Respiratory illness in children Assessment and management of acute episodes

1. Respiratory illness in childrenAssessment and management of acute episodes Jeremy Hull, CHOX Oxford Children’s Hospital

2. What are acute episodes? • Breathlessness • Cough • Noisy breathing Oxford Children’s Hospital

3. What are the likely causes? likely • Asthma • Croup • Bronchiolitis • Pneumonia • Pertussis • Inhaled foreign body • Anaphylaxis • Pneumothorax • Not respiratory • sepsis • diabetic ketoacidosis • heart failure rare Oxford Children’s Hospital

4. Assessment • History! • previously well, or previous episodes • coryza • onset of symptoms – sudden, gradual, precipitant • any history of choking • eating and drinking • exercise / general activity levels • usual medication Oxford Children’s Hospital

5. Assessment • Examination • Global assessment – well or ill? • ABC • Conscious level • Respiratory rate – COUNT don’t guess • Heart rate • Work of breathing – recession plus use of accessory muscles • Oxygen saturation – use paediatric probe for < 2yrs • Breathing noises – stridor or audible wheeze • Auscultate – wheeze and/or crackles Oxford Children’s Hospital

6. Breathing noises • Stridor • Harsh noise coming from trachea • Usually predominantly inspiratory • Usually heard without a stethoscope • Wheeze • Turbulent airflow in small to medium sized airways • Usually high-pitched and polyphonic • Always loudest on expiration • May be heard without a stethoscope • Crackles (crepitations) • Coarse or fine snapping noises heard on inspiration or expiration • Only heard with a stethoscope Oxford Children’s Hospital

7. Heart rate and respiratory rate • Heart rate • Will change with distress and anxiety • Higher in febrile children • Varies with age • Respiratory rate • May be the only abnormal sign • Varies with age Oxford Children’s Hospital

8. Heart rate and respiratory rate Oxford Children’s Hospital

9. Assessment – Asthma (Bucks) Oxford Children’s Hospital

10. Assessment – Asthma (BTS) https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/ Oxford Children’s Hospital

11. Assessment – bronchiolitis (Oxford CCG)

12. Generic Assessment – my suggestions Oxford Children’s Hospital

13. What to do - options • Get help, call an ambulance • Oxygen • Inhaled beta-agonists • nebulised • via spacer • Antibiotics • Oral steroids • Intra-muscular adrenaline • Nebulised adrenaline • Give advice – feeding, illness duration, safety net, follow-up Oxford Children’s Hospital

14. Wheeze – mild to severe • Treat with beta-2 agonist – salbutamol (think twice if <1 year) • Spacer if normal saturations • Slow deep inhalations are most effective • Nebuliser if de-saturated or will not tolerate spacer • Give oral steroids (20-40mg); 3 days is usually enough. • NB: steroids don’t work for viral wheeze Oxford Children’s Hospital

15. Wheeze • Mild to moderate wheeze can be treated at home • Can safely use upto 10 puffs (<5yrs) or 20 puffs (<5 years) every 4 hours • Reduce frequency according to symptoms • Need to check on the child at least once during the night • Need to seek further help if wheeze worsens • Need review if not better in 3 days Oxford Children’s Hospital

16. Life-threatening wheeze • Give oxygen • Call an ambulance • Give salbutamol (2.5 – 5mg) nebuliser driven by oxygen • Continuous nebulisers if necessary (top-up every 10 minutes) • If you have it, add nebulised ipratropium (250mcg) for 2 nebs • If the child can swallow, give a dose of prednisolone (20-40mg) Oxford Children’s Hospital

17. Croup • Symptoms and signs • <5 years • coryza for 24 hours • barking cough, stridor • low grade fever, not toxic • If intermittent stridor, give oral steroid • dexamethasone 0.15mg/kg or prednisolone 1mg/kg 2 doses 12 hours apart • Need planned review if stridor present • Hospital review if • stridor at rest • recession at rest • If desaturated, severe stridor and recession • Give oxygen, call an ambulance, give nebulised adrenaline 5ml of 1 in 1000 Oxford Children’s Hospital

18. Bronchiolitis • Symptoms and signs • infants • coryza, breathlessness, poor feeding • cough, low grade fever • tachypnoea, recession, crackles +/- wheeze • Supportive treatment • frequent, smaller volume feeds • paracetamol • Hospital review if • recession at rest • desaturated, • taking <50% of feeds, • history of apnoea • low threshold for infants < 6 weeks old and ex-preterm infants. Oxford Children’s Hospital

19. Pneumonia • Symptoms and signs • lethargy and fever • cough, breathlessness, chest pain • crackles or bronchial breathing • not bilateral wheeze! • Give amoxycillin • Hospital review if • significant respiratory distress (see slide 11) • gets less well or remains febrile after 72 hours despite amoxycillin Oxford Children’s Hospital

20. Anaphylaxis • Symptoms and signs • puffy face / lips/ tongue • urticarial rash • stridor and/or wheeze • known history of severe allergy • hypotension and collapse • If respiratory distress, give • oxygen • IM 1 in 1,000 adrenaline • 0.5ml (adult / large child) • 0.125ml - 0.25ml for smaller children • Adrenaline given IM is safe and a good treatment for asthma Oxford Children’s Hospital

21. Be suspicious if • Very young infant (< 4 weeks) • Increases possibility of a congenital problem (heart or lungs) • There is tachypnoea but no recession, consider • sepsis • acidosis • fever • anxiety • The child has not been previously well Oxford Children’s Hospital

22. Follow-up after exacerbations • Follow up within 48 hours (NICE) or at the longest 7 days of discharge – certainly by phone, preferably face – to – face • Identify any avoidable factors and review PAAP – or provide if not already given • Review inhaler technique and adherence • Adjust management if necessary Oxford Children’s Hospital

23. Duncan’s slides on coding Oxford Children’s Hospital

24. Follow up after asthma exacerbations • Code and capture asthma admissions and ED attendances – key outcome measure of practice asthma care

25. Read Coding Asthma Exacerbations

26. High Risk Asthma Register • Consider establishing a register for patients • On BTS Step 4 or Step 5 • Frequent admissions or ED attendances • Post any ITU / HDU admission • Psychosocial problems or known non-adherence causing poor control • High beta agonist use • >8 blue inhalers per year

27. Possible Coding for High Risk Asthma • 13Zu • “At Risk of Emergency Hospital Admission” • Makes health professionals aware of their risk status, prompts rapid response to calls, notification of OOH service via special patient notes etc. • This code is used for the avoiding unplanned admissions DES and would involve provision of a care plan