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.

1. +
Paediatric Shortness of
Breath EMC
Dr Dane Horsfall FACEM
Cabrini Hospital

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?

15. +

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

18. +
6 yo SOB/Chest pain/Dysphagia
– r/o Popcorn L main bronchus

19. +
Case 3
 2 1/2 yo M presents at 2am with runny nose, fever,
dry cough, quiet inspiratory stidor at rest
 https://www.youtube.com/watch?v=Wvg7HFoKFtY
 Dx Croup
 AKA Laryngotracheobronchitis

20. +
Croup
 Parainfluenza virus
 6/12 – 3 years old
 Typically present onight, fevers, dry/barking cough,
stridor

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

28. +

29. +

30. +

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