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CHILD WITH
BREAHTHING
PROBLEMS
May / 2018 PELS / SLCP 1
PELC Course
Objectives
Recognition of
• “immediately life threatening” asthma
• “severe” asthma
Case presentation
Management principles
Specific treatments
May / 2018 PELS / SLCP 2
Signs of deterioration
• Increasing recession
• Increasing respiratory rate
• Increasing pulse rate
• Fatigue
• Altered mental status
• Cyanosis
May / 2018 PELS / SLCP 3
Key Features
May / 2018 PELS / SLCP 4
Stridor
Wheeze
Fever
Heart failure
Ingestion
Urticaria/
allergen ingestion
upper airway obstruction
lower airway obstruction
pneumonia
heart disease
poisoning
anaphylaxis
Upper airway noises
Secretions – poor cough reflex
Snoring – poor conscious level
Loud stridor & cough – croup or FB
Soft stridor & septic – tracheitis, epiglottitis
Sudden onset cough & stridor – FB
May / 2018 PELS / SLCP 5
BLUE PRINT
What do you next ?
May / 2018 PELS / SLCP 6
PELS Approach
“The Blueprint”
Triage
Initial Stabilisation
Position
Airway
Breathing
Circulation
Disability
Measurement
Monitoring
Reassess
Directed History and
Examination and Ix –
Reassess
Commence Specific
Treatment
Ongoing Care
May / 2018 PELS / SLCP 7
Initial resuscitation
• Prop up
• Open airway (Sniffing position)
• High-flow oxygen
• Ventilatory support
May / 2018 PELS / SLCP 8
Breathing difficultiesViral croup – emergency treatment
• Oxygen
• Adrenaline nebulised
• 0.5mL/kg of 1:1000 (max 5mL)
• Give dexamethasone
• Seek expert help if intubation and ventilation required
Avoid unnecessary upset for child
May / 2018 PELS / SLCP 9
Breathing difficultiesEpiglottitis – emergency treatment
Avoid unnecessary upset for child
• Oxygen
• Seek expert help to intubate and ventilate
• IV antibiotics
May / 2018 PELS / SLCP 10
Breathing difficultiesForeign body – emergency treatment
Avoid unnecessary upset for child
• Choking child algorithm
• Complete obstruction
• Direct laryngoscopy
• Cricothyroidotomy
• Severe respiratory distress
• Seek help – anaesthetist & ENT
• Urgent larnygoscopy/bronchoscopy
with anaesthesia
May / 2018 PELS / SLCP 11
Breathing difficultiesBronchiolitis
• Infants
• Seasonal
• Characteristics
• Cough
• Wheeze
• Respiratory distress
• Apnoea
CXR – Hyper inflated lungs
May / 2018 PELS / SLCP 12
Bronchiolitis – management
• Monitoring
• Airway clearance
• Oxygen
• High-flow nasal oxygen (HFNO)
• Hydration
May / 2018 PELS / SLCP 13
Pneumonia – Assessment & Management
• Effort, efficacy and effect of breathing
• CXR
• Oxygen
• Antibiotics
• Ventilation may be require
May / 2018 PELS / SLCP 14
Clinical Scenario
•8 years old Child with acute
wheezing
May / 2018 PELS / SLCP 15
How severe? What next?
Asthma Severity
May / 2018 PELS / SLCP 16
Severe Life-threatening
Too breathless to talk
or feed
Exhaustion
Resp >30/min (>5yr)
>50/min (2-5yr)
Poor respiratory effort
Silent chest
Hypotension
HR >120/min(>5yr)
>130/min(2-5yr)
Conscious level depressed/agitated
Breathing – Interventions
• Sniffing position
• Assess breathing / Check SpO2 in air
• High flow oxygen through non-rebreathing face mask
• Nebulisation
• Salbutamol
• Salbutamol + Ipravent
• Hydrocortisone 4-6mg/kg 6hourly
May / 2018 PELS / SLCP 17
Breathing – Nebulisations
May / 2018 PELS / SLCP 18
• Oxygen source – 6 liters per minute
• Medications
• Salbutamol / Ipratropium bromide / Combined
• How often
• 2 hourly / 4 hourly / continuous
• Continuous Nebulisation (Back to back )
• Use two units (breathing circuits with oxygen
source)
Circulation / Hydration
• Dehydration / Normal hydration
• Check Pulse rate, Volume, BP and capillary refill
• Attach to a cardiac monitor
• Insert an IV line (if not already done)
• Blood tests ( RBS, FBC, BC, SE-Na/K+, Mycoplasma ab)
May / 2018 PELS / SLCP 19
Measure
May / 2018 PELS / SLCP 20
Blood sugar
Temperature
Venous blood gas
Monitor – Signs of deterioration
May / 2018 PELS / SLCP 21
• Increasing resp rate or slow resp rate
• Falling oxygen saturation
• Abdominal breathing
• Unequal or poor air entry
• Unequal chest expansion on either side
Reassess
May / 2018 PELS / SLCP 22
Check for Worsening of disease condition
SpO2 Best
Wheeze Poor
CXR Poor
Arterial blood gases Rarely needed
Trends are better than single observations
Directed History
ASK ABOUT
• Current event
• History suggestive of infection
• Past history of ICU admission
• Current regular medications ( theophylline,
Inhalers)
May / 2018 PELS / SLCP 23
SPECIFIC
MEDICATIONS
May / 2018 PELS / SLCP 24
Specific Treatment
IV Salbutamol
• 5 µg / kg loading dose over 5 mins
• Follow with infusion 5-10 µg / kg / hr (may go much
higher than this)
• Tachycardia is not a contra-indication
May / 2018 PELS / SLCP 25
Specific Treatment
What about?
• Aminophylline Magnesium sulphate
May / 2018 PELS / SLCP 26
Look for
• Differential diagnoses – FB inhalation
• associated co-morbidity – Heart disease
• Sudden deterioration – Pneumothorax
• Gradual deterioration – Pneumonia
• Surgical emphysema – Rupture of bullae
May / 2018 PELS / SLCP 27
Treat treatable
May / 2018 PELS / SLCP 28
• Antibiotics for bacterial infections
• Clarithromycin for mycoplasma
• Rule out FB inhalation
STATUS ASTHMA
May / 2018 PELS / SLCP 29
Q&A
Important Points
Assess for signs of severity
Treatment is PROMPT + AGGRESSIVE
TREAT before TESTING
IF IN DOUBT, OVERTREAT
Easier to manage unintubated
Frequently reassess clinical status
May / 2018 PELS / SLCP 30