Makindo Medical Notes.com

Related Subjects:Sick Neonate |APGAR Scoring |Approach to Assessing Sick Child |Sick Child with Acute Gastroenteritis |Sick Child with Respiratory Distress |Sick Child Diabetes Mellitus Type 1 and DKA

Introduction

• When a child presents with difficulty in breathing, it is essential to establish the site of the disease i.e. whether it involves upper airways (oropharynx, nasopharynx, larynx), lower airways (trachea, bronchi, bronchioles), lung parenchyma, central control of breathing or a combination of these. When respiratory effort is inadequate to sustain the effective gas exchange (oxygenation and removal of CO₂), respiratory failure ensues.
• Respiratory failure is the end stage of respiratory distress, and it requires urgent intervention to prevent deterioration to cardiac arrest. It is important to realize here that the majority of cardiac arrests in paediatric practice are secondary to progressive respiratory failure, and thus if intervened timely and effectively, will prevent the fatal outcome.
• Clinical signs of respiratory distress include
  • Abnormal respiratory rate or effort- Tachypnoea, bradypnoea or hypoventilation, nasal flaring, chest retractions and use of accessory muscles
  • Abnormal airway sounds- Stridor, wheezing, grunting
  • Deterioration in skin colour- Pale, cool skin, cyanosis
  • Changes in level of consciousness- Drowsy, markedly irritable or agitated

General Management

• Keep the child in the position of comfort and minimize agitation.
• If upper airway obstruction is suspected, then perform manual airway measures such as head tilt -chin lift, jaw thrust (in case of suspected cervical spine injury).
• Suctioning of nose or mouth if secretions are present.
• Provide humidified oxygen, preferably with a high concentration delivery device e.g., Headbox (for infants less than 6 mo), Oxymask or non-rebreathing mask (for older children).
• Start inhaled medications as indicated.
• Monitor heart rate, respiratory rate, blood pressure and SpO₂.
• Establish vascular access (for fluid therapy and medications as indicated).

Specific Management

• After initial stabilization of the child with respiratory distress, further management depends upon the underlying aetiology
• Croup: NB Oximetry is not a reliable marker of severity in croup
  • Mild Barking cough, but no stridor at rest, mild retractions may be present. Reassure parents, explain warning signs, no specific treatment
  • Moderate Stridor at rest, chest retractions, use of accessory muscles but is interactive, alert. Nebulized Adrenaline 0.5 ml/kg of 1:1000 solution (max 5 ml) Oral/IV/IM Dexamethasone 0.3 mg/kg OR Prednisone/ prednisolone 1 mg/kg Observe for at least 4 h
  • Severe: Marked respiratory distress, restless, irritable, tachycardia. Shift to paediatric centre with ICU facility
• Bronchiolitis:
  • Mild - Little or no respiratory distress, able to feed, SpO₂ above 95% on room air. Home management with nasal saline drops
  • Moderate Features of respiratory distress with SpO₂ 90-95% on room air, difficulty in feeding but able to take more than 50% of normal feed. Requires admission and monitoring Humidified oxygen, nasogastric feeding, nebulization with hypertonic saline and adrenaline
  • Severe Marked respiratory distress, restless, irritable, tachycardia. Shift to paediatric centre with ICU facility Requires non-invasive ventilation (NIV) such as humidified high flow nasal cannula, or ventilator support
• Asthma
  • Mild: Little or no respiratory distress, SpO₂ above 95% on room air. Alert and oriented. No supplemental oxygen needed. Manage with salbutamol and inhaled steroids by Metered Dose Inhaler (MDI) and spacer
  • Moderate Features of respiratory distress with SpO₂90-94% on room air, mild tachycardia. Able to talk in phrases (if normally able) or have a shortened cry. Alert and oriented. Requires admission and monitoring - Humidified oxygen, manage with salbutamol and ipratropium, MDI and spacer - Salbutamol (Albuterol) 100 mcg. Give 6 puffs (children under 6 y) or 12 puffs (children 6 y and over) - Consider Ipratropium 20 mcg 4 puffs (children under 6 y) or 8 puffs (children 6 y and over) every 20 min together with salbutamol(Albuterol) - Oral prednisone (1-2 mg/kg/d)
  • Severe Marked respiratory distress, tachycardia, SpO₂ < 90% on room air. Able to talk in words (if normally able) with a weak cry or unable to speak or cry. Confused, restless, irritable.Shift to paediatric centre with ICU facility Nebulize with salbutamol(Albuterol), Ipratropium, IV steroids Requires non-invasive ventilation (NIV) such as continuous positive airway pressure (CPAP), or ventilator support
• Respiratory Distress: Paediatric Emergency Pearls
  • Rapid breathing may be due to the following which should be clinically identified:
  • Cardiac failure, Metabolic acidosis, Neurological diseases
  • Don't use bronchodilators in infants < 6 mo of age.
  • When to Refer: Tachypnoea, tachycardia, Chest indrawing, Severe cough, Cyanosis, Too sick to feed