7 Lower respiratory tract conditions lower respiratory tract usually present with Objectives one or more signs of breathing difficulty. When you have completed this unit you Lower respiratory tract disorders usually present should be able to: with one or more signs of breathing difficulty. • Give the signs of breathing difficulty and respiratory distress. • List the important lower respiratory 7-2 What are the signs of breathing tract conditions. difficulty? • Diagnose these conditions. The major signs are : • Understand the causes and possible prevention of these conditions. • stridor • Provide primary management of these • indrawing of the lower chest wall conditions. (recession) • Describe a syndromic approach to a • wheeze child with a cough. • fast breathing (tachypnoea) • shortness of breath with grunting, nasal flaring, head nodding and refusal to feed.INTRODUCTION These signs of breathing difficulty suggest that the child’s breathing difficulty is becoming progressively more severe and could lead to7-1 What is the lower respiratory tract? respiratory distress.The lower respiratory tract consists of: 7-3 What are the signs of respiratory• Larynx and trachea distress?• Bronchi• Bronchioles Respiratory distress is the clinical condition• Alveoli (lungs) where the respiratory difficulty has become so severe that the child is likely to die unless givenTherefore, the respiratory tract from the larynx respiratory support (e.g. oxygen or ventilation).down is called the lower respiratory tract whilethe respiratory tract above the larynx is called • Central cyanosis (or a low oxygenthe upper respiratory tract. Disorders of the saturation) • Drowsiness, lethargy or unconsciousness
LOWER RESPIRATOR Y TRACT INFECTIONS 123• Restlessness Always look for central cyanosis if a child has• Apnoea peripheral cyanosis.7-4 What is stridor? Pulse oximetry is a very useful method of assessing the oxygen saturation (the amountStridor is a crowing sound made in the throat, of oxygen being carried in the red cells ofmost commonly during inspiration. Any the blood). The normal oxygen saturation isnarrowing of the airway in the region of the above 95% (above 92 % in newborn infants).larynx may result in stridor. Narrowing of the An oxygen saturation below 90% is abnormalairway above (e.g. epiglottis) or below (e.g. and an indicator for oxygen therapy. A pulsetrachea) the larynx may also cause stridor. oximeter (or oxygen saturation monitor) is used for measuring the oxygen saturation. The7-5 What is chest indrawing? probe is clipped onto the child’s finger, hand orWith chest indrawing, the lower ribs on both foot and the device displays the heart rate andsides of the chest are pulled in when the child oxygen saturation.breathes in. This is very abnormal as the As central cyanosis is an important sign oflower chest normally moves out when a child respiratory failure, measuring the oxygenbreathes in. When resting, children should saturation is very useful.never have chest indrawing.7-6 What is a wheeze? VIRAL CROUPThis is a noise made during expiration due tonarrowing of the lower airways. 7-9 What is viral croup?7-7 How can you tell when a child is This is an acute viral infection of thebreathing too fast? larynx, trachea and bronchi (acute viral laryngotracheobronchitis). With croup theRapid respiration (tachypnoea) is one of the area around the vocal cords is swollen as ismost important signs of pneumonia. A child the area just below the cords. Viral croupat rest is breathing too fast when the following typically presents in children around 2 yearsrates are exceeded: of age (between 6 months and 6 years),• 60 breaths or more per minute in an infant especially in autumn. Viral croup is usually of 2 months or less mild and the signs of croup usually clear• 50 breaths or more per minute in children in a few days but may recur. Some children 2 months to 1 year develop viral croup whenever they have a• 40 breaths or more per minute in children common cold or pharyngitis. older than 1 year The most common cause of viral croup is anThe normal respiratory rate decreases with age. infection with parainfluenza virus.By the age of 12 years healthy children should NOTE Other viruses, such as the respiratory syncytialnot breathe faster than 20 breaths per minute. virus, metapneumovirus, measles, adenovirus and Herpes simplex, can also cause croup.7-8 What is central cyanosis? 7-10 What are the presenting signs of viralA blue colour of the tongue. The lips may croup?also appear blue instead of the normal pink.Central cyanosis is a very important and The characteristic signs of viral croup are:dangerous sign which indicates that the • The infection often starts with a commoncells are not receiving enough oxygen. Cold cold or pharyngitis.hands and feet may show peripheral cyanosis.
124 LOWER RESPIRATOR Y TRACT INFECTIONS• A mild fever obstruction. Stridor becomes softer with severe• A typical ‘barking’ cough obstruction.• Inspiratory stridor is often, but not always, present. It is usually worse at night and 7-12 What is the correct management of then much better in the morning. viral croup?• Hoarseness of the voice is a less common 1. The degree of airways obstruction must be sign in viral croup. continually observed.Viral croup typically presents at night with 2. Keep the child comfortable and calm asinspiratory stridor and a barking cough. crying worsens the airways obstruction. NOTE Stridor can also be cause by an inhaled 3. Keeping the room warm helps. foreign body, retropharyngeal abscess, epiglottitis Humidifying the air may also help. Do not or, rarely, by diphtheria. accidently burn the child with steam from a kettle. Cold mist does not help.7-11 How is the degree of stridor assessed? 4. If the child has fever above 38 °C give paracetamol.The degree of respiratory obstruction is diffi- 5. Continue to give frequent, small amountscult to assess as it may vary from moment to of oral fluid unless the airway obstructionmoment. Stridor usually becomes worse if is severe. Continue breastfeeding if thethe child cries or becomes agitated. Therefore child is not distressed.stridor in a quiet child should be regarded as 6. The child can be closely observed at homesevere. if the airways obstruction is mild and1. Inspiratory stridor only, without lower chest the home circumstances are adequate. wall indrawing (recession or retraction) Communication and transport to the suggests mild airway obstruction. These nearest health facility are needed if the children usually only have stridor when child is to be managed at home. they are upset or crying. There is no stridor 7. Oral dexamethasone 0.5 mg/kg as a single when they are sleeping or at rest. dose (not if measles or herpes is the cause2. The addition of lower chest wall indrawing of the stridor). If no improvement, repeat or stridor during both inspiration and after 24 hours. Steroids are the most expiration are very important clinical important treatment in severe viral croup. signs as they indicate worsening airways 8. There is no indication for antibiotics or obstruction. Therefore, expiratory stridor bronchodilators in viral croup. is a sign of severe airway obstruction. 9. Move to hospital if the airways obstruction Stridor at rest in a quiet child also suggests becomes worse, especially if there is both severe stridor. inspiratory and expiratory stridor. It is best3. The obvious use of chest and abdominal to move the child to hospital if there is muscles during expiration (active stridor when the child is at rest. If possible, expiration, restlessness or fast breathing give oxygen during transport. (tachypnea) are signs of dangerous airway 10. Nebulised adrenaline (1:1000 solution) obstruction obstruction. in hospital is the treatment of choice for worsening or severe airways obstruction. It will often provide temporary relief. If the Expiratory stridor is a sign of worsening airway child responds to the nebulised adrenaline obstruction. admit the child to hospital for 24 hours to observe for rebound airway obstruction NOTE Disappearance or weakening of the as the effect of adrenaline usually last only peripheral pulse on light palpation during about 2 hours. inspiration (pulsus paradoxis), marked recession, 11. Intubation or tracheotomy under general apathy and cyanosis are signs of severe airway anaesthetic is only needed if respiratory
LOWER RESPIRATOR Y TRACT INFECTIONS 125 failure develops (cyanosis, restlessness, green secretions indicates a secondary severe chest wall indrawing or inadequate bacterial infection. oxygen saturation in room air). Intubation • There may be chest pain with excessive must be seriously considered if the child coughing. has expiratory stridor and uses the chest • Mild fever and abdominal muscles during expiration. • Wheezing may occasionally occur in an12. Oxygen should only be given in cases of older child. This should always suggest severe airway obstruction as the method asthma. of delivering (e.g. nasal prongs) could Acute bronchitis in children is very different make the child frightened and agitated and from chronic bronchitis in adults. worsen the airway obstruction. NOTE Loose crackles are heard, especially on NOTE Mix 1 ml of 1:1000 adrenaline with 1 ml auscultation (with a stethoscope). These noises saline. Nebulise the entire volume with oxygen. clear with coughing. Repeat every 15 minutes until the expiratory obstruction has resolved. Observe the child very carefully for signs of deterioration. Laryngoscopy 7-15 What is the management of acute to look for other causes of stridor is important in bronchitis? children who require intubation. 1. Make sure the child drinks enough fluid. Often there is a loss of appetite. 2. Inhaling warm, moist air may relieve theBRONCHITIS cough. Warm drinks may also help. 3. Cough mixtures are of little help, but salbutamol syrup may relieve the cough.7-13 What is bronchitis? 4. Give paracetamol for the fever.Bronchitis is an inflammation of the lining on 5. Oral antibiotics should only be given if thethe large airways of the lung (the large bronchi). mucus becomes yellow-green.The inflammation is usually due to a viral It is important to observe for signs ofinfection, but there may also be a secondary pneumonia, especially in small children. Abacterial infection. Bronchitis usually follows wheeze suggests asthma or bronchiolitis. Boutsan upper respiratory infection (common cold, of severe coughing with an inspiratory whoop,pharyngitis or influenza). With inflammation apnoea or vomiting suggest whooping cough.of the bronchi, the glands in the walls of thelarge airways produce excessive secretions(mucus or phlegm) with a ‘productive cough’.These secretions may partially block the BRONCHIOLITISairways. Children with bronchitis do nothave breathing difficulties (the only lower 7-16 What is bronchiolitis?respiratory tract infection that does not causebreathing difficulties in children). Bronchitis in Bronchiolitis is an acute viral infection of thechildren is usually acute and recovers in 1 to 2 small airways of the lungs (the bronchioles).weeks. Bronchitis is more common in a smoky It typically presents with airways obstruction.environment (cigarette smoke or an open fire in Bronchiolitis is usually caused by thethe home) and is usually seen in older children. respiratory syncytial virus (RSV) and occurs commonly in children under one year of7-14 What are the symptoms and signs of age. When severe it can be life threatening.acute bronchitis? Bronchiolitis usually occurs in winter and follows a few days after the onset of a• A persistent cough. At first the cough is common cold. The small airways become dry, but it may later become loose and produce clear, sticky secretions. Yellow-
126 LOWER RESPIRATOR Y TRACT INFECTIONSinflamed and narrowed. Secondary bacterial inability to feed, tachycardia or low oxygeninfection may occur. saturation. 3. Oxygen therapy with nasal prongs (flow 1 to 2 litres/minute) is indicated if there are Bronchiolitis causes serious narrowing of the signs of respiratory distress or the oxygen small airways in young infants. saturation is low (below 90%). 4. Bronchodilators usually do not help in7-17 What are the signs of bronchiolitis? bronchiolitis. 5. Steroids are of little help.• Recession (indrawing of the lower chest) 6. Ensure an adequate fluid intake. If the and a hyperinflated chest (over expanded child will not drink give nasogastric fluid. due to air trapping). Intravenous fluid should only be given with• Wheezing is usually present and is not great caution as overhydration is dangerous. relieved by an inhaled bronchodilator. 7. Antibiotics are usually not given unless Occasionally wheeze may be absent. there are also signs of pneumonia or the• Rapid breathing and breathlessness child is less than 3 months. If pneumonia is (difficulty breathing) suspected give amoxycillin.• Prolonged expiration 8. If the child has a fever give paracetamol.• A dry coughing 9. Physiotherapy is contraindicated and can• Reluctance or difficulty in feeding be dangerous.• Mild fever 10. Careful observation is important for signsCyanosis, decreased level of consciousness, of respiratory failure or apnoea.inability to feed or persistent vomiting and 11. Intubation and ventilation for respiratorya marked tachycardia (fast heart rate) are all failuredangerous signs and indicates respiratoryfailure. Apnoea is common in infants less than Oxygen is the treatment for severe bronchiolitis.3 months. Bronchiolitis takes about a week torecover. NOTE Bronchodilators by nebulisation, e.g.Repeated bronchiolitis, especially in an older salbutamol, are sometimes used in severechild, suggest asthma. bronchiolitis with variable results. Children with a history of 2 or more attacks of bronchiolitis and NOTE There is poor air entry over both lungs respond to inhaled bronchodilators probably on auscultation. Fine crackles may be present. have early asthma. Do not use aminophylline as it A chest X-ray shows air trapping due to small is dangerous. airway narrowing without signs of consolidation (pneumonia). Pneumothorax is an uncommon complication of bronchiolitis. 7-19 When should children with bronchiolitis be referred to hospital?7-18 What is the correct management of Bronchiolitis is a serious condition whichbronchiolitis? can suddenly deteriorate. Therefore, only the1. Children with mild bronchiolitis may mildest cases should be managed at home or be managed at home provided they are at a primary care clinic. The following children carefully observed, they take adequate should be referred to hospital: fluids, the home circumstances are good • Children with signs of respiratory failure and that communication and transport are (e.g. cyanosis or depressed level of available if needed. consciousness)2. All other children with bronchiolitis • If there is no improvement must be admitted to hospital, especially if • Signs of pneumonia they are under 3 months, or if there is an
LOWER RESPIRATOR Y TRACT INFECTIONS 127• Oxygen saturation below 90% with examination and chest X-ray. Often pneumonia oximetry (saturation monitor) is due to bacteria complicating a viral infection.PNEUMONIA 7-22 What are the symptoms and signs of pneumonia? • The child is generally unwell.7-20 What is pneumonia? • Fever, often high feverPneumonia is an inflammation of the small • Coughair sacs of the lungs (alveoli), usually due to • Breathlessness (difficulty breathing). Thea viral or bacterial infection. Pneumonia is breathing is usually fast and shallow.often a complication of an upper respiratory • Chest wall indrawing (recession ortract infection. It may involve only part of retraction)one lung or be more extensive and even • Refusal to eat or drink due to shortness ofinvolve both lungs. The common causes breathof pneumonia depends on the child’s age. • The infant may become cyanosed (with aBreastfeeding and avoiding cigarette smoke low oxygen saturation).helps to prevent pneumonia. • Chest pain may be present.7-21 What are the causes of pneumonia? Fast breathing is the most important sign of• Pneumonia in newborn infants is usually pneumonia. due to a bacterial infection such as Group B Streptococcus and Gram negative bacilli There are some causes of fast breathing, other (e.g. Klebsiella). than lung conditions, such as a high fever or• Viruses especially the respiratory syncytial a metabolic acidosis (seen in diarrhoea with virus, cause most pneumonias in infancy. severe dehydration). It is best to look for fast• In young children Mycoplasma is a breathing when the child is calm and the fever common cause of pneumonia. has been lowered.• Pneumonia in older children is usually due to bacteria such as Pneumococcus, A normal breathing rate usually excludes Haemophilus and Staphylococcus. pneumonia. Pneumococcus is the most common cause of community-acquired pneumonia in NOTE Nothing abnormal may be heard on children. auscultation with a stethoscope as the classical• Tuberculosis is an important cause of chest signs of pneumonia (dullness, bronchial pneumonia in poor communities. breathing, crepitations) are often not present in• Pneumocystis is an important cause children with pneumonia. of pneumonia in HIV infected infants between 2 and 6 months of age. This is 7-23 Should all children with pneumonia a very unusual cause of pneumonia in have chest X-rays? children who do not have AIDS.• Gram negative organisms such as Klebsiella A routine chest X-ray need not be taken in and E. coli are also an important cause of all children suspected of having pneumonia. severe pneumonia in children with HIV However, if facilities are available, it should be infection. done where: NOTE Chlamydia can cause pneumonia in infants. • Complications are expected (e.g. pneumothorax).It is difficult to decide whether the pneumonia • The diagnosis of tuberculosis is suspected.is due to a virus, bacteria or TB on both clinical
128 LOWER RESPIRATOR Y TRACT INFECTIONS• The pneumonia is severe or does not 3. Give oxygen by nasal prongs (or catheter) respond to treatment after 2 days. or face mask for severe pneumonia. Monitor with the use of a saturation monitor and give oxygen if saturations are The diagnosis of pneumonia in a child is usually below 90%. made on general examination rather than by 4. Give an appropriate antibiotic. While listening to the chest. oral antibiotics can be used with mild pneumonia, intramuscular or intravenous NOTE Bronchopneumonia is common in small antibiotics must be used with more severe children while lobar pneumonia is often seen in cases. All children with pneumonia must older children. Always look for a pleural effusion receive an antibiotic as it is difficult to tell or other signs of tuberculosis. whether the pneumonia is due to a virus or bacteria.7-24 Is pneumonia a serious infection? 5. If a wheeze is present give an inhaledYes. Pneumonia is a common reason for bronchodilator.hospital admission and a major cause of 6. Give paracetamol to lower the fever.death in children, especially in developing 7. Remove thick secretion from the nose bycountries, such as South Africa, and in gentle suctioning.children with AIDS. Pneumonia acquired in 8. Encourage breastfeeding. If the child doeshospital is particularly dangerous. not take fluids by mouth, give nasogastric feeds or start an intravenous infusion. 9. Physiotherapy may be helpful. Pneumonia is a major cause of death in children. 10. All children with signs of severe pneumonia must be urgently referred to7-25 How can you recognise severe hospital. Give the first dose of antibioticpneumonia? before referring the child. 11. In very severe cases of pneumonia,Any of the following clinical signs suggest that intubation and ventilation may be needed.the child has severe pneumonia:• Chest wall indrawing (recession) Oxygen and antibiotics are the main form of• Cyanosis (needs oxygen to keep the oxygen treatment for pneumonia. saturation above 90%)• Depressed level of consciousness• Refusal to eat or drink due to shortness of 7-27 What antibiotics are used in breath pneumonia?These are danger signs which mean that the 1. Amoxycillin 30 mg/kg orally 3 timeschild needs urgent treatment and then referral a day for 5 days in children with mildto hospital. community-acquired pneumonia that is treated at home.7-26 What is the correct management of 2. Intramuscular ampicillin 20 mg/kg beforepneumonia? referring a child with severe pneumonia. In hospital, ampicillin and gentamicin,1. If possible, all children with pneumonia or cefotaxime (or ceftriaxone) are usually should be admitted to hospital. Only mild used. The choice of antibiotic may change cases should be managed at home or in a when the sputum and blood cultures and primary care clinic. sensitivities are received.2. Observe the child carefully. Monitoring the 3. Cloxacillin 50 mg/kg/dose orally 6 hourly oxygen saturation is very important. Look is given if Staphylococcus is suspected. for signs of severe pneumonia.
LOWER RESPIRATOR Y TRACT INFECTIONS 1294. Hospital-acquired pneumonia may be due • Difficulty breathing (breathlessness or to organisms resistant to many antibiotics. shortness of breath or a ‘tight chest’)5. Search for tuberculosis if there is no Most, but not all, children with asthma response to antibiotics. have wheezing. Some children present with NOTE Erythromycin or co-trimoxazole are the coughing only, especially at night. Both the antibiotics of choice if Mycoplasma pneumonia wheezing and coughing are worse at night and is suspected in older children (5 years or older). often wake the child. Asthma is usually seen in Additional co-trimoxazole 6 hourly in high children of one year or older. doses is used to treat suspected Pneumocystis pneumonia in HIV infected children. Always think of asthma when a child presents with wheezing.ASTHMA 7-31 What are the clinical signs of asthma?7-28 What is asthma? The clinical signs of asthma on examination are:Asthma is a chronic inflammatory condition • A generalised, expiratory wheeze,with repeated episodes (or attacks) of especially on forced expiration.reversible narrowing of the small airways • The chest may appear full (hyperexpanded(bronchi) of the lung that respond to due to air trapping) with prolongedbronchodilators. Children with asthma have expiration.‘hyperactive airways’, i.e. their small airways • There may be lower chest wall indrawing.become narrow in response to a number of • The use of muscles in the abdomen or neckfactors. Asthma usually presents as repeated during expiration suggests severe airwaysacute attacks. Each attack lasts hours to days. obstruction.While some children only have a few attacks • Cyanosis, drowsiness or panic are signs ofa year others are rarely free from asthma. If respiratory failure.acute asthma is not controlled, the asthma • Usually there is no fever.may become persistent. • Long standing, poorly controlled asthma may result in chest deformity and poor growth. Asthma presents with repeated episodes of • Between acute attacks the chest airway narrowing. examination is usually normal. NOTE Asthma is an inflammatory disease. The The sudden onset of wheezing during play in inflammation leads to airway narrowing. To control a well child with no history of asthma suggests asthma the inflammation must be treated. the inhalation of a foreign body.7-29 How common is asthma? 7-32 What is the cause of asthma?Asthma occurs in about 10% of children in Asthma results from a combination ofSouth Africa, especially children living in towns inherited and trigger factors which causeand cities. Asthma is becoming more common inflammation of the bronchi. Most, but not all,as more rural families move into town. children with asthma have a family history of allergic conditions (asthma, eczema, or allergic7-30 What are the symptoms of asthma? rhinitis). Children with asthma often have other allergic conditions.Children with asthma complain of : Inflammation of the bronchi results in:• Expiratory wheezing• Cough
130 LOWER RESPIRATOR Y TRACT INFECTIONS1. Mucosal oedema (swelling of the linings of NOTE In allergic people the body responds the bronchi) abnormally to foreign proteins by producing IgE2. Bronchospasm (contraction of the smooth rather than IgG (atopy). muscle in the bronchi)3. Increased secretion of sticky mucus 7-35 What trigger factors may start an attack of asthma?These factors cause narrowing of the bronchi,especially in small children who normally have A wide range of trigger factors may start annarrower bronchi than do older children. acute attack of asthma. They include: NOTE The causes of asthma are multifactorial and • Upper respiratory tract infections result in airway hyperresponsiveness. • Allergens in the environment • Active or passive smoking7-33 How do inherited factors increase the • Exercise, especially runningrisk of asthma? • A sudden drop in environmental temperature (cold air)There may be a history of asthma on either the • Emotion (sadness, anger or excitement)mother’s or father’s side of the family. Often a • Irritants in the environment, e.g. paintparent or sibling has an allergic condition. The fumestendency to have asthma is, therefore, passedfrom one generation to the next and closefamily members with asthma are an important 7-36 How is asthma diagnosed?risk factor for children to develop the condition. Asthma is mainly a clinical diagnosis based on a history of repeated acute attacks of wheezing, coughing and breathlessness, often with a Children with asthma usually have a family positive family history of allergy. history of allergies. NOTE A high risk of allergic conditions is inherited Asthma is mainly a clinical diagnosis based on the as an autosomal dominant with variable past and family history. inheritance. The most useful special investigations are:7-34 What is allergy? 1. Lung function tests: Children over theAllergy (or atopy) is an abnormal or age of 5 years can use a peak flow meter toexaggerated reaction by the body to certain measure their peak expiratory flow rate.foreign proteins. In these allergic people the They take a deep breath and then blow asbody produces an inflammatory response to hard as they can into the peak flow meter,these proteins which are called allergens. This which measures how fast they can blowabnormal inflammatory response is present air out of their lungs (like blowing out ain all common allergic conditions. Allergens candle). Children with asthma have a lowerdo not produce an inflammatory response in peak flow rate than normal due to theirpeople who are not allergic. narrow airways.Common allergens are: 2. Skin tests: Skin tests are done by placing a drop of a specific allergen on the child’s• House dust mite forearms. The underlying skin is then• Foods, e.g. cows milk protein, eggs, wheat, pricked with a special lancet through peanuts, fish and soya the drop of allergic testing solution. The• Pollens, e.g. grass or tree pollen test site is examined after 15 minutes. A• Dog and cat hair swelling (wheal) at the test site indicates• Fungus (mould) spores that the person is allergic to that allergen. Skin tests are simple to perform, cheap
LOWER RESPIRATOR Y TRACT INFECTIONS 131 and accurate. A blood test (RAST) can 2. Control the acute attack also be used to identify a response to 3. Prevent recurrent attacks specific allergens. The child should not be 4. Avoid trigger factors on an antihistamine for 48 hours before 5. Education and support performing a skin prick test. Skin tests are used as supportive evidence for asthma as 7-39 How is the severity of acute asthma they diagnose allergies only. assessed?3. Response to a short acting bronchodilator: The following are features of severe asthma: A good clinical and peak flow rate response to a dose of inhaled bronchodilator is the • Previous history of severe acute asthma best way to confirm the clinical diagnosis indicates that any further attack should be acute asthma. In preschool children the regarded as severe. diagnosis usually depends on a clinical • Lack of response to bronchodilator therapy response to treatment while in older • Inability to speak or cry or feed due to children an improvement in the peak flow severe respiratory distress is important. • Cyanosis • Oxygen saturation below 90% NOTE A silent chest when examined with a Asthma presents with repeated episodes of stethoscope or peak expiratory flow rate below wheezing, coughing or shortness of breath that 60% indicates severe asthma. respond to bronchodilators. 7-40 How should acute asthma be treated?7-37 How is the severity of asthma graded? The aim of treating acute asthma (whetherWith intermittent asthma there are only intermittent or persistent) is to relieve theoccasional episodes of wheezing or coughing airway narrowing (bronchospasm) as soon(less than once a month). Most children with as possible and make sure that the patient isasthma only have intermittent asthma. The getting adequate oxygen.symptoms of intermittent asthma are usually 1. Nebulised or inhaled short actingeasily controlled and do not affect the quality bronchodilators (beta 2 agonists),of life. e.g. salbutamol (Ventolin) orWith persistent asthma the episodes are more fenoterol (Berotec). Oral short actingfrequent (at least once a month). Persistent bronchodilators are rarely used as theasthma may be: inhaled drugs are better and safer. 2. Antibiotics are usually not needed.• Mild: Episodes of coughing or wheezing 3. Sedatives and antihistamines must be occur once or twice a week avoided.• Moderate: Episodes of coughing or 4. Oral theophylline is only rarely used. wheezing at least 4 times a week Rectal and intravenous theophylline, and• Severe: They have daily symptoms which subcutaneous adrenaline, are dangerous interfere with sleep and schooling and should not be used. NOTE With intermittent or mild persistent asthma Acute intermittent asthma is usually mild and the peak expiratory flow is usually 80% or more of predicted. This falls to 60–80% with moderate can be treated at home. ‘Reliever’ treatment and less than 60% with severe asthma. can be given at home with inhaled short acting bronchodilators using a spacer (e.g. 1 or 2 puffs of salbutamol or fenoterol, i.e. 100–2007-38 What is the correct management of μg). This can be repeated after an hour ifasthma? needed. The child must be carefully observed1. Assess the of severity of the asthma and moved to hospital if the wheeze gets
132 LOWER RESPIRATOR Y TRACT INFECTIONSworse. An inhaled short acting bronchodilator Specially designed commercial spacers arecan also be taken before exercise to prevent available but they are expensive. A face maskwheezing or cough. is needed in young children. Older children should use a mouthpiece.7-41 What should you do if there is no Metered dose inhalers can be used in childrenresponse? of 8 years or more when they are able to co-If there is no clinical response within 20 operate and use the inhalers correctly. Spacersminutes of giving an inhaled bronchodilator, are used for younger children.repeat the dose, give a dose of oral steroids Nebulisers can be used in hospital to veryand refer the child to hospital for further efficiently give inhaled drugs. The drug intreatment. Also consider transfer to hospital liquid form is added to the nebuliser whichif the child refuses fluids, becomes restless or produces a fine mist. The dose is usually 1 mllethargic, or becomes cyanosed. Give oxygen of drug with 1 ml of saline.during transfer.The management of acute asthma in hospital 7-43 How can repeated attacks of asthmaconsists of: be prevented?1. Nebulised or inhaled bronchodilators If the child has persistent asthma (more than every hour. one episode a month) or severe attacks of2. A short course of oral steroids for 7 days asthma (requiring admission to hospital) the (e.g. oral prednisone 2 mg/kg daily). aim of management should be to prevent3. Reassess hourly. If no response consider these acute attacks. These children should admission for intensive care. be referred to an asthma clinic for chronic maintenance management if possible. The7-42 How should inhaled and nebulised aim of treatment is to allow the child to havedrugs be given? a good quality of life, i.e. play sport, attend school normally and sleep well. TreatmentInhaled medication (e.g. bronchodilators requires the use of both anti-inflammatoryand anti-inflammatory drugs) are safer and and bronchodilator drugs.more effective than oral drugs. They are bestgiven to children using a spacer. A spacer is a The treatment of persistent asthma:container that is placed between the metered 1. In mild persistent asthma (with repeateddose inhaler (MDI or ‘puffer’) and the patient’s mild episodes of cough and wheezing whichmouth. This allows the drug to mix well with occur once or twice a week) a low dailythe air in the container before it is inhaled. In dose of inhaled corticosteroid (‘prevention’this way the drugs are better absorbed through therapy e.g. beclomethasone 100–200 μg)the linings of the airway. should be given in addition to the shortThe inhaler is pushed through a hole made in acting bronchodilator. Inhaled steroids arethe bottom end of a 500 ml cooldrink bottle very effective and safer than oral steroids.while a face mask is attached to the mouth Inhaled steroids should be used with aof the bottle. This home-made spacer works spacer. Rinse out the mouth after inhalingwell and is much better than a small plastic or the steroid to avoid excessive absorption.polystyrene cup. 2. Moderate persistent asthma requires higher doses of daily inhaled steroids (e.g.For older children the child places her mouth beclomethasone 200–400 μg).directly over the top of the bottle rather than 3. In severe persistent asthma, oral steroidsusing a face mask. The child then breathes may be needed. These patients shouldnormally into the bottle. be management by an asthma clinic at a regional or tertiary health centre.
LOWER RESPIRATOR Y TRACT INFECTIONS 1334. Short acting inhaled bronchodilators are AN APPROACH TO LOWER needed in all patients with asthma and should be used when necessary. Use a RESPIRATORY TRACT spacer whenever possible. CONDITIONSExercise-induced asthma can be preventedby inhaling a short acting bronchodilator 10minutes before starting the exercise. 7-46 What is the syndromic approach to acute respiratory tract disorders? In severe or repeated attacks of asthma, daily This is a simple way of using important clinical signs to classify and manage acute treatment is needed to give the child as normal a respiratory tract disorders. It is based on quality of life as possible. what you and the mother observe (see and hear) in the child. In the older child, the NOTE A long acting bronchodilator (beta 2 history (symptoms) given by the child is agonist) such as salmeterol, or sustained release also important. This is the method used by oral theophylline, or a leukotriene antagonist may be added as a steroid sparing agent. IMCI (Integrated Management of Childhood Illness) for primary care management.7-44 How can trigger factors be avoided? The two main signs of lower respiratory tract disorders are:1. No one should smoke in the house.2. Avoid contact with people who have upper • Cough respiratory tract infections, especially • Difficulty breathing common colds.3. Avoids cats and dogs if allergic to them. 7-47 What are the important causes of a Ban pets from the bedroom. cough?4. Reduce house dust mites, especially in Most children become ill and cough a number the child’s bedroom. Cover the pillow and of times a year: mattress with plastic sheeting, vacuum the carpet daily, wash the sheets and covers 1. Usually a cough is due to a mild upper frequently in hot water and dry them in respiratory tract infection (cold, the sun. Synthetic bedding is best. pharyngitis or sinusitis) due to a virus and does not last more than 3 weeks.7-45 What education and support is useful 2. A cough may be due to a lower respiratoryin asthma? tract infection (pneumonia, croup, bronchitis, bronchiolitis and asthma). ItAsthma is frightening to the child and parents. is, therefore, important to look for signs ofThey should understand the causes, symptoms these conditions.and treatment of the condition. Children 3. A cough lasting more than 3 weeks ( 21should be encouraged to manage their own days) may be a sign of tuberculosis (TB).use of bronchodilators. 4. Think of whooping cough if a bout ofParents can be reassured that asthma tends to couching leads to vomiting.improve with age. 5. Think of asthma if the cough is worse at night or after exercise. In bronchiolitis the cough is also worse at night. Asthmatics usually have a recurrent wheezy cough. 6. A cough that starts soon after lying down suggests a post-nasal drip in acute sinusitis.
134 LOWER RESPIRATOR Y TRACT INFECTIONS7. The sudden onset of coughing after a If any of these signs are present, the child choking episode suggests an inhaled should be carefully examined and considered foreign body. for urgent transfer to hospital.8. A barking cough is suggestive of croup. 7-50 When and how should oxygen be7-48 What is the management of a cough? given?1. If the child has a cough but no signs of Children with rapid breathing, indrawing of breathing difficulty, the cause is usually an the chest, expiratory stridor or cyanosis, restless upper respiratory tract viral infection. They and saturations less than 90% should be given do not need an antibiotic but something to oxygen. Usually 1 to 2 litres per minute of 100% soothe the throat (warm water or tea with oxygen is given by nasal prongs or 3 to 4 litres honey or sugar). Cough mixtures usually via face mask. Measuring the oxygen saturation only help by soothing the throat. Therefore, is very helpful. use a simple cough linctus.2. The cough should get better by 3 weeks. If not, think of TB, asthma or whooping CASE STUDY 1 cough. These children should be referred for further investigation and management. During the early evening a 2-year-old child Always think of tuberculosis in a child develops a strange cough and a crowing noise with a chronic cough and weight loss. when she breathes in. She had a mild fever and3. If the child has signs of breathing difficulty, a runny nose during the day. When the child refer for management of the underlying cries, the noise during inspiration becomes condition. worse. The mother became anxious and NOTE There is no scientific evidence that cough brought the child to the casualty department suppressants, expectorants or mucolytics are of the local hospital. effective for an acute cough cause by a viral infection. 1. What is the crowing sound during inspiration called?7-49 What signs of breathing difficultysuggest specific diagnoses? Stridor. The sound is caused by breathing in through swollen vocal cords. Mild stridor onlyThese signs must be assessed when the child is occurs during inspiration and is usually onlycalm and not crying: heard when the child cries.1. Stridor is usually due to viral croup.2. Indrawing of the lower chest wall may 2. What is the most likely cause? occur with most severe lower respiratory Viral croup. This is an acute viral infection tract problems, i.e. pneumonia, stridor, of the larynx, trachea and bronchi bronchiolitis or asthma. (laryngotracheobronchitis). It usually follows3. Wheezing suggests bronchiolitis (in an the start of a common cold or pharyngitis. infant) or asthma (in an older child).4. Fast breathing suggests pneumonia, bronchiolitis or asthma. 3. What other sign is common with this condition?Older children with a severe lower respiratorytract problem may complain of shortness of A ‘barking’ cough.breath. Always look for danger signs in anychild with breathing difficulty.The sudden onset of stridor or wheeze in awell child suggests a foreign body.
LOWER RESPIRATOR Y TRACT INFECTIONS 1354. What signs would suggest that the 3. What is the cause?stridor is becoming worse? Probably the respiratory syncytial virusBoth inspiratory and expiratory stridor, which can start as a common cold. Infectionespecially if present at rest, and indrawing of with the respiratory syncytial virus isthe lower ribs during inspiration. The obvious commoner in winter.use of chest and abdominal muscles duringexpiration, restlessness or fast breathing are 4. What is the correct management?signs of dangerous airway obstruction. Bronchiolitis is best managed in hospital where humidified oxygen can be given if necessary.5. What is the main treatment of severestridor? 5. Should antibiotics be given?Nebulised adrenaline. A single dose of steroidshelps. There is no indication for bronchodilators Usually not, except in infants under 3 monthsor antibiotics. If respiratory failure develops, and where pneumonia is difficult to exclude.intubation or a tracheotomy may be needed tobypass the laryngeal narrowing. 6. What are danger signs with bronchiolitis? Cyanosis, refusal to drink, apnoea, a marked6. What diagnosis should you consider with tachycardia, restlessness or a depressed levelthe sudden onset of stridor in a well child? of consciousness. An oxygen saturation belowAn inhaled foreign body. 90% is cause for great concern. This child does not have any of these danger signs.CASE STUDY 2 CASE STUDY 3An infant of 6 months develops fast breathingand recession 3 days after the start of a common A 5-year-old child develops a cough andcold. On inspection the chest appears over blocked nose. The next day his mother noticesexpanded and a wheeze is heard. There is a mild that he is breathing fast and has a fever. Onfever and the child does not appear seriously examination he has a respiratory rate of 45ill. He takes his bottle well and has no cyanosis. with chest indrawing. He refuses to drink andThere is no family history of asthma and this is has mild central cyanosis.the first time the child has been ill. 1. Why is this child breathing fast?1. What is the most likely diagnosis? He probably has pneumonia.Bronchiolitis. This is an acute inflammation andnarrowing of the small airways of the lungs. 2. What is the definition of fast breathing? It depends on the child’s age as younger2. Why is this unlikely to be asthma? children normally breathe faster than olderThe infant is young for asthma, this is the first children. A respiratory rate above 40 breathsepisode of wheezing and there is no family per minute is abnormally fast in any childhistory of asthma. No other features of allergy older that one year.are mentioned. 3. What is the likely cause? Probably viral as he has an upper respiratory tract infection. However the cause of the pneumonia may be bacterial.
136 LOWER RESPIRATOR Y TRACT INFECTIONS4. What is chest indrawing? 2. What is this clinical condition?Chest indrawing (recession or retractions) is Asthma is a chronic condition that presentsa clinical sign where there is indrawing of the with repeated attacks of airway narrowing.lower chest when the child breathes in. It isseen with pneumonia as well as a number of 3. What is the cause?other lower respiratory tract conditions. Asthma is caused by a combination of an inherited factor (i.e. allergy) plus trigger5. How severe is the pneumonia in this factors.child?It is severe as he has 3 signs of severe 4. What are common trigger factors?pneumonia (chest indrawing, refusal to drinkand cyanosis). These are danger signs. Viral infections, exercise, exposure to allergens or irritants (e.g. smoke), cold air and emotion. In this child the trigger factor was a viral6. What management is needed? upper respiratory airway infection.1. Give oxygen to keep the child pink.2. Start antibiotics. 5. Can you name a few common allergens?3. Try to get the child to take oral fluids. Otherwise start an intravenous infusion. House dust mite, pollens, cat or dog hair, some4. Urgently transfer the child to hospital. foods and fungus spores.7. What antibiotic would you choose? 6. How is a clinical diagnosis of asthma confirmed?Intramuscular ampicillin. It can be givenintravenously if an intravenous infusion (a drip) By lung function tests for airway narrowingis started. In hospital gentamicin may be added. and response to an inhaled bronchodilator. A skin prick test provides supportive evidence for allergies.8. What is the value of measuring theoxygen saturation? 7. How should his acute attack be treated?This is a very useful method of assessingwhether there is enough oxygen in the blood. He will probably respond well to an inhaled short acting bronchodilator. If not, he should be referred to hospital for assessment andCASE STUDY 4 further treatment 8. Can acute attacks be prevented?A 7-year-old child has a history of repeatedattacks of coughing and wheezing, especially at Yes. Every attempt should be made to preventnight and during sport at school. He now has acute attacks by identifying and removingwheezing for the past few hours, complicating trigger factors. In children with persistenta common cold. There is a strong family asthma, steroids should be added to thehistory of allergies. regular use of an inhaled bronchodilator.1. Why is this child coughing andwheezing?He has an acute attack of asthma.