityn eg piriton, clarityn

(IV or oral)(IV or oral)

That’s all!!That’s all!!

Thanks – Any questions??Thanks – Any questions??