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THE CHILD WITH NOISY BREATHING ASTHMA

Asthma and wheeze Aetiology Transient early wheezing Non-atopic wheezing IgE-mediated wheezing (atopic asthma) - normal lung function early in life - recurrent wheeze develop w allergic sensitisation - increased blood IgE + positive skin prick test - hv persistent symptoms + decreased lung function later in childhood - FHx of asthma/ allergy - Hx of eczema

RF

Causes of recurrent wheeze in infancy

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- infant wheezer - normal lung function early in - virus life associated - LRTI d/t viral (wheezy bronchitis) infxn (RSV)  - small airways increased being more wheezing during likely to the 1st 10 years obstruct d/t of life inflammation - Less severe 20 to viral persistent infxn wheezing - decreased - Symptoms lung function improve during from birth adolescence - mom smoking during / after pregnancy - prematurity transient early wheezing non atopic wheezing in preschool child IgE mediated wheezing (atopic asthma) Recurrent aspiration of feeds CF Cow’s milk protein intolerance Inhaled FB Congenital abnormality of lung, airway or heart idiopathic

Pathophysiolog y

PEFR – for child >5 years old. adrenal suppression + altered bone metabolism (when high dose used.how frequent are the symptoms? . poor growth  bronchiectasis or CF .effective for 2-4 hours .How much school has been missed d/t asthma? . generally no significant SE) .Are sport + general activities affected by asthma? .rapid onset of action (reliever) .prolonged expiratory phase . clubbing. terbutaline B2-agonist .asthma .hx of recurrent wheeze .Eczema – examn of nasal mucosa for allergic rhinitis .skin prick testing – to identify the allergens .How often is sleep disturbed by asthma? .Optimising pulmonary function Bronchodilator Short acting .allergic conjunctivitis .allergic rhinitis .Ipratropium bromide c .Given to young infant when other bronchodilator is bronchodilato ineffective r .How severe are the interval symptoms between exacerbation Signs: .have few SE.generalised polyphonic expiratory wheeze long-standing asthma . no Ix needed .Growth .Atopy and allergy Diagnosis Investigations Management .used as required for increased symptoms.w exacerbations usually precipitated by viral infxn . .Salbutamol.SE: impaired growth.patho: decrease airway inflammation  decreased steroids symptoms.chest x ray – normal . asthma exacerbations + bronchial (preventer) hypersensitivity .clinical diagnosis.Minimising treatment + SE . sputum production.Allow child to lead a normal life by controlling symptoms + exacerbations . depends on diurnal variabilty (morning PEFR usually lower than evening) and day-to-day variability Aim .hyperinflation of the chest .food + drug allergies Symptoms: .urticaria + angioedema .Used in tx of severe acute asthma Preventive/ prophylactic treatment Inhaled .eczema . Anticholinergi . and in high doses for acute asthma attack .Wet cough.Harrison’s sulci (onset on infancy) .Increasingly used in conjunction w inhaled LABA.

headache. stress .Consider triggers: allergic rhinitis. poor concentration .montelukast .prednisolone .given on alternate days to minimise the SE on height Monitor: . insomnia.Long acting B2-agonists (LABA) Leukotriene inhibitor Methylxanthi nes Oral steroids .rarely used . time off school .slow release oral Theophylline .Inhaler technique .severity + frequency of symptoms .salmeterol. formoterol .Use of preventer + reliever medication – are they appropriate? .peak flow diary .effective for 12 hours .as add on therapy when inhaled steroids w LABA fail to control symptoms .is sleep disturbed? .useful in severe persistent asthma where other tx has failed .exercise tolerance .used in conjunction w regular inhaled corticosteroids (not used in acute asthma + not be used w/o corticosteroid) . allergens.interference with life.high incidence of SE: vomiting.orally .useful in exercise induced asthma .blood level need to monitored .

PEFR routinely measured in school age children .cyanosis.Acute asthma Clinical features: . >30/min in children ≥5 years) – but poor guide to severity .increasing tachycardia (>130/min in children 2-5 years. fatigue.the presence of marked pulsus paradoxus (abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration) indicates moderate to severe in children but is difficult to measure accurately  unreliable . So: . >120/min in children ≥5 years) – better guide to severity .wheeze + tachypnoea (RR >50/min in children 2-5 years.Arterial SaO2 should be measured w pulse oximeter – SaO2<92% = severe/ life threatening asthma . may hv silent chest on auscultation as little air is being exchanged Severity may be underestimated by clinical examn alone.if SOB interferes w talking  attack is severe . drowsiness  late signs = life threatening asthma.the use of accessory muscle + chest recession – also better guide to severity .

lobar collapse) .when drugs should be used (regularly or ‘as required’) Treatment Patient education .sign of severe infection In children .ABG indicated in life threatening / refractory cases As above ‘assessment and management of acute asthma’ Need to know: .unusual features (asymmetry of chest sign  pneumothorax.indications: .Not responded adequately – persisting SOB.Marked reduction in predicted PEFR .Criteria for hosp admission if. tachypnoea .severe dyspnoea .Have a reduced O2 saturation (<92% in air) Chest Xray . after high dosed inhaled bronchodilator therapy. they: .Exhausted .

feeding difficulty a/w increasing dyspnoea  reason for admission . infants w congenital heart disease Signs: .o Nebuliser – deliver high dose therapy + are used in sevre acute attacks CLASSIFICATION OF RESPIRATORY INFECTION URTI DDx: o Croup  Viral laryngotracheitis (very common)  Acute on chronic stridor ie from floppy larynx (laryngomalacia)  Bacterial tracheitis (rare) o Rare causes  Epiglottitis  Inhalation of smoke and hot air in fires  Trauma to the throat  Retropharyngeal abcess  Laryngeal FB  Allergic laryngeal oedema (angioedema)  Tetany d/t poor vit D intake  Infectious mononucleosis  Measles  Diphtheria - ACUTE BRONCHOLITIS Introduction Clinical features .how to use the drug (inhaler technique) what each drug does (relief vs prevention) how often and how much can be used (frequency + dosage) .apnoea in infants <4months .RF : premature infant who develop bronchopulmonary dysplasia.recurrent apnoea is a serious complication in young infants .coryzal symptoms precede a dry cough .what to do if asthma worsens (management of acute attack) .commonest serious respiratory infection in infancy .sharp. walking.cyanosis or pallor .when to start steroid at home + what dose to give signs of poorly controlled asthma: .o: dry powder inhaler (terbutaline sulphate + salbutamol) or MDI w correct inhaler inhaler <4 y.difficulty in talking. use mask if <2y.increasing cough.decreasing relief from bronchodilators Written personalised asthma action plan Choosing the 4-10 y.wheeze .o: MDI w spacer. wheeze. SOB . dry cough .Respiratory Syncytial Virus (RSV) (80%) Symptoms: . sleeping .

monoclonal antibody to RSV (palivizumab.hyperinflation of the lungs (d/t small airways obstruction.Infant is monitored for apnoea .required in most severe cases  show lowered arterial O2 + CO2 tension . antibiotics.Investigations tacypnoea high pitched wheezes – expiratory > inspiratory tachycardia hyperinflation of the chest: .subcostal + intercostal recession .increased hilar hilar bronchial marking . steroid – not helpful) . trachea and bronchi the oedema of subglottic area is potentially dangerous in young children bcoz it may result in critical narrowing of trachea 6 months to 6 years old ( the peak incidence in the 2nd year of life) Commonest in autum barking cough .liver displaced downwards .note: Chest X ray rarely helpful in bronchiolitis ABG .Supportive . air trapping + often focal atelectasis) .Can give nebulised bronchodilators ie salbutamol or ipratropium – hv not shown to reduced the severity + duration of illness . given monthly by IM) – reduces no.Fluids via NG tube or IV .Humidified O2 delivered via nasal cannulae/ into headbox – conc required determined by pulse oximetry .(Mist.Auscultation: . common in infants and children parainfluenza viruses (the commonest) metapneumovirus RSV Influenza mucosal inflammation and increased secretion affecting the larynx.recover from acute infection within 2 weeks .flattening of diaphragm .Fine end-inspiratory crackles .sternum prominent .RSV – highly infectious  infection control measure  good hand hygiene  to prevent cross infection to other infant .Prolonged expiration RSV – can be identified rapidly on nasopharyngeal secretions  demonstrating binding of fluorescent antibody Chest X ray . of hosp admission in high risk preterm infants - Management Prognosis Prevention CROUP Definition Causative organism Pathophysiolog y Epidemiology Clinical features - - - Croup is breathing difficulty and a "barking" cough. d/t swelling around the vocal cords.horizontal ribs .Mechanical ventilation .

(introduction of universal Hib immunisation lead to decrease of incidence of epiglottitis) Intense swelling of epiglottis and surrounding tissue a/w septicaemia Children aged 1-6 years but affects all age group .the symptoms start at night and worse at night Mild viral croup .high fever in an ill.severity of illness .parents give close monitoring for signs of increasing severity Admit or not? . toxic-looking child .Tracheal intubation ACUTE EPIGLOTTITIS Causative organism Pathophysiolog y Epidemiology Clinical features H.the child sits immobile.hoarseness .soft inspiratory stridor + rapidly increasing respiratory difficulty over hours . influenza type b .children w clinical features of severe croup . oral prednisolone + nebulised steroids (budesonide)  reduce the severity + duration of croup + need for hospitalisation . the stridor + chest recession disappear when child at rest .oral dexametahsone.harsh stridor .manage at home .Management .inhalation of warm moist air  widely used but unproven benefit .parental understanding + confidence about the disorder Medical .when upper airway obstruction is mild.the child’s age (low threshold for admission for those <12 months old) .severe upper airways obstruction . w an open mouth to optimise the - . upright.an intensely painful throat that prevents the child from speaking or swallowing.SaO2 <93% in air (give together O2 by face mask + close monitoring) .nebulised epinephrine (adrenaline)  give transient improvement in: . saliva drools down the chin .preceded by fever and coryza .ease of access to hospital .time of day .

most commonly causing a characteristic high-pitched squeaking noise on inhalation (inspiratory stridor).Transferred to ICU .After airway secured  blood taken for C+S . very ill >38. IV antibiotic (cefuroxime) started (given for 3-5 days) .Child recover within 2-3 days . immature cartilage of the upper larynx collapses inward during inhalation  causing airway obstruction - partial airway obstruction. paediatrician + ENT surgeon tx initiated w/o delay . whispering Muffled.the soft. rasping hoarse EPIGLOTTITIS Over hours No Investigation Management Absent or slight No Yes Toxic.5 oC Soft. barking yes no unwell <38.5oC Harsh. reluctant to speak Should not attempt to lie child down or examine the throat w spatula or perform a lateral neck X ray  can precipitate total airway obstruction .Hospital admission .Senior anaesthetist. cry LARYNGOMALACIA Definition and pathophysiolog y Clinical features . urgent tracheostomy is life saving) .airway CROUP Over days yes Severe. .Tracheal tube remove after 24 gours .Prophylaxis Rifampicin (for close household contact) Onset Preceding coryza Cough Able to drink Drooling saliva Appearance Fever Stridor Voice.Intubate the child under GA (rarely possible.

- feeding difficulties - stridor .