Acute Respiratory Disorders in Children Dr Donna Traves Paediatric Consultant 3 rd October 2012.
-
Upload
arlene-greene -
Category
Documents
-
view
227 -
download
0
Transcript of Acute Respiratory Disorders in Children Dr Donna Traves Paediatric Consultant 3 rd October 2012.
Acute Respiratory Acute Respiratory Disorders in ChildrenDisorders in Children
Dr Donna TravesDr Donna Traves
Paediatric ConsultantPaediatric Consultant
33rdrd October 2012 October 2012
Objectives Objectives
Be able to:Be able to: Discuss a range of childhood acute Discuss a range of childhood acute
respiratory problemsrespiratory problems Understand when to refer in children Understand when to refer in children
with acute respiratory diseasewith acute respiratory disease Understand the acute management of Understand the acute management of
paediatric acute respiratory diseasepaediatric acute respiratory disease
AimsAims
To discuss:To discuss: Recognising Sick child with respiratory Recognising Sick child with respiratory
diseasedisease Infection Infection
– – bronchiolitis, pneumonia, croup, bronchiolitis, pneumonia, croup, EpiglottitisEpiglottitis
Inflammatory respiratory disease Inflammatory respiratory disease
- Asthma, allergy- Asthma, allergy
Recognising sick child - respiratory
Effort of breathing Recession Resp rate - ? Slow/shallow Grunting – may indicate atelectasis Accessory muscle use Nasal flare
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
Recognising sick child - respiratory
Feeding history Reduced, absent Eating v drinking Wet nappies etc
General activity Happy playing – eg happy wheezer Lethargic flat
Examples of Increased Respiratory Distress
APLS video
InfectionInfection
BronchiolitisBronchiolitis
Viral illnessViral illness Affects children <2 yrsAffects children <2 yrs Oedema and mucus of the Oedema and mucus of the
bronchioles (lower airways), leading bronchioles (lower airways), leading to over inflation and collapseto over inflation and collapse
Causes – RSV ( 70%), para influenza, Causes – RSV ( 70%), para influenza, adenovirus, influenzaadenovirus, influenza
Bronchiolitis - SymptomsBronchiolitis - Symptoms
Coryzal symptoms 2-3 daysCoryzal symptoms 2-3 days Dry, wheezy CoughDry, wheezy Cough WheezeWheeze Difficulty in BreathingDifficulty in Breathing CyanosisCyanosis Apnoea (esp <6 weeks)Apnoea (esp <6 weeks) Poor Feeding Poor Feeding
Bronchiolitis - SignsBronchiolitis - Signs
Cyanosis/ ↓ O2 SatsCyanosis/ ↓ O2 Sats TachypnoeaTachypnoea Hyperinflation (liver displaced↓)Hyperinflation (liver displaced↓) Recession/ tracheal tugRecession/ tracheal tug Widespread fine inspiratory cracklesWidespread fine inspiratory crackles WheezeWheeze Fever >38ºC Fever >38ºC not usuallynot usually a feature a feature
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
Bronchiolitis - InvestigationsBronchiolitis - Investigations
Oxygen satsOxygen sats NPANPA CXRCXR
Bronchiolitis - TreatmentBronchiolitis - Treatment
Supportive – mostly at homeSupportive – mostly at home Small frequent feedsSmall frequent feeds Nasal saline dropsNasal saline drops PositioningPositioning
Admission treatmentAdmission treatment OxygenOxygen NG feedingNG feeding SuctionSuction
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)
PneumoniaPneumonia
Infection of the lung Infection of the lung parenchyma/tissueparenchyma/tissue
Bacterial or ViralBacterial or Viral Commonly:Commonly:
Strep pneumoniaeStrep pneumoniae StaphylococcusStaphylococcus Haemophilus influenzaeHaemophilus influenzae mycoplasmamycoplasma
PneumoniaPneumonia
SymptomsSymptoms CoughCough TemperatureTemperature Lethargy, decreased eating/drinkingLethargy, decreased eating/drinking vomitingvomiting
SignsSigns Temperature, increased resp rate, decreased Temperature, increased resp rate, decreased
oxygen satsoxygen sats Increased work of breathing, tachycardiaIncreased work of breathing, tachycardia Crackles heardCrackles heard
Pneumonia - DiagnosisPneumonia - Diagnosis
ClinicalClinical CXRCXR Blood tests – culture, serologyBlood tests – culture, serology Sputum sampleSputum sample
PneumoniaPneumonia
Persistent CXR changesPersistent CXR changes
If no response to course of antibiotics If no response to course of antibiotics needs further investigation/ referralneeds further investigation/ referral
Can be investigated with Can be investigated with Immune Immune Bronchoscopy Bronchoscopy
Flexible – thin and more mobileFlexible – thin and more mobile Rigid – large, inflexible, good for removing foreign Rigid – large, inflexible, good for removing foreign
bodiesbodies BAL ( Broncho-alveolar- lavage) BAL ( Broncho-alveolar- lavage)
Samples of secretions taken during bronchoscopySamples of secretions taken during bronchoscopy Sent for culture and sensitivitySent for culture and sensitivity
Pneumonia-TreatmentPneumonia-Treatment
AntibioticsAntibiotics Eg amoxicillin, clarithromycinEg amoxicillin, clarithromycin Usually 5 daysUsually 5 days
AdmissionAdmission OxygenOxygen Severe respiratory distressSevere respiratory distress Very youngVery young Dehydrated – NG feeding or IV fluidsDehydrated – NG feeding or IV fluids
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
EmpyemaEmpyema
Complication of pneumoniaComplication of pneumonia Collection of pus – usually in pleural Collection of pus – usually in pleural
cavitycavity SignsSigns
Pneumonia - not improving on abxPneumonia - not improving on abx Cough, temperatureCough, temperature Chest painChest pain
Empyema - DiagnosisEmpyema - Diagnosis
CXR – fluid seenCXR – fluid seen USS – site of collectionUSS – site of collection CT chest – if complicatedCT chest – if complicated
Empyema - CXREmpyema - CXR
CroupCroup
Infection of the upper airwayInfection of the upper airway Oedema, swelling and inflammationOedema, swelling and inflammation =laryngotracheobronchitis=laryngotracheobronchitis
Usually viral Usually viral adenovirus, parainfluenzae, RSVadenovirus, parainfluenzae, RSV
AnatomyAnatomy
<------bronchus
Croup – SymptomsCroup – Symptoms
Barking coughBarking cough Noisy breathing – inspiratory stridorNoisy breathing – inspiratory stridor Mild temperatureMild temperature Often cold/coryzal symptomsOften cold/coryzal symptoms Often wake at nightOften wake at night Not usually acutely unwellNot usually acutely unwell
Croup - SignsCroup - Signs
Cough = often diagnosticCough = often diagnostic TemperatureTemperature Stridor ( due to sub-glottic Stridor ( due to sub-glottic
narrowing)narrowing) Respiratory distress: mild – severeRespiratory distress: mild – severe Decreased oxygen saturations – if Decreased oxygen saturations – if
severesevere
Croup - TreatmentCroup - Treatment
Minimal handling/ examinationMinimal handling/ examination Oral steroids – Dexamethasone (0.15-Oral steroids – Dexamethasone (0.15-
0.3mg/kg) or prednisolone (1mg/kg)0.3mg/kg) or prednisolone (1mg/kg) Nebulised budesonideNebulised budesonide Nebulised adrenalineNebulised adrenaline If severe – intubate and ventilateIf severe – intubate and ventilate
Keep child calm to maintain airwayKeep child calm to maintain airway
When to refer: Marked respiratory difficulty Marked stridor at rest Agitated Decreased O2 sats (if available) Trial of dexamethasone = no
improvement after 1 hour
EpiglottitisEpiglottitis
Infection/ cellulitis of the epiglottisInfection/ cellulitis of the epiglottis
Caused by Haemophilus influenzaeCaused by Haemophilus influenzae
Commonest 2-5 years – but any ageCommonest 2-5 years – but any age
AnatomyAnatomy
Epiglottitis - Signs and Epiglottitis - Signs and SymptomsSymptoms
Very acute onsetVery acute onset Fever, ill toxic looking childFever, ill toxic looking child Very sore throat – drooling, not Very sore throat – drooling, not
speakingspeaking Soft stridor, respiratory distressSoft stridor, respiratory distress Child sits upright, protecting own Child sits upright, protecting own
airwayairway
Epiglottitis - DiagnosisEpiglottitis - Diagnosis
No investigations initiallyNo investigations initially Clinical – appearance on intubationClinical – appearance on intubation Throat swabsThroat swabs Blood culturesBlood cultures
Epiglottitis - TreatmentEpiglottitis - Treatment
Keep child calm, no cannulas/ IM Keep child calm, no cannulas/ IM injections etcinjections etc
Intubate -> ventilate ~ 24 – 48hrsIntubate -> ventilate ~ 24 – 48hrs IV antibioticsIV antibiotics
Epiglottitis – when to refer
Always!
Inflammatory conditionsInflammatory conditions
AsthmaAsthma
Chronic inflammatory disorder, Chronic inflammatory disorder, inflammation that is variable; with inflammation that is variable; with hyper-responsiveness and reversible hyper-responsiveness and reversible airways disease.airways disease.
Treatment – acute and chronicTreatment – acute and chronic Reliever and preventer inhalersReliever and preventer inhalers
Asthma: Symptoms Asthma: Symptoms
WheezeWheeze Cough – day/ nightCough – day/ night BreathlessnessBreathlessness Increased work of breathingIncreased work of breathing
DiagnosisDiagnosis
Age - > 2 yearsAge - > 2 years HistoryHistory
Acute – exacerbationAcute – exacerbation Chronic – interval symptomsChronic – interval symptoms
ExaminationExamination Wheeze, hyperexpansion, chest deformityWheeze, hyperexpansion, chest deformity
PEFRPEFR Not in exacerbationNot in exacerbation
Allergy testsAllergy tests
TreatmentTreatment
Acute Acute Salbutamol, Atrovent (always with spacer)Salbutamol, Atrovent (always with spacer) MonteleukastMonteleukast Prednisolone – 3 daysPrednisolone – 3 days
Chronic/ interval symptomsChronic/ interval symptoms Inhaled steroids (beclomethasone, fluticasone)Inhaled steroids (beclomethasone, fluticasone) MonteleukastMonteleukast Long acting salmeterol = seretideLong acting salmeterol = seretide
When to refer:
Acute: 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
AllergensAllergens
AllergyAllergy
Symptoms:Symptoms: Wheeze, cough, upper airway obstruction, stridor,Wheeze, cough, upper airway obstruction, stridor, Angioedema, rash, collapseAngioedema, rash, collapse
SignsSigns Rash, swelling, increased work of breathingRash, swelling, increased work of breathing Increased respiratory rate, noisy breathing/stridorIncreased respiratory rate, noisy breathing/stridor TachycardiaTachycardia Decreased GCSDecreased GCS
DiagnosisDiagnosis
Acutely – identify trigger => historyAcutely – identify trigger => history Investigations Investigations
Skin prick testingSkin prick testing Blood tests – RAST testingBlood tests – RAST testing Food challengeFood challenge
When to refer?
Anaphylaxis/ severe reaction Unknown/unclear trigger Multiple allergy Dietician input needed Concurrent diagnosis Asthma/wheeze
Need epipen
Skin prick testingSkin prick testing
RAST TestsRAST Tests
Blood testBlood test Levels if IgE to specific allergensLevels if IgE to specific allergens Many different allergens testedMany different allergens tested Grade of response/IgE level givenGrade of response/IgE level given >4 significant>4 significant
Allergy - TreatmentAllergy - Treatment
Severe reaction – call for help, 999, Severe reaction – call for help, 999, hospital admissionhospital admission
ABC, oxygen,ABC, oxygen, Adrenaline – IM or IVAdrenaline – IM or IV Steroids – IV or oralSteroids – IV or oral Anti histaminesAnti histamines eg piriton, clarityn eg piriton, clarityn
(IV or oral)(IV or oral)
That’s all!!That’s all!!
Thanks – Any questions??Thanks – Any questions??