EVIDENCE BASED GUIDELINE FOR MANAGEMENT OF CHILDREN PRESENTING WITH ACUTE BREATHING DIFFICULTY

EVIDENCE BASED GUIDELINEFOR MANAGEMENT OF CHILDREN PRESENTING WITH ACUTE BREATHING DIFFICULTY Produced by the Paediatric Accident and Emergency Research Group at Queens Medical Centre , Nottingham supported by Children Nationwide Next slide

ACUTE BREATHING DIFFICULTY • To run through the programme, click on: • for further information, • to return to the previous page • to return to this page For grades of evidence used see Click here to begin.

ACUTE BREATHING DIFFICULTY Resuscitate if needed ABC • ASSESS: • Respiration rate over 60 secs • Work of breathing-degree of distress • Wheeze,cough, stridor ? • Signs of serious illness • Age and / or complicating factors • SaO2 Next slide Previous page

This guide takes you through each of these points. It offers guidance on actions to take. At each stage you can access the level of evidence behind each step. For full discussion of the evidence please see the full report by Lakhanpaul M et al on www.cccccc The guideline has been appraised by the Quality of Practice Committee of the Royal College of Paediatrics and Child Health (2002) Next slide

INITIAL ASSESSMENT PROTOCOL ACUTE BREATHING DIFFICULTY Presence of pre-terminal signs or signs requiring urgent attention Click if NO Click if YES

CHECK: Airway Breathing Circulation Start basic life support&Call appropriate team for advanced life support ADMITto HDU/PICU Previous page

Measure respiratory rate for 60 seconds & oxygen saturation If O2sat <= 92%Give oxygen and admit ? Admit ? Signs of increased work of breathing Yes No ? Signs of serious illness/complicating factors Click ifYes Stridor/stertor/wheeze or cough? No No Yes ? URTI Home with GP Follow up;Patient Education D/W senior Dr Consider alternative diagnoses Arrange appropriate investigations Admit Previous page

STRIDOR/STERTOR WHEEZE COUGH Yes Mild/moderate distressAdmit if complicating factors/serious illness Admit ifsevere distress Previous page

STRIDOR (limited airflow at larynx or trachea) or STERTOR (noise due to obstruction at pharyngeal level) ? BARKING COUGH Yes No ? Toxic &High Fever ? Agitated/ Drooling Click if NO Click if YES Click if NO Click if YES Previous page

Agitated/Drooling ? Epiglottis Secure Airway Call for senior assistance Consider ENT referral Admit to PICU/HDU Previous page

? STERTOR Yes No ?Enlarged Tonsils ?Foreign body aspiration CXR Refer urgently to ENT ?Normal Yes No Refer to appropriate doctor for bronchoscopy If strong suspicion of aspiration Previous page

Toxic+ High Fever ? Bacterial tracheitis Secure Airway Admit to PICU/HDU Previous page

? CROUPTreat with: Oral dexamethasone If vomiting: Use nebulised budesonide ?Signs of potential respiratory failure No Yes 1. Signs of severe resp distress 2. Signs of serious illness 1. Give l-epinephrine (adrenaline) nebuliser 2. Admit for close observation 3. PICU/HDU No Yes HOME with GP follow up, patient education and call back instructions 1. Consider adrenaline nebuliser 2. ADMIT Previous page

WHEEZE History of choking or paroxysmal cough Yes Continue management as for other children presenting with wheeze BUT CXR if ?foreign body aspiration/other atypical features e.g. focal signs but no symptoms of bronchiolitis Assess severity If high suspicion refer to appropriate surgical team Age >2 Age <2 Previous page

Age >2 ? Mild/moderate symptoms Yes No 1. B2-agonist via spacer Moderate/severe Yes 1. B2-agonist (volumatic if not on 02) 2. Oral steroid 3. +/- 4-6hrly anticholinergic 1. HOME 2. Follow up instructions Life threatening 1. Check ABC 2. Follow BTS guidelines, i.e. IV aminophyline + steroids + frequent B2-agonist 3. ADMIT TO HDU/PICU 4. X-RAY when stable 1. ADMIT TO WARD 2. If no improvement, inc. frequency of B2-agonist up to ½ hourly or continuously 3. Follow BTS guidelines 4. Consider X-RAY Previous page

Age <2 1. Dry wheezy cough 2. Fever 3. Nasal discharge 4. Fine insp crackles and/or high pitched exp wheeze Yes ? Bronchiolitis See cough algorithm No 1. TRIAL of B2-agonist/anticholinergic 2. Monitor 02 sats 3. Discontinue if no effect 4. X-ray if ?pneumothorax (unilateral reduced air entry +hyperresonnance on percussion) Mild/moderate Moderate/Severe/Life threatening 1. HOME 2. Follow up instructions 1. ADMIT 2. Short course of oral steriods 3. ?X-ray if no improvement 4. Follow BTS guidelines, i.e. inc frequency of bronchodilator Previous page

COUGH If accompanied by whee ze or stridor see appropriate algorithm ? Paroxysmal cough or high suspicion of foreign body CXR Yes No ? Referral to appropriate team for bronchoscopy • 1. Dry wheezy cough and age under 2 • Fever +/- • Nasal discharge • 4. Fine insp crackles and/orhigh pitched exp rhonchi Click if NO Click if YES Previous page

Bronchiolitis 1. Trial of bronchodilator 2. Stop if no clinical improvement 3. Monitor 02 sat 4. No steroids 5. No routine blood tests/X-rays ? Severe distress Yes No 1. Discuss with senior clinician 2. Consider trial of nebulised adrenaline 3. ADMIT for close observation, e.g. HDU/PICU ADMIT if: 1. Signs of serious illness 2. Complicating factors 3. Inc risk of serious disease Previous page

Combination of cough &breathing difficulty and: 1. Fever 2. High resp rate 3. Grunting 4. Chest in-drawing No Re-assess child Yes PNEUMONIA Mild/moderate distress Severe distress 1. CXR 2. Oral/IV antibiotics according to local protocol 3. FBC & B.culture if requires IV antibiotics 4. No routine blood tests if on oral rx 5. ADMIT CXR ? 1. X-ray child under 2 months/if no response to antibiotics/recurrent pneumonia 2. No routine blood tests 3. Oral antibiotics if clinically suspected 4. HOME with follow up instructions. Previous page

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Table 9: Indications for treatment with parenteral antibiotics in a child clinically suspected to have pneumonia Back

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EVIDENCE BASED GUIDELINE FOR MANAGEMENT OF CHILDREN PRESENTING WITH ACUTE BREATHING DIFFICULTY