This document discusses shortness of breath in pediatric patients. It outlines common causes like respiratory infections, congestive heart failure, foreign body inhalation, and metabolic derangements. Assessment focuses on work of breathing, accessary muscle use, and associated symptoms. Key differences in the pediatric airway are described, along with implications for airway management. Five case examples demonstrate approaches to common conditions like bronchiolitis, croup, pneumonia, asthma, and foreign body inhalation. Management strategies for each condition are provided.
2. +
Outline
SOB DDx by age
Most commonly primary resp/infective
Don’t forget other causes:
CCF
Foreign body inhalation
Anaphylaxis
Metabolic – Eg DKA, sepsis, shock – RR very
sensitive marker of “unwellness”
3. +
Assessment
RR, O2sats*
Key is recognition of Resp Distress
Work of Breathing
Recession-subcostal/intercostal/suprasternal
Nasal Flaring
Accessory muscle use- sternomastoid
Leaning forward
Inspiratory vs Expiratory Eg’s
Assoc Symptoms
Wheeze
Fever
Cough
Stridor
4. +
Paediatric Airway
Smaller, Shorter, Floppy, small mandible
Large head (neck flexed), Large tongue
High larynx
Funnelled shaped with anterior angulation
Epiglottis long and stiff
<8 yo narrowest portion = cricoid cartilage (adults = vocal cords)
small diameter of airways -> higher resistance to air flow, easily
blocked
highly compliant -> kink
trachea short & in line with right main bronchus
5. +
Implications
Towel under body/shoulders extend
neck, ETT Formula?
ETT size = age/4 + 4 (age > 1 years)
or Broselow Tape or size of little finger
(-1 if cuffed tube)
Depth Tip to lip = age/2 + 12, tip
follows chin
6. +
Paeds Airway
Classically uncuffed <5mm, cuffed
>5mm due to ?laryngeal stenosis
but can use cuffed tubes in most
(esp high volume low pressure)
but probably need uncuffed in <
1yo, reduce size by 0.5-1mm for
cuffed tubes
small, straight blade(Miller-
neonate/infant/paed) - lift epiglottis
– vagal stim.
7. +
Paeds Airway
Atropine 20mcg/kg
difficult to perform a tracheostomy
NGT therapeutic
http://lifeinthefastlane.com/ccc/paediatric-airway/
8. +
Case 1 - 11/12 M with SOB, wheeze
2/7 runny nose, sneezing, cough
1/7 wheeze, increased WOB, reduced feeds
PHx Normal Preg, NVD at Term, IUTD no medical
Hx
3yo sibling has “cold”
FHx –Asthma, Eczema
Dx?
9. +
Bronchiolitis
2/12 – 1 yrs
RSV
Widespread wheeze
Peaks day 2-3, lasts 7-10/7
Mild - no resp distress O2sats >93% “Happy Wheezer”
Mod - some resp distress, reduced feeding, O2sats 90-93%
Severe - resp distress, lethargy, not feeding, apnoea,
O2sats <90%
10. +
Bronchiolitis
R/F for severe illness:
Young < 6/52
Ex prem
Congenital/Chronic Heart/Resp/Neuro
Reasons for admission:
Hypoxia <92%
Not feeding
<6/52 lower threshold - apnoeas
11. +
Bronchiolitis
Ix
NPA
CXR
bloods
Mx
Mild - Smaller, more frequent feeds
Mod - O2 aims Sats >92%, 2/3 of maintenance fluids
Severe - CPAP/Vent
Experimental/Controversial:
Hypertonic Saline neb (24 studies pooled -mod improvement)
Salbutamol – reasonable in nearly 1 yo
Steroids
Adrenaline nebs
Ribavirin/Immunoglobulin
12. +
DDx CCF
Similar Wheeze and resp distress without
infective symptoms
From newly Dx Congenital Heart Disease, or
arrhythmias
CHD Multiple types:
Transposition of great vessels
Pulmonary/Aortic stenosis
Hypoplastic left heart
Tetrallogy of Fallot
13. +
Duct Dependent CHD
Adequate Circulation is dependent on a patent
ductus arteriosus:
Right Heart obstruction – PDA allows blood flow
thru lungs
Left Heart Obstruction – PDA supplies systemic
circulation
Transposition allows mixing
PDA Closure in first few days of life can
precipitate Cardiogenic shock
Rx is Supportive and Prostaglandin E1 -
Alporstadil to reopen Ductus Arteriosus
14. +
Case 2
3 yo SOB with cough, wheeze –
Previously well, Playing Lego with sibling sudden
onset coughing/SOB/wheeze/vomiting/gagging
o/e reduced breath sounds on R
DDx?
16. +
Inhaled Foreign Body
Esp 1-3yo incomplete chewing, food propelled
posteriorly, triggers reflex inhalation
Most foreign bodies are radiolucent; need indirect
radiologic findings
Hyperinflation from ball/valve effect in affected lung
CXR 70%-80% sensitive, (50% airtrapping, 12%
atelectasis, 18% infection) if N and high index suspicion -
Bronchoscopy
Can use CT
17. +
Location, Location
Small cylindrical/smooth/round - Seeds, nuts, nails,
toys, coins, bone, anything
Proximal - occluded airway and can’t remove from
mouth – “Café Coronary”
Back blows and chest thrusts
Positive pressure ventilation
Surgical airway
Partially occluded, distal to Carina – Bronchoscopy
21. +
Management
O2 sats 96%RA – OK?
Minimal Handling
Adrenaline Nebs
Oral Prednisolone or IM Dexamethasone Big Dose:
(Frank Schann)
0.6mg/kg IM 2 ½ yo M wt (2.5 +4) x 2 = 13kg
Dose 13 x 0.6mg = 8mg
22. +
Racemix v Standard Adrenaline??
Standard Adrenaline 100% L-isomer,
1:1000 : 1ml amp = 1mg,
1:10,000: 10ml amp = 1mg
Racemix Adrenaline: (Ophthalmic solution)
50% L-isomer + 50% D-isomer (only 10% as
potent as L-isomer but ? longer effect)
Equivalent to 1:100 Standard Adrenaline (ie 10 x
more potent that 1:1000)
Previously thought that D-isomer has less
chronotropic effect on heart
23. +
Racemix v Standard Adrenaline??
Both equivalent efficacy
Dose:
4-5 vials 1mg Adrenaline in 1ml(1:1000) 0r 1ml of 1% Racemix
Adrenaline solution + 3ml n/saline
1ml = 0.5ml L-isomer = 5mg Adrenaline, 0.5ml D-isomer =
0.05mg Adrenaline, both effective dose 5.5mg Standard
Adrenaline
Onset 10mins, Lasts up to 2 hours
24. +
Case 4
2 yo F with SOB/fevers/cough/grunting for 5/7
Pneumonia
25. +
Pneumonia
Grunting – from closed vocal cords to
provide increased PEEP and keep their
lower airways open- LRTI
26. +
Pneumonia Bugs and Antis
Age Organisms Antibiotcs
0-1 month Gp B Strep, E Coli,
Listeria, CMV, HSV
Benzyl Pen/Gent
1-3 months C trachomonas-
afeb/mildly unwell
Viral, Strep Pn, S
Aureus
Azithro
BenzylPen
Ceft/Fluclox
3months – 5
yo
Viral, Strep Pn/Staph Amoxil
BenzylPen
Ceftx/Fluclox
> 5yo Viral, Mycoplasma,
Strep Pn, Chlamydia Pn
Adult typical/atypical
Amoxil/Doxy/Azithro
Ceftx/Fluclox
27. +
Pneumonia Admit v Discharge?
Admit: iv antis, O2, supportive care
age < 6/12
Sp02 <92%
toxic appearance or severe respiratory distress
suspected complications (e.g. empyema)
Immunocompromised
vomiting/dehydration/not tolerating o intake
Social
31. +
Case 5
7 yo F with SOB, wheeze, cough, runny nose
for 2/7
Dx?
Asthma
32. +
Management 1
“Hour of Power” nebs vs MDI with spacer
B agonists 6 puffs < 6yo, 12puffs > 6yo
Antichol- Ipratropium bromide (Atrovent
20mcg/puff)4 puffs< 6 yo, 8 puffs>6 yo
O2
Steroids
Pred 2mg/kg first dose, then 1mg/kg
subsequent doses
Iv Methypred 1mg/kg
33. +
Management 2
Magnesium (50% 500mg/ml) 50mg/kg iv dilute to 200mls over 20mins
Consider i.v. Salbutamol (Limited evidence) 5 mcg/kg/min for one
hour as a load, followed by 1-2 mcg/kg/min
BiPAP/CPAP
Pros - decreased WOB, improves V/Q Mismatch, recruits alveoli,
increase FiO2
Cons - hyperinflation – barotrauma, delayed indicated intubation,
vomiting
No large RCT, 2013 Cochrane Review 5 trials- 206 pts –
inconclusive, some support in observational studies and case series
Consider in severe asthma with compliant pt to delay/avoid
intubation
BiPAP PEEP at 3-5 cmH20 iPAP at 7-15 cmH20, target RR<25/min
I:E ratio 1:5
34. +
Pitfalls
?CXR in severe Asthma
Beware normal pCO2 on VBG
Should be low with increased RR, will start to rise to normal as pt
tires and then rise above normal values as they develop resp failure
“Gas Trapping”
Asthma is disease of expiration
Progressive inflation of chest
High Risk of pneumothorax
Post Intubation – low RR 4-6, normal Tidal volumes, low I:E ratio
“permissive hypercapnia”
Disconnect ETT and manually decompress chest and allow
prolonged expiration
35. +
Paeds SOB - Summary
Mostly primary resp/infective
Assess WOB, RR, insp v exp – observe child, don’t
increase distress
Remember differences in airway Mx eg Miller blade,
uncuffed tube
Don’t forget CCF, inhaled foreign body
36. +
References
RCH clinical guidelines
EMC Pediatric Breathing Problems
Life in the Fast Lane
Medscape
Waisman Y, Klein BL, Boenning DA et al: Prospective randomized
double-blind study comparing L-epinephrine and racemic
epinephrine aerosols in the treatment of laryngotracheitis (croup).
Pediatrics 1992. Feb; 89(2): 302-6.
Nebulized Hypertonic Saline for Acute Bronchiolitis in Infants?
Zhang L et al. Pediatrics 2015 Sep 28