more towards approach of a child with breathing difficulties and a brief topic of congestive cardiac failure

1. Amalina Aminuddin
0820121000 67

2. Contents
 Introduction
 Etiology
 Approach
 Investigations
 Congestive heart failure

3. Introduction
 Aka Shortness of breath, breathlessness,
dyspnea
“Abnormally uncomfortable awareness of
breathing”
 Harrison's Principles of Internal Medicine, 16th Edition
“A subjective experience of breathing
discomfort that consists of qualitatively distinct
sensations that vary in intensity“
 American Thoracic Society

4. Etiologies

5. Respiratory
 Parenchyma
 Pulmonary embolism
 Bronchiolitis
 Bronchial asthma
 Pneumonia
 Pulmonary
hypertension
 Airway
 Foreign body
aspiration
 Croup
 Epiglotitis

6. Respiratory: Newborn
Cause Time of onset
Meconium aspiration
syndrome
First few hours of life
Respiratory distress
syndrome
First 6 hours of life
Transient tachypnea of
newborn
First 6 hours of life
Persistent pulmonary
hypertension
Any age
Congenital malformations Any age

7. Cardiac Others
 Congestive heart
failure
 Congenital heart
disease
 Allergies
 High altitude
 Emotional distress
(anxiety, stress, panic
attack)
 Obesity

8. Approach
 Assess severity
 Evaluate history and
physical examination
 Distinguish between
respiratory and cardiac
causes

9. i) Grading

10. i) Grading

11. ii) Red flag signs
 Sudden onset
 Dyspnea at rest
 Decreased level of consciousness
 Accessory muscle use
 Tightness in the throat or barking crouping cough
 Chest pain
 Wheezing

12. History
 Onset, duration, course, severity , exacerbating
factors (allergen exposure, cold, exertion, supine
position)
 Any other associated symptoms
 chest pain or pressure (pulmonary embolism, myocardial
ischemia, pneumonia)
 dependent edema, orthopnea, and paroxysmal nocturnal
dyspnea (heart failure)
 fever, chills, cough, and sputum production (pneumonia)
 weight loss or night sweats (cancer or chronic lung
infection)
 Past history: asthma, heart disease, TB, pneumonia

13. Physical examination
 Vitals
 Examination focuses on the cardiovascular and
pulmonary systems.

14. Distinguishes
Respiratory Cardiovascular
 Cough with
expectorant
 Fever
 Seasonal variation
 Abnormal breath
sounds
 PND and orthopnea
 Associated syncope,
palpitation, anginal
pain
 Distended neck vein,
edema

15.  Pulse oximetry
 Chest X Ray
 ECG
 ABG
 Echocardiography
 Bronchoscopy
Initial studiesInvestigations

16. Congestive
Cardiac
Failure

17. 1. Inability of the heart to maintain output (systolic
failure)
2. Inability to receive blood into ventricles at low
pressure during diastole (diastolic failure)

18. Etiology
Infants Children
 Congenital heart disease
 Myocarditis and primary
myocardial disease
 Tachyarrhythmias and
bradyarrythmias
 Pulmonary hypertension
 Miscellaneous causes :
Anemia, hypoglycemia,
infections, hypocalcemia,
neonatal asphyxia
 RF, RHD
 CHD complicated with
anemia, infection,
endocarditis
 Systemic hypertension
 Myocarditis, primary
myocardial disease
 Pulmonary
hypertension

19. Systolic
dysfunction
Diastolic
dysfunction
 Myocarditis
 Valvular lesions
causing stenosis or
regurgitation
 CAD
 Myocardial ischemia
 Cardiomyopathy
 Drugs and toxic
agents
 Mitral or tricuspid
stenosis
 Constrictive pericarditis
 Restrictive
cardiomyopathy
 Myocardial ischemia
 Marked ventricular
hypertrophy
 Dilated cardiomyopathy

20. Onset of Congestive Heart Failure
Age Lesion
Birth – 1 week Congenital mitral and tricuspid regurgitation,
neonatal Ebstein anomaly
1 – 4 weeks PDA in preterms, VSD with coarctation, persistent
truncus arteriosus, transposition with large VSD or
PDA, severe coarctation, congenital mitral or aortic
stenosis
1 – 2 months Transposition with VSD or PDA, VSD, PDA,
endocardial cushion defect, severe coarctation
2 – 6 months VSD, PDA, endocardial cushion defect

21. Clinical features
 Poor weight gain
 Facial puffiness, pedal edema
 Poor feeder
 Irritability, excessive perspiration and
restlessness
 Breathes too fast ; breathes better when
held against shoulder

23. Investigations
• Chest X-ray
• ECG
• ECHO
• Blood culture
• Hemoglobin for anaemia
• Arterial blood gas

24. Treatment
Reducing cardiac work
Inotropic agents
Reduce preload
Correcting the underlying
cause

25. 1) Reduce Cardiac Work
 Restrict activity
 Treat fever, anemia, infection
 Neonate:
 Incubator ,inclined position with oxygen
 Restless child:
 Morphine sulfate 0.05mg/kg SC
 Midazolam
 Vasodilators
 Nitrates, hydralazine, ACE inhibitors

26. 2) Inotropic Agents
 Digoxin :
 Initial ½
 ¼ in 6-8 hr
 Cathecolamines inotropes : dopamine,
dobutamine and adrenaline
 PDE inhibitor : milrinone, amrinone
Age Dose (mg.kg) Maintainance
Premature/
neonates
0.04 mg/kg , 1/4
1 month – 1
year
0.08 mg/kg, 1/3 to 1/4
1-3 year : 0.06 mg/kg, 1/3 to 1/4
Above 3 year : 0.04 mg/kg, 1/3

27. 3) Reduce preload
 Diuretics
 Frusemide 1-3mg/kg/d oral
 Spirinolactone 1 mg/kg orally every 12 hours
 Restrict sodium intake

28. Prognosis
 High mortality
 Prognosis depend on underlying cause

29. Reference
 Vinod, Arvind, Ghai Essential Pediatrics ,8th
edition
 Kliegman, Stanton, St Geme, Schor, Nelson
Textbook of Pediatric, 1st south asian edition
 N. K. Burki, MD, PHD, acute dyspnea: is the
cause cardiac or pulmonary—or
both?,November 16, 2012
 Cardinal symptoms in cardiology... an analysis Dr
S Venkatesan.MD,DM Madras Medical college
SIMS March 4 th 2016
 http://www.msdmanuals.com/professional/pulmonary-
disorders/symptoms-of-pulmonary-
disorders/dyspnea#false