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PAEDIATRIC BREATHING DIFFICULTIES & COMMON CHEST PROBLEMS IN CHILDREN Dr. Shamanthakamani Narendran MD (pead), PhD (Yoga Science)

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Discussion points <ul><li>Are breathing problems common in children? </li></ul><ul><li>What to look out for </li></ul><ul><li>What can be done by the family </li></ul><ul><li>When to call for help </li></ul>

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OBJECTIVES <ul><li>BRONCHIOLITIS </li></ul><ul><li>CROUP </li></ul><ul><li>EPIGLOTTITIS </li></ul><ul><li>FOREIGN BODY </li></ul><ul><li>NASAL OBSTRUCTION </li></ul><ul><li>ASPIRATION </li></ul><ul><li>PERTUSSIS </li></ul><ul><li>PNEUMONIA </li></ul><ul><li>PERITONSILLAR ABSCESS </li></ul><ul><li>RETRO-PHARYNGEAL ABSCESS </li></ul><ul><li>ASTHMA </li></ul>

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Areas of the respiratory tract to discuss <ul><li>The upper airway – nose, throat & windpipe </li></ul><ul><li>The large airways (bronchi) </li></ul><ul><li>The medium sized airways </li></ul><ul><li>The small airways </li></ul>

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Frequency of breathing problems <ul><li>Coughs, colds and URT problems – commonest reason to go to GP </li></ul><ul><li>Wheezing and asthma – 1:4 preschool children </li></ul><ul><li>– 1:7 school-aged children </li></ul><ul><li>Viral bronchiolitis – 20,000 infants admitted yearly between November and March </li></ul><ul><li>25% of all out-patient visits </li></ul><ul><li>Up to 30% of all admissions </li></ul>

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Presenting features <ul><li>Sneezing, runny/blocked nose </li></ul><ul><li>Noisy breathing (inspiration/expiration) </li></ul><ul><li>Rattly chest / wheezing </li></ul><ul><li>Production of phlegm </li></ul><ul><li>Breathlessness – rapid breathing </li></ul><ul><li>Colour change </li></ul>

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Things to do <ul><li>Keep comfortable & warm </li></ul><ul><li>If hot use paracetamol </li></ul><ul><li>Keep hydrated but don’t give solid foods </li></ul><ul><li>Keep away from smoky environments </li></ul><ul><li>Give all immunisations </li></ul><ul><li>Healthy diet, vitamins </li></ul>

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When to ask for help <ul><li>Above not working </li></ul><ul><li>Getting worse </li></ul><ul><li>Breathing rate ↑ temp ↑ </li></ul><ul><li>Working hard to breathe </li></ul><ul><li>Not drinking /dehydrated </li></ul><ul><li>Very poor colour </li></ul><ul><li>Lack of sleep / worried </li></ul>

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The upper airway <ul><li>Nose is small, gets easily blocked </li></ul><ul><li>Clean it – tissue / saline drops </li></ul><ul><li>Babies are often nose breathers </li></ul><ul><li>Affects lower airway if nose blocked </li></ul><ul><li>Over-the-counter medicines are available </li></ul>

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Acute viral croup <ul><li>Still common, often mild </li></ul><ul><li>Comes on suddenly in evening. Inspiratory noise </li></ul><ul><li>Comfort and warmth </li></ul><ul><li>Humidity </li></ul><ul><li>Paracetamol </li></ul><ul><li>Para-influenza virus </li></ul><ul><li>Steroids by mouth </li></ul><ul><li>May need admission </li></ul>

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Cough <ul><li>Natural mechanism </li></ul><ul><li>Upper/lower? Dry/wet? </li></ul><ul><li>Single, repetitive </li></ul><ul><li>Painful? – paracetamol </li></ul><ul><li>Can recur ++ </li></ul><ul><li>Still consider whooping coup </li></ul><ul><li>Vomit as well </li></ul><ul><li>Colour change </li></ul>

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Chronic cough <ul><li>Worse at night. </li></ul><ul><li>Present for > 3 wks </li></ul><ul><li>Poor weight gain </li></ul><ul><li>Still probably viral </li></ul><ul><li>May need investigations </li></ul><ul><li>Culture in lab </li></ul><ul><li>Chest x-ray </li></ul><ul><li>Probably not asthma </li></ul>

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Wheezing in young children <ul><li>Very common / viral cause </li></ul><ul><li>Whistling noise / feeding or sleeping OK? </li></ul><ul><li>Any eczema / hay fever / food allergy? </li></ul><ul><li>Distressed or happy? </li></ul><ul><li>Family history </li></ul><ul><li>Paracetamol may be all that is needed </li></ul>

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Other treatments for wheezing <ul><li>Blue reliever inhaler – salbutamol </li></ul><ul><li>Once daily granules / cherry tablet </li></ul><ul><li>Brown regular preventor inhaler (inhaled steroids) </li></ul><ul><li>Short courses 1-3 days oral prednisolone </li></ul><ul><li>Differences with asthma – interval symptoms, severity etc. </li></ul>

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Acute viral bronchiolitis <ul><li>Very common – 1:3 1yr </li></ul><ul><li>– 100% by 3yrs </li></ul><ul><li>2% infants need admitting (feeding etc) </li></ul><ul><li>5% admitted may need intensive care </li></ul><ul><li>Worse in tiny babies, heart disease, immune problems </li></ul><ul><li>Warmth, oxygen, fluids/hydration </li></ul><ul><li>No medical treatment </li></ul><ul><li>Vaccines etc. </li></ul>

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Symptoms after bronchiolitis <ul><li>Recurrent cough and wheeze </li></ul><ul><li>30-40% of those admitted </li></ul><ul><li>Admissions over 1 st 2 yrs of life </li></ul><ul><li>Symptoms can continue into teens </li></ul><ul><li>Not asthma </li></ul><ul><li>Treatment </li></ul><ul><li>– inhalers </li></ul><ul><li>– montelukast </li></ul>may be needed

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Pneumonia <ul><li>Infection deep in the lung </li></ul><ul><li>Virus or bacterium </li></ul><ul><li>Ill, high temp, rapid decline, rapid breathing, breathlessness </li></ul><ul><li>Bacterial pneumonia – common cause of death in developing countries </li></ul><ul><li>Antibiotics if bacterial </li></ul>

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ASTHMA Thorax 2003; 58 (Suppl I): i1-i92 <ul><li>differential clues </li></ul><ul><li>pattern of illness </li></ul><ul><li>severity/control </li></ul>Detailed history and physical examination <ul><li>breathlessness </li></ul><ul><li>noisy breathing </li></ul><ul><li>wheeze </li></ul><ul><li>dry cough </li></ul>Presenting features Is it asthma?

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DIFFERENTIAL Thorax 2003; 58 (Suppl I): i1-i92 <ul><li>developmental disorder; postinfective disorder; recurrent aspiration; inhaled foreign body; bronchiectasis; tuberculosis </li></ul><ul><li>focal or persistent radiological changes </li></ul>Investigations <ul><li>cystic fibrosis; recurrent aspiration; host defence disorder </li></ul><ul><li>reflux (  aspiration) </li></ul><ul><li>swallowing problems (  aspiration) </li></ul><ul><li>laryngeal problem </li></ul><ul><li>developmental disease; postviral syndrome; bronchiectasis; tuberculosis </li></ul><ul><li>central airway or laryngeal disorder </li></ul><ul><li>cystic fibrosis; host defence defect; gastro-oesophageal reflux </li></ul><ul><li>persistent wet cough </li></ul><ul><li>excessive vomiting </li></ul><ul><li>dysphagia </li></ul><ul><li>abnormal voice or cry </li></ul><ul><li>focal signs in the chest </li></ul><ul><li>inspiratory stridor as well as wheeze </li></ul><ul><li>failure to thrive </li></ul>Symptoms and signs Possible diagnosis Clinical clue <ul><li>cystic fibrosis; chronic lung disease; ciliary dyskinesia; developmental anomaly </li></ul><ul><li>cystic fibrosis; developmental anomaly; neuromuscular disorder </li></ul><ul><li>defect of host defence </li></ul><ul><li>symptoms present from birth or perinatal lung problem </li></ul><ul><li>family history of unusual chest disease </li></ul><ul><li>severe upper respiratory tract disease </li></ul>Perinatal and family history

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Response to treatment in children aged >2 years in A&E IF POOR RESPONSE TO TREATMENT NOT RESPONDING TO TREATMENT RESPONDING TO TREATMENT Life threatening exacerbation Severe exacerbation Moderate exacerbation ARRANGE IMMEDIATE TRANSFER TO PICU/HDU ARRANGE ADMISSION (lower threshold if concern over social circumstances) <ul><li>DISCHARGE PLAN </li></ul><ul><li>Continue ß 2 agonists 1-4 hourly prn </li></ul><ul><li>Consider prednisolone 20mg (2-5 years) 30-40mg (>5 years) daily for up to 3 days </li></ul><ul><li>Advise to contact GP if not controlled on above treatment </li></ul><ul><li>Provide a written asthma action plan </li></ul><ul><li>Review regular treatment </li></ul><ul><li>Check inhaler technique </li></ul><ul><li>Arrange GP follow up </li></ul>

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Treatment of acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92 * Dose can be repeated every 20-30 minutes IV salbutamol (15 m g/kg) is effective adjunct in severe cases B Individualise drug dosing according to severity and adjust according to response B pMDI and spacer are preferred delivery system in mild to moderate asthma A Inhaled ß 2 agonists are first line treatment for acute asthma * A Use structured care protocols detailing bronchodilator usage, clinical assessment, and specific criteria for safe discharge D Children with life threatening asthma or SpO 2 <92% should receive high flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations 

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Steroid therapy for acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92 Do not initiate inhaled steroids in preference to steroid tablets to treat acute childhood asthma  Give prednisolone early in the treatment of acute asthma attacks A <ul><li>Use prednisolone 20mg (2-5 years), 30-40mg (>5 years) </li></ul><ul><li>Those already receiving maintenance steroid tablets should receive 2 mg/kg oral prednisolone up to a maximum dose of 60 mg </li></ul><ul><li>Repeat the dose of prednisolone in children who vomit and consider IV steroids </li></ul><ul><li>Treatment up to 3 days is usually sufficient, but tailor to the number of days for recovery </li></ul>

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Other therapies for acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92 * Dose can be repeated every 20-30 minutes If poor response to  2 agonist treatment, add nebulised ipratropium bromide (250 mcg /dose mixed with  2 agonist) * A Aminophylline is not recommended in children with mild to moderate acute asthma A ECG monitoring is mandatory for all intravenous treatments  Consider aminophylline for children in high dependency/intensive care with severe or life threatening bronchospasm unresponsive to maximal doses of bronchodilators and steroid tablets C Do not give antibiotics routinely in the management of acute childhood asthma 

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Hospital admission for acute asthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92 Consider intensive inpatient treatment for children with SpO 2 <92% on air after initial bronchodilator treatment B Decisions about admission should be made by trained physicians after repeated assessment of the response to further bronchodilator treatment  Transfer children with severe or life threatening asthma urgently to hospital to receive frequent doses of nebulised  2 agonists (2.5-5mg salbutamol or 5-10 mg terbutaline)  Children with acute asthma failing to improve after 10 puffs of  2 agonist should be referred to hospital. Further doses of bronchodilator should be given as necessary whilst awaiting transfer  Treat with oxygen and nebulised  2 agonists during the journey to hospital 

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Treatment of acute asthma in children aged <2 years Thorax 2003; 58 (Suppl I): i1-i92 Oral  2 agonists are not recommended for acute asthma in infants B For mild to moderate acute asthma, a pMDI with spacer is the optimal drug delivery device A Consider inhaled ipratropium bromide in combination with an inhaled  2 agonist for more severe symptoms B Consider steroid tablets in infants early in the management of moderate to severe episodes of acute asthma in the hospital setting C Steroid tablet therapy (10 mg of soluble prednisolone for up to 3 days) is the preferred steroid preparation 

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Summary <ul><li>Breathing problems are very common in children </li></ul><ul><li>Most are due to infections, usually viral </li></ul><ul><li>Many situations can be managed without the need for medical support </li></ul><ul><li>Keep comfortable, paracetamol for high temperature and discomfort </li></ul><ul><li>Give enough liquids by mouth to prevent dehydration </li></ul><ul><li>Don’t panic </li></ul>