RESPIRATORY EMERGENCIES IN

PAEDIATRIC PATIENTS 23/ 04/ 2015

Disorders of the respiratory tract are the most common forms of illnesses in

childhood. They are the most frequent reason for children to be seen by a

Doctor and account for 30> 40% of acute admissions to hospital.

Many respiratory illnesses are self- limiting minor infections but others present

as potentially life threatening emergencies. This small group is where accurate

diagnosis is essential to avoid unnecessary morbidity and mortality.

SUSCEPTIBILITY OF CHILDREN TO SEVERE RESPIRATORY ILLNESS.

The pattern of children suffering respiratory illness is different from adults as it

does involve the immune status, the structure and function of the lungs and

the chest wall of children and adults.

Children and particularly infants are susceptible to infection with many

organisms to which adults have acquired immunity to.

The upper and lower airways in children are smaller and are more easily

obstructed to swelling foreign body or mucosal secretions. It all centres

around the radius the 1mm reduction of a 5mm diameter trachea in a

child is much greater than the swelling of an adults trachea that is 10

mm in diameter.

The thoracic cage of a young child is much more compliant than that of

adults. When there is airway obstruction and increased respiratory

effort this increased compliance results in the efficiency of breathing.

Respiratory muscles of an infant or child are relatively inefficient. In infancy the

Diaphragm is the principle respiratory muscle and the intercostal and

accessory do not really make any contribution. Respiratory muscle fatigue can

develop rapidly and result in respiratory failure and apnoea.

ASSESSMENT OF RESPIRATORY EMERGENCIES IN CHILDHOOD

Respiratory illnesses that present most commonly as emergencies are as

follows

Upper airways obstruction

Lower airways obstruction

Pneumonia

Croup

Asthma / bronchiolitis

Epiglottitis

Although all these diseases result in respiratory distress, it is possible to

distinguish between them with careful history and clinical examination. As the

appropriate treatment for each of these disorders id quite specific, it is

imperative that the correct diagnosis of the distress is made.

HISTORY

Breathlessness ? At rest

? Walking up stairs

? When talking

? When sleeping (older children)

? When feeding (infants)

Cough Barking like a seal – like in Croup

Dry and wheezy in Bronchiolitis

Noisy Breathing Stridor, mainly inspiratory due to narrowing of trachea

Or larynx

Wheezy mainly expiratory, due to more distal obstruction

of the respiratory tree.

Hoarseness Vocal cord involvement

Drooling and unable to

Drink Epiglottitis

Abdominal pain sometimes present in Pneumonia

Meningism Sometimes present in Pneumonia (neck stiffness),

Photophobia, Headaches.

High fever, lethargy and anorexia are common in children

with respiratory infections.

Examination

Careful inspection of the Childs respiratory pattern, posture, and behaviour

pattern is often the most informative part of a physical examination. In

younger children you must straight away gain their trust, approach the child at

their level do not tower over them where possible let the parent or guardian

hold them as a comfort blanket if the child is very young. REMEMBER! That

diseases other than respiratory illnesses can produce many of these signs and

symptoms For example, deep rapid respirations may indicate metabolic

acidosis or salicylate poisoning, it can be difficult to distinguish between

respiratory disease and congenital heart disease in the young child.

Both give rise to tachypnoea, tachycardia, and cyanosis. Congenital heart

disease is more likely if there is evidence of heart failure such as Liver

enlargement cardiac murmurs or an irregular pulse may suggest primary heart

disease.

Further useful information will be from Oxygen saturation readings and blood

gasses done in hospital. In children over 5 years of age with asthma a peak flow

reading should be routine part of the assessment.

UPPER AIRWAY OBSTRUCTION.

Obstruction of the upper airway (Larynx / Trachea) is potentially life

threatening. As mentioned earlier the Childs airway is very small in diameter

and any blockage EG (coins, batteries, small toys, sweets, or small pieces of

food) or secretions is dangerous. Auscultation may reveal unilateral

wheezing or decreased air entry leading to possible collapsed lung.

Removal with Magill’s forceps may be lifesaving if that is your only answer if blockage can be visualised with the laryngoscope blade.

The cardinal feature of upper airway obstruction is STRIDOR! This is heard

predominantly on inspiration, but may be heard also on expiration. Like the

wheeze in asthma the intensity of the stridor does not indicate the severity of

the obstruction. Other signs such as hoarseness, swelling of the vocal cords,

barking seal like cough, sternal and subcostal recession, respiratory and heart

rate increase central cyanosis and agitation all indicate severe Hypoxemia and

a need for urgent intervention.

DIFFERENTIAL DIAGNOSIS OF ACUTE UPPER AIRWAY OBSTRUCTION.

Most cases of upper airway obstruction in children are a result of infection, but

other causes such as foreign body obstruction, house fire (Hot gasses)

Angioneurotic oedema and trauma can all result in such obstructions.

CROUP

Croup (or laryngotracheobronchitis) is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The

infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness. Fever in children < 38.5C. It

may produce mild, moderate, or severe symptoms, which often worsen at night. It is often treated with a single dose of oral steroids;

occasionally inhaled epinephrine is used in more severe cases. Hospitalization is rarely required.

Croup is diagnosed on clinical grounds, once potentially more severe causes of symptoms have been excluded (i.e. epiglottitis or an airway

foreign body). Further investigations—such as blood tests, X-rays, and cultures—are usually not needed. It is a relatively common condition that

affects about 15% of children at some point, most commonly between 6 months and 5–6 years of age. It is almost never seen in teenagers or adults.

SIGNS AND SYMPTOMS

Croup is characterized by a "barking" cough, stridor, hoarseness, and difficult breathing which usually worsens at night. The "barking"

cough is often described as resembling the call of a seal or sea lion. The stridor is worsened by agitation or crying, and if it can be heard at rest, it may indicate critical narrowing of the airways. As croup worsens, stridor

may decrease considerably.

Other symptoms include fever, coryza (symptoms typical of the common

cold), and chest wall in-drawing. Drooling or a very sick appearance indicate other medical conditions.

TREATMENT

Children with croup are generally kept as calm as possible. Steroids are given routinely, with epinephrine used in severe cases. Children with

oxygen saturations under 92% should receive oxygen (Humidified) if possible and those with severe croup may be hospitalized for observation. If oxygen is needed, "blow-by" administration (holding an

oxygen source near the child's face) is recommended, as it causes less agitation than use of a mask with treatment, less than 0.2% of people

require endotracheal intubation

Steroids

Corticosteroids, such as dexamethasone have been shown to improve outcomes in children with all severities of croup Significant relief is obtained as early as six hours after administration. While effective when

given orally, the oral route is preferred. A single dose is usually all that is required, and is generally considered to be quite safe. Dexamethasone

at doses stated in the JRCALC guidelines appear to be all equally effective.

PROGNOSIS

Viral croup is usually a self-limited disease with half of cases going away

in a day and 80% of cases in two days. It can very rarely result in death

from respiratory failure and/or cardiac arrest. Symptoms usually improve

within two days, but may last for up to seven days. Other uncommon

complications include bacterial tracheitis, pneumonia, and pulmonary Oedema.

ACUTE EPIGLOTTITIS

The epiglottis is a flap that is made of elastic cartilage tissue covered

with a mucous membrane, attached to the entrance of the larynx. It

projects obliquely upwards behind the tongue and the hyoid bone, pointing dorsally. There are taste buds on the epiglottis.

Inflammation of the epiglottis is known as epiglottitis. Epiglottitis is mainly caused by Haemophilus influenzae B. A person with epiglottitis

may have a fever, sore throat, difficulty swallowing, and difficulty

breathing. For this reason, in children, acute epiglottitis is considered a medical emergency, because of the risk of obstruction of the pharynx.

Epiglottitis is often managed with antibiotics and may require tracheal intubation or a tracheostomy if breathing is difficult.

Treatment

We should not try and examine the Childs airway as we do not want to induce choking or vomiting, the Epiglottis will be cherry red with the

inflammation and we should just encourage the parent or care provider to sit the child forward and let them drool into a paper towel and offer comfort. If the O2 saturation is showing <92% then we should encourage

oxygen therapy but wafting the oxygen over the patients face and nose to encourage an increase in the saturation levels. As a last resort Do-

not attempt intubation in the field unless acute airway obstruction is present. ET Tube to be one half to one size SMALLER for age and size of patient to accommodate the subglottic oedema, the event of

respiratory failure or obstruction, if emergency medical services (EMS) is unable to intubate, then cricothyroidotomy are the next lines of

treatment. (Speed to A&E is with ASHICE call is essential)!

LOWER AIRWAY OBSTRUCTION

Asthma

Acute exacerbation of asthma is the most common reason for a child to be

admitted to hospital. The classic features of acute asthma are cough, wheeze

and breathlessness an increase in these symptoms and difficulty in walking,

talking and sleeping. Upper respiratory tract infections are most common in

pre-school children. Ninety per cent are caused by viruses. Exercise induced

symptoms are more likely in the older child. Heat and water loss seem to be

the mechanism that induces bronchoconstriction.

ASSESSMENT OF SEVERITY

Except in a young infant it is rarely a problem diagnosing acute asthma, an

inhaled foreign body croup, epiglottitis or bronchiolitis should be considered as

alternative diagnosis. The peak expiratory flow is a reliable measure of severity

and should be routinely be part of the assessment.

Features of severe asthma

Too breathless to feed or talk

Recession / use of accessory muscles

Respiratory rate > 50breaths per min

Pulse rate > 140 bpm

Peak flow <50% expected best

Features of life life-threatening asthma

Conscious levels depressed / agitation

Exhaustion

Poor respiratory effort

Oxygen saturation <85% in air cyanosis

Silent chest

Peak flow <33% expected best.

Predicted values of peak expiratory flow rate in children

Height (cm) Peak flow (L/min)

110 150

120 200

130 250

140 300

150 350

160 400

170 450

Treatment

All treatment for this condition will be based around currant best practice

guidelines and the JRCALC drug administration protocols for Paediatrics.

Salbutamol, Ipratropium Bromide, Hydrocortisone, Epinephrine 1,1000

Nebulised drugs given by oxygen at all times,

If the child fails to improve they must be observed at all times ECG taken O2

saturation recorded the journey time will dictate how frequently you nebulise

but it can be continuously if needed.

BRONCHIOLITIS

This is the most common, serious, respiratory infection of childhood 2 -3% of

all infants are admitted to hospital with the disease each year. 1 to 9 months

age range it is rare after 1 year of age.

° Acute, infectious, inflammatory disease of the upper and

Lower respiratory tracts; major cause of respiratory disease

Worldwide. Obstruction of bronchioles from inflammation, oedema,

And debris leads to hyperinflation, increased airway resistance, and atelectasis.

Although wheezing is common, bronchoconstriction is not.

Most cases are mild and self-limiting; however, inpatient

Mortality can be as high as 5%.

Causes

Bronchiolitis is most often caused by respiratory

Syncytial virus (RSV)

Common in infants and during the autumn and winter time.

EMERGENCY TREATMENT

As there is no specified treatment for Bronchiolitis, management is supportive,

Humidified Oxygen is delivered into a head box in hospital. Sometimes IV fluids

or nasogastric fluids are commenced if needed. Pulse oximetry is helpful in

assessing the severity of hypoxemia. Because of the risk of Apnoea small

infants will be placed on monitors in hospital.

Pneumonia

This condition in children is still responsible for 150 deaths each year. Infants

and children with congenital abnormalities or chronic illnesses are at greater

risk. Viruses are the most common cause in younger children as they grow

older the bacteria is more frequent as part of the infection.

Fever, cough, dyspnoea, and lethargy following upper respiratory infection are

the usual presenting symptoms. The cough is often dry but then becomes

loose. Older children may produce purulent sputum, but those below the age

of 5 it is usually swallowed. It can produce pleuritic chest pains, neck stiffness

and abdominal pains if there is pleural inflammation. Classic signs of

consolidation such as impaired percussion decreased breath sounds and

bronchial breathing are often absent. Particularly in infants. A chest X-ray will

be needed. This may show the Dr Consolidation or widespread pneumonia.

EMERGENCY TREATMENT

As it’s not possible to differentiate between bacterial and viral infection

children should receive antibiotics, the antibiotic given is age dependant by the

Doctor. If over a period of time the child keeps getting reoccurring infections

then other tests need to be carried out to rule out conditions such as cystic

fibrosis or immunodeficiency problems.

(This Paper reflects what we as health care professionals may be able to care

for at our skill level out in the pre-hospital environment).

REFERENCES:-

WWW.WIKIPAEDIA.ORG

http://www.cs.amedd.army.mil/borden/FileDownloadpublic.

http://www.patient.co.uk/health/pneumonia-leaflet

http://image.slidesharecdn.com/emergenciesinchildren-140310043441-

phpapp02/95/otolaryngological-emergencies-in-neonateinfant-and-child-32-

638.jpg?cb=1394444149

Advanced Paediatric Life Support ISBN No 0-7279-1069-8

Clinical Practice Guidelines 2013 ISBN 978 185959 364 9

Emergency Care in the Streets 6th edition ISBN 13-978-7637-5057-2

Mark Dunkerley

HCPC Paramedic

PA00479.