WEEK 2 – RESPIRATORY & RESUS Flashcards
7 KEY POINTS regarding paediatric respiratory conditions?
6 Key Respiratory Symptom Presentations & their Associated Diagnoses in Paediatric population?
CAHS Clinical Guideline - Neonatal Resuscitation Algorithm
- What percetnage of newborns require some degree of active resuscitation at birth?
- Umbilical cord clamping timing?
Potential Risk - Approximately 5-10% of newborns require some degree of active resuscitation at birth.
Adverse health outcomes may occur in the event of failure to recognize the need for resuscitation, delay in providing resuscitation or ineffective techniques.
For infants who are vigorous or deemed not to require immediate resuscitation at birth:
- Term and late preterm infants born at ≥34 weeks’ gestation deferred clamping of the cord (DCC) at ≥ 60 seconds.
- < 34 weeks’ gestational age deferring clamping the cord (DCC) for at least 30 seconds.
- There is insufficient evidence to recommend milking of the intact cord for term and preterm infants >34 weeks’ gestation and ANZCOR suggests against milking a cut cord for all newborns, irrespective of gestational age.
CAHS Clinical Guideline - Neonatal Resuscitation Algorithm
- Newborn life support flowchart?
CAHS Clinical Guideline - Respiratory Distress Syndrome (RDS)
- Epidemiology?
- Risk Factors?
- Protective factors?
- Pathophysiology?
Epidemiology
- A common neonatal respiratory disorder most frequently seen in preterm infants, however some near term infants can also be affected typically from 34-37 weeks.
- The incidence of RDS increases with decreasing gestational age.
- Risk factors: male sex, Caucasian, maternal diabetes, elective caesarean section, multiple pregnancy, perinatal asphyxia.
- Protective factors: antenatal corticosteroids, chronic foetal stress (maternal drug abuse, chronic congenital infections, prolonged rupture of membranes), IUGR/SGA.
CAHS Clinical Guideline - Respiratory Distress Syndrome (RDS)
- 6 Investigations?
- Clinical Presentation?
Investigations
1. Baseline observations and SaO2.
2. Arterial blood gas (hypoxemia, hypercarbia and sometimes a mild metabolic acidosis).
3. FBC and U&Es, glucose.
4. Septic screen.
5. CXR (AP and Lateral) will demonstrate increased density of both lung fields with reticulogranular (ground glass) appearance, air bronchograms and elevation of the diaphragm.
6. ECG/cardiac USS if suspecting CHD
CAHS Clinical Guideline - Respiratory Distress Syndrome (RDS)
- 6 Indications for Intubation?
- Management?
Indications for Intubation
1. A rising PaCO2 > 60 mmHg or falling pH < 7.25.
2. Recurrent apnoea requiring stimulation and resuscitation.
3. Increased work of breathing (sternal and intercostal recession, grunting and tachypnoea) in conjunction with abnormal blood gas analysis.
4. Consideration should be given to hypoxia, increasing oxygen requirements, and saturation trends.
5. Incipient collapse.
6. Agitation that cannot be relieved and other causes eg. pneumothorax have been ruled out.
CAHS Clinical Guideline - Respiratory Distress Syndrome (RDS)
- Ventilation: Starting Guidelines?
- Preterm Neonate?
- Term Neonate?
Ventilation: Starting Guidelines
- Avoidance of high tidal volumes is essential for prevention of air leak syndromes, especially in the period of rapid increase in compliance following surfactant administration. Volume guarantee (VG) should be commenced as soon as the infant is placed on a ventilator equipped with flow monitoring.
- VG should be monitored prior to and after surfactant administration. Initially
4.5ml/kg working up to 6 mL/kg tidal volume if required.
- The initial starting ventilation parameters are dependent on the size of the infant and clinical condition.
CAHS Clinical Guideline - Pneumonia
- How is Neonatal pneumonia categorised?
CAHS Clinical Guideline - Pneumonia
- Causes of Aspiration pneumonia?
- Pathophysiology of Aspiration pneumonia?
- Investigations for Aspiration pneumonia?
- Management of Aspiration pneumonia?
Investigations
- Chest X-ray may show changes especially in the RUL or RLL. Alternative diagnoses especially infection should be considered.
- If the infant is very unwell-investigate as per general respiratory management.
- A barium swallow may be indicated to examine feeding coordination and to whether aspiration is present.
Management
As pneumonia is possible, we would advise to treat with antibiotics if the infant is clinically very unwell, or the infant has an immune-deficiency. Otherwise treatment is dependent on
the extent of pulmonary compromise and the reason for aspiration.
CAHS Clinical Guideline - Transient Tachypnoea of the Newborn (TTN)
- Epidemiology of TTN?
- 6 Risk Factors for TTN?
- Pathophysiology of TTN?
- Clinical Presentation of TTN?
Epidemiology
- TTN occurs in ~10% of infants born between 33 and 34 weeks gestational age, ~5% of infants delivered at 35 to 36 weeks, and less than 1% of all term infants.
Risk factors for TTN include:
1. elective caesarean section
2. delivery before completing 39 weeks of gestation
3. maternal diabetes
4. maternal asthma
5. male gender
6. small or large-for-gestational
age.
CAHS Clinical Guideline - Transient Tachypnoea of the Newborn (TTN)
- 7 Differential Diagnoses of TTN?
CAHS Clinical Guideline - Transient Tachypnoea of the Newborn (TTN)
- 5 Investigations?
CAHS Clinical Guideline - Transient Tachypnoea of the Newborn (TTN)
- Management?
PCH ED Guidelines - Advanced Paediatric Life Support
- Flowchart?
PCH ED Guidelines - Acute Asthma
- Background?
- 5 Key Points?
- What history will you take?
Key points
1. If unsure if a child has anaphylaxis or asthma, treat for anaphylaxis. Treatment of both is time critical.
2. Metered dose inhalers (MDI) are preferable to nebulisers given their rapid delivery, comparable efficacy and fewer side effects.
3. Short acting beta agonist (SABA) therapy is crucial to the management of asthma.
4. Give steroids early in moderate, severe and life-threatening asthma.
5. Adolescents on combination reliever/ preventer therapy (ie budesonide/formoterol dry powder inhalation) should be managed with salbutamol for an acute exacerbation requiring treatment in hospital.
PCH ED Guidelines - Acute Asthma
- 5 Red flags for alternative diagnosis?
- What investigations will you do?
- Examination?
Investigations
- Investigations are generally not needed. Chest x-ray is not required.
- Bloods are rarely performed. Blood gases are distressing and can cause a child with respiratory compromise to deteriorate further. They are not usually required and the child’s clinical state is more important in guiding treatment.
- Measurement of serum potassium may be indicated when there has been prolonged or frequent salbutamol use.
PCH ED Guidelines - Acute Asthma
- Classification of asthma severity?
PCH ED Guidelines - Acute Asthma
- Management of Mild Asthma Flowchart?
PCH ED Guidelines - Acute Asthma
- Management of Moderate Asthma Flowchart?
PCH ED Guidelines - Acute Asthma
- Management of Severe Asthma Flowchart?
PCH ED Guidelines - Acute Asthma
- Management of Life-Threatening Asthma Flowchart?
PCH ED Guidelines - Acute Asthma
- IV magnesium sulfate 50% dosing?
- Other management considerations?
IV magnesium sulfate 50% dosing
- Product specifications: 1 mL = 2 mmol = 500 mg
- Check doses carefully
- 0.2 mmol/kg = 50 mg/kg = 0.1 mL/kg (undiluted magnesium sulfate)
- max 8 mmol
- Dilute as per local guidelines and check concentrations carefully before administration
PCH ED Guidelines - Acute Asthma
- Discharge instructions?
Australian Asthma Handbook
- Give an overview of the management of Asthma in Children aged 0–12 months?
- Give an overview of the management of Asthma in Children aged 1-5 years?
Children aged 0–12 months
- Wheezing infants aged less than 12 months old should not be treated for asthma. Wheezing in this age group is most commonly due to acute viral bronchiolitis or to small and/or floppy airways.
- Advice should be obtained from a paediatric respiratory physician or paediatrician before administering short-acting beta2 agonists, systemic corticosteroids or inhaled corticosteroids to an infant under 12 months.
- Children with clinically significant wheezing that necessitates hospitalisation or occurs frequently (e.g. more than once per 6 weeks) should be referred to a paediatric respiratory physician or paediatrician.
Australian Asthma Handbook
- Give an overview of the management of Asthma in Children aged 6 years and over?
- Avoivable & Unavoidable Asthma triggers?
Children aged 6 years and over
- The diagnosis of asthma can be made with more certainty in school-aged children. In this age group, the presence of reversible expiratory airflow limitation on spirometry supports the diagnosis of asthma.
- All school-aged children with asthma need a reliever to use when they have asthma symptoms.
- Regular preventer treatment is indicated for those with frequent intermittent asthma (flare-ups every 6 weeks or more often) or persistent asthma symptoms (daytime asthma symptoms more than once per week or night-time symptoms more than twice per month) and those with severe flare-ups, irrespective of the frequency of flare-ups or symptoms between flare-ups.
Australian Asthma Handbook
- Classification of preschool wheeze and indications for preventer treatment in children aged 1-5 years?
- Indicated: Prescribe preventer and monitor as a treatment trial. Discontinue if ineffective.
- Not indicated: Preventer is unlikely to be beneficial. Consider prescribing preventer according to overall risk for severe flare-ups.
- Symptoms: wheeze, cough or breathlessness. May be triggered by viral infection, exercise or inhaled allergens.
- Flare-up: increase in symptoms from usual day-to-day symptoms (ranging from worsening asthma over a few days to an acute asthma episode)
- Preventer options: an inhaled corticosteroid (low dose) or montelukast.
Australian Asthma Handbook
- Stepped approach to adjusting asthma medication
in children aged 1-5 years?
Australian Asthma Handbook
- Stepped approach to adjusting asthma medication
in children aged 6-11 years?
- Preventer should be started as a treatment trial. Assess response after 4–6 weeks and review before prescribing long term.
- Indicated: Prescribe preventer and monitor as a treatment trial. At follow-up, discontinue if ineffective
- Not indicated: Preventer is unlikely to be beneficial. Consider prescribing preventer according to overall risk for severe flare-ups.
- Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents/carers and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).
Australian Asthma Handbook
- Stepped approach to adjusting asthma medication in children aged 6-11 years?
Australian Asthma Handbook
Definition of levels of recent asthma symptoms:
- Good control?
- Partial control?
- Poor control?
- SABA: short-acting beta2 agonist
- e.g. wheezing or breathing problems
- child is fully active; runs and plays without symptoms.
- including no coughing during sleep
- e.g. wheeze or breathlessness during exercise, vigorous play or laughing
- e.g. waking with symptoms of wheezing or breathing problems
- Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.
PCH ED Guidelines - Brief Resolved Unexplained Event (BRUE)
- What is the definition of BRUE?
- Key points?
Definitions
This guideline will refer to all events as BRUE noting that evidence from literature is based on previous ALTE definitions.
BRUE is described as an event observed in an infant (<1 year) which is:
- sudden
- brief (<1 minute)
- now resolved
- unexplained
BRUE involves at least one of 1:
- Colour change - central cyanosis or pallor only
- Breathing change – absent, decreased or irregular
- Marked change in tone – hypertonia or hypotonia
- Altered level of responsiveness.
There are many medical causes of BRUE-like events. The term BRUE is applied only when a medical cause of the event is not established.
PCH ED Guidelines - Brief Resolved Unexplained Event (BRUE)
- What history will you take?
- Examination?
Examination
- Vital signs including pulse oximetry is essential.
- Thorough multisystem examination bearing in mind possible causes.
- Growth
- Dysmorphic features / craniofacial abnormalities.
PCH ED Guidelines - Brief Resolved Unexplained Event (BRUE)
- What are the 3 most common differentials of BRUE?
The three most common differentials of BRUE include:
1. Gastro-oesophageal Reflux Disease (GORD)
2. Lower Respiratory Tract Infection (LRTI)
3. Seizures
PCH ED Guidelines - Brief Resolved Unexplained Event (BRUE)
- 4 Immediate investigations to be considered in the Emergency Department?
- When is BRUE considered low risk?
Immediate investigations to be considered in the Emergency Department:
1. Blood gas and glucose
2. Nasopharyngeal swab for pertussis
3. ECG (QT interval)
4. Septic workup where indicated.
PCH ED Guidelines - Brief Resolved Unexplained Event (BRUE)
- Management of Low Risk BRUE?
- Management of High Risk BRUE?
High risk BRUE
- In cases that do not meet criteria for low risk, an underlying cause or serious medical problem may be possible.
- Further investigation and admission under general paediatrics may be warranted.
- Ward monitoring for up to 24 hours should include continuous pulse oximetry as a minimum.
- Respiratory monitoring (inductance plethysmography) for apnoea and cardiac monitoring may also be considered.
PCH ED Guidelines - Bronchiolitis
- Background?
- 4 Key Points?
- 5 Symptoms?
- 7 Risk factors for more serious illness?
Key points
1. Bronchiolitis is a clinical diagnosis
2. No investigations should be routinely performed
3. Management includes supporting feeding and oxygenation as required
4. No medication should be routinely administered
PCH ED Guidelines - Bronchiolitis
- Assessment of Severity?
PCH ED Guidelines - Bronchiolitis
- Investigations?
- Treatment?
Investigations
- In most children with bronchiolitis no investigations are required.
- Investigations should only be undertaken when there is deterioration or diagnostic uncertainty (eg cardiac murmur with signs of congestive cardiac failure).
- Chest X-ray (CXR) is not routinely indicated and may lead to unnecessary treatment with antibiotics.
- Blood tests (including blood gas, FBE, blood cultures) rarely have a role in management.
- Virological testing (nasopharyngeal swab or aspirate) has no role in management of individual patients.
PCH ED Guidelines - Bronchiolitis
- Treatment - Oxygen therapy?
Oxygen Therapy
- Oxygen therapy should be instituted when oxygen saturations are persistently <90%.
- Infants with bronchiolitis will have brief episodes of mild/moderate desaturations to levels <90%. These brief desaturations are not a reason to commence oxygen therapy.
- Oxygen should be discontinued when oxygen saturations are persistently ≥90%.
- Once not requiring oxygen for 2 hours, discontinue oxygen saturation monitoring. Continue other observations 2–4 hourly and reinstate intermittent oxygen monitoring if deterioration occurs.
PCH ED Guidelines - Bronchiolitis
- Treatment?
PCH ED Guidelines - Bronchiolitis
- Treatment - Hydration/Nutrition?
Hydration/nutrition
- Children are often more settled if comfort oral feeds are continued.
- When non-oral hydration is required nasogastric (NG) hydration is the route of choice.
- If IV fluid is used it should be isotonic with added glucose.
- NG or IV fluids should be commenced at two-thirds maintenance because of potential for increased ADH secretion.
PCH ED Guidelines - Bronchiolitis
- Which medications are indicated for bronchiolitis?
Medications are not indicated in the treatment of bronchiolitis!
PCH ED Guidelines - Choking
- Differece between a partial and total obstruction?
PCH ED Guidelines - Choking
- What is the management for a total obstruction?
General
- Upper airway obstruction may be caused by infection (e.g. epiglottitis, croup), and in these cases any attempt to relieve airway obstruction using the methods described are dangerous.
- Children with known or suspected infectious causes of obstruction or those in whom the cause of obstruction are unknown may require anaesthetic management.
PCH ED Guidelines - Choking
- Management if the child is coughing?
- When should active attempts to physically clear the airway be performed?
- The Choking Child Management Flowchart?
Management - If the child is coughing, this should be encouraged:
- No intervention should be attempted unless the cough becomes ineffective (quieter) or the child loses consciousness.
- A spontaneous cough is more effective than any manoeuvre.
Active attempts to physically clear the airway should only be performed if:
1. The diagnosis of foreign body aspiration is clear-cut or strongly suspected.
2. The cough is ineffective, dyspnoea is worsening or apnoea or loss of consciousness have occurred.
3. Airway opening manoeuvres fail to maintain an adequate airway.
PCH ED Guidelines - Inhaled foreign body
- History?
- Exam?
- Investigations?
PCH ED Guidelines - Cough
Defining the spectrum of paediatric cough:
- On duration of cough?
- On likelihood of an underlying disease or process?
- On cough quality?
General
- Although cough is burdensome, the function of cough serves as a vital defensive mechanism for lung health.
- Cough prevents pulmonary aspiration, promotes ciliary activity and clears airway debris.
PCH ED Guidelines - Cough
- History?
- Signs & Symptoms & Possible Underlying aetiologies?
PCH ED Guidelines - Cough
- Examination?
- 3 Investigations?
- 6 Cough types & Suggested underlying processes?
General and chest examination
- Vital signs (including temperature)
- Nutritional status (beware loss of muscle bulk and subcutaneous fat stores)
- Clubbing
- Cardiovascular system (beware abnormal cardiac examination)
- Chest signs: wheeze, crepitations, asymmetrical breath sounds.
Investigations
1. Chest X-ray
2. Spirometry (if age appropriate)
3. Specimen collection – microbiology (if appropriate)
PCH ED Guidelines - Cough
- Differentials for acute cough?
PCH ED Guidelines - Cough
- Differentials for chronic isolated cough in an otherwise healthy child?
- Differentials for chronic isolated cough in a child with underlying disease?
PCH ED Guidelines - Cough
- 8 Common indications for referral in chronic childhood cough?
- Management of acute cough - URTI?
- Management of habit cough (psychogenic cough)?
- Management of the otherwise well child with a persistent dry non-productive cough?
Common indications for referral in chronic childhood cough:
1. Chronic cough (>4 weeks) of unclear aetiology (with or without failure to thrive)
2. Suspected airway malformation e.g., tracheo-oesophageal fistula, vascular ring
3. Cough and feeding difficulties (suspected aspiration disease)
4. Clinical features of chronic lung disease e.g. clubbing
5. Persisting auscultatory findings e.g. crepitations
6. Recurrent pneumonias
7. Abnormalities on chest X-ray or spirometry
8. Failure to respond to treatment e.g. in asthma.
PCH ED Guidelines - Croup
- Definition?
- Background?
- Assessment?
Definition
Croup (laryngotracheobronchitis) is an upper respiratory illness characterised by a hoarse voice, barking cough, and stridor. The clinical symptoms are a result of inflammation and narrowing of the upper airway (larynx, trachea and bronchi).
PCH ED Guidelines - Croup
- History?
- Examination?
History - Ask about the onset and duration of symptoms:
- Coryza
- Cough
- Stridor
- Increased work of breathing.
- Possibility of inhaled foreign body or anaphylaxis
- Past history – e.g. previous episodes of croup, underlying upper airway, abnormality, underlying neuromuscular conditions.
PCH ED Guidelines - Croup
- Investigation?
- 5 Differential diagnoses?
- Clinical Severity - Mild, Moderate, Severe?
Investigations
1. Not required in clinical diagnosis of croup
2. Routine viral testing is not required and does not alter management
3. Chest X-ray is not indicated (except for those in extremis, i.e. those considered for Paediatric Critical Care (PCC) admission).
Differential diagnoses
1. Underlying congenital abnormality eg: laryngomalacia, tracheomalacia
2. Inhaled foreign body
3. Anaphylaxis
4. Epiglottitis
5. Bacterial tracheitis.
PCH ED Guidelines - Croup
- Initial Management?
- Flowchart?
Management
- All children who present to ED with croup should receive corticosteroids.
- Additional treatments depend on the severity and may include nebulised adrenaline (epinephrine).
PCH ED Guidelines - Croup
- Resus for Life threatening croup?
- Initial management of severe, moderate, mild croup?
PCH ED Guidelines - Croup
- Which 2 medications and doses?
- Admission criteria?
Admission criteria
- As a ‘rule of thumb’ children without stridor do not need to be admitted.
- This decision would be influenced by the distance parents live from the hospital, the reported severity of symptoms at home and past history of severe croup.
PCH ED Guidelines - Croup
- 4 Discharge criteria?
- Nursing points?
Discharge criteria - The child must meet all of the following criteria:
1. Clinically improved
2. Steroids received
3. No stridor at rest
4. No other clinical or social concerns.
PCH ED Guidelines - Pertussis
- Definition?
- Incubation period?
- Infectious period?
- 4 Complications?
- 2 Risk factors?
- Isolation?
- Immunity?
- Definition: Pertussis (Whooping Cough) is a highly infectious respiratory illness caused by Bordatella pertussis.
- Incubation period: 7-21 days
- Infectious period: Patients are infectious from the initial catarrhal period to 3 weeks after onset of cough.They are considered non infectious after completion of a 5 day course of antibiotics.
- Complications: pertussis pneumonia, seizures, hypoxic encephalopathy and death.
- Risk factors: Infants less than 6 months of age & Unimmunised patients.
PCH ED Guidelines - Pertussis
- Assessment?
- Investigations?
- 3 Differential diagnoses?
- History?
- Examination?
Assessment
- Paroxysmal cough followed by inspiratory whoop is the classical presentation.
- Young infants may not have characteristic inspiratory whoop.
Investigations: Nasopharyngeal aspirate or pernasal swab for pertussis PCR, IgA and culture.
Differential diagnoses
1. Bronchiolitis
2. Mycolasma pneumonia
3. Chlamydia pneumonia.
PCH ED Guidelines - Pertussis
- Management?
- Admission criteria?
- Medications?
Management
- Patients with cyanosis or apnoea should be admitted for antibiotics and observation
- Non-admitted patients with suspected pertussis should be isolated from child care, school and health care settings until 5 days of antibiotic therapy has been completed.
- Oxygen for hypoxia
- Respiratory support for apnoea – involve PICU early.
Admission criteria: Have a low threshold for admitting young infants <3 months with suspected pertussis for observation.
PCH ED Guidelines - Pneumonia
- Background?
- Definition?
- Assessment?
- Examination?
Definition: Pneumonia is a lower respiratory tract infection caused by viruses or bacteria. It may involve a lobe (lobar pneumonia) or be more diffuse (bronchopneumonia).
Assessment
- Differentiation between viral and bacterial pneumonia is best done by clinical acumen.
- Neither X-ray appearance, WCC, neutophil count or CRP is reliable in trying to distinguish between viral and bacterial pneumonia.
PCH ED Guidelines - Pneumonia
- 4 Investigations?
PCH ED Guidelines - Pneumonia
- Management?
- Medication?
- 7 Admission criteria?
Management
- Most children with bacterial pneumonia can be treated at home with oral antibiotics and General Practitioner follow up in 24 hours.
- Children presenting with mild symptoms of lower respiratory tract infection are likely to be viral and should not be treated with antibiotics.
Medication
- Antibiotic management for community acquired pneumonia (CAP), aspirate pneumonia and empyema is guided by the Children’s Antimicrobial Management Program (ChAMP) - acute respiratory tract infection.
What is the APGAR test and what does it include?
- 5 minute APGAR score interpretation?
- 10 minute APGAR score interpretation?
APGAR tests, which measure a child’s vital signs and response to stimuli in the first minutes of life, can tell us more than we previously thought about risks of developing neurological disorders such as cerebral palsy and epilepsy.
ALS for Infants and Children Flowchart?
This young boy has been brought in by his parents because they were worried he has been coughing and his appetite is reduced. When saturations are taken they are 98% in air. With this information, what would your impression be?
- He has moderate intercostal recession and moderate respiratory distress
- You must look closely for head bobbing
- He does not need to be referred to a paediatric ward
- He has sternal recession and therefore severe respiratory distress
This young boy has had a mild fever and reduced appetite in the last 3 days. His mother has brought him to the Emergency Department because she is concerned about his breathing.
This child’s cheeks are red and he is sleeping.
- He is comfortable and has an upper respiratory tract infection.
- Pulse oximetry/saturations will be useful.
- His respiratory rate is very fast.
- He most likely has bronchiolitis.
This young girl has been wheezing and couging for 3-4 days. She is feeding very well and having regular wet nappies. Which features of respiratory distress does the child show.
- Recession
- Nasal Flaring
- Grunting
- None of these
- This infant has a typical bronchiolitic cough with mild to moderate recession.
This young boy developed a cold 2 days ago and developed a cough overnight. This child demonstrates:
- Airway obstruction from obesity
- Wheezing, and I would try an inhaler.
- A barking cough and I would try oral steroids.
- Stridor, therefore potentially life-threatening illness.
A barking cough and I would try oral steroids.
This two year old girl presents with a 2 day history of increased coughing and shortness of breath. This child has what category of respiratory distress:
- Mild
- Moderate
- Severe
- Life threatening
= Mild - This child is alert and chatty. She has moderate recession and a moderately raised respiratory rate but is comfortable enough to yawn. This shows she is not breathless. Good safety-netting advice will be needed in case she gets tired over the next day, but she is currently well.
The young boy is on inhalers for asthma. He developed a cold three days ago and overnight his parents found that his blue inhaler was not being effective. They took him to the GP who called an ambulance. Which, if any, of the following red flag signs does this child have?
- Unable to speak in full sentences
- Cyanosis
- He looks tired
- Wheezing
= He looks tired
This 8 year old boy has had a persistent cough for the last month which is worse at night. His parents are smokers and his sister has eczema. There were no focal signs on chest examination except some mild scattered wheeze. His oxygen saturations were normal. It would now be useful to do:
- A chest X-Ray
- His Peak Flow measurement
- Some blood tests, including a blood gas
- Check for a history of food allergies
= His Peak Flow measurement
This infant has had a fever for five days with breathing difficulty in the last 48 hours. He did not sleep last night and his mother describes his breathing as noisy. His temperature is 39.2 degrees. His heart rate is 160/min. His saturations were 91% on arrival. With regard to this childs observations:
- The heart rate is high for his age.
- They should be repeated 4 hourly
- If paracetamol brings his temperature down it makes pneumonia unlikely
- The degree of temperature is worrying
= The heart rate is high for his age.
A 1 hour old neonate, born after 36 weeks gestation to a mother with unknown GBS status develops respiratory distress. What is your approach to management?
Options for EOS risk assessment among infants born ≥35 weeks’ gestation.
A, Categorical risk assessment.
B, Neonatal Early-Onset Sepsis Calculator.
C, Enhanced observation.
Consider lumbar puncture and CSF culture before initiation of empiric antibiotics for infants who are at the highest risk of infection, especially those with critical illness. Lumbar puncture should not be performed if the infant’s clinical condition would be compromised, and antibiotics should be administered promptly and not deferred because of procedure delays. Adequate GBS IAP is defined as the administration of penicillin G, ampicillin, or cefazolin ≥4 hours before delivery.
A 1 hour old neonate, born after 36 weeks gestation to a mother with unknown GBS status develops respiratory distress. What is your approach to management? (12 steps)
Outline an algorithm for SECONDARY PREVENTION OF EARLY-ONSET GBS AMONG NEWBORNS.
Outline an algorith for Neonatal management of early onset sepsis?
How can airway noises (e.g. stertor, stridor, wheeze) distinguish the anatomical location of respiratory disease in paediatric patients? For each of the following Abnormal breath sounds describe their sound, the location and the causes?
- Stertor
- Stridor
- Wheeze
- Grunting
- Crackles/Rales
- Rhonchi
Airway noises such as stertor, stridor, and wheeze can provide valuable clues about the anatomical location of respiratory disease in pediatric patients. These noises can help differentiate whether the issue is occurring in the upper airway (above the vocal cords), the lower airway (below the vocal cords), or within the lungs.
Compare the management of a 3 year old child with wheeze of moderate severity, with a 13 year old with wheeze of moderate severity, with regard to both acute presentation and chronic management. And how are the acute (mild, moderate, severe…) and long-term (persistent, frequent-intermittent…) classifications of asthma used in directing management?
Acute Classification (Mild, Moderate, Severe):
- The classification helps guide the level of intervention needed during acute exacerbations.
- It guides decisions on the use of bronchodilators, oxygen, and corticosteroids.
- The severity is determined based on clinical signs such as respiratory rate, heart rate, oxygen saturation, and work of breathing.
Long-Term Classification (Persistent, Frequent-Intermittent):
- This classification guides the choice of treatment strategy for long-term control of asthma.
- Persistent asthma implies that symptoms are present frequently and may necessitate daily controller medications like inhaled corticosteroids.
- Frequent-intermittent asthma implies less frequent symptoms and might require rescue bronchodilators as needed.
What are the differential diagnoses and management considerations/options for a child with chronic cough (>6 weeks)?
- 11 Pulmonary causes & their risk factors & diagnosis?
- 4 Extrapulmonary causes & their risk factors & diagnosis?
Algorithm for the evaluation of chronic cough in children?
Australasian Bronchiolitis Guidelines
- Diagnosis?
- 5 Features?
- 9 Risk factors for more seriuos illness?
Diagnosis: Viral bronchiolitis is a clinical diagnosis, based on typical history and examination. Peak severity is usually at around day two to three of the illness with resolution over 7-10 days. The cough may persist for weeks. Bronchiolitis most commonly occurs in the winter months, but can be seen all year round.
Features: Bronchiolitis typically begins with an acute upper respiratory tract infection followed by onset of
respiratory distress and fever and one or more of:
1. Cough
2. Tachypnoea
3. Retractions
4. Widespread crackles or wheeze
5. Bronchiolitis is usually self-limiting, often requiring no treatment or interventions.
Australasian Bronchiolitis Guidelines
- Initial Assessment?
Explain the management of an 18 month old fully immunized girl with acute stridor. How would management differ for a 3 month old child?
National Immunisation Program Schedule
- Childhood vaccination?
Give a conceptual epidemiological explanation of childhood wheezing illnesses?
Compare Stertor, Stridor and Wheeze.
- What is intrathoracic and what is extrathoracic?
Stertor tends to be chronic whereas stridor and wheeze can be both acute nad chronic.
Stertor - nasopharynx
Stridor - extrathoracic
Wheeze - intrathoracic
When are extrathoracic noises more prominent?
- Explain the physiology.
extrathoracic = more prominent during INSPIRATION & vice versa for intrathoracic - expansion of airways because of the positive airways pressure.
- eg. wheeze heard less on inspiration & stridor is worse on inspiration
Flipped for expiration
What are the differentials for Wheeze & Stridor in children?
Takeaway messages
- Be able to describe respiratory noises as relatively high or low pitched.
- Be able to describe noises as relatively monophonic (most stridor) or polyphonic (most wheeze).
- Be careful to clarify what people (parents/caregivers) mean when they say “wheeze” or “noise breathing”.
- Be aware that extra-thoracic respiratory obstructions, if they are creating noise, are usually louder on inspiration.
- Be aware that intra-thoracic respiratory obstructions, if they are creating noise (and they don’t always), are usually louder on expiration.
- The volume of noise does not necessarily correlate with severity.
- This physiological understanding can be of benefit clinically when carefully observing and listening to a child in respiratory distress.
- Sats are more reliable in lower airway obstruction than upper.
Treatments for nasal symptoms of the common cold: Evidence for efficacy and associated risks.
- Children?
- Adults?
What is the resuscitation dose of adrenaline for kids?
What is the difference between Mild, Moderate, & Severe Asthma in terms of:
- Severity Proportion <5 years?
- Clinical Features?
- Treatment?
General Principles of Asthma Management in Children?
- Drug side effects?
Drug side effects
Bronchodilators
1. Tachycardia
2. Shaky
3. Tachyphlaxis
- Long acting vs short acting
- Short acting by itself increases inflammation
Steroids oral vs inhaled
1. Growth oral thrush
2. Weight gain effective
- Quality of life/ lifestyle effects
Immune modulators
1. ?affect mood behaviour?
2. Use over age 2
3. Lifestyle quality is the most NB factor
Croup
- What is it?
- Peak incidence?
- Aetiology? Most common pathogen?
Croup (Laryngotracheitis, Laryngotracheobronchitis)
- Peak incidence: 6 months to 3 years.
- Most common in fall and winter - Viral infections are more likely to be acquired and transmitted in cold temperatures and dry air, conditions that predominate during fall and winter.
- Most common pathogen: parainfluenza viruses (75% of cases)
- Other pathogens: respiratory syncytial virus (RSV), adenovirus, influenza virus, SARS-CoV-2 (COVID-19).
Croup
- Pathophysiology?
- Clinical Features: Mild, Moderate, Severe Croup?
Pathophysiology of Croup
Important membrane-bound virulence factors of parainfluenza virus include:
- Hemagglutinin: binds sialic acid → viral entry.
- Neuraminidase: release and spread of virions
- Viral infection → inflammation of the upper airway with edema formation and infiltration of inflammatory cells → narrowing of subglottic airway (inspiratory stridor) and increased work of breathing.
Croup - Diagnostics
- General Principles?
- 3 Indications for diagnostic studies?
- Imaging?
- 3 Lab studies?
General principles of Diagnosing Croup
- Croup is most commonly diagnosed based on the presence of characteristic clinical features of croup.
- Diagnostic studies are not routinely required; do not delay treatment in unstable patients to obtain studies.
- Do not delay treatment of stridor to perform diagnostic studies.
- Indications for diagnostic studies include:
1. Atypical presentation or diagnostic uncertainty, to rule out differential diagnoses of pediatric stridor.
2. Severe disease
3. Recurrent episodes of croup
Croup
- Management?
- Nebulized racemic epinephrine rapidly relieves symptoms of respiratory distress. Dexamethasone provides longer symptom relief but takes up to 6 hours to reduce airway swelling.
- Humidified air, both in the hospital and as a home remedy (e.g., steam inhalation), has been used to treat croup, but there is no evidence that it is effective.
Overview of differential diagnoses of stridor?
What are 6 Differentials of Croup?
Prognosis of Croup?
- Respiratory failure (rare)
- Pulmonary edema
- Pneumothorax
- Pneumomediastinum
- Secondary bacterial infection (e.g., bacterial tracheitis)
- Cardiac arrest and death
Bronchiolitis
- What is it?
- Epidemiology?
- Aetiology?
- 6 Risk factors for severe bronchiolitis?
Epidemiology
- Primarily affects children < 2 years of age
- Peak incidence: 2–6 months of age
- Common during winter months
Risk factors for severe bronchiolitis
1. Age < 12 weeks
2. Preterm birth (< 34 weeks’ gestational age)
3. Congenital heart or lung disease
4. Neurological disease
5. Immunodeficiency
6. Exposure to tobacco smoke
Bronchiolitis
- Clinical Features?
- Diagnostics - General Principles?
- Diagnostics - Lab Studies?
- Diagnostics - Imaging?
General Principles of Diagnosing Bronchiolitis
- Bronchiolitis is a clinical diagnosis based on the patient’s age (< 2 years) and the presence of classic clinical features of bronchiolitis.
- Further testing is not usually required but may be considered in patients with:
1. Severe disease, e.g., if there is concern for respiratory failure
2. Suspected complications of bronchiolitis
3. Diagnostic uncertainty to rule out differential diagnoses of bronchiolitis
Bronchiolitis - Management
- Approach?
- 6 Criteria for Hospital Admission?
- Inpatient management?
Admission criteria for bronchiolitis
1. Unwell appearance, lethargy
2. Moderate to severe signs of respiratory distress (including significantly elevated respiratory rate for age)
3. Ongoing respiratory support required
4. Need for supplemental hydration
5. History of apnea
6. Consider if: Risk factors for severe bronchiolitis are present, Supportive care at home is not feasible
Bronchiolitis
- Differential Diagnoses?
- 5 Complications?
- Prognosis?
- Prevention?
Complications
1. Apnea
2. Respiratory failure
3. Pneumonia
4. Dehydration
5. Otitis media
Prognosis - With timely diagnosis and adequate treatment, the prognosis is good. Bronchiolitis in infancy is associated with an increased risk of developing asthma.
Clinical Progression & Pathogenesis of Respiratory Syncytial Virus (RSV)?
American Academy of Pediatrics Guidance for Diagnosis and Management of Bronchiolitis?
American Academy of Pediatrics Guidance for Palivizumab Immunoprophylaxis?
Bronchiolitis
- History?
- Examination?
- Treatment?
Additional care
- Under 6 weeks ADMIT watch for apneas.
- Premature babies (<30 weeks gest) careful, can have chronic lung disease they can deteriorate rapidly.
- 6 to 12 weeks close follow up
- Over 8 months fully immunised only admit if severe see RCH hand book.
- PO Azithyromycin
- PO Augmentin
- IV Cetriaxone
- IV Tazobactam
- IV Penicillin
= Bacterial pneumonia – fever, cough, localised sxs, usually if they are drinking they can take PO. In a vomiting child or one that is not drinking, then IV
= PO Augmentin
= 60bpm at a rate of 100-120bpm
Inhaled corticosteroids – acute presentations of asthma in >5yrs – definitely never steroids in <1yo, and 1-4yrs = grey area
- PO Prednisalone
- IV Penicillin
- CXR
- PO Augmentin
- 6 puffs salbutamol
= 6 puffs salbutamol
- Re-examine & see if focal signs are persistent (can be mucus plugging)
Management of child with severe croup?
Mycoplasma = most likely agent at this age = Azithromycin
- Neonatal pneumonia
- Sepsis
- Tracheo-esophageal fistula
- Transient Tachypnoea of the Newborn
- IEM with hyperammonaemia
What is the purpose of grunting?
= Transient tachypnoea of the newborn
Grunting = generating your own PEEP to hold open alveoli
3.5yo child choked three days prior - you’re in regional Australia. Best management?
- PO Augmentin & insp/exp films
- IV Ceftriaxone & CT
- IV Ceftriaxone & Transfer
- IV Penicillin & review
- IV Ceftriaxone & review
- IV Ceftriaxone & Transfer
A 1 hour old neonate, born after 36 weeks gestation to a mother with unknown GBS status develops respiratory distress. What is your approach to management?
Analysis: As always “management” is considering that data which inform diagnostic reasoning & refinement, and determining which treatments, education and follow-up are required. In the case of neonates, it’s largely about interpreting the perinatal risk factors. Physical examination of neonates should always consider primary (ie. lung related) as well as secondary (heart, metabolic, sepsis) causes of respiratory distress.
How can airway noises (e.g. stertor, stridor, wheeze) distinguish the anatomical location of respiratory disease in paediatric patients?
Analysis: This is important for diagnostic reasoning, whilst being aware that it is also possible to have a number of different respiratory sounds all at the same time.
Compare the management of a 3 year old child with wheeze of moderate severity, with a 13 year old with wheeze of moderate severity, with regard to both acute presentation and chronic management. And how are the acute (mild, moderate, severe…) and long-term (persistent, frequent-intermittent…) classifications of asthma used in directing management?
Analysis: Well, there’s a lot to talk about here. Wheeze usually means bronchiolitis (but that’s only in infants), “viral wheeze” or asthma, but there may be other aetiologies for wheeze in both the acute (anaphylaxis, foreign body) and chronic (bronchomalacia, There is an implied difference between different age categories to explain, and also a difference in strategies between acute hospital, and long-term outpatient management.
Answer: Let’s focus on viral wheeze and asthma. Acute presentations are generally managed according to the acute asthma management flowchart copied below, generally in any child with acute wheeze and dyspnoea from age 1y upwards (ie.would be similar/same for both the 3yo, and the 13yo):
What are the differential diagnoses and management considerations/options for a child with chronic cough (>6 weeks)?
Analysis: The previous focus question considered asthma, this question might consider other causes of chronic cough (other than asthma, even though under-treated asthma may be the most common reason for chronic cough).
Describe the levels of escalation of respiratory support for a young infant with bronchiolitis.
Analysis: Seems relatively straightforward, but what are the elements of respiratory support? Is there any nuance here to consider?
Explain the management of an 18 month old fully immunized girl with acute stridor.
How would management differ for a 3 month old child?
Analysis: This is really about age related vulnerabilities to different illnesses. People working in child health regularly adjust their diagnostic & clinical reasoning according to the age of the person they are caring for.
