Assessment of wheeze in children(Acute setting) Dr. Tajana Weli
Comments • Should there be an option to titrate prednisolone dose according to weight? • Should there be an option to add nebulised Ipratropium at ‘urgent’ step • Practicality of reassessing children after 30 minutes? • Concerns expressed over Beta-agonist weaning down regime at moderate step • Not comfortable with ‘subjective’ assessment (e.g. severity of recession)
Cause? Asthma (Pattern of wheeze, atopy, FH) Bronchiolitis (Age, season) FB (sudden onset, time of day) LRTI Other? (reflux,heart failure, CHD, CF, tracheo-oesophageal fistula, bronchiectasis, immunodeficiency, tracheobronchomalacia etc!
Assessments ABC Resuscitate if necessary
Examination • Observe from distance • Alert? • Colour? • Posture? • Speaking sentences? • Feeding? • Fontanelle? Mucous membranes? • Audible wheeze?
Respiratory Rate • Measure for 60 seconds • Ideally with chest exposed (over clothes if patient going to become distressed) • Watch out for prolonged expiration in wheezy kids • IN FINAL STAGES OF RESPIRATORY FAILURE RATE REDUCES
Work of breathing • Nasal flaring • Use of accessory muscles (sternocleidomastoid- head bobbing, diaphragm- abdominal breathing) • Recession (mild/ moderate/ severe?)
Recession- severity? • Difficult in chubby child • Age dependent- in older children chest not as soft, represents greater degree of distress) • Type Tug, supraclavicular, intercostal, subcostal, sternal If sternal indication of more severe distress
Examination • HR + Sats (N.B. bradycardiapreterminal event), Peripheries (cold? Mottled?), Skin turgor, CRT • Auscultation- Wheeze normally audible. Consider transmitted noises, bronchial breathing, creps. May not present with focal signs. Don’t forget mycoplasma. • Temperature
Peak flow in acute setting Is child used to doing it? Are they co-operative? Do the parents know the best peak flow? Need to document on chart, correlate with height and compare
A child who is decompensating can look deceptively well. A child with normal parameters who looks ill is ill.
References BTS: Guidelines for the management of Community Acquired Pneumonia in Children update 2011 Breathing difficulty: An evidence-based guideline for the management of children presenting with acute breathing difficulty; Paediatric Accident and Emergency Research Group 2002 Thompson M, Mayon-White R, Harden A et al. Using vital signs to assess children with acute infections: a survey of current practice. BJGP April 2008; 236-241 Thompson M et al. How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Child 2009;94:888-893 DoH: Spotting the sick child NICE: Feverish illness in children- assessment and initial management in children younger than 5 years.2007 SIGN: Bronchiolitis in Children Guideline 91 BTS: British Guideline on the Management of asthma Revised Jan 2011