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EVIDENCE BASED GUIDELINEEVIDENCE BASED GUIDELINEFOR MANAGEMENT OF CHILDREN FOR MANAGEMENT OF CHILDREN
PRESENTING WITH ACUTE PRESENTING WITH ACUTE BREATHING DIFFICULTYBREATHING DIFFICULTY
Produced by the Paediatric Accident and Emergency Research Group at Queens Medical Centre , Nottingham supported by
Children Nationwide
Next slideNext slide
ACUTE BREATHING DIFFICULTYACUTE BREATHING DIFFICULTY
Click here to begin.
To run through the programme, click on:
for further information,
to return to the previous page to return to this page
For grades of For grades of evidence used evidence used
seesee
ACUTE BREATHING DIFFICULTYACUTE BREATHING DIFFICULTY
ASSESS:• Respiration rate over 60 secs• Work of breathing-degree of distress• Wheeze,cough, stridor ?• Signs of serious illness• Age and / or complicating factors• SaO2
ABCABC Resuscitate Resuscitate if neededif needed
Next slideNext slidePrevious page
This guide takes you through each of these points.This guide takes you through each of these points.
It offers guidance on actions to take.It offers guidance on actions to take.
At each stage you can access the level of evidence At each stage you can access the level of evidence behind each step.behind each step.
For full discussion of the evidence please see the full For full discussion of the evidence please see the full report by Lakhanpaul M et al on www.cccccc report by Lakhanpaul M et al on www.cccccc
The guideline has been appraised by the Quality of The guideline has been appraised by the Quality of Practice Committee of the Royal College of Paediatrics Practice Committee of the Royal College of Paediatrics
and Child Health (2002)and Child Health (2002)
Next slideNext slide
ACUTE BREATHING DIFFICULTYACUTE BREATHING DIFFICULTY
INITIAL ASSESSMENT PROTOCOLINITIAL ASSESSMENT PROTOCOL
Presence of pre-terminal Presence of pre-terminal signs or signs requiring signs or signs requiring
urgent attentionurgent attention
ClickClick if NO
Click if Click if
YES
Start basic life supportStart basic life support&&
Call appropriate team Call appropriate team for advanced life for advanced life
supportsupport
Start basic life supportStart basic life support&&
Call appropriate team Call appropriate team for advanced life for advanced life
supportsupport
CHECK:CHECK:AirwayAirway
BreathingBreathingCirculationCirculation
CHECK:CHECK:AirwayAirway
BreathingBreathingCirculationCirculation
ADMITADMIT to to HDU/PICUHDU/PICUADMITADMIT to to HDU/PICUHDU/PICU
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Measure respiratory rate for 60 Measure respiratory rate for 60 seconds & oxygen saturationseconds & oxygen saturation
Measure respiratory rate for 60 Measure respiratory rate for 60 seconds & oxygen saturationseconds & oxygen saturation
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If OIf O22sat <= 92%sat <= 92%
Give oxygen and admitGive oxygen and admit
If OIf O22sat <= 92%sat <= 92%
Give oxygen and admitGive oxygen and admit
NoNo
? URTI ? URTI HomeHome with GP Follow up; with GP Follow up;
Patient EducationPatient Education
? URTI ? URTI HomeHome with GP Follow up; with GP Follow up;
Patient EducationPatient Education
YesYes
D/W senior DrD/W senior DrConsider alternative diagnosesConsider alternative diagnosesArrange appropriate investigationsArrange appropriate investigationsAdmitAdmit
D/W senior DrD/W senior DrConsider alternative diagnosesConsider alternative diagnosesArrange appropriate investigationsArrange appropriate investigationsAdmitAdmit
? Signs of increased work of breathing
Stridor/stertor/wheeze or cough?
NoNoNoNo
? Signs of serious illness/
complicating factors
YesYes
Click ifYes
Click ifYes
? ? Admit
Mild/moderate distressMild/moderate distressAdmit if complicating Admit if complicating factors/serious illnessfactors/serious illness
Mild/moderate distressMild/moderate distressAdmit if complicating Admit if complicating factors/serious illnessfactors/serious illness
Admit ifAdmit if
severe distresssevere distressAdmit ifAdmit if
severe distresssevere distress
YesYes
STRIDOR/STERTORSTRIDOR/STERTORSTRIDOR/STERTORSTRIDOR/STERTOR
COUGHCOUGHCOUGHCOUGH
WHEEZEWHEEZEWHEEZEWHEEZE
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STRIDOR (limited airflow at larynx or trachea) or STERTOR (noise due to obstruction at pharyngeal
level)
STRIDOR (limited airflow at larynx or trachea) or STERTOR (noise due to obstruction at pharyngeal
level)
NoNo YesYes
?BARKING COUGH
?Agitated/Drooling
?Toxic &
High Fever
Click if YES
Click if YESClick if
NOClick if
NOClick if
YESClick if
YESClick if
NOClick if
NO
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Secure Secure AirwayAirwaySecure Secure AirwayAirway
Call for senior assistanceCall for senior assistanceConsider ENT referralConsider ENT referral
Admit to PICU/HDUAdmit to PICU/HDU
Call for senior assistanceCall for senior assistanceConsider ENT referralConsider ENT referral
Admit to PICU/HDUAdmit to PICU/HDU
?Epiglottis
Agitated/DroolingAgitated/Drooling
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Refer urgently to Refer urgently to ENTENT
Refer urgently to Refer urgently to ENTENT
? STERTOR
YesYes NoNo
?Enlarged Tonsils ?
Foreign body aspiration
CXRCXRCXRCXR
?Normal
If strong suspicion If strong suspicion of aspirationof aspiration
If strong suspicion If strong suspicion of aspirationof aspiration
Refer to appropriate Refer to appropriate doctor for doctor for
bronchoscopybronchoscopy
Refer to appropriate Refer to appropriate doctor for doctor for
bronchoscopybronchoscopy
NoNoYesYes
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Secure Secure AirwayAirwaySecure Secure AirwayAirway
Admit to PICU/HDUAdmit to PICU/HDUAdmit to PICU/HDUAdmit to PICU/HDU
?Bacterial tracheitis
Toxic+ High FeverToxic+ High Fever
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? CROUP Treat with: Oral dexamethasoneIf vomiting: Use nebulised budesonide
?Signs of potential respiratory failure
HOME with GP follow up, HOME with GP follow up, patient education and call patient education and call
back instructionsback instructions
HOME with GP follow up, HOME with GP follow up, patient education and call patient education and call
back instructionsback instructions
1.1. Give l-epinephrine (adrenaline) Give l-epinephrine (adrenaline) nebulisernebuliser
2.2. Admit for close observationAdmit for close observation3.3. PICU/HDUPICU/HDU
1.1. Give l-epinephrine (adrenaline) Give l-epinephrine (adrenaline) nebulisernebuliser
2.2. Admit for close observationAdmit for close observation3.3. PICU/HDUPICU/HDU
1.1. Signs of severe resp distressSigns of severe resp distress2.2. Signs of serious illnessSigns of serious illness1.1. Signs of severe resp distressSigns of severe resp distress2.2. Signs of serious illnessSigns of serious illness
NoNo
NoNo
1.1. Consider adrenaline nebuliserConsider adrenaline nebuliser2.2. ADMITADMIT1.1. Consider adrenaline nebuliserConsider adrenaline nebuliser2.2. ADMITADMIT
YesYes
YesYes
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WHEEZEWHEEZE
YesYesHistory of choking or paroxysmal
cough
Assess severityAssess severityAssess severityAssess severity
Age >2Age >2Age >2Age >2 Age <2Age <2Age <2Age <2
Continue management as for Continue management as for other children presenting with other children presenting with wheeze wheeze BUTBUT CXR if ?foreign body CXR if ?foreign body aspiration/other atypical features aspiration/other atypical features e.g. focal signs but no symptoms e.g. focal signs but no symptoms of bronchiolitisof bronchiolitis
Continue management as for Continue management as for other children presenting with other children presenting with wheeze wheeze BUTBUT CXR if ?foreign body CXR if ?foreign body aspiration/other atypical features aspiration/other atypical features e.g. focal signs but no symptoms e.g. focal signs but no symptoms of bronchiolitisof bronchiolitis
If high suspicion refer If high suspicion refer to appropriate to appropriate surgical teamsurgical team
If high suspicion refer If high suspicion refer to appropriate to appropriate surgical teamsurgical team
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Age >2
YesYes
? Mild/moderate symptoms
1. B1. B22-agonist via spacer-agonist via spacer1. B1. B22-agonist via spacer-agonist via spacer
1.1. HOMEHOME2.2. Follow up Follow up
instructionsinstructions
1.1. HOMEHOME2.2. Follow up Follow up
instructionsinstructions
Moderate/severeModerate/severeModerate/severeModerate/severe
Life threateningLife threateningLife threateningLife threatening 1.1. BB22-agonist (volumatic if not on 0-agonist (volumatic if not on 022))
2.2. Oral steroidOral steroid3.3. +/- 4-6hrly anticholinergic+/- 4-6hrly anticholinergic
1.1. BB22-agonist (volumatic if not on 0-agonist (volumatic if not on 022))
2.2. Oral steroidOral steroid3.3. +/- 4-6hrly anticholinergic+/- 4-6hrly anticholinergic
1.1. Check ABCCheck ABC2.2. Follow BTS guidelines, i.e. IV Follow BTS guidelines, i.e. IV
aminophyline + steroids + frequent aminophyline + steroids + frequent B2-agonistB2-agonist
3.3. ADMITADMIT TO HDU/PICU TO HDU/PICU4.4. X-RAY when stableX-RAY when stable
1.1. Check ABCCheck ABC2.2. Follow BTS guidelines, i.e. IV Follow BTS guidelines, i.e. IV
aminophyline + steroids + frequent aminophyline + steroids + frequent B2-agonistB2-agonist
3.3. ADMITADMIT TO HDU/PICU TO HDU/PICU4.4. X-RAY when stableX-RAY when stable
1.1. ADMIT TO WARDADMIT TO WARD2.2. If no improvement, inc. frequency of If no improvement, inc. frequency of
B2-agonist up to ½ hourly or B2-agonist up to ½ hourly or continuouslycontinuously
3.3. Follow BTS guidelinesFollow BTS guidelines4.4. Consider X-RAY Consider X-RAY
1.1. ADMIT TO WARDADMIT TO WARD2.2. If no improvement, inc. frequency of If no improvement, inc. frequency of
B2-agonist up to ½ hourly or B2-agonist up to ½ hourly or continuouslycontinuously
3.3. Follow BTS guidelinesFollow BTS guidelines4.4. Consider X-RAY Consider X-RAY
YesYes
NoNo
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Age <2
1. Dry wheezy cough2. Fever3. Nasal discharge4. Fine insp crackles and/or high pitched
exp wheeze
1.1. HOMEHOME2.2. Follow up Follow up
instructionsinstructions
1.1. HOMEHOME2.2. Follow up Follow up
instructionsinstructions
Mild/moderateMild/moderateMild/moderateMild/moderate Moderate/Severe/Life threateningModerate/Severe/Life threateningModerate/Severe/Life threateningModerate/Severe/Life threatening
1.1. TRIALTRIAL of B of B22-agonist/anticholinergic-agonist/anticholinergic
2.2. Monitor 0Monitor 022 sats sats
3.3. Discontinue if no effectDiscontinue if no effect4.4. X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion)X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion)
1.1. TRIALTRIAL of B of B22-agonist/anticholinergic-agonist/anticholinergic
2.2. Monitor 0Monitor 022 sats sats
3.3. Discontinue if no effectDiscontinue if no effect4.4. X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion)X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion)
1.1. ADMITADMIT2.2. Short course of oral steriodsShort course of oral steriods3.3. ?X-ray if no improvement?X-ray if no improvement4.4. Follow BTS guidelines, i.e. inc frequency of Follow BTS guidelines, i.e. inc frequency of
bronchodilatorbronchodilator
1.1. ADMITADMIT2.2. Short course of oral steriodsShort course of oral steriods3.3. ?X-ray if no improvement?X-ray if no improvement4.4. Follow BTS guidelines, i.e. inc frequency of Follow BTS guidelines, i.e. inc frequency of
bronchodilatorbronchodilator
YesYes
? Bronchiolitis? BronchiolitisSee cough algorithmSee cough algorithm? Bronchiolitis? BronchiolitisSee cough algorithmSee cough algorithmNoNo
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Click if
NOClick if
NO
COUGHCOUGH
YesYes CXRCXRCXRCXR
? Referral to ? Referral to appropriate team for appropriate team for
bronchoscopybronchoscopy
? Referral to ? Referral to appropriate team for appropriate team for
bronchoscopybronchoscopy
If accompanied by whee ze If accompanied by whee ze or stridor see appropriate algorithmor stridor see appropriate algorithm
If accompanied by whee ze If accompanied by whee ze or stridor see appropriate algorithmor stridor see appropriate algorithm
? Paroxysmal cough or high suspicion of
foreign body
1. Dry wheezy cough and age under 22. Fever +/-3. Nasal discharge4. Fine insp crackles and/or
high pitched exp rhonchi
NoNo
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Click ifYES
Click ifYES
BronchiolitisBronchiolitisBronchiolitisBronchiolitis
ADMIT if:ADMIT if:1. Signs of serious illness1. Signs of serious illness2. Complicating factors2. Complicating factors3. Inc risk of serious disease3. Inc risk of serious disease
ADMIT if:ADMIT if:1. Signs of serious illness1. Signs of serious illness2. Complicating factors2. Complicating factors3. Inc risk of serious disease3. Inc risk of serious disease
1. Trial of bronchodilator1. Trial of bronchodilator2. Stop if no clinical improvement2. Stop if no clinical improvement3. Monitor 03. Monitor 022 sat sat
4. No steroids4. No steroids5. No routine blood tests/X-rays5. No routine blood tests/X-rays
1. Trial of bronchodilator1. Trial of bronchodilator2. Stop if no clinical improvement2. Stop if no clinical improvement3. Monitor 03. Monitor 022 sat sat
4. No steroids4. No steroids5. No routine blood tests/X-rays5. No routine blood tests/X-rays
? Severe distress
1. Discuss with senior clinician1. Discuss with senior clinician2. Consider trial of nebulised adrenaline2. Consider trial of nebulised adrenaline3. ADMIT for close observation, e.g. HDU/PICU3. ADMIT for close observation, e.g. HDU/PICU
1. Discuss with senior clinician1. Discuss with senior clinician2. Consider trial of nebulised adrenaline2. Consider trial of nebulised adrenaline3. ADMIT for close observation, e.g. HDU/PICU3. ADMIT for close observation, e.g. HDU/PICU
NoNoYesYes
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1.1. X-ray child under 2 months/if no X-ray child under 2 months/if no response to antibiotics/recurrent response to antibiotics/recurrent pneumoniapneumonia
2.2. No routine blood testsNo routine blood tests3.3. Oral antibiotics if clinically suspectedOral antibiotics if clinically suspected4.4. HOME with follow up instructions.HOME with follow up instructions.
1.1. X-ray child under 2 months/if no X-ray child under 2 months/if no response to antibiotics/recurrent response to antibiotics/recurrent pneumoniapneumonia
2.2. No routine blood testsNo routine blood tests3.3. Oral antibiotics if clinically suspectedOral antibiotics if clinically suspected4.4. HOME with follow up instructions.HOME with follow up instructions.
PNEUMONIAPNEUMONIAPNEUMONIAPNEUMONIA
Combination of cough &breathing difficulty and:1. Fever2. High resp rate3. Grunting4. Chest in-drawing
NoNo
Re-assess childRe-assess childRe-assess childRe-assess child
Mild/moderate Mild/moderate distressdistressMild/moderate Mild/moderate distressdistress
Severe distressSevere distressSevere distressSevere distress
1.1. CXRCXR2.2. Oral/IV antibiotics according to Oral/IV antibiotics according to
local protocollocal protocol3.3. FBC & B.culture if requires IV FBC & B.culture if requires IV
antibioticsantibiotics4.4. No routine blood tests if on oral No routine blood tests if on oral
rxrx5.5. ADMITADMIT
1.1. CXRCXR2.2. Oral/IV antibiotics according to Oral/IV antibiotics according to
local protocollocal protocol3.3. FBC & B.culture if requires IV FBC & B.culture if requires IV
antibioticsantibiotics4.4. No routine blood tests if on oral No routine blood tests if on oral
rxrx5.5. ADMITADMIT
YesYes
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CXR ?CXR ?
Table 1 Pre-terminal signs
Exhaustion
Bradycardia
Silent chest
Significant apnoea
Table 2 Signs of severely ill child requiring urgent attention
Inappropriate drowsiness (difficult to rouse)
Agitation
Cyanosis in air
Back More Information
Table 3 Signs of increased work of breathing
Increased respiratory rate
Chest in-drawing
Nasal flaring
Tracheal tug
Use of accessory muscles
Grunting
Back More Information
Table 4 Assessment of severity of breathing difficulty adapted from WHO management of acute repiratory infections in children. World Health Organisation, Geneva, 1995
Assessment of severity(breathing difficulty)
Mild Moderate Severe
Oxygen saturation in air 92-95% <92%
Chest wall in-drawing none/mild moderate severe
Nasal flaring absent may be present present
grunting absent absent present
Apnoea/pausing normal absent present
Feeding history normal Approximately half of normal intake
Quantity, half normal
Behavior normal irritable Lethargic Unresponsive Flaccid Decreased level of consciousness Inconsolable
Back
< 3 months 3 months - 3 years 4 years-adult
Responsiveness and activity Flaccid Cannot awaken or keep awake Weak cry or weak suck Inconsolable Refuse feedings
Responsiveness and activity Unresponsive Cannot awaken or keep awake Markedly decreased activity Inconsolable Weak suck or weak cry(if infant) Refuses feeding
Responsiveness and activity Decreased level of consciousness Markedly decreased activity Cannot awaken or keep awake
Dehydration and vomiting reduced wet nappies> 8 hrs
Dehydration and vomiting no urine> 6-8 hrs if < 1yr no urine> 12 hrs if > 1yr
Dehydration and vomiting no urine> 12 hrs
Meningeal signs stiff neck persistent vomiting
Meningeal signs stiff neck persistent vomiting severe headache
Other petechial and purpuric rash convulsions very high fever hypothermia capillary refill<3 sec
Other petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill<3sec
Other decreased urination with decreased intake petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill> 3 sec
Table 5: Symptoms of Serious Illness (adapted from Viral Upper Respiratory Tract Guideline by Institute for Clinical Systems Improvement and the WHO recommendations on the management of children with cough or breathing difficulty)
Table 6:Complicating Factors contributing to the clinician’s decision regarding admission or discharge
Co-morbidity e. g prematurity, congenital heart disease, any chronic lung disease, neurological disorder
Social problems e. g previous non-accidental injury, ill parents, parents having difficulty coping
Infants younger than 2 months of age
Back
Table 7: Severity of Asthma Based on BTS Guidelines
Age Under 5 years Over 5 years
Mild to Moderate Wheeze and cough with tightness and mild dyspnoea, no distress, no speech or feeding difficultyMild respiratory distressRespiratory rate <50Pulse <140 bpmSaturations >92% in air
Wheeze and cough with tightnessAble to talkPEFR >50% predictedPulse <120Saturations >92% in air
Moderate to Severe Too breathless to talkToo breathless to feedRespiratory rate >50/minPulse >140/minUse of accessory muscles
Too breathless to talkToo breathless to feedRespiratory rate >40Pulse >120/minPEFR <50%predicted
Life Threatening CyanosisSilent chestPoor respiratory effortFatigue or exhaustionAgitation or reduced level of consciousness
CyanosisSilent chestPoor respiratory effortFatigue or exhaustionPEFR <33%predictedAgitation or reduced level of consciousness
Back
Table 8: Infants at risk of developing severe bronchiolitis(adapted from Management of acute bronchiolitis by Rakshi and Couriel,
Archives of Disease in Childhood, 1994; 71:463-469)
Apnoea
Preterm birth
Underlying disorders Lung disease e.g. bronchopulmonary dysplasia,cystic fibrosis Congenital heart disease Immunodeficiency (congenital or acquired) Multiple congenital abnormalities Severe neurological disease
Back
Toxic appearance
Severe respiratory distress
Vomiting
Immunocompromised
Dehydrated and requiring intravenous fluids
Table 9: Indications for treatment with parenteral antibiotics in a child clinically suspected
to have pneumonia
Back
Table 10: Differential diagnosis of less obvious causes of respiratory distress(Adapted from Fleischer's Textbook of Emergency Medicine, Chapter 65)
Metabolic Disorders
Central Nervous System
Dysfunction
Neuromuscular Disorders
Chest Wall Disorders
Diabetes mellitus Meningitis Spinal cord injury Flail chest
Dehydration Encephalitis Infantile botulism Congenital anomalies
Sepsis Tumour Guillain-Barre
Liver/renal disease Intoxication Myopathy
Intoxication Status epilepticus
Inborn errors of metabolism
Trauma
Hydrocephalus
Back
Back
Statement Strength ofevidence
Recommendation Consensus
A1 The most important pre-terminal signs of a childwith breathing difficulty are:a) Exhaustionb) Bradycardiac) silent chestd) significant apnoea(Listed in Table 1)
4 D More than 83%
A2 The following signs indicate that a child with abreathing difficulty is severely ill and requiresimmediate and urgent attention:a) Inappropriate drowsiness (difficult to rouse)b) Agitationc) Cyanosis in air(Listed in Table 2)
4 D More than 83%
A3 The child presenting with breathing difficulty andlife threatening or pre-terminal signs will requirefurther investigation and blood tests oncestabilized.
4 D 94%
Statement Strength of evidence
Recommendation Consensus
A4 All children presenting to hospital with an acute breathing difficulty should have their oxygen saturation measured.
4 C 96%
A5 A child's oxygen saturation should be maintained above 92%. If necessary, oxygen therapy should be given to achieve this.
4 D 88%
Back
Back
Statement Strength of evidence
Recommendation Consensus
A7 Signs of increased work of breathing include: (Listed in Table 3) Increased respiratory rate, chest in-drawing and nasal flaring:
2 C 92%, 98%, 88% respectively
A7 Signs of increased Tracheal tug, accessory muscles and grunting.
4 D 94%, 92%, and 92%
A8 In children under 6 months of age respiratory rate is not an accurate measurement of respiratory illness.
2 B
A9 No recommendation can be provided for respiratory rate indicating tachypnoea. Further research is required.
very difficult to find an evidence-based definition of tachypnoea
panel could not reach the required 83%
Back
Statemet Evidence Strength
Recommendation Consensus
A10 The following are recommendations of definitions to be used for children presenting with acute breathing difficulty:
Stridor indicates limitation of airflow in the upper airway at the larynx or tracheal level. It is a harsh or rasping respiratory noise reflecting upper airway obstruction, usually inspiratory but may be biphasic.
4 D 94% and 96%
Wheeze indicates limitation of airflow in the lower airway. It is a high pitched whistling noise heard on auscultation which is usually more pronounced in the expiratory phase indicating intrathoracic airway obstruction
4 D 92% and 100%
Stertor is an airway generated sound caused by obstruction at pharyngeal level e.g. due to large tonsils.
4 D
Back
Statement Evidence Recommendation ConsensusA11 The adapted table 4 can be used to identifythe severity of a child presenting with a breathingdifficulty
4 D 76%
Back
B1 In a child with stridor, epiglottitis must be considered if the child is agitated, or drooling or there is absence of a cough.
2 C 88%
B2 Bacterial tracheitis can cause severe airway obstruction and should be considered in a child with a croup-like illness (barking cough and stridor) if there is a combination of the following: a) Toxicity b) High fever c) No response to treatment for croup i.e. no improvement in respiratory distress following accepted treatment for croup
3 D 98%, 86%, 84%
respectively
In a child with inspiratory stridor and a barking cough and who is therefore unlikely to have epiglottitis or bacterial tracheitis and more likely to have croup:
B3a Nebulised budesonide or dexamethasone are effective in treating croup
1 A 96%
B3b In a child with suspected croup, oral dexamethasone is cheaper and as efficacious as budesonide. Until more evidence becomes available, oral dexamethasone should therefore be used in preference to nebulised budesonide except in those children who are vomiting or unable to tolerate oral treatment.
4 D 90%
B4a L-epinephrine (adrenaline) can be used in children with severe croup in addition to oral or nebulised steroids
1 B 96%
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Back
Statement Evidence Recommendation ConsensusB4b If treated with L-epinephrine (adrenaline) achild with severe disease requires closeobservation. Admission to intensive care or highdependency for observation should be considered.
4 D 92% and 98%
The next section refers to a child presentingwith stridor or stertor but has no barking coughand no evidence of epiglotittis.B5 Enlarged tonsils should be considered in a childpresenting with breathing difficulty and stertor. Thechild should be referred to the ENT surgeons.
4 D ENT surgeon
B6 Aspiration of a foreign body should beconsidered in a child presenting with stridor. Thechild could also present with cough, wheeze, orbreathlessness.
2 C 84%, 90%, 92%,and 94%
B7 A child presenting with a history of choking,paroxysmal cough or any suspicion of foreign bodyshould have a chest x-ray.
4 D 96%
B8 A normal chest x-ray cannot rule out thediagnosis of foreign body aspiration.
2 C 100%
Back
C. Child presenting with wheeze. C1 The presence of a foreign body should be considered in a child presenting with acute breathing difficulty and wheeze.
2 C 66% consensus achieved when the word 'excluded' was used. More than 93% consensus would have been achieved if we had originally used the word 'considered'.
C2 During the acute management of a child with wheeze it is not possible to differentiate between those who will have transient symptoms and those who will later develop asthma. After consideration of diagnosis of a foreign body the acute management should focus on the relief of symptoms rather than the ultimate diagnosis
2 B 84%
C3 The criteria suggested by the British Thoracic Society regarding the differentiation between mild, moderate, severe and life threatening asthma or wheeze should be accepted . Table 7
4 D 88%
C4 In children under the age of 2, the limited evidence does not support the widespread indiscriminate use of anticholinergic agent i.e. anticholinergic agents should only be used on a trial basis on children under the age of 2 until further research is available
1 A 80%
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Back
Statement Evidence Recommendation ConsensusC5 In a child under the age of 2 with wheeze, a trialof either an anticholinergic agent, beta-2 agonist orboth can be used to relieve symptoms. Oxygensaturation and response to treatment must bemonitored.
4 D 92%
C6 In children over the age of 2 with moderate tosevere asthma, the addition of 4-6 hrlyanticholinergics to the beta 2-agonists inhalationregimen is indicated if there has been poorresponse to beta 2 agonist alone.
1 A 92%
C7 In children over the age of 2, without life-threatening asthma (Table 7) and not requiringoxygen, holding chambers (spacers) could be usedinstead of nebulisers in most situations.
1 A 90%
C8 All children, regardless of their age, withmoderate-severe or life threatening wheeze shouldbe prescribed a short course of oral steroids.
4 D 84%
C9 Aminophylline should continue to be used forthe treatment of acute severe life threateningasthma when other treatments including salbutamoland corticosteroids have been unsuccessful
1 A 88%
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Back
The next section will consider investigations for a child presenting with wheeze or asthma
C10 Chest x-rays do not routinely need to be performed on every child presenting with their first acute attack of wheeze. Consider if there are atypical clinical features (e.g. focal signs, suspicion of foreign body).
2 C 76%
C11 A child presenting with acute asthma/wheeze do not routinely require a chest x-ray
2 C 98%
C12 A child presenting with acute wheeze/asthma with the following unusual signs should have a chest x-ray when stable: a) Unilateral reduced air entry and hyperresonance
on percussion (signs of pneumothorax) b) no improvement after treatment of severe
symptoms
4 D 96% and 98%
C 13 A child presenting or admitted with acute wheeze does not routinely require blood tests.
4 D 92% and 94%
Back
D This section discusses a child under the ageof 2 who presents with wheeze.Statement Evidence Recommendation ConsensusD1. Bronchiolitis is a seasonal viral illnesscharacterised by fever, nasal discharge, and drywheezy cough. On examination there are fineinspiratory rackles and/or high pitched expiratorywheeze.
4 D 90%
D2 In a child clinically diagnosed with bronchiolitis,bronchodilators should not be routine practice. Atrial may be considered but stopped if found to beof no help.
1 A 86%
D3 During a trial of bronchodilator therapy the childshould be closely monitored for clinicaldeterioration and hypoxaemia and treatmentstopped if there is no clinical improvement.
1 A 86%
D4 Budesonide is not recommended in themanagement of a child with bronchiolitis.
1 A 100%
D5 Oral or intramuscular steroids are notrecommended in the routine treatment of a childwith bronchiolitis.
1 A 98%
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D6 In a child with bronchiolitis and severe respiratory distress, a trial therapy of nebulised adrenaline (L-epinephrine) may be considered after discussion with a senior clinician
1 B 60%
D7 If treated with adrenaline (L-epinephrine) the child requires close observation. Admission to intensive care or high dependency for observation should be considered
4 D 98% and 92%
D7 Blood tests are not routinely recommended in the management of a child with bronchiolitis.
4 D 96%
D8 Routine x-ray of a child with clinically diagnosed bronchiolitis is not recommended.
2 C 92%
D9 A child aged less than 2 months with clinical signs of bronchiolitis should be admitted if they are at risk of developing serious disease (see Table 8)
4 D 98%
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E Child presenting with a cough
E1 A child who has aspirated a foreign body can present with a cough
2 C 90%
E2 A child presenting with a breathing difficulty and a history of paroxysmal cough or any suspicion of foreign body aspiration should have a chest x-ray.
4 D 96%
E3 In a child with cough and breathing difficulty the probability of pneumonia is increased in the presence of any of the following: a) Tachypnoea b) Grunting c) Chest in-drawing d) Fever e) Nasal flaring f) Crepitations
2 C 88% and 93% consensus achieved respectively for a) and b) Consensus not achieved for c), d)(66% consensus), e)(68% consensus), f)(82% consensus) but based on level 2 evidence
E4(a)All children under the age of 2 months with clinically suspected pneumonia should have a chest x-ray
4 D 94%
E4(b)Children over the age of 2 months with signs suggesting pneumonia but who do not require admission to hospital do not routinely require a chest x-ray. An x-ray may be indicated if there has been no response to oral antibiotics or the patient is not presenting with the first episode of pneumonia
1 A 80%
E4( c)A child admitted to hospital with clinically suspected pneumonia i.e. with cough and severe respiratory distress should have a chest x-ray
4 D 89%
E5 Even when a chest x-ray is taken, this may not allow differentiation between viral and bacterial pneumonia.
2 C 96%
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Statement Evidence Recommendation
Consensus
E6 In children with clinically suspected pneumonia anormal chest x-ray cannot exclude pneumonia
2 C 88%
E7 (a) No laboratory tests should be routinely performedon children with clinically suspected pneumonia who arenot admitted to hospital
2 C 94%
E7 (b) It is not necessary to carry out blood tests in a childadmitted to hospital with clinically suspected pneumoniabut who is treated with oral antibiotics
2 C 82%
E7 (c) All children admitted to hospital with clinicallysuspected pneumonia and who will be treated withintravenous antibiotics should have a full blood count andblood culture. Acute phase reactants, urea, andelectrolytes are not required routinely.
2 C 76% consensus achievedoriginally butrecommendation wasreworded after re-appraising the evidence
E7 (d) Acute phase reactants such as ESR and CRP donot help distinguish between viral and bacterial infection.
2 C
E8 A child admitted to hospital with clinically suspectedpneumonia should be prescribed parenteral antibiotics ifthey have any of the following:
a) Toxic appearanceb) Severe respiratory distressc) Vomitingd) Immunocompromisede) dehydrated and requiring intravenous fluids
4 D 90%, 94%, 94%, 92%,and 94%
E9 The antibiotic used for the treatment of a child withcommunity acquired pneumonia should be chosenaccording to the local protocol
4 D 90%
Table 4 Assessment of severity of breathing difficulty adapted from WHO management of acute repiratory infections in children. World Health Organisation, Geneva, 1995
Assessment of severity(breathing difficulty)
Mild Moderate Severe
Oxygen saturation in air 92-95% <92%
Chest wall in-drawing none/mild moderate severe
Nasal flaring absent may be present present
grunting absent absent present
Apnoea/pausing normal absent present
Feeding history normal Approximately half of normal intake
Quantity, half normal
Behavior normal irritable Lethargic Unresponsive Flaccid Decreased level of consciousness Inconsolable
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< 3 months 3 months - 3 years 4 years-adult
Responsiveness and activity Flaccid Cannot awaken or keep awake Weak cry or weak suck Inconsolable Refuse feedings
Responsiveness and activity Unresponsive Cannot awaken or keep awake Markedly decreased activity Inconsolable Weak suck or weak cry(if infant) Refuses feeding
Responsiveness and activity Decreased level of consciousness Markedly decreased activity Cannot awaken or keep awake
Dehydration and vomiting reduced wet nappies> 8 hrs
Dehydration and vomiting no urine> 6-8 hrs if < 1yr no urine> 12 hrs if > 1yr
Dehydration and vomiting no urine> 12 hrs
Meningeal signs stiff neck persistent vomiting
Meningeal signs stiff neck persistent vomiting severe headache
Other petechial and purpuric rash convulsions very high fever hypothermia capillary refill<3 sec
Other petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill<3sec
Other decreased urination with decreased intake petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill> 3 sec
Table 5: Symptoms of Serious Illness (adapted from Viral Upper Respiratory Tract Guideline by Institute for Clinical Systems Improvement and the WHO recommendations on the management of children with cough or breathing difficulty)
Back More Information
Table 6: Complicating Factors contributing to the clinician’s decision regarding admission or discharge
Co-morbidity e. g prematurity, congenital heart disease, any chronic lung disease, neurological disorder
Social problems e. g previous non-accidental injury, ill parents, parents having difficulty coping
Infants younger than 2 months of age
< 3 months 3 months - 3 years 4 years-adult
Responsiveness and activity Flaccid Cannot awaken or keep awake Weak cry or weak suck Inconsolable Refuse feedings
Responsiveness and activity Unresponsive Cannot awaken or keep awake Markedly decreased activity Inconsolable Weak suck or weak cry(if infant) Refuses feeding
Responsiveness and activity Decreased level of consciousness Markedly decreased activity Cannot awaken or keep awake
Dehydration and vomiting reduced wet nappies> 8 hrs
Dehydration and vomiting no urine> 6-8 hrs if < 1yr no urine> 12 hrs if > 1yr
Dehydration and vomiting no urine> 12 hrs
Meningeal signs stiff neck persistent vomiting
Meningeal signs stiff neck persistent vomiting severe headache
Other petechial and purpuric rash convulsions very high fever hypothermia capillary refill<3 sec
Other petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill<3sec
Other decreased urination with decreased intake petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill> 3 sec
Table 5: Symptoms of Serious Illness (adapted from Viral Upper Respiratory Tract Guideline by Institute for Clinical Systems Improvement and the WHO recommendations on the management of children with cough or breathing difficulty)
Back
Table 6: Complicating Factors contributing to the clinician’s decision regarding admission or discharge
Co-morbidity e. g prematurity, congenital heart disease, any chronic lung disease, neurological disorder
Social problems e. g previous non-accidental injury, ill parents, parents having difficulty coping
Infants younger than 2 months of age
Statement Strength of evidence
Recommendation
Consensus
A12 A child with acute breathing difficulty should be admitted to hospital if they fall into any of the following category: a) Has signs indicating that a child with a
breathing difficulty is severely ill and requires immediate and urgent attention (Table 1 and 2).
b) Oxygen saturation less than 92% in air c) Has signs of severe respiratory distress
(Table 4) d) A child with mild to moderate breathing
difficulty who has other signs of serious illness (Table 5).
4 D 98%, 98%, 100%, 96%
Statement Strength ofevidence
Recommendation Consensus
C4 In children under the age of 2,the limited evidence does notsupport the widespreadindiscriminate use of anticholinergicagent i.e. anticholinergic agentsshould only be used on a trial basison children under the age of 2 untilfurther research is available
1 A 80%
C5 In a child under the age of 2 withwheeze, a trial of either ananticholinergic agent, beta-2 agonistor both can be used to relievesymptoms. Oxygen saturation andresponse to treatment must bemonitored.
4 D 92%
Statement Strength ofevidence
Recommendation Consensus
C10 Chest x-rays do not routinelyneed to be performed on every childpresenting with their first acuteattack of wheeze. Consider if thereare atypical clinical features (e.g.focal signs, suspicion of foreignbody).
2 C 76%
C11 A child presenting with acuteasthma/wheeze do not routinelyrequire a chest x-ray
2 C 98%
C12 A child presenting with acutewheeze/asthma with the followingunusual signs should have a chestx-ray when stable:a) Unilateral reduced air entry and
hyperresonance on percussion(signs of pneumothorax)
b)no improvement after treatment ofsevere symptoms
4 D 96% and 98%
Statement Strength ofevidence
Recommendation
Consensus
C7 In children over the age of 2,without life-threatening asthma(Table 7) and not requiringoxygen, holding chambers(spacers) could be used insteadof nebulisers in most situations.
1 A 90%
C8 All children, regardless oftheir age, with moderate-severeor life threatening wheeze shouldbe prescribed a short course oforal steroids.
4 D 84%
Statement Strength ofevidence
Recommendation
Consensus
E3 In a child with cough andbreathing difficulty the probabilityof pneumonia is increased in thepresence of any of the following:a) Tachypnoeab) Gruntingc) Chest in-drawingd) Fevere) Nasal flaringf) Crepitations
2 C 88% and 93%consensus achievedrespectively for a) andb)Consensus notachieved for c),d)(66% consensus),e)(68% consensus),f)(82% consensus)but based on level 2evidence
E4(a)All children under the age of2 months with clinicallysuspected pneumonia shouldhave a chest x-ray
4 D 94%
Statement Strength ofevidence
Recommendation
Consensus
E4(b)Children over the age of 2months with signs suggestingpneumonia but who do notrequire admission to hospital donot routinely require a chest x-ray. An x-ray may be indicated ifthere has been no response tooral antibiotics or the patient isnot presenting with the firstepisode of pneumonia
1 A 80%
E4( c)A child admitted to hospitalwith clinically suspectedpneumonia i.e. with cough andsevere respiratory distress shouldhave a chest x-ray
4 D 89%
E5 Even when a chest x-ray istaken, this may not allowdifferentiation between viral andbacterial pneumonia.
2 C 96%
E6 In children with clinicallysuspected pneumonia a normalchest x-ray cannot excludepneumonia
2 C 88%
Statement Strength ofevidence
Recommendation
Consensus
E7 (a) No laboratory tests shouldbe routinely performed onchildren with clinically suspectedpneumonia who are not admittedto hospital
2 C 94%
E7 (b) It is not necessary to carryout blood tests in a child admittedto hospital with clinicallysuspected pneumonia but who istreated with oral antibiotics
2 C 82%
E7 (c) All children admitted tohospital with clinically suspectedpneumonia and who will betreated with intravenousantibiotics should have a fullblood count and blood culture.Acute phase reactants, urea, andelectrolytes are not requiredroutinely.
2 C76% consensus
achieved originally but
recommendation was
reworded after re-
appraising the
evidence
Statement Strength ofevidence
Recommendation
Consensus
A12 A child with acute breathingdifficulty should be admitted tohospital if they fall into any of thefollowing category:a) Has signs indicating that a child
with a breathing difficulty isseverely ill and requiresimmediate and urgent attention(Table 1 and 2).
b) Oxygen saturation less than 92%in air
c) Has signs of severe respiratorydistress (Table 4)
d) A child with mild to moderatebreathing difficulty who has othersigns of serious illness (Table 5).
4 D 98%, 98%, 100%,96%
< 3 months 3 months - 3 years 4 years-adult
Responsiveness and activity Flaccid Cannot awaken or keep awake Weak cry or weak suck Inconsolable Refuse feedings
Responsiveness and activity Unresponsive Cannot awaken or keep awake Markedly decreased activity Inconsolable Weak suck or weak cry(if infant) Refuses feeding
Responsiveness and activity Decreased level of consciousness Markedly decreased activity Cannot awaken or keep awake
Dehydration and vomiting reduced wet nappies> 8 hrs
Dehydration and vomiting no urine> 6-8 hrs if < 1yr no urine> 12 hrs if > 1yr
Dehydration and vomiting no urine> 12 hrs
Meningeal signs stiff neck persistent vomiting
Meningeal signs stiff neck persistent vomiting severe headache
Other petechial and purpuric rash convulsions very high fever hypothermia capillary refill<3 sec
Other petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill<3sec
Other decreased urination with decreased intake petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill> 3 sec
Table 5: Symptoms of Serious Illness (adapted from Viral Upper Respiratory Tract Guideline by Institute for Clinical Systems Improvement and the WHO recommendations on the management of children with cough or breathing difficulty)
Back More Information
Table 6: Complicating Factors contributing to the clinician’s decision regarding admission or discharge
Co-morbidity e. g prematurity, congenital heart disease, any chronic lung disease, neurological disorder
Social problems e. g previous non-accidental injury, ill parents, parents having difficulty coping
Infants younger than 2 months of age
Statement Strength ofevidence
Recommendation
Consensus
A12 A child with acute breathingdifficulty should be admitted tohospital if they fall into any of thefollowing category:a) Has signs indicating that a child
with a breathing difficulty isseverely ill and requiresimmediate and urgent attention(Table 1 and 2).
b) Oxygen saturation less than 92%in air
c) Has signs of severe respiratorydistress (Table 4)
d) A child with mild to moderatebreathing difficulty who has othersigns of serious illness (Table 5).
4 D 98%, 98%, 100%,96%
Statements in this algorithm are derived from a critical appraisal of literature Statements in this algorithm are derived from a critical appraisal of literature and a subsequent two round Delphi consensus process. Thus the levels of and a subsequent two round Delphi consensus process. Thus the levels of evidence and recommendations made follow the grading system used by evidence and recommendations made follow the grading system used by SIGN and the last column in the tables which follow refer to the degree of SIGN and the last column in the tables which follow refer to the degree of
consensus reached in the Delphi panel process where 86% was accepted as consensus reached in the Delphi panel process where 86% was accepted as an acceptable level of agreement.an acceptable level of agreement.
Based on development and studies by the Paediatric Accident and Emergency Based on development and studies by the Paediatric Accident and Emergency Research Group in Queens Medical Centre NottinghamResearch Group in Queens Medical Centre Nottingham
Supported by Children NationwideSupported by Children Nationwide
Full technical report is available at:Full technical report is available at:
www.nnnnnnnnwww.nnnnnnnn
Levels of evidence
Level Type of evidence (based on SIGN 2000)
1++
1+
1-
Evidence from high quality meta-analyses, systematic reviews of
RCTs, or RCTs with a very low risk bias
Evidence from well conducted meta-analyses, systematic reviews of
RCTs, or RCTs with a low risk of bias
Evidence from meta-analyses, systematic reviews of RCTSs, or RCTs
with a high risk of bias
2++
2+
2-
Evidence from high quality systematic reviews of case-control or
cohort studies or high quality case-control or cohort studies with a very
low risk confounding, bias, or change and a moderate probability that
the relationship is causal
Evidence from well conducted case-control or cohort studies with a
low risk of confounding, bias, or chance and a moderate probability
that the relationship is causal
Evidence from case-control or cohort studies with a high risk of
confounding, bias, or chance and a significant risk that the relationship
is not causal
3 Evidence from non-analytical studies eg case reports, case series
4 Evidence from expert opinion
Grading of recommendations
Grade Type of recommendation (based on SIGN 2000)
A Requires at least one meta-analyses, systematic review of RCT rated
as 1++, and directly applicable to the target population, and
demonstrating overall consistency or results
B Requires a body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; or extrapolated evidence from studies rated as
1++ or 1+
C Requires a body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; or extrapolated evidence from studies rates as
2++
D Evidence level 3 or 4; or extrapolated evidence from studies rates as
2+
Parent advice
When you take your child home:• It is important that you:• 1. encourage your child to drink plenty
little and often• 2.check their breathing and colour (see
below)• 3.give your child the medication
prescribed by the doctor(list)•
Parent return advice (2)
You must call a doctor or go back to the hospital if:
• 1.your child is struggling to breathe and getting very tired
• 2. your child is too breathless to talk or your baby is grunting or unable to feed
• 3.your child changes colour and becomes pale grey, white or blue around the lips
• 4.you are worried that your child has got worse
Parent advice
When you take your child home:• It is important that you:• 1. encourage your child to drink plenty
little and often• 2.check their breathing and colour (see
below)• 3.give your child the medication
prescribed by the doctor(list)•
Parent return advice (2)
You must call a doctor or go back to the hospital if:
• 1.your child is struggling to breathe and getting very tired
• 2. your child is too breathless to talk or your baby is grunting or unable to feed
• 3.your child changes colour and becomes pale grey, white or blue around the lips
• 4.you are worried that your child has got worse
Parent advice
When you take your child home:• It is important that you:• 1. encourage your child to drink plenty
little and often• 2.check their breathing and colour (see
below)• 3.give your child the medication
prescribed by the doctor(list)•
Parent return advice (2)
You must call a doctor or go back to the hospital if:
• 1.your child is struggling to breathe and getting very tired
• 2. your child is too breathless to talk or your baby is grunting or unable to feed
• 3.your child changes colour and becomes pale grey, white or blue around the lips
• 4.you are worried that your child has got worse
Table 3 Signs of increased work of breathing
Increased respiratory rate
Chest in-drawing
Nasal flaring
Tracheal tug
Use of accessory muscles
Grunting
Back More Information
Table 4 Assessment of severity of breathing difficulty adapted from WHO management of acute repiratory infections in children. World Health Organisation, Geneva, 1995
Assessment of severity(breathing difficulty)
Mild Moderate Severe
Oxygen saturation in air 92-95% <92%
Chest wall in-drawing none/mild moderate severe
Nasal flaring absent may be present present
grunting absent absent present
Apnoea/pausing normal absent present
Feeding history normal Approximately half of normal intake
Quantity, half normal
Behavior normal irritable Lethargic Unresponsive Flaccid Decreased level of consciousness Inconsolable
Back
Back
The next section will consider investigations for a child presenting with wheeze or asthma
C10 Chest x-rays do not routinely need to be performed on every child presenting with their first acute attack of wheeze. Consider if there are atypical clinical features (e.g. focal signs, suspicion of foreign body).
2 C 76%
C11 A child presenting with acute asthma/wheeze do not routinely require a chest x-ray
2 C 98%
C12 A child presenting with acute wheeze/asthma with the following unusual signs should have a chest x-ray when stable: a) Unilateral reduced air entry and hyperresonance
on percussion (signs of pneumothorax) b) no improvement after treatment of severe
symptoms
4 D 96% and 98%
C 13 A child presenting or admitted with acute wheeze does not routinely require blood tests.
4 D 92% and 94%
Next Page
Statement Strength ofevidence
Recommendation Consensus
C10 Chest x-rays do not routinelyneed to be performed on every childpresenting with their first acuteattack of wheeze. Consider if thereare atypical clinical features (e.g.focal signs, suspicion of foreignbody).
2 C 76%
C11 A child presenting with acuteasthma/wheeze do not routinelyrequire a chest x-ray
2 C 98%
C12 A child presenting with acutewheeze/asthma with the followingunusual signs should have a chestx-ray when stable:a) Unilateral reduced air entry and
hyperresonance on percussion(signs of pneumothorax)
b)no improvement after treatment ofsevere symptoms
4 D 96% and 98%
Back
D This section discusses a child under the age of 2 who presents with wheeze.
Statement Evidence Recommendation Consensus D1. Bronchiolitis is a seasonal viral illness characterised by fever, nasal discharge, and dry wheezy cough. On examination there are fine inspiratory rackles and/or high pitched expiratory wheeze.
4 D 90%
Back
B1 In a child with stridor, epiglottitis must be considered if the child is agitated, or drooling or there is absence of a cough.
2 C 88%
B2 Bacterial tracheitis can cause severe airway obstruction and should be considered in a child with a croup-like illness (barking cough and stridor) if there is a combination of the following: a) Toxicity b) High fever c) No response to treatment for croup i.e. no improvement in respiratory distress following accepted treatment for croup
3 D 98%, 86%, 84%
respectively
In a child with inspiratory stridor and a barking cough and who is therefore unlikely to have epiglottitis or bacterial tracheitis and more likely to have croup:
B3a Nebulised budesonide or dexamethasone are effective in treating croup
1 A 96%
B3b In a child with suspected croup, oral dexamethasone is cheaper and as efficacious as budesonide. Until more evidence becomes available, oral dexamethasone should therefore be used in preference to nebulised budesonide except in those children who are vomiting or unable to tolerate oral treatment.
4 D 90%
B4a L-epinephrine (adrenaline) can be used in children with severe croup in addition to oral or nebulised steroids
1 B 96%
Table 1 Pre-terminal signs
Exhaustion
Bradycardia
Silent chest
Significant apnoea
Table 2 Signs of severely ill child requiring urgent attention
Inappropriate drowsiness (difficult to rouse)
Agitation
Cyanosis in air
Back More Information
Table 3 Signs of increased work of breathing
Increased respiratory rate
Chest in-drawing
Nasal flaring
Tracheal tug
Use of accessory muscles
Grunting
Back More Information
Table 3 Signs of increased work of breathing
Increased respiratory rate
Chest in-drawing
Nasal flaring
Tracheal tug
Use of accessory muscles
Grunting
Back More Information
Table 4 Assessment of severity of breathing difficulty adapted from WHO management of acute repiratory infections in children. World Health Organisation, Geneva, 1995
Assessment of severity(breathing difficulty)
Mild Moderate Severe
Oxygen saturation in air 92-95% <92%
Chest wall in-drawing none/mild moderate severe
Nasal flaring absent may be present present
grunting absent absent present
Apnoea/pausing normal absent present
Feeding history normal Approximately half of normal intake
Quantity, half normal
Behavior normal irritable Lethargic Unresponsive Flaccid Decreased level of consciousness Inconsolable
Back
< 3 months 3 months - 3 years 4 years-adult
Responsiveness and activity Flaccid Cannot awaken or keep awake Weak cry or weak suck Inconsolable Refuse feedings
Responsiveness and activity Unresponsive Cannot awaken or keep awake Markedly decreased activity Inconsolable Weak suck or weak cry(if infant) Refuses feeding
Responsiveness and activity Decreased level of consciousness Markedly decreased activity Cannot awaken or keep awake
Dehydration and vomiting reduced wet nappies> 8 hrs
Dehydration and vomiting no urine> 6-8 hrs if < 1yr no urine> 12 hrs if > 1yr
Dehydration and vomiting no urine> 12 hrs
Meningeal signs stiff neck persistent vomiting
Meningeal signs stiff neck persistent vomiting severe headache
Other petechial and purpuric rash convulsions very high fever hypothermia capillary refill<3 sec
Other petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill<3sec
Other decreased urination with decreased intake petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill> 3 sec
Table 5: Symptoms of Serious Illness (adapted from Viral Upper Respiratory Tract Guideline by Institute for Clinical Systems Improvement and the WHO recommendations on the management of children with cough or breathing difficulty)
Back
Table 6: Complicating Factors contributing to the clinician’s decision regarding admission or discharge
Co-morbidity e. g prematurity, congenital heart disease, any chronic lung disease, neurological disorder
Social problems e. g previous non-accidental injury, ill parents, parents having difficulty coping
Infants younger than 2 months of age
< 3 months 3 months - 3 years 4 years-adult
Responsiveness and activity Flaccid Cannot awaken or keep awake Weak cry or weak suck Inconsolable Refuse feedings
Responsiveness and activity Unresponsive Cannot awaken or keep awake Markedly decreased activity Inconsolable Weak suck or weak cry(if infant) Refuses feeding
Responsiveness and activity Decreased level of consciousness Markedly decreased activity Cannot awaken or keep awake
Dehydration and vomiting reduced wet nappies> 8 hrs
Dehydration and vomiting no urine> 6-8 hrs if < 1yr no urine> 12 hrs if > 1yr
Dehydration and vomiting no urine> 12 hrs
Meningeal signs stiff neck persistent vomiting
Meningeal signs stiff neck persistent vomiting severe headache
Other petechial and purpuric rash convulsions very high fever hypothermia capillary refill<3 sec
Other petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill<3sec
Other decreased urination with decreased intake petechial or purpuric rash convulsions very high fever unresponsive to treatment capillary refill> 3 sec
Table 5: Symptoms of Serious Illness (adapted from Viral Upper Respiratory Tract Guideline by Institute for Clinical Systems Improvement and the WHO recommendations on the management of children with cough or breathing difficulty)
Back
Table 6: Complicating Factors contributing to the clinician’s decision regarding admission or discharge
Co-morbidity e. g prematurity, congenital heart disease, any chronic lung disease, neurological disorder
Social problems e. g previous non-accidental injury, ill parents, parents having difficulty coping
Infants younger than 2 months of age
Recommended