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PAEDIATRIC BREATHING DIFFICULTIES

PAEDIATRIC BREATHING DIFFICULTIES. LEE WALLIS. BRONCHIOLITIS CROUP EPIGLOTTITIS FOREIGN BODY NASAL OBSTRUCTION. ASPIRATION PERTUSSIS PNEUMONIA PERITONSILLAR ABSCESS RETRO-PHARYNGEAL ABSCESS ASTHMA. OBJECTIVES. BRONCHIOLITIS. WHEEZING IN A LITTLE KID INFANTS 50% RSV

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PAEDIATRIC BREATHING DIFFICULTIES

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  1. PAEDIATRIC BREATHING DIFFICULTIES LEE WALLIS

  2. BRONCHIOLITIS CROUP EPIGLOTTITIS FOREIGN BODY NASAL OBSTRUCTION ASPIRATION PERTUSSIS PNEUMONIA PERITONSILLAR ABSCESS RETRO-PHARYNGEAL ABSCESS ASTHMA OBJECTIVES

  3. BRONCHIOLITIS • WHEEZING IN A LITTLE KID • INFANTS • 50% RSV • RUNNY NOSE FROM HELL • TINY BABIES MAY HAVE APNOEA (ALTE) • HUGE VARIATION IN DURATION • DAYS TO WEEKS

  4. BRONCHIOLITIS • TESTS • (RSV TITRE) • FOR ISOLATION • URINE DIPSTICK • CXR BILATERAL AIR TRAPPING

  5. BRONCHIOLITIS • NEBULISED ADRENALINE • 1:1000, 4-5ml • DOSE IRRELEVANT – GENERATE OWN Vt • STEROIDS • NEBULISED NO HELP • ORAL ?HELP

  6. BRONCHIOLITIS • Schidler, 2002 Crit Care • META ANALYSIS 12 STUDIES (n=843) • 75% β AGONISTS NO HELP • 5 (n=223) ADRENALINE: WORKED IN ALL • STEROIDS MAY OR NOT HELP • VARIED RESULTS. WHY? MIXED DISEASES – MULTIPLE CAUSES • RSV, RHINOVIRUS etc

  7. BRONCHIOLITIS • Keenie,2002 Arch Ped & Adol Medicine • Average LoS 3 days • Either get better quickly or are sick! • Obs ward not suitable

  8. CROUP • Toddlers, Pre-schoolers • Prodrome 2 days • RHINORRHOEA, COUGH • Then very bad night • STRIDOR ++ • BARKING COUGH • Often better when at EU

  9. CROUP • Para-influenza, other virus • Previously well, > 4 months, immunised against diphtheria • FB • Diphtheria • Candida • Epiglottitis

  10. GRADING OF STRIDOR • BECOMES SOFTER AS OBSTRUCTION GETS WORSE • I Insp only • II Insp & Passive Exp • III Insp & Active Exp (pulsus paradoxus) • IV As III + recession, cyanosis, tired etc.

  11. CROUP • COOL MIST • cf BOILING WATER WHEN IN LABOUR…. • ADRENALINE NEBS • Gd II + stridor • DEXAMETHASONE • IM / PO – 0.6 mg/kg • NEBS – 2-4mg • PREDNISOLONE • PROBABLY FINE TOO • ? SINGLE OR MULTIPLE DOSES

  12. CROUP • CXR • To exclude something else (?FB) • ADMISSION • GD II+ STRIDOR • Grade III-IV need ICU

  13. CROUP • Luria,2001 arch ped adol med • RCT n=264, 6/12 – 6 yrs • Mild Croup • Neb dex vs oral dex vs no dex • Oral best by far

  14. EPIGLOTTITIS • HiB • GONE IN WEST • TODDLERS, PRE-SCHOOL • ABRUPT ONSET • FEVER, SORE THROAT, DROOLING, MUFFLED VOICE, LEAN FORWARD • No cough • TOXIC

  15. EPIGLOTTITIS • INTUBATE • GAS INDUCTION, CALM, EXPERIENCED • 3rd GENERATION CEPHALOSPORIN

  16. FOREIGN BODY • 80% RADIO LUCENT • PEANUTS • COUGHING, CHOKING, BREATHLESS, UNILATERAL WHEEZE • MOST ARE SMALL KIDS • NEED BRONCHOSCOPY

  17. FOREIGN BODY • IF UNSURE, CXR: • INSPIRATION & EXPIRATION • ALLOWS VISUALISATION OF BALL VALVE EFFECT. I FILMS LOOKS FINE, E FILM SHOWS AIR TRAPPING • DECUBITUS • SIDE WITH FB STAYS INFLATED WHEN SHOULD COLLAPSE

  18. FOREIGN BODY • Silva , 1998 ann otol rhinol laryngol • Retrospective review (n=93) • 88% history, 82% wheeze, 51% reduced BS • CXR sens 63% spec 47% • 83%, 50% after 24 hrs

  19. NASAL OBSTRUCTION • WHY IS AN EMERGENCY? • TINY BABIESCAN’T BREATHE • OBLIGATE NASAL BREATHING SO MUCUS BECOMES AN EMERGENCY! • NASAL SUCTION

  20. ASPIRATION PNEUMONIA • (CHEMICAL PNEUMONITIS) • KEROSENE, PARAFFIN • COUGH, WHEEZE, LOW GCS • DON’T INDUCE VOMITING • MICRO-ASPIRATION OF HYDROCARBONS • NO ACTIVATED CHARCOAL • ANTIBIOTICS WHEN INDICATED

  21. PERTUSSIS • WHOOPING COUGH • INFANTS • UNIMMUNISED • FEVER & REPETITIVE COUGH • SEIZURES, ENCEPHALOPATHY, PNEUMONIA • ERYTHROMYCIN

  22. PNEUMONIA • VERY WELL ---- SEPTIC SHOCK • ACUTE ABDOMEN • ONE SIDE DIFFERENT TO THE OTHER! • WHEEZE, BRONCHIAL BREATHING • NEONATES • BETA HAEM STREP, CHLAMYDIA, G NEG • OLDER • PNEUMOCOCCUS, HIB, MYCOPLASMA

  23. PNEUMONIA • ADMIT IF RECESSION, NOT FEEDING, SATS <90% • AMOXYL • MILD & MODERATE • AMPICILLIN & GENTAMICIN • SEVERE • ?ERYTHROMYCIN

  24. PERITONSILLAR ABSCESS • QUNISY • OLDER KIDS • TEENS? >8? • BAD SORE THROAT, UVULA DEVIATED • ABSCESS = DRAINAGE (OR ASPIRATION, 18G NEEDLE)

  25. RETROPHARYNGEAL ABSCESS • SORE THROAT • SUPPURATIVE CERVICAL ADENOPATHY • OR PENETRATION • FEVER • STIFF NECK • OFTEN MISTAKEN FOR MENINGITIS

  26. RETROPHARYNGEAL ABSCESS • LATERAL NECK X RAY • PREVERTEBRAL SOFT TISSUE SWELLING • CT NECK • EVALUATE UNDER ANAESTHESIA • 3RD GENERATION CEPHALOSPORIN

  27. ASTHMA Thorax 2003; 58 (Suppl I): i1-i92

  28. DIFFERENTIAL Thorax 2003; 58 (Suppl I): i1-i92

  29. Initial assessment of acute asthma in children aged >2 years in A&E Thorax 2003; 58 (Suppl I): i1-i92

  30. Management of acute asthmain children aged >2 years in A&E

  31. Response to treatment in children aged >2 years in A&E

  32. Treatment of acute asthmain children aged >2 years *Dose can be repeated every 20-30 minutes Thorax 2003; 58 (Suppl I): i1-i92

  33. Steroid therapy for acuteasthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92

  34. Other therapies for acuteasthma in children aged >2 years *Dose can be repeated every 20-30 minutes Thorax 2003; 58 (Suppl I): i1-i92

  35. Hospital admission for acuteasthma in children aged >2 years Thorax 2003; 58 (Suppl I): i1-i92

  36. Treatment of acute asthmain children aged <2 years Thorax 2003; 58 (Suppl I): i1-i92

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