+

Paediatric Shortness of Breath EMCDr Dane Horsfall FACEMCabrini Hospital

+Outline SOB DDx by age Most commonly primary resp/infective Don’t forget other causes:

CCF Foreign body inhalation Anaphylaxis Metabolic – Eg DKA, sepsis, shock – RR very

sensitive marker of “unwellness”

+Assessment RR, O2sats* Key is recognition of Resp Distress Work of Breathing

Recession-subcostal/intercostal/suprasternal Nasal Flaring Accessory muscle use- sternomastoid Leaning forward

Inspiratory vs Expiratory Eg’s Assoc Symptoms

Wheeze Fever Cough Stridor

+Paediatric Airway Smaller, Shorter, Floppy, small mandible Large head (neck flexed), Large tongue High larynx Funnelled shaped with anterior angulation Epiglottis long and stiff <8 yo narrowest portion = cricoid cartilage (adults = vocal

cords) small diameter of airways -> higher resistance to air flow, easily

blocked highly compliant -> kink trachea short & in line with right main bronchus

+Implications Towel under body/shoulders

extend neck, ETT Formula? ETT size = age/4 + 4 (age > 1

years) or Broselow Tape or size of little finger (-1 if cuffed tube)

Depth Tip to lip = age/2 + 12, tip follows chin

+Paeds Airway

Classically uncuffed <5mm, cuffed >5mm due to ?laryngeal stenosis but can use cuffed tubes in most (esp high volume low pressure) but probably need uncuffed in < 1yo, reduce size by 0.5-1mm for cuffed tubes

small, straight blade(Miller-neonate/infant/paed) - lift epiglottis – vagal stim.

+Paeds Airway Atropine 20mcg/kg difficult to perform a tracheostomy NGT therapeutic

http://lifeinthefastlane.com/ccc/paediatric-airway/

+Case 1 - 11/12 M with SOB, wheeze 2/7 runny nose, sneezing, cough 1/7 wheeze, increased WOB, reduced feeds

PHx Normal Preg, NVD at Term, IUTD no medical Hx

3yo sibling has “cold” FHx –Asthma, Eczema Dx?

+Bronchiolitis 2/12 – 1 yrs RSV Widespread wheeze Peaks day 2-3, lasts 7-10/7

Mild - no resp distress O2sats >93% “Happy Wheezer” Mod - some resp distress, reduced feeding, O2sats 90-

93% Severe - resp distress, lethargy, not feeding, apnoea,

O2sats <90%

+Bronchiolitis

R/F for severe illness: Young < 6/52 Ex prem Congenital/Chronic Heart/Resp/Neuro

Reasons for admission: Hypoxia <92% Not feeding <6/52 lower threshold - apnoeas

+Bronchiolitis Ix

NPA CXR bloods

Mx Mild - Smaller, more frequent feeds Mod - O2 aims Sats >92%, 2/3 of maintenance fluids Severe - CPAP/Vent Experimental/Controversial:

Hypertonic Saline neb (24 studies pooled -mod improvement) Salbutamol – reasonable in nearly 1 yo Steroids Adrenaline nebs Ribavirin/Immunoglobulin

+DDx CCF Similar Wheeze and resp distress without

infective symptoms From newly Dx Congenital Heart Disease, or

arrhythmias CHD Multiple types:

Transposition of great vessels Pulmonary/Aortic stenosis Hypoplastic left heart Tetrallogy of Fallot

+Duct Dependent CHD Adequate Circulation is dependent on a

patent ductus arteriosus: Right Heart obstruction – PDA allows blood

flow thru lungs Left Heart Obstruction – PDA supplies

systemic circulation Transposition allows mixing

PDA Closure in first few days of life can precipitate Cardiogenic shock

Rx is Supportive and Prostaglandin E1 - Alporstadil to reopen Ductus Arteriosus

+Case 2

3 yo SOB with cough, wheeze – Previously well, Playing Lego with sibling

sudden onset coughing/SOB/wheeze/vomiting/gagging

o/e reduced breath sounds on R

DDx?

+

+Inhaled Foreign Body

Esp 1-3yo incomplete chewing, food propelled posteriorly, triggers reflex inhalation

Most foreign bodies are radiolucent; need indirect radiologic findings

Hyperinflation from ball/valve effect in affected lung

CXR 70%-80% sensitive, (50% airtrapping, 12% atelectasis, 18% infection) if N and high index suspicion - Bronchoscopy

Can use CT

+Location, Location Small cylindrical/smooth/round - Seeds, nuts,

nails, toys, coins, bone, anything Proximal - occluded airway and can’t remove

from mouth – “Café Coronary” Back blows and chest thrusts Positive pressure ventilation Surgical airway

Partially occluded, distal to Carina – Bronchoscopy

+6 yo SOB/Chest pain/Dysphagia – r/o Popcorn L main bronchus

+Case 3 2 1/2 yo M presents at 2am with runny nose,

fever, dry cough, quiet inspiratory stidor at rest

https://www.youtube.com/watch?v=Wvg7HFoKFtY

Dx Croup AKA Laryngotracheobronchitis

+Croup

Parainfluenza virus 6/12 – 3 years old Typically present onight, fevers, dry/barking

cough, stridor

+Management

O2 sats 96%RA – OK?

Minimal Handling Adrenaline Nebs Oral Prednisolone or IM Dexamethasone Big

Dose: (Frank Schann) 0.6mg/kg IM 2 ½ yo M wt (2.5 +4) x 2 =

13kg Dose 13 x 0.6mg = 8mg

+Racemix v Standard Adrenaline?? Standard Adrenaline 100% L-isomer,

1:1000 : 1ml amp = 1mg, 1:10,000: 10ml amp = 1mg

Racemix Adrenaline: (Ophthalmic solution)

50% L-isomer + 50% D-isomer (only 10% as potent as L-isomer but ? longer effect)

Equivalent to 1:100 Standard Adrenaline (ie 10 x more potent that 1:1000)

Previously thought that D-isomer has less chronotropic effect on heart

+Racemix v Standard Adrenaline?? Both equivalent efficacy Dose: 4-5 vials 1mg Adrenaline in 1ml(1:1000) 0r 1ml of 1%

Racemix Adrenaline solution + 3ml n/saline 1ml = 0.5ml L-isomer = 5mg Adrenaline, 0.5ml D-

isomer = 0.05mg Adrenaline, both effective dose 5.5mg Standard Adrenaline

Onset 10mins, Lasts up to 2 hours

+Case 4 2 yo F with SOB/fevers/cough/grunting for 5/7

Pneumonia

+Pneumonia

Grunting – from closed vocal cords to provide increased PEEP and keep their lower airways open- LRTI

+Pneumonia Bugs and AntisAge Organisms Antibiotcs0-1 month Gp B Strep, E Coli,

Listeria, CMV, HSVBenzyl Pen/Gent

1-3 months C trachomonas- afeb/mildly unwell

Viral, Strep Pn, S Aureus

Azithro

BenzylPenCeft/Fluclox

3months – 5 yo

Viral, Strep Pn/Staph AmoxilBenzylPenCeftx/Fluclox

> 5yo Viral, Mycoplasma, Strep Pn, Chlamydia Pn

Adult typical/atypicalAmoxil/Doxy/AzithroCeftx/Fluclox

+Pneumonia Admit v Discharge?

Admit: iv antis, O2, supportive care age < 6/12 Sp02 <92% toxic appearance or severe respiratory

distress suspected complications (e.g. empyema) Immunocompromised vomiting/dehydration/not tolerating o intake Social

+

+

+

+Case 5

7 yo F with SOB, wheeze, cough, runny nose for 2/7

Dx?

Asthma

+Management 1 “Hour of Power” nebs vs MDI with

spacer B agonists 6 puffs < 6yo, 12puffs >

6yo Antichol- Ipratropium bromide

(Atrovent 20mcg/puff)4 puffs< 6 yo, 8 puffs>6 yo

O2 Steroids

Pred 2mg/kg first dose, then 1mg/kg subsequent doses

Iv Methypred 1mg/kg

+Management 2 Magnesium (50% 500mg/ml) 50mg/kg iv dilute to 200mls

over 20mins Consider i.v. Salbutamol (Limited evidence)5 mcg/kg/min for

one hour as a load, followed by 1-2 mcg/kg/min BiPAP/CPAP

Pros - decreased WOB, improves V/Q Mismatch, recruits alveoli, increase FiO2

Cons - hyperinflation – barotrauma, delayed indicated intubation, vomiting

No large RCT, 2013 Cochrane Review 5 trials- 206 pts – inconclusive, some support in observational studies and case series

Consider in severe asthma with compliant pt to delay/avoid intubation

BiPAP PEEP at 3-5 cmH20 iPAP at 7-15 cmH20, target RR<25/min I:E ratio 1:5

+Pitfalls ?CXR in severe Asthma Beware normal pCO2 on VBG

Should be low with increased RR, will start to rise to normal as pt tires and then rise above normal values as they develop resp failure

“Gas Trapping” Asthma is disease of expiration Progressive inflation of chest High Risk of pneumothorax Post Intubation – low RR 4-6, normal Tidal volumes, low I:E ratio “permissive hypercapnia” Disconnect ETT and manually decompress chest and allow

prolonged expiration

+Paeds SOB - Summary Mostly primary resp/infective Assess WOB, RR, insp v exp – observe child, don’t

increase distress Remember differences in airway Mx eg Miller

blade, uncuffed tube Don’t forget CCF, inhaled foreign body

+References

RCH clinical guidelines EMC Pediatric Breathing Problems Life in the Fast Lane Medscape Waisman Y, Klein BL, Boenning DA et al: Prospective

randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 1992. Feb; 89(2): 302-6.

Nebulized Hypertonic Saline for Acute Bronchiolitis in Infants? Zhang L et al. Pediatrics 2015 Sep 28