1. Acute Respiratory Disorders in Children
Dr Donna Traves
Paediatric Consultant
3rd October 2012

2. Objectives
Be able to:
Discuss a range of childhood acute respiratory problems
Understand when to refer in children with acute respiratory disease
Understand the acute management of paediatric acute respiratory disease

3. Aims To discuss: Recognising Sick child with respiratory disease
Infection
– bronchiolitis, pneumonia, croup, Epiglottitis
Inflammatory respiratory disease
- Asthma, allergy

4. Recognising sick child - respiratory
Effort of breathing
Recession
Resp rate - ? Slow/shallow
Grunting – may indicate atelectasis
Accessory muscle use
Nasal flare

5. 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

6. Recognising sick child - respiratory
Feeding history
Reduced, absent
Eating v drinking
Wet nappies etc
General activity
Happy playing – eg happy wheezer
Lethargic
flat

7. Examples of Increased Respiratory Distress
APLS video

8. Infection

9. Bronchiolitis Viral illness Affects children <2 yrs
Oedema and mucus of the bronchioles (lower airways), leading to over inflation and collapse
Causes – RSV ( 70%), para influenza, adenovirus, influenza

10. Bronchiolitis - Symptoms
Coryzal symptoms 2-3 days
Dry, wheezy Cough
Wheeze
Difficulty in Breathing
Cyanosis
Apnoea (esp <6 weeks)
Poor Feeding

11. Bronchiolitis - Signs Cyanosis/ ↓ O2 Sats Tachypnoea
Hyperinflation (liver displaced↓)
Recession/ tracheal tug
Widespread fine inspiratory crackles
Wheeze
Fever >38ºC not usually a feature

12. 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

13. Bronchiolitis - Investigations
Oxygen sats
NPA
CXR

14. Bronchiolitis - Treatment
Supportive – mostly at home
Small frequent feeds
Nasal saline drops
Positioning
Admission treatment
Oxygen
NG feeding
Suction

15. 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)

16. Pneumonia Infection of the lung parenchyma/tissue Bacterial or Viral
Commonly:
Strep pneumoniae
Staphylococcus
Haemophilus influenzae
mycoplasma

17. Pneumonia Symptoms Signs Cough Temperature
Lethargy, decreased eating/drinking
vomiting
Signs
Temperature, increased resp rate, decreased oxygen sats
Increased work of breathing, tachycardia
Crackles heard

18. Pneumonia - Diagnosis Clinical CXR Blood tests – culture, serology
Sputum sample

19. Pneumonia

20. Persistent CXR changes
If no response to course of antibiotics needs further investigation/ referral
Can be investigated with
Immune
Bronchoscopy
Flexible – thin and more mobile
Rigid – large, inflexible, good for removing foreign bodies
BAL ( Broncho-alveolar- lavage)
Samples of secretions taken during bronchoscopy
Sent for culture and sensitivity

21. Pneumonia-Treatment Antibiotics Admission
Eg amoxicillin, clarithromycin
Usually 5 days
Admission
Oxygen
Severe respiratory distress
Very young
Dehydrated – NG feeding or IV fluids

22. 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

23. Empyema Complication of pneumonia
Collection of pus – usually in pleural cavity
Signs
Pneumonia - not improving on abx
Cough, temperature
Chest pain

24. Empyema - Diagnosis CXR – fluid seen USS – site of collection
CT chest – if complicated

25. Empyema - CXR

26. Croup Infection of the upper airway Oedema, swelling and inflammation
=laryngotracheobronchitis
Usually viral
adenovirus, parainfluenzae, RSV

27. Anatomy
<------bronchus

28. Croup – Symptoms Barking cough Noisy breathing – inspiratory stridor
Mild temperature
Often cold/coryzal symptoms
Often wake at night
Not usually acutely unwell

29. Croup - Signs Cough = often diagnostic Temperature
Stridor ( due to sub-glottic narrowing)
Respiratory distress: mild – severe
Decreased oxygen saturations – if severe

30. Croup - Treatment Minimal handling/ examination
Oral steroids – Dexamethasone ( mg/kg) or prednisolone (1mg/kg)
Nebulised budesonide
Nebulised adrenaline
If severe – intubate and ventilate
Keep child calm to maintain airway

31. When to refer: Marked respiratory difficulty Marked stridor at rest
Agitated
Decreased O2 sats (if available)
Trial of dexamethasone = no improvement after 1 hour

32. Epiglottitis Infection/ cellulitis of the epiglottis
Caused by Haemophilus influenzae
Commonest 2-5 years – but any age

33. Anatomy

36. Epiglottitis - Signs and Symptoms
Very acute onset
Fever, ill toxic looking child
Very sore throat – drooling, not speaking
Soft stridor, respiratory distress
Child sits upright, protecting own airway

37. Epiglottitis - Diagnosis
No investigations initially
Clinical – appearance on intubation
Throat swabs
Blood cultures

38. Epiglottitis - Treatment
Keep child calm, no cannulas/ IM injections etc
Intubate -> ventilate ~ 24 – 48hrs
IV antibiotics

39. Epiglottitis – when to refer
Always!

40. Inflammatory conditions

41. Asthma
Chronic inflammatory disorder, inflammation that is variable; with hyper-responsiveness and reversible airways disease.
Treatment – acute and chronic
Reliever and preventer inhalers

42. Asthma: Symptoms Wheeze Cough – day/ night Breathlessness
Increased work of breathing

43. Diagnosis Age - > 2 years History Examination PEFR Allergy tests
Acute – exacerbation
Chronic – interval symptoms
Examination
Wheeze, hyperexpansion, chest deformity
PEFR
Not in exacerbation
Allergy tests

44. Treatment Acute Chronic/ interval symptoms
Salbutamol, Atrovent (always with spacer)
Monteleukast
Prednisolone – 3 days
Chronic/ interval symptoms
Inhaled steroids (beclomethasone, fluticasone)
Long acting salmeterol = seretide

45. When to refer: Acute: Chronic: 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

46. Allergens

47. Allergy Symptoms: Signs
Wheeze, cough, upper airway obstruction, stridor,
Angioedema, rash, collapse
Signs
Rash, swelling, increased work of breathing
Increased respiratory rate, noisy breathing/stridor
Tachycardia
Decreased GCS

48. Diagnosis Acutely – identify trigger => history Investigations
Skin prick testing
Blood tests – RAST testing
Food challenge

49. When to refer? Anaphylaxis/ severe reaction Unknown/unclear trigger
Multiple allergy
Dietician input needed
Concurrent diagnosis Asthma/wheeze
Need epipen

50. Skin prick testing

51. RAST Tests Blood test Levels if IgE to specific allergens
Many different allergens tested
Grade of response/IgE level given
>4 significant

52. Allergy - Treatment
Severe reaction – call for help, 999, hospital admission
ABC, oxygen,
Adrenaline – IM or IV
Steroids – IV or oral
Anti histamines eg piriton, clarityn (IV or oral)

53. That’s all!!
Thanks – Any questions??