1. Seasonal/Winter Illness Focusing On Acute Winter Illness In Children Dr Shane Campbell Paediatric Anaesthetist PICU & Paediatric Retrieval, Glasgow 5 th November 2015

2. Topics Acute Winter Illness In Children Bronchiolitis Croup Management Expectations Important Differential Diagnosis

3. Acute Winter Illness In Children Colds Asthma Norovirus Paraflu Flu

4. Acute Winter Illness In Children Bronchiolitis; RSV Non-RSV Adenovirus, metapneumovirus, rhinovirus, enterovirus, mycoplasma pneumoniae) Croup

5. Bronchiolitis – Topics to discuss Diagnostic characteristics Seasonality Risk factors for severe disease Assessment and referral Investigations

6. Bronchiolitis – Topics to discuss Treatment Symptom duration and hospital discharge Limiting disease transmission

7. 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

8. 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

9. 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

10. 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

11. Bronchiolitis – Diagnostic characteristics Rhinorrhoea Can be one of the first symptoms Cough Dry and wheezy Resp. rate Important to pick up an increased rate

12. Bronchiolitis Respiratory Rate (APLS normal values) Newborn 40-60 1m 30-50 3m 30-45 6m 25-35 1y 20-30 2y 20-28

13. 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)

14. 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

15. Bronchiolitis - Seasonality Figure – RSV lab. reports to Health Protection Scotland by 4-week period

16. Bronchiolitis – Demo. https://www.youtube.com/watch?v=RFwr_zbgJII

17. 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

18. Bronchiolitis – Risk Factors for Severe Disease Social Factors Breast-feeding reduces the risk of hospitalisation Parental smoking increases the risk of hospitalisation

19. 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

20. 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

21. Bronchiolitis – Referral Any of the indicators of severe disease above SpO 2 ≤94% Uncertainty regarding the diagnosis Rapidly worsening picture To seek reassurance about the documented clinical course +/- treatment, if unsure

22. Bronchiolitis – Indication for HDU/PICU consultation Failure to maintain SpO 2 >92% with increasing O 2 therapy Deteriorating resp. status with signs of increasing resp. distress &/or exhaustion Recurrent apnoeas

23. Bronchiolitis - Investigations SpO 2 Blood Gas Only usually in those who are tiring or entering resp. Failure CXR Perform if diagnostic uncertainty In bronciolitis, usually clear but hyperinflated

24. Bronchiolitis - Investigations Virology testing NPA testing for RSV Bacteriological testing Not specifically indicated Haematology & Biochemistry Not specifically indicated

25. Bronchiolitis - Treatment Supportive Sit the child up Nasal clearance, if blocked with secretions O 2 if SpO 2 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

26. Bronchiolitis - Treatment NOT specifically indicated Anti-virals Antibiotics Inhaled bronchodilators (β 2 agonists, anticholinergics) Inhaled adrenaline Inhaled or systemic steroids Leukotriene receptor antagonists

27. 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 SpO 2 for 8-12h after stopping O 2 Discharge only after maintaining >75% daily intake

28. 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

29. Okay, we’ll now move on to Croup https://www.youtube.com/watch?v=d8k-4GI429o

30. 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

31. Croup – diagnostic characteristics Hoarse voice Respiratory distress (due to upper airway obstruction) Symptoms usually worse at night May be pyrexial up to 40°C

32. 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

33. 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

34. Croup – Assessment ABC approach SpO 2 Stridor Chest recession Resp. rate HR, Cap. refill time Conscious level DO NOT examine the throat or distress the child

35. 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

36. Croup – Consider admitting to hospital if... Inadequate fluid intake Poor response to initial treatment Uncertain diagnosis Your clinical acumen predicts a poor trajectory

37. 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

38. 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

39. 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 O 2 Only needed for mod.-but-worsening or severe cases

40. 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

41. Croup - Treatment NO ROLE for the following; Cough medicine Decongestants β 2 -agonists (e.g. Salbutamol) Antibiotics (unless additionally there is a secondary bacterial infection)

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

43. Differential diagnosis Acute FB aspiration Acute anaphylaxis Bacterial upper airway infections Tracheitis Epiglottitis

44. Differential diagnosis

45. 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

46. 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

47. 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) O 2 titrated to SpO 2 ~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

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

49. An important differential diagnosis *Not to be missed* Cardiac failure Many causes (e.g. Congenital heart disease) Must think of it

50. Cardiac Failure - recognition Cardiac failure; Rapid breathing Desaturated (may/may not look cyanosed) Failing to thrive Fatigue (esp. with activity)

51. Cardiac Failure - recognition Cardiac failure; Feeding difficulties Cool peripheries &/or mottled Restless/handles poorly Murmur (may not be present)

52. 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

53. Key-learning points Bronchiolitis Non-toxic infants ~70% of febrile infants will need O 2 Supportive treatment Croup Non-toxic infants Steroid and nebulised adrenaline treatment

54. Key-learning points Bronchiolitis and croup Always think of FB aspiration Always entertain cardiac failure Monitor closely for deterioration

55. 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!

56. References SIGN Guideline 91 – Bronchiolitis in children http://www.sign.ac.uk/pdf/sign91.pdf (full guideline) http://www.sign.ac.uk/pdf/sign91.pdf http://www.sign.ac.uk/pdf/qrg91.pdf (2-page ref. guide) http://www.sign.ac.uk/pdf/qrg91.pdf 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 http://www.clinicalguidelines.scot.nhs.uk/Emergency% 20Medicine/YOR-AE-008%20Croup.pdf