Breathlessness

C1 and C2
 Table of contents
01 Case 01 07 Evaluate the clinical findings and formulate
the differential diagnoses

02 Case 02
Justify choice of investigations and be
08 able to interpret the results
03 Case 03
Plan management strategies appropriate for
Identify the aspects of anatomy and
09 children presenting with breathlessness.
04 pathophysiology of the respiratory system
relevant to breathlessness.

Describe the common paediatric

05 conditions causing breathlessness

06 Elicit history and physical signs

in children with breathlessness
Case 01
A 10 month old girl presented to the hospital with fever and cough for 3
days and breathlessness for a day. She has also been noted to be
feeding poorly for the past 2 days. There was a strong family history of
bronchial asthma in the father and an elder sibling.

On examination, the child was found to be lethargic with a temperature

of 39 °C. Her pulse rate was 170 beats per minute and respiratory rate
was 60 breaths per minute. Her oxygen saturation via the pulse
oximeter was 88%. There was marked subcostal and intercostal
recession and the chest was hyperinflated. There was a soft ejection
murmur heard over the left sternal edge. Air entry was decreased
bilaterally with occasional rhonchi and crepitations. Liver was palpable
3 cm below the right subcostal margin.

A blood count done showed the following: Hb 107 g/l, TW 25 X 10⁹/L,

neutrophils 75%, Lymphocytes 20%, Platelets 486 X 10 ⁹/L.
Key points:
● 10 month old girl
● Fever and cough x3/7
● Breathlessness x1/7
● Poor oral feeding x2/7
● Family hx of bronchial asthma

Physical examination:
● Lethargy → poor feeding + breathlessness
● Air entry decreased bilaterally
● Febrile 39°C
● Occasional rhonchi
● Tachypneic (60 breaths/min)
● Crepitations
● Tachycardic (170 bpm)
● Soft ejection murmur over the left
● Hypoxic (oxygen saturation is 88%)
sternal edge → innocent murmur
● Hyperinflated chest
● Liver palpable 3 cm below the costal
● Subcostal and intercostal recession
margin → Hyperinflation -> liver
pushed down
 Differential Diagnosis
1. Cough + fever + breathlessness + tachypnoea
● LRTI → respiratory infection

Bronchiolitis Pneumonia Bronchial asthma

Clinical signs & ● Common in infants 1-6 ● High fever and chills ● Age > 5 years
symptoms months old (< 2 yr old) ● Severe malaise ● Wheeze
● RSV (common cause) ● Cough with purulent sputum ● Chest tightness
● Mild coryza ● Breathlessness (nasal flaring) ● Tachycardia
● Low grade fever ● Tachypnoea ● Tachypnoea
● Cough ● Breathlessness
Progresses to: ● Cough
● Tachypnoea
● Respiratory distress
● Wheeze

Physical ● Hyperinflated chest ● Decreased breath sounds ● Hyperinflated chest

examination ● Chest wall recession ● Crackles and bronchial breath ● Rhonchi
● Fine crepitations sounds ● Hyperresonance on
● Rhonchi ● Dullness on percussion percussion
●

Provisional diagnosis: Bronchiolitis

 Investigations
Full blood count

Hb 10.7 g/l - Normal

TWC 25 X10⁹/L - High

Neutrophils 75% - High

Lymphocytes 20% - Low

Platelets 486 X 10 ⁹/L- High?

Interpretation- Possible bacterial infection

Final diagnosis : Acute bronchiolitis

● Hx of Fever, cough , Breathlessness
● Physical exam: tachypnea, low SPO2, hyperinflated lungs, subcostal and intercostal recession,
rhonchi, crepitations
● Ix: High TWC + neutrophils with low lymphocytes
 Treatment & Management
General measures
1. Careful assessment of the respiratory status and
oxygenation is critical.
2. Arterial oxygenation by pulse oximetry (SpO₂) should be
performed at presentation and maintained above 93%.
- Administer supplemental humidified oxygen if necessary.
3. Monitor for signs of impending respiratory failure:
- Inability to maintain satisfactory SpO₂ on inspired oxygen >
40%, or a rising pCO₂.
4. Very young infants who are at risk of apnoea require
greater vigilance.
5. Blood gas analysis may have a role in the assessments of Note : Chest x-ray not routinely done.
Recommended for children with :
infants with severe respiratory distress or who are tiring ● Severe respiratory distress.
and may be entering respiratory failure. ● Unusual clinical features.
● An underlying cardiac or chronic
respiratory disorder.
● Admission to intensive care.
Nutrition & fluid therapy :
1. Infants admitted with bronchiolitis -> frequently have poor feeding -> at risk of aspiration and may be
dehydrated.
a. Small frequent feeds as tolerated can be allowed in children with moderate respiratory
distress.
b. Nasogastric feeding, although not universally practiced, may be useful in these children who refuse feeds and
to empty the dilated stomach.
c. Intravenous fluids for children with severe respiratory distress, cyanosis and apnoea.
d. Fluid therapy should be restricted to maintenance requirement of 100 ml/kg/day for infants, in the absence
of dehydration.

Pharmacotherapy :
● 3% saline solution via nebulizer has been shown to increase mucus clearance and significantly reduce hospital stay
among non-severe acute bronchiolitis
● Inhaled β₂-agonists.
● Antibiotics are recommended for all infants with
○ Recurrent apnoea and circulatory impairment.
○ Possibility of septicaemia.
○ Acute clinical deterioration.
○ High white cell count.
○ Progressive infiltrative changes on chest radiograph.
Case 02
A six week old infant presented with a 2 day history of breathlessness and poor
feeding. The baby was born at term with a birth weight of 3.2 kg. Since two weeks
after birth, the mother had noticed that the baby always required longer time to
finish her milk feeds. For the past 2 days, the baby had been extremely fretful and the
mother had difficulty in feeding her any milk at all.
On examination, the baby weighed 3.8 kg and appeared tachypneic, with a respiratory
rate of 60 per minute. However, the baby still appeared alert and active.

The pulse rate was 180 per minute, but not bounding. The apex beat was situated
over the 5th intercostal space, 1 cm lateral to the midclavicular line. There was a
gallop rhythm with a grade 3/6 pansystolic murmur heard throughout the
precordium.
There were fine crepitations over the bases of both lung fields. Liver was palpable 3
cm below the right subcostal margin.

A chest X-ray done showed a cardio-thoracic ratio of 0.65. An ECG was done which
showed left axis deviation.
 Key Points:
Investigations:
● Six weeks infant (1 month and half)
● At birth 3.2 kg → 3.8 kg at 6 weeks (Failure to thrive) ● CXR → Cardio-thoracic ratio of 0.65.
(Cardiomegaly)
● 2 day history of breathlessness and poor feeding.
● ECG → Left axis deviation. (LVH)- structural
● Required longer time to finish her milk feeds. defect/ heart disease
Extremely fretful for past 2 days
●
? Failure
Provisional Diagnosis: Congestive Heart
● Difficulty in feeding her any milk at all.

Physical Examination:

● Tachypnoeic: RR high → 60 per minute

● Tachycardic: PR high → 180 per min (not bounding)
● Gallop rhythm with a grade 3/6 pansystolic murmur heard
throughout the precordium.
● Fine crepitations over the bases of both lung fields.
● Hepatomegaly : Liver was palpable 3 cm below the right subcostal
margin.
 Differential Diagnoses
Tachycardic, Tachypneic, Hepatomegaly ,

● Heart Failure ( can mimic pulmonary disease and sepsis)

Clinical presentation
Symptoms of heart failure in infancy:
● Feeding difficulty: poor suck, prolonged time to feed, sweating during feed.
● Recurrent chest infections.
● Failure to thrive

Signs of heart failure in infancy:

● Resting tachypnoea, subcostal recession.
● Tachycardia, Poor peripheral pulses, poor peripheral perfusion.
● Hyperactive praecordium, praecordial bulge.
● Hepatomegaly.
● Wheezing

Investigations
● CXR → cardiothoracic ratio >0.50 is a well-known indicator of cardiomegaly
on chest radiographs.
● ECG → sinus tachycardia, LV hypertrophy, ST-T changes, and conduction blocks patterns.
axis deviation
● Echocardiogram → LV systolic dysfunction - ejection fraction (EF) <55%.
VSD
Coarctation of the Aorta
● Small defects: loud Pansystolic murmur grade ● Systolic murmur at interscapular region
2-5 at LLSB ● Normal S1 and S2
● Medium to large defects: increased right-to
-left ventriculular impulses
Pulmonary stenosis
○ Thrill at LLSB
○ Split or loud single S2
● Systolic murmur grade 2-5 at USLB
○ Holosystolic murmur at LLSB without radiating to infrascapular regions,
radiation grade 2-5 axillae and back
● normal / loud S1 , Variable S2
ASD ● Systolic ejection flick may be heard at
left sternal border
● Systolic ejection murmur (grade 2 or 3) @USLB
● Wide split S2
● Grade 1 or 2 diastolic flow rumble at LLSB Provisional Diagnosis: CHF 2° to
PDA Ventricular Septal Defect
● Continuous murmur (grade 1-5) in ULSB
(crescendo in systole and descrescendo into
diastole)
● Normal S1,S2 can be buried by the murmur

Aortic stenosis

● Continuous murmur (grade 1 to 5) in USLB

Investigations

These are directed at finding a cause and quantifying function.

● SpO2: compare pre- ductal (right arm) with post- ductal (either foot).
● CXR:
○ Cardiac enlargement?
○ Lungs— oligaemia/ oedema?
● ECG: rarely diagnostic, but may assist in establishing aetiology.
● Serum electrolytes: hyponatraemia due to water retention
● ABG: reduced PaO2 and metabolic acidosis.
● Hyperoxia test:
○ Administer 100% oxygen via headbox at 15 L/min for 15 mins.
○ ABG taken from right radial artery.
○ Cyanotic heart diseases: pO₂ < 100 mmHg; rise in pO₂ is < 20 mmHg.(note: in severe
lung diseases & PPHN, pO₂ can be < 100 mmHg).
● Echocardiography: congenital heart defects and function.
 Treatment and Management
The underlying cause of heart failure must be treated (usually include surgical repair)
General measures may be employed while awaiting more definitive treatment.

General measures
● Supplemental O2: give if acute hypoxia (caution in left- to- right shunt, pulmonary
vasodilation may increase shunting).
● Diet: sufficient caloric intake to enable growth. (feed via NG tube) refer to dietician
● Diuretics: reduce volume load.
● ACE inhibitors: reduce afterload.
● Respiratory support: reduces preload and volume load, and MV assists left ventricular
function.
● Inotropic support: if acute cardiac decompensation is detected.

Specific treatment
VSD
- Small defect: No treatment; high rate of spontaneous closure.
● SBE prophylaxis + Yearly follow up for aortic valve prolapse, regurgitation.
● Surgical closure indicated if prolapsed aortic valve.
- Large defects:: Early primary surgical closure.
● Pulmonary artery banding followed by VSD closure in multiple VSDs.
Case 03
A 10 year old boy presented with acute onset of breathlessness for one day. He had
been having fever for the past 5 days, associated with vomiting and abdominal pain.
At the same time, he also had frequent micturition. On the day of admission, he
had made a turn for the worse and was not able to walk about.

Key points from the history Further history to be elicited

● Breathlessness : Noisy breathing, hx of cough, runny

● 10 year old boy
● Breathlessness (1/7)
● Fever, vomiting, abdominal pain
(5/7)
● Frequent micturition
● Day of admission, he was unable to
walk -> weakness ?
nose
● Fever : Pattern of fever, temperature, chills, rigors
○ Associated symptoms : rash, retro-orbital pain,
bleeding gums, diarrhea, arthralgia, headache
● Abdominal pain : SOCRATES
● Vomiting : frequency, amount, content
● Frequent micturition : LUTS, changes in appearance of
urine, flank pain, polydipsia
● Travel history
● Past medical history of asthma or atopy
● Family history of asthma or atopy
● Sick contact, living in a dengue prone area
Examination revealed a drowsy boy with a respiratory rate of 40 per minute. His lips
and tongue were dry and he was tachycardic with a heart rate of 120 per minute.
Lungs were clear and the heart size was normal. Abdomen was soft with tenderness
over the peri-umbilical region.

Key points from examination and Further Physical Examination

interpretation
● Drowsy -> altered mental status
and lethargic
● RR : 40 breaths per minute ->
tachypneic
● HR : 120 bpm -> tachycardia
● Lips and tongue dry ->
dehydration
● Lungs : clear
● Heart size : normal
● Abdomen : soft and tenderness
over the peri-umbilical region
● General examination : pale, cyanosis, able to
speak in full sentences, use of accessory
muscles while breathing, wheezing, intercostal
and subcostal recession, fruity breath smell,
rashes, weight
● Hydration status : sunken eyes, capillary refill,
pulse volume, cool peripheries, skin turgor
● Respiratory examination : chest expansion,
percussion
● Abdominal examination : Liver span, renal angle
tenderness, bowel sounds
 Differential Diagnosis and relevant investigations
Differential
Diabetic Ketoacidosis
Dengue Fever with warning signs
Justification
● Symptoms of DKA
○ Hyperglycemic
symptoms (polyuria)
○ Lethargy
○ Abdominal pain
○ Vomiting
○ Shortness of breath
○ Drowsiness
● Can be precipitated by
infection (fever?)
● Signs of dehydration
● Fever
● Vomiting
● Abdominal pain
● Signs of dehydration
● Drowsiness and lethargy
Investigations
● ABG
● Renal profile and electrolytes
● Plasma glucose
● HBA1c
● Plasma osmolality
● Blood ketone
● Urinalysis
● FBC (to check for underlying
infection)
● Appropriate cultures (blood,
urine and throat)
● Serum lipase (pancreatitis
can precipitate DKA)
● ECG for cardiac monitoring
● FBC (TWC, hematocrit,
platelet count)
● LFT : raised transaminases
● Renal profile and electrolytes
● Dengue rapid combo test
(NS1, IgM and IgG)
● ABG
 Differential Diagnosis and relevant investigations

Differential Justification Investigations

Pyelonephritis ● Fever ● FBC

● Abdominal pain ● Urinalysis
● Vomiting ● Urine culture and sensitivity
● Frequent micturition
● Renal profile and
● Signs of dehydration
electrolytes
● KUB ultrasound

Acute gastroenteritis ● Fever ● FBC

● Vomiting ● Renal profile and
● Abdominal pain electrolytes
● Signs of dehydration ● ABG
● Drowsiness and lethargy

Atypical Pneumonia ● Fever ● FBC

● Breathlessness ● Renal profile
● Abdominal pain and ● CXR
vomiting ● LFT
● Affects school going children
 Provisional Diagnosis
Investigations to do
Diabetic Ketoacidosis (DKA) ● ABG
● Renal profile and electrolytes
1. Presence of an underlying fever can ● Plasma glucose
precipitate DKA ● HBA1c

2. Symptoms : Polyuria, abdominal pain, ● Plasma osmolality

vomiting, breathlessness ● Blood ketone

● Urinalysis
3. Signs : drowsiness and weakness, dry lips
● FBC (to check for underlying infection)
and tongue, tachycardia, periumbilical
● Appropriate cultures (blood, urine and throat)
tenderness
● Serum lipase (pancreatitis can precipitate DKA)
● ECG for cardiac monitoring
An arterial blood gas showed the following results: pH 7.05, pCo2 20mmhg, pO2 150 mmhg, Base
excess -12.

ABG results

pH : 7.05 (reduced)

pCO2 : 20mmHg (reduced)

pO2 : 150 mmHg (increased)

Base excess : -12 (reduced)

Interpretation : Metabolic acidosis

with partial respiratory compensation
Treatment Insulin therapy

• Insulin therapy in DKA should begin with a rate of 0.05 - 0.1 unit/kg/h
Goals of therapy
about 1 - 2 hours after starting fluid replacement therapy (to reduce the
- Correct dehydration
- Correct acidosis and reverse ketosis risk of cerebral oedema and exacerbation of hypokalemia)
- Restore blood glucose to near normal
-BG level typically decreases at a rate of 2-5 mmol/L/hr, depending
- Avoid complications of therapy
on the timing and amount of glucose administration, hence
- Identify and treat any precipitating event
duration & dose of insulin has to be carefully monitored to avoid
hypokalemia

- Once glucose <17 mmol/L → add 5% glucose to IV fluid

Fluid replacement
- Minimally dehydrated & can tolerate orally →
give oral fluids
- Moderately dehydrated → 0.9% NS over 48hr
- Severely volume depleted but not in shock →
10-20 ml/kg 0.9% NS over 1-2hr
- Shock → 0.9% NS 10-20 ml/kg ASAP, then
reassess after each bolus. Continue infusion over
48 hr ECG changes:
• Hypokalaemia: prolonged PR interval, T-wave flattening and
inversion,ST depression, prominent U waves and apparent long QT
interval.
• Hyperkalaemia: tall, peaked and symmetrical T waves, and
shortening of the QT interval.
Potassium replacement

- Potassium replacement is needed irrespective of the serum potassium level unless

renal failure is present
- IV potassium replacement must not exceed 0.5 mmol/kg/hour
- Hypokalemia: give <20 mmol/L K+ at initial volume expansion & 40 mmol/L during
rehydration
- Normokalemia: start K+ replacement after initial volume expansion & before
starting insulin infusion (20 mmol/L of potassium)
- Hyperkalemia: only start K+ replacement after urine output documentation

Acidosis

• Bicarbonate therapy may cause paradoxical CNS acidosis, hypokalaemia and increasing
osmolality.

Administration is not recommended except in life threatening hyperkalemia.

 Ethics
After 2 days on the ward, he has made a good recovery and is able to go home. On leaving hospital, the boy told the
mother he would like to be a “medical researcher” - just like the woman who spoke to a couple of children on his ward.
His mother is concerned about the ethics of clinical research involving participation of children - did their mothers’
know?

Decision-making involving the health care of older children and MREC guideline stated that assent for minors aged less
adolescents should include, to the greatest extent feasible, the than 7 years is not required as they are deemed
assent of the patient as well as the participation of the parents and incapable of comprehending the research process.
the physician. If physicians recognize the importance of assent, they Assent for minors aged 7 to less than 18 years is
empower children to the extent of their capacity. required and investigators must first obtained the
permission of the parents or guardians for the
Assent should include at least the following elements:
participation of the minor in the research and to solicit
1. Helping the patient achieve a developmentally appropriate assent from the minor. However, emancipated minors
awareness of the nature of his or her condition. can consent to participation in research without the
2. Telling the patient what he or she can expect with tests and permission or consent of the parent or guardian.
treatment(s).
3. Making a clinical assessment of the patients understanding
of the situation and the factors influencing how he or she is
responding (including whether there is inappropriate pressure
to accept testing or therapy).
4. Soliciting an expression of the patient's willingness to accept
the proposed care.
Identify the aspects of anatomy and
pathophysiology of the respiratory
system relevant to breathlessness.
Ventilation Drive
Primary motor cortex → respiratory
muscle

Brain stem (pontine respiratory center,

medullary respiratory centers)

- Intercostal muscles & Diaphragm

Peripheral Chemoreceptors → carotid

bodies and the Aortic arch

PaO2 and PaCO2 → brain stem

Central chemoreceptors (H+ and Co2) →

direct air hunger experience
 igher centers of the brain (voluntary control)
- Pain
- Emotion
- Temperature
Muscle and Joints (receptors)
- Stimulate the receptors

ungs (Mechanoreceptors)
- airways, trachea, lung, and pulmonary vessels provide sensory information
to the respiratory center in the brain with regards to lung volume, airway
stretch, and vascular congestion.Two primary types of thoracic sensors: slow
adapting stretch spindles (vloume) and rapid adapting irritant receptors
(chemicals).
- Transmits → Cranial nerve X (the vagus nerve) to increase the breathing
rate, the volume of breathing, or to stimulate cough.
- A notable example is the Pulmonary stretch reflex, also called the
Herring-Breuer reflex, which prevents the lungs from over-inflating by
sending inhibitory impulses to the inspiration center.
Describe the common paediatric
conditions causing breathlessness
 I. Pneumonia
- Infection/ Inflammation of interstitial tissue of the lungs.

Causes:
- Can be classified by age-specific versus pathogen-specific organisms.

Neonates →risk for bacterial pathogens present in the birth canal, and this includes organisms
- Group B streptococci, Klebsiella, Escherichia coli, and Listeria monocytogenes.

Late-onset neonatal pneumonia.

- Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus

In children 2 to 5 years old

- Respiratory viruses → most common.
- S. pneumoniae and H. influenzae type B

5 to 13 years old
- S. pneumoniae is still the most commonly identified organism.
- Mycoplasma pneumonia

- Viruses: Influenza (flu)

- Fungal – rare
- Aspiration of food.
Clinical features:

· High grade fever/chills/rigor

· Cough: productive (Green sputum, pus, and bloody sputum)
· Dyspnea
· Rapid breathing
· Tachycardia
· Severe malaise
· Vomiting
· Diarrhea

*When children develop pneumonia, their lungs become stiff. One of the body’s responses to stiff lungs and hypoxia (too little
oxygen) is fast breathing. When the pneumonia becomes more severe, the lungs become even stiffer. Chest indrawing may
develop. Chest indrawing is a sign of severe pneumonia.
- Symptoms of atypical pneumonia (Mycoplasma pneumoniae, Legionella pneumophila and Chlamydophila pneumoniae)
· Low grade fever (often)
· Nonproductive cough
· Dyspnea
· Normal auscultation/labs
· Interstitial bilateral infiltrates on CXr.
· Erythema multiforme: Multiple skin lesions with blue livid center, pale intermediate zone, and dark red peripheral
rim.
· Common extrapulmonary features include fatigue, headaches, sore throat, myalgias, and malaise.

*Legionella features: High fever >39°C, contaminated water, diarrhea, confusion (hyponatremia) and CXr: patchy, unilateral,
lobar infiltrates (consolidation).

*Typical: Rapid onset

*Atypical: Slow/Insidious onset.
 II. Bronchiolitis
· Bronchiolitis is inflammation of the bronchioles.
· Spread by airborne droplets or direct contact with respiratory secretions.
· Bronchiolitis is a lower respiratory tract infection occurring in children less than 2 years of age (because children already have
narrower bronchioles).
· It most commonly occurs between 1 and 6 months
· Usually precedes with URTI symptoms followed by symptoms of LRTI.
· Most commonly causes by Respiratory Syncytial Virus
· It can be caused by other viruses :
1. Rhinovirus (Second most common)
2. Human Metapneumovirus
3. Influenza Virus
4. Adenovirus
5. Parainfluenza Virus (Usually present as croup)
· It is a self-limiting disease and most children who do not require hospitalization recover by 28 days.

Risk factors:
· Premature/ lower weight for gestation.
· Immunodeficiency
· Congenital heart disease
· Neurological conditions: neuromuscular
disorders – cannot easily clear airways.
· Chronic respiratory illness.
· Exposure to tobacco smoke (in ureto or
after delivery)
Clinical Manifestations:
1. URTI Symptoms – Mild Coryza symptoms (because the virus replicates at
nasopharynx), Low Grade Fever (<38.3), nasal congestion and cough.
2. LRTI Symptoms: can begin 1-3 days later following URTI.
1. Dry Cough
2. Rapid Breathing/Tachypnea
3. Wheeze
4. Chest Hyperinflation (Liver can be pushed down)
5. Signs of Respiratory Distress:
1. Nasal Flaring
2. Chest Wall Recession (Supraclavicular, Subcostal, and Intercostal)
3. Grunting
4. Cyanosis
3. Dehydration – Due to Poor Oral Intake
4. Spo2 – Hypoxemia (<95%)
5. Auscultatory Findings:
1. Rhonchi
2. Prolonged Expiratory Phase
3. Fine Crepitation
III. Asthma
- Chronic airway inflammation leading to increase airway responsiveness that leads to recurrent episodes of wheezing,
breathlessness, chest tightness and coughing particularly at night or early morning.
- Often associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with
treatment.

Diagnosis of Asthma in Children >5: Similar to that of adults

Diagnosis of Asthma in Children < 5:
· It is difficult to diagnose asthma because many children present with wheeze but only less than half of them have asthma
Features suggestive of asthma in children younger than 5 years old

• Cough: recurrent/persistent non-productive cough that worsens at night or accompanied by wheeze or breathlessness. Cough in the
absence of respiratory infections, usually with laughing, crying or exposure to tobacco smoke.

• Wheezing: Recurrent wheezing during sleep or with triggers such as activity, laughing, crying or exposure to tobacco smoke or air
pollution

• Difficult or heavy breathing or shortness of breath occurring with crying, laughing or playing.

• Reduced activity: not running, playing, or laughing at the same intensity as other children.

• Past/family history of allergic disease or asthma in first degree relative.

• Therapeutic trial with moderate dose inhaled steroids: Clinical improvement in 2-4 wks of controller treatment and worsening when
treatment is stopped.
IV. Croup
• A result of viral inflammation of the larynx, trachea and bronchi, hence the term laryngotracheobronchitis.
● 3 months to 3 years old child

Aetiology and epidemiology

• A clinical syndrome characterised by barking cough, inspiratory stridor, hoarse voice and respiratory distress of varying severity.

• The most common pathogen is parainfluenza virus (74%), (types 1, 2 and 3).

Others:
- Respiratory Syncytial Virus, Influenza virus types A and B, Adenovirus, Enterovirus, Measles, Mumps and Rhinoviruses and rarely
Mycoplasma pneumoniae and Corynebacterium Diptheriae.

Clinical Features
• Low grade fever, cough and coryza for 12-72 hours, followed by:
• Increasingly bark-like cough and hoarseness.
• Stridor that may occur when excited, at rest or both.
• Respiratory distress of varying degree.
Elicit history and physical signs
in children with breathlessness
History
1. History of presenting illness
a. Onset + Duration (eg, 12-72hrs of fever and coryza followed by cough, suggestive
of croup)
b. Associated symptoms: Cough (nature of cough - barking cough indicating
croup) , fever, tachypnea (LRTI), noisy breathing, trouble sleeping, poor feeding
c. Any previous admissions due to similar symptoms
2. Sick contact + Travel history
3. Birth complications in neonates
a. Preterm babies
4. Social history
a. Living conditions, overcrowding, allergies, pets
5. Family history of asthma / eczema
Physical signs
1. General inspection
a. Pink, BMI (weight + height)
b. Level of consciousness
c. Signs of respiratory distress
2. Inspection of the chest
a. Throat: Any foreign bodies (if indicated in hx) (obstruction → breathlessness)
b. Chest deformities
c. Check for any chest indrawing / intercostal recession or hyperinflation (indicate
bronchiolitis)
3. Auscultation
a. Listen for any wheeze or stridor (croup)
b. Auscultate for rales / rhonchi / crepitations and air entry
Evaluate the clinical findings and
formulate the differential diagnoses
Condition Clinical findings

Asthma Hyperinflated chest, rhonchi, hyperresonance on percussion

Broncholitis Hyperinflated chest, fine crepitations, rhonchi, chest wall recession

Pneumonia Reduced breath sounds, dull on percussion, crepitations, bronchial breath sounds

CCF Bilateral basilar rales, dull on percussion, coolness of peripheries, jugular venous
distention, kussmaul sign

Croup Reduced air entry is decreased, altered mental state

Epiglottitis Odynophagia, pain over larynx on palpation, respiratory distress, hypoxia, toxic
appearance, dysphagia, stridor, drooling, muffled voice, absence of hoarseness, cough

Pneumothorax Reduced or absent breath sounds, hyperresonant percussion, decreased fremitus on

the ipsilateral side
Justify choice of investigations and
be able to interpret the results
FBC

Bacterial bronchopneumonia

● Elevated WBC (> 20 000 cu.mm) mainly neutrophils - tachypnea , high fever

Bronchial Asthma

● Elevated eosinophil - afebrile with tachypnea

Chlamydia trachomatis pneumonia

● Elevated eosinophil count

Viral bronchopneumonia

● Normal / mildly elevated WBC - predominantly lymphocytes

Pulse Oximetry (adequate for monitoring purposes)

Oxygen saturation level - as an index of severity of respiratory distress - identifies the

need for hospitalization
Pneumonia
Chest X-ray
● Airspace opacification (consolidation)
○ Initially patchy → becomes confluent as infection
develops
● Air bronchogram

Bronchiolitis
Chest Radiography
● Increased lung radiolucency , normal lung fields or areas
of increased density
● Hyperinflation with horizontal ribs , flattened diaphragm
● Patchy atelectasis often in right upper lobe
● Peribronchial thickening

● Nasopharyngeal aspirate - detection of RSV

● Immunologic tests - IFA (2-6 mins) , ELISA (30 mins)
● PCR - rapid viral diagnosis - identify RSV , parainfluenza ,
influenza , adenovirus
Plan management strategies
appropriate for children presenting
with breathlessness.
General:

- Supplemental O2 (maintain pulse oximetry above 93%)

- Place patient on cardiac monitor
- Maintain airway if needed (imminent respiratory failure)
- Watch and administer feeding/hydration where necessary

Asthma:
Bronchiolitis:

- Supportive treatment
- Give humidified 02 (conc. determined by pulse oximetry reading)
- Assisted ventilation in the form of nasal or facemask CPAP or full ventila tion is
required in a small percentage of infants
- RSV (highly contagious) so take appropriate measurements to prevent spread in
the hospital setting

Croup:

- When the upper airway obstruction is mild, the stridor and chest recession
disappear when the child is at rest. The child can usually be managed at
home.
Pneumonia :

- Treat causative agent

- Supportive treatment:
- Fluids (in severe pneumonia, ADH is releases
so no dehydration so don’t overhydrate)
- Give 02 (maintain above 95%)
- Symptomatic treatment (cough and fever)