key: cord-0035721-vw859md4 authors: Thangavelu, S.; Sharada, R. C.; Balamurugan, N. title: Respiratory Emergencies in Children date: 2015-11-06 journal: Clinical Pathways in Emergency Medicine DOI: 10.1007/978-81-322-2713-7_14 sha: 73d885799229e52101a3454d6bbda841369d3cc2 doc_id: 35721 cord_uid: vw859md4 Focused clinical observation is the key in the initial recognition of respiratory distress in an acutely ill child. Fever and respiratory distress are the most common reasons for hospital visit by an acutely ill child. A child with respiratory distress (RD) can quickly worsen to respiratory failure (RF) and fi nally to cardiac arrest if left untreated [ 1 ] . Hence a precise recognition and management is essential (Flowchart 14.1 ). As a part of the initial primary survey, look for the three "E"-effort, effi cacy and effect of breathing [ 2 ] . • Effort of breathing -Increased effort or work of breathing if the following is present: tachypnoea, sternal/subcostal/intercostals recession, use of accessory muscles, fl aring of ala nasi and stridor/wheeze/grunt. Subcostal recession is more signifi cant than intercostal recession. Bradypnoea is a sign of exhaustion and suggests impending respiratory arrest. Increased work of breathing may be absent in central causes like CNS depression and peripheral nervous system failure as in Guillain-Barre syndrome. Check respiratory rate for 30-60 s ( RD is an early stage of physiological disturbance. After the initial steps to correct hypoxia (this may require high-fl ow nasal cannula or non-invasive ventilation or intubation), specifi c management should be provided based on the underlying illness. Respiratory rate, respiratory effort, level of consciousness, trends in oxygen saturation via pulse oximeter (SpO 2 ), response to oxygen therapy and looking for signs of improvement or worsening are the most important components of monitoring. Exact anatomical site of the underlying disease can be inferred by careful stepwise evaluation (Table 14. 2 ). • If the child is presenting with wheeze, absence of fever, or cardiac symptoms and past history of response to nebulisation, it will support the diagnosis of underfi ve wheeze or asthma in children above 5 years. • Child (6 months to 2 years of age) with rhinorrhoea, low-grade fever, cough followed by noisy breathing, stridor and sternal and suprasternal retractions -viral croup causing stridor. • Child above 3 years of age with high-grade fever, soft stridor, toxaemia, drooling, dysphagia with sniffi ng position -epiglottitis, rare but potentially fatal disease. • Toddler developing breathlessness for the fi rst time, dramatic onset, found to be playing with small round objects such as a button battery or a coin (Fig. 14. 3 ) -choking due to foreign body in the airway presenting with obstructive emphysema or collapse. • Child with high-grade fever, cough, fast breathing, grunting, subcostal and intercostal retractions, no past history of breathlessness -pneumonia. Suspect empyema if there is stony dullness and absent breath sounds on one side. • Child with acute-onset breathlessness, grunting without fever, lethargy, puffi ness of face, disproportionate tachycardia, gallop with or without murmur, hepatomegaly -myocarditis or dilated cardiomyopathy. • With the above said features, if the child has pericardial rub or muffl ed breath sounds and pulsus paradoxus suspect pericardial effusion. • If the child has low voice volume, fl oppiness, weak cough, bradypnoea, see-saw breathing and shallow breathing, it is indicative of acute fl accid paralysis affecting respiratory muscles -respiratory failure due to disordered control of breathing. • Similar situation in a different presentation will be seen in a child with acute seizures. • Common indications for CXR in a child with respiratory distress are pneumonia, pulmonary oedema, suspected pneumothorax and foreign body inhalation. Cardiomegaly, collapse or congenital anomalies like eventration of diaphragm, congenital lobar emphysema, bronchogenic cyst or diaphragmatic hernia are sometimes seen as surprise. • Blood counts and blood culture: Any radiological shadow in the background of fever is an indication for antibiotic in paediatric emergency department, but FBC and CRP will aid in suggesting a bacterial aetiology if not confi rming. Blood culture is rarely positive in pneumonia unless there is septicaemia. • In viral infections like H1N1, PCR of respiratory tract secretions is a useful investigation when a child presents with pneumonia during an epidemic situation particularly with normal WBC count and negative CRP. Specifi c management: 1. Management of asthma -see relevant section in this chapter. 2. For management of croup -see relevant section in this chapter. 3. Once the diagnosis of epiglottitis is suspected, PICU team, ENT surgeon and anaesthetist are involved in the management early. Antibiotics such cefotaxime should be given early. Child should be admitted in high dependency unit (HDU) or paediatric intensive care unit (PICU). Airway has to be secured early by intubation or tracheostomy because they can deteriorate very fast. 4. If pneumothorax or empyema is suspected, diagnosis should be confi rmed by CXR and ultrasonography of the chest. Immediate needle thoracocentesis will relieve the respiratory distress, and it should be followed by intercostal drainage. 5. Appropriate antibiotics to treat the underlying pneumonia or empyema. 6. For management of foreign body, see relevant chapter under ENT. In most of the situations, early recognition and management in HDU or PICU will help in good recovery. Asthma is a cause of reversible airway obstruction secondary to chronic airway infl ammation and bronchial hyperreactivity. Approximately 10 % of the children are affected, and about 50 % of them will attend their GP or an ED before the age of 10 years. They often present with wheeze and shortness of breath. Occasionally the presenting complaint is that of cough at night or early morning, cough brought on by exercise/cold weather and limitation in carrying out sporting activities (exercise tolerance). • Look out for a family history of asthma or atopic disease such as hay fever, eczema or allergy. • Based on the number of episodes experienced, asthma can be classifi ed into three subgroups: Infrequent (<4 episodes/year) -three out of four asthmatics will fall into this category (75 % of cases). Frequent (episodes every 2-4 weeks) -one in fi ve asthmatics will fall into this category (20 % of cases). Persistent (three or more episodes every week) -1 in 20 asthmatics will fall into this category (5 % of cases). Moderate Consider in this order: Reassess. Reassess. Consider CXR. Blood gas and measure serum K+. ECG monitoring. [ 3 ] • Weaning regime of bronchodilator. • Prednisolone for 3 days. • Consider regular inhaled steroids, i.e. beclomethasone 100-200 mcg BD, if: -Needing B2 agonist >3 times per week -Nocturnal symptoms disturbing sleep more than once per week -Exacerbations requiring oral steroids In children under 5 years with viral-associated wheeze, steroids (oral and inhaled) may not be benefi cial. [ 3 ] • GP follow-up within 48 h • If >2 attendances to ED within 1 year or two courses of oral steroid, refer to asthma clinic for urgent review. Bronchiolitis is a common respiratory tract infection in infancy and a common cause for admission in young children and often leads to a lot of morbidity in infants. It is typically caused by viruses and the common aetiologic agent being the respiratory syncytial virus. Usual age group is 2 months to 2 years. Bronchiolitis is practically defi ned as the fi rst episode of wheezing in a child younger than 12-24 months who has physical fi ndings of a viral respiratory infection and has no other explanation for the wheezing, such as pneumonia or atopy [ 4 ] . It is usually a seasonal viral illness characterised by low-grade fever, nasal discharge and dry, wheezy cough. On examination there are fi ne inspiratory crackles and expiratory wheeze. Within 1-2 days of these prodromal symptoms, the cough worsens and child may also develop rapid respiration, chest retractions, irritability, poor feeding and vomiting. Though, in majority of cases, the disease remains mild and recovery starts in 3-5 days, some of these children may continue to worsen and become sick, and prompt management is needed. • Chronological age less than 6 weeks • History of apnoea before assessment • Known structural cardiac anomaly (e.g. VSD) • Known pre-existing lung disease (e.g. cystic fi brosis) • Signifi cant prematurity (<32 weeks) The diagnosis of bronchiolitis is mostly clinical, and laboratory investigations have a limited role in diagnosis and management. The current management primarily consists of supportive care: • Widely accepted line of management is adequate hydration, supplemental oxygen and careful monitoring of vital signs and SpO 2 . • At this point, there is no other specifi c treatment for bronchiolitis for which there is a strong or convincing evidence of effectiveness and the role of each modality is debatable [ 5 ] . • Hypertonic saline nebulisation with salbutamol 2.5 mg may reduce the length of stay for admitted children. • Consider nebulised epinephrine if considering ventilation. • Consider 1-3-month course of montelukast (4 mg at night) [ 6 ] as it may reduce risk of relapse/recurrent wheeze. This is one of the most common causes of stridor in children presenting to the emergency department. It is most commonly due to a viral illness caused by parainfl uenza virus which accounts for 80 % of the cases [ 7 ] . Children often present with typical barking cough and harsh stridor. These symptoms are often preceded by a viral prodrome of low-grade fever, running nose and cough. Usually the children are not toxic and they do not have drooling of saliva. The illness usually lasts for 2-5 days. If obstruction worsens, the child becomes increasingly tachypnoeic with respiratory distress indicated by retractions. Rarely respiratory failure occurs. Cyanosis, tachycardia and altered level of consciousness if present indicate that there is hypoxia and it needs prompt management. Westley croup score is helpful in assessing the severity [ 8 ] . Croup is essentially a clinical diagnosis. Steeple sign seen in x-ray is seen in croup but is not pathognomic of the condition. Chest x-ray is done only when there are chest retractions and diagnosis is in doubt. • Keep the child in the mother's lap. Administer oxygen in a nonthreatening manner if needed. • Steroids [ 9 ] are the drug of choice in managing croup. There is role for IV, IM, oral and inhaled corticosteroids. Their action usually starts 1-2 h after administration. Popularly a single oral or intramuscular dose of dexamethasone 0.15 mg/ kg for the mild variety up to 0.6 mg/kg in severe cases is used in the emergency room/OP and is suffi cient. Rarely the second dose is administered after 8-12 h based on clinical need. Oral prednisolone 1-2 mg/kg/day for 24 h is another option. Inhaled budesonide 2 mg in 3 ml normal saline also has rapid effect and is found to be useful. • Epinephrine nebulisation is used in cases of moderate to severe croup, whenever there is evidence of respiratory distress and retractions are present even at rest. Nebulised adrenaline (epinephrine) solution 1 in 1,000 (1 mg/mL) should be given with close clinical monitoring in a dose of 400 μg/kg (maximum 5 mg) repeated after 30 min if necessary. Administration of three doses of nebulised adrenaline within 60 min has caused dysrhythmia and myocardial infarction in children. The effects of nebulised adrenaline last 2-3 h; the child should be closely monitored/observed for at least 4 h after giving. • There is no role for antibiotics unless when croup is thought to be caused by a Mycoplasma pneumoniae infection. Respiratory distress and failure Advanced paediatric life support BTS/SIGN asthma guideline Oski's pediatrics: principles and practice Recent advances in management of bronchiolitis A randomized intervention of montelukast for postbronchiolitis: effect on eosinophil degranulation Pathogenesis of acute respiratory illness caused by human parainfl uenza viruses Croup Clin Evid (Online) Glucocorticoids for croup