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Dyspnoea

History​

  • A good history will help you to make a diagnosis and assess the severity of illness
  • Age:
    • different illnesses at different ages
    • small babies get more ill more quickly
  • Past medical history:
    • Prematurity
    • Cardiac/respiratory disease
  • Fast/noisy breathing? (is this unusual for the baby?)
  • Eating and drinking?
  • Level of activity? quiet or clingy?
  • Fever?
  • Apnoea in babies < 3 months - require hospital admission
  • Characteristic stories:
    • Baby with snuffly nose, wet cough, wheeze – Bronchiolitis
    • Pre-schooler with runny nose then dry cough and wheeze – Viral induced wheeze
    • Older child with recurrent wheezy episodes, atopy in family - Asthma

Examination​

  • General: are they well, unwell but compensating, or decompensating to respiratory failure
    • Level of alertness, fatigued?
    • Interested in surroundings?
    • Posture: accessory muscles
    • Ability to speak

Looking for specific signs of respiratory illness to assess how unwell the child is. Avoid upsetting the child as this will worsen their respiratory distress. Children compensate very well for respiratory illness

  • Noisy breathing?

    • Coryza (runny nose) – common in URTIs, bronchiolitis and well infants!
    • Wheeze – lower airway narrowing – asthma, bronchiolitis, viral-induced wheeze
    • Stridor – upper airway narrowing, harsh sound – croup, other rarer infections, foreign body, anaphylaxis, epiglottitis
    • Grunting – closure of glottis to generate end expiratory pressure, infants with severe respiratory distress

  • Respiratory rate?

    • Rate increases as illness gets more severe – until decompensation when rate slows
    • Remember to adjust for age
    • Look out for prolonged expiration (asthma, bronchiolitis)

  • Work of breathing?

    • Recession (mild-moderate-severe)
    • Tracheal tug
    • Supraclavicular
    • Sternal - severe illness
    • Intercostal
    • Subcostal

  • Accessory muscles?

    • Head Bobbing
    • Abdominal breathing

  • Oxygen saturations and heart rate

    • Detects hypoxia well before the naked eye can see cyanosis
    • Give supplemental oxygen if O2 saturations <94%
    • Children whose saturations are still low despite oxygen are very unwell
    • Tachycardia (adjust for age) = ill child
    • Bradycardia (adjust for age) = pre-arrest

  • Auscultation

    • Limitations:
      • Often hear noisy breathing without stethoscope
      • Sounds do not always relate to how ill the child is
      • Small chests transmit sounds all over
      • Children cry
    • Wheeze
    • Crackles/crepitations, bronchial breathing – pneumonia?
    • Beware a “silent chest” – could be life-threatening asthma

  • Peak flow

    • Beware children who have little work of breathing may be tired and about to decompensate

Differential of Dyspnoea​

  • Viruses and bacteria:
    • Strep pneumonia
    • RSV
    • Mycoplasma
    • Human metapneumovirus
    • Pertussis
    • Influenza/parainfluenza
  • Asthma, Bronchiolitis, Pneumonia, Croup

Epidemiology​

Most commonly in the first 3 years of life

Strep pneumoniae, Haemophilus influenzae, Pertussis, Mycoplasma, and the influenza viruses

Red Flag Presentations​

Choking​

  • Foreign bodies

    • Upper airway (larynx) – life-threatening
    • Bronchi – wheeze, chest infection
    • Oesophagus – discomfort, drooling

  • Stuck in larynx

    • Spontaneous cough? – encourage coughing
    • No/ineffective cough? – back blows, abdominal thrust (>1 yr) or chest thrusts (<1 yr)
    • Unconscious? – standard CPR
    • In hospital – contact ENT and anaesthetics urgently

  • Stuck in main bronchus

    • Wheezing or chest infection some time after the event which may not be recalled
    • Chest X-ray may be helpful

  • Stuck in oesophagus

    • No respiratory compromise (able to talk or cry)
    • Drooling
    • Refer to surgery/anaesthetics

  • Manoeuvres

    • Bang on the back, with the child inverted
    • Age > 4 -> Heimlich Manoeuvre
    • Age < 4 -> Chest Thrusts

Apnoea​

  • Apnoea: Pause in breathing/stopping breathing, may present with floppiness or cyanosis
  • Brief Resolved Unexplained Event (BRUE)
    • Floppiness, cyanosis, and/or apnoea
    • Many possible causes: infants with bronchiolitis, Pertussis (whooping cough), sepsis, meningitis, fits
  • Apnoea in infants require 999 hospitalisation

Status Asthmaticus​

  • Classify attack as moderate, severe or life-threatening

TODO: Stratification Guidelines

  • Acute severe: requires hospitalisation for repeated nebulisers +/- IV treatment
  • Features
    • History of severe attacks in the past
    • Increased work or breathing
    • Fatigue
    • Hypoxia
    • Tachycardia
    • PICU involvement
    • Marked improvement after treatment

Asthma​

British guideline on the management of asthma

  • Hyper-reactive airways with mucous secretion causing coughing and wheezing
  • Wheeze - high pitched expiratory sound
  • “Viral-induced wheeze” in pre-schoolers – not necessarily asthma
  • Asthma triggers: smoke, exercise, excitement, dust, pollen, allergies
  • Inhaler via spacer +/- mask
  • Age < 1: beta agonists less effective, require admission if not feeding or need oxygen

Croup​

  • Viral upper airway infection causing airway inflammation/obstruction in toddlers
  • Clinical Features
    • Stridor - inspiratory and/or expiratory - harsh sound, louder if more severe
    • Barking cough, hoarse voice, shortness of breath, febrile
    • Signs of airway obstruction: intercostal recession, subcostal recession, sternal recession, tracheal tug
    • Progressing to fatigue and respiratory failure (stridor quieter)
  • Try not to distress a child with croup as this can worsen obstruction
  • Steroids (po / nebulised) +/- adrenaline nebuliser

Bronchiolitis​

NICE Bronchiolitis in Children: diagnosis and management

  • Caused by viral infection of bronchioles, normally RSV, causing secretions
  • Mainly infants < 1 yr
  • Clinical Features
    • Shortness of breath, wheezy wet cough, mild fever, runny nose
    • Progressing to fatigue, poor feeding
  • Winter months
  • Manage at home or admit for feeding support, oxygen, suction

Pneumonia​

Guidelines for the management of community acquired pneumonia in children: update 2011

  • Clinical signs often subtle in children, CXR indicated in septic children
  • Generally unwell, febrile (>38.5 C), tachypnoeic
  • May not have a cough, look for
  • General signs of severe illness: lethargy, fever, and tachycardia
  • Check O2 saturations and look for signs of respiratory distress