This post in the St Emlyn’s Induction Series covers the approach to the child who is short of breath.
Check out the induction podcast below, followed by some learning points and further reading
Step One – Don’t Panic!
You have plenty of skills from your adult practice you can adapt to approaching the child who is short of breath.
Step Two – Do I Need Help Right Now?
Assess the level of consciousness and the need for immediate resuscitation. Get senior help if the child is unconscious or semi-conscious, gasping or you have other immediate concerns.
Step Three – Systematic Assessment
Effort: accessory muscle use, subcostal/intercostal/sternal recession, tracheal tug, nasal flaring, headbobbing – how much work is the child putting into breathing? Count the respiratory rate.
Efficacy: listen to the chest – is there good bilateral air entry? Is the work of breathing effective enough to get air into the chest? (You might hear extra sounds which could give some clues as to underlying pathology, such as wheeze)
Effects: how well are they achieving the aims of ventilation (gas exchange) – what is the SpO2? Look for effects on other systems such as level of consciousness and heart rate
Step Four – Consider Oxygen
Short term, oxygen is generally not going to cause big problems for the vast majority of paediatric patients – you can always take it off
Step Five – More Information
History, as ever, is important: ask about the chronology of the illness (remember to consider an inhaled foreign body if there was a very sudden onset), ask about fever and other markers of illness (vomiting, coryzal symptoms, family contacts, smokers at home…)
Step Six – What’s Going On?
Most of these kids can be treated clinically and do not require blood tests or chest x-rays.
Bronchiolitis and viral wheeze
This is a viral-mediated illness which occurs on a spectrum.
These kids are usually working quite hard and breathing fast with wheeze everywhere. They can have some crackles too and the presentation is often associated fever and coryzal symptoms. No need to x-ray here!
Remember, increased work of breathing means increased insensible losses (so increased risk of dehydration) and increased calorie requirement BUT these patients usually have a reduced feed and fluid intake as a full stomach makes breathing harder – all kids tend to feed poorly when unwell but be sure to ask about reduced urine output/number and frequency of wet nappies, which may point to dehydration. Young babies are obligate nasal breathers, so having a nose full of snot makes life extra tough and makes feeding extra difficult for them.
There is a limited amount of help you can give for bronchiolitis: supportive therapies may be helpful dependent on clinical state – some children need oxygen, babies may benefit from nasal suction or temporary feeding by NG tube with only a tiny proportion requiring fluids intravenously.
A trial of bronchodilators probably won’t help but is unlikely to do harm (although the latest Cochrane review advises that bronchodilators are “not helpful” in viral induced wheeze – trying them is more sensible in older children with a history consistent with asthma [multiple previous wheezy illnesses]). As a rule I don’t give oral steroids to wheezy preschool children unless they are known to have asthma.
If you’re asking “Bronchiolitis; seriously, what do I do?” try this post at PED EM Morsels which answers exactly that question.
Patients who definitely need admission – those who are dehydrated, who have an oxygen requirement, ex-prems and very young babies (especially if there is a history of apnoeas), and those with co-existing pathology (respiratory, cardiac or neurological/neuromuscular).
Croup is sometimes known as viral tracheolaryngobronchitis – the child presents with a typical dog bark/seal cough somewhere on spectrum between the well child who runs around the waiting room making their parents look like liars to the kid in severe respiratory distress. Croup usually presents in the evening or overnight. The child often has a hoarse voice and stridor when upset – so don’t upset them! If they are really struggling, get senior help; stay calm and remember even nebs can make the child upset and therefore worse.
Use croup scores to determine severity and guide treatment; for mild-moderate croup a single dose of dexamethasone is an appropriate therapy (follow your local protocol but there is no evidence for higher dose vs lower dose).
Remember croup may be worse again the next night so be cautious if the child is presenting in daytime hours and if discharging ensure the parents can get back to the ED if things get worse suddenly (check they live near the hospital and have access to a car); if not, consider admitting for observation.
Less common than the viral causes. These children tend to have a history of fever, they are often working less hard than those with viral respiratory tract infections and often have slightly low SpO2 – there is usually no wheeze on auscultation. In these patients it is reasonable to consider a chest x-ray – I tend not to order CXRs very often, so if in doubt – ask a senior doctor!
Caveats and Cautions
Particular groups deserve special thought:
- Babies presenting with signs of increased work of breathing early in the clinical course of bronchiolitis (usually worst on day 5/6 so you can predict if they are struggling on day 1 things will get worse before they get better)
- Children with co-existing respiratory, cardiac or neuromuscular pathology
- Remember that cardiac disease can present with respiratory signs
- If the child has increased respiratory rate but no other chest signs, check a blood sugar!
- Remember to consider an inhaled foreign body (usually in a toddler with sudden onset of breathing difficulty without preceding history of illness, fever etc)