Seasonal/Winter Illness Focusing On Acute Winter Illness In Children

Dr Shane CampbellPaediatric Anaesthetist

PICU & Paediatric Retrieval, Glasgow

5th November 2015

Topics

Acute Winter Illness In Children Bronchiolitis Croup

Management Expectations

Important Differential Diagnosis

Acute Winter Illness In Children

Colds Asthma Norovirus Paraflu Flu

Acute Winter Illness In Children

Bronchiolitis; RSV Non-RSV

Adenovirus, metapneumovirus, rhinovirus, enterovirus, mycoplasma pneumoniae)

Croup

Bronchiolitis – Topics to discuss

Diagnostic characteristics

Seasonality

Risk factors for severe disease

Assessment and referral

Investigations

Bronchiolitis – Topics to discuss

Treatment

Symptom duration and hospital discharge

Limiting disease transmission

Bronchiolitis – Introduction

UK definition A seasonal viral illness characterised by fever,

nasal discharge and dry, wheezy cough A clinical diagnosis based on Hx and

examination

O/E Fine insp. crackles &/or high-pitched exp.

wheeze

Likely to deteriorate clinically in the first 72h

Bronchiolitis - Background

Caused by Respiratory Syncitial Virus (RSV) in 75% of cases

70% of all infants will be infected with RSV in the first year of life

22% develop symptomatic disease In Scotland

translates into 15,000 infants per year ~2,000 infants <1yr old admitted to hospital

Bronchiolitis - Background

RSV-attributed death rate in infants 1-12 months old is 8.4 per 100,000

~ 1-2 deaths per year in Scotland

20% of infants with bronchiolitis proceed to grumbling, protracted resp. syndrome with cough and recurrent viral wheeze

Bronchiolitis –Diagnostic characteristics Age

Mainly infants <2yrs 90% of those hospitalised are <12 months

Fever May be present Rarely high (31% >38°C) 71% of febrile infants had a severe disease

course

Bronchiolitis – Diagnostic characteristics Rhinorrhoea

Can be one of the first symptoms

Cough Dry and wheezy

Resp. rate Important to pick up an increased rate

Bronchiolitis

Respiratory Rate (APLS normal values)

Newborn 40-60 1m 30-50 3m 30-45 6m 25-35 1y 20-30 2y 20-28

Bronchiolitis – Diagnostic characteristics Poor feeding

Often the reason for hospital admission

Increasing WOB & recession Dyspnoea, subcostal, intercostal &

supraclavicular recession are commonly seen May be visibly hyperinflated (c.f. pneumonia)

Bronchiolitis – Diagnostic characteristics Crackles/crepitations

Fine inspiratory common If present - hallmark of bronchiolitis in UK

Wheeze Exp. wheeze common

Apnoea Can be the presenting feature in the very young,

premature and low birthweight infants

Bronchiolitis - SeasonalityFigure – RSV lab. reports to Health Protection Scotland by 4-week period

Bronchiolitis – Demo.

https://www.youtube.com/watch?v=RFwr_zbgJII

Bronchiolitis –Risk Factors for Severe Disease

Age The very young

Significant co-morbidities Prematurity (<35/40) Congenital Heart Disease Chronic Lung Disease of prematurity

Atopy No evidence of atopy being a risk factor

Bronchiolitis –Risk Factors for Severe Disease

Social Factors

Breast-feeding reduces the risk of hospitalisation

Parental smoking increases the risk of hospitalisation

Bronchiolitis –Risk Factors for Severe Disease

Social Factors cont’d

Number of siblings & nursery/day care attendance

Siblings at home increase the risk of hospitalisation

Socioeconomic deprivation one study demonstrated an association

Bronchiolitis – Severe Disease

Poor feeding <50% usual fluid intake in preceding 24h

Lethargy History of apnoea RR >70/min Presence of nasal flaring &/or grunting Severe chest wall recession Cyanosis

Bronchiolitis – Referral

Any of the indicators of severe disease above SpO2 ≤94% Uncertainty regarding the diagnosis Rapidly worsening picture To seek reassurance about the documented

clinical course +/- treatment, if unsure

Bronchiolitis –Indication for HDU/PICU consultation

Failure to maintain SpO2 >92% with increasing O2 therapy

Deteriorating resp. status with signs of increasing resp. distress &/or exhaustion

Recurrent apnoeas

Bronchiolitis - Investigations

SpO2

Blood Gas Only usually in those who are tiring or entering

resp. Failure

CXR Perform if diagnostic uncertainty In bronciolitis, usually clear but hyperinflated

Bronchiolitis - Investigations

Virology testing NPA testing for RSV

Bacteriological testing Not specifically indicated

Haematology & Biochemistry Not specifically indicated

Bronchiolitis - Treatment Supportive

Sit the child up

Nasal clearance, if blocked with secretions

O2 if SpO2 below 95%

High index of suspicion for deterioration unless you see an improvement

Low threshold for referral in Remote & Rural areas esp. in those with risk factors for severe disease

Bronchiolitis - Treatment

NOT specifically indicated Anti-virals Antibiotics Inhaled bronchodilators (β2 agonists,

anticholinergics) Inhaled adrenaline Inhaled or systemic steroids Leukotriene receptor antagonists

Bronchiolitis –Symptom duration & hospital discharge

From the onset of acute bronchiolitis ~ 50% of infants without co-morbidities are asymptomatic by 2 weeks

Symptoms can last beyond 4 weeks

Monitor SpO2 for 8-12h after stopping O2

Discharge only after maintaining >75% daily intake

Bronchiolitis –Limiting disease transmission

RSV Highly infectious Transmitted through contagious secretions or

environmental surfaces In resp. droplets, can spread up to 2m Can survive up to 6-12h on surfaces Destroyed by soap and water or alcohol gel

Okay, we’ll now move on to Croup

https://www.youtube.com/watch?v=d8k-4GI429o

Croup – diagnostic characteristics

Croup (virally-induced laryngotracheitis) Most commonly parainfluenza virus

Most commonly affects children 6m – 3y Peak incidence 12 – 24m

Sudden onset of seal-like barking cough

Usually accompanied by inspiratory stridor

Croup – diagnostic characteristics

Hoarse voice

Respiratory distress (due to upper airway obstruction)

Symptoms usually worse at night

May be pyrexial up to 40°C

Croup – diagnostic characteristics

Often a preceding history of 1-4 days of a non-sp. cough, rhinorrhoea and fever

Most children will have mild croup and can be managed at home

Are not usually toxic

Should not drool continuously

Croup – Severe Disease

Frequent barking cough with prominent insp. stridor at rest

Marked sternal wall recession Significant distress and agitation, or lethargy

or restlessness (hypoxia) Tachycardia

With more severe obstruction and hypoxia

Croup – Assessment

ABC approach SpO2

Stridor Chest recession Resp. rate HR, Cap. refill time Conscious level

DO NOT examine the throat or distress the child

Croup – Consider admitting to hospital if...

History of severe obstruction, previous severe croup, know structural upper airways abnormalities (laryngomalacia, vascular ring, tracheomalacia, Down’s syndrome)

<6m old

Immumocompromised

Croup – Consider admitting to hospital if...

Inadequate fluid intake

Poor response to initial treatment

Uncertain diagnosis

Your clinical acumen predicts a poor trajectory

Croup - Treatment

Steroid

Beneficial in mild, mod. & severe croup

Literature recommends 0.15mg/kg po dexamethasone (i.e. 1mg/kg pred. or

4mg/kg hydrocort.) As a single dose

Croup - Treatment

Steroid

PICU routinely advises 0.6mg/kg po dex. (i.e. 4mg/kg pred. or 16mg/kg

hydrocort.) Can repeat once if needed

Can take up to 6 hours before it works Need to keep the infant under close review

Croup - Treatment

Nebulised Adrenaline Usually only for severe croup Can be given in mod. croup if worsening 5mL of 1:1,000 This child should not be in a remote / rural setting

O2

Only needed for mod.-but-worsening or severe cases

Croup - Treatment

Anti-pyretics / Analgesics Paracetamol &/or ibuprofen No need for tepid sponging or over/under-

dressing

Ensure adequate fluid intake

Humidified air/Steam inhalation The is NO ROLE for this

Croup - Treatment

NO ROLE for the following; Cough medicine Decongestants β2-agonists (e.g. Salbutamol) Antibiotics (unless additionally there is a

secondary bacterial infection)

Croup - Prognosis

Usually Self-limiting Resolves within 48h May last for up to a week Resolution can be accompanied by a upper

RTI

Differential diagnosis

Acute FB aspiration

Acute anaphylaxis

Bacterial upper airway infections Tracheitis Epiglottitis

Differential diagnosis

Expectations from a R&R setting

• Realisation that you work with limited resources in an isolated environment

Acute Hospital expects; Deal appropriately with mild cases Refer as soon as it’s realised that the mild is

progressing to moderate or severe

Expectations from a R&R setting

Retrieval Service expects;

When a child has been accepted for transfer, (s)he should not be left without medical supervision

Expectations from a R&R setting

Retrieval Service expects;

Carry out instructions given by retrieval team; At least one point of iv access (unless advised

against) O2 titrated to SpO2

~70% maintenance iv fluids with isotonic fluids Usually 0.9%NaCl & 5% Dextrose +/- 10mmol KCl

per 500mL In the very young may use 10% Dextrose (we will

advise) Prepare for a potential resuscitation scenario

Differential diagnosis of an Acute Winter Illness Asthma Pneumonia Congenital lung disease CF Inhaled FB Sepsis Metabolic acidosis

An important differential diagnosis

*Not to be missed*

Cardiac failure Many causes (e.g. Congenital heart disease) Must think of it

Cardiac Failure - recognition

Cardiac failure;

Rapid breathing

Desaturated (may/may not look cyanosed)

Failing to thrive

Fatigue (esp. with activity)

Cardiac Failure - recognition

Cardiac failure;

Feeding difficulties

Cool peripheries &/or mottled

Restless/handles poorly

Murmur (may not be present)

Cardiac Failure

Causes;

Neonates and younger infant most likely related to structural heart disease systemic or pulmonary circulation may depend on

the patency of the ductus arteriosus

Older infant/child myocarditis or cardiomyopathy, hypertension,

renal failure, arrhythmias or myocardial ischemia

Key-learning points

Bronchiolitis Non-toxic infants ~70% of febrile infants will need O2

Supportive treatment

Croup Non-toxic infants Steroid and nebulised adrenaline treatment

Key-learning points

Bronchiolitis and croup Always think of FB aspiration Always entertain cardiac failure

Monitor closely for deterioration

Please...

Never EVER forget that we are here to help and support you do the best for children under your primary care, so...

USE US!

References

SIGN Guideline 91 – Bronchiolitis in children http://www.sign.ac.uk/pdf/sign91.pdf (full guideline) http://www.sign.ac.uk/pdf/qrg91.pdf (2-page ref. guide)

NICE Guideline Clinical Knowledge Summary (CKS) September 2012 http://cks.nice.org.uk/croup

NHS Greater Glasgow and Clyde, Clinical Guideline: Emergency Medicine - Croup http://www.clinicalguidelines.scot.nhs.uk/Emergency%

20Medicine/YOR-AE-008%20Croup.pdf