Acute wheeze assessment & initial management in children.

1. Acute wheeze assessment & initialmanagement in children. “It ain’t easy being wheezy” Dr Steve Foster Consultant in PEM – RHC Glasgow

2. Key outcomes • How to recognise an ‘acute’ wheezing presentation • How to assess the severity of the episode • Key immediate management strategies • Thresholds for transfer to hospital based services & key factors to ensure ‘safe’ transfer.

3. Recognising an ‘acute’ wheezing event

4. Why acute wheeze and not asthma? • Asthma is recurrent wheezing episodes • EVW versus MTW ? • Presentation can vary hugely with age. • Age of patient & detailed Hx imperitive • Identification of alternative causes.

5. Primary trigger infection rather than triggered allergen (Dondi et al 2017) • Only 3% <6yr olds versus 33% of >6yr olds • Pre-schoolers are particularly challenging. • Often no previous Hx of wheeze or interval Sx. • Insidious onset in context of URTI Sx. • Wheeze often confused with other respiratory noises reported by parents. • Throat or abdominal pain can be primary presenting feature.

6. Wheeze – on auscultation! • Breathlessness – not always straightforward • Chest tightness. • In a child who is unwilling to communicate this assessment can be challenging! • Assessing the respiratory effort is key!

7. Assessing the severity of the wheezing event.

8. Accurate assessment of severity guides: • Initial management – avoids under/over treatment. • Likely patient disposition destination. • Markers for degree of breathlessness: • Inability to complete sentences in 1 breath • Interrupted cry • Inability to complete feeds due to dyspnoea • Agitation / distress often due to dyspnoea

9. Clinical signs may correlate poorly to severity of airway obstruction. • The timing and intensity of wheezing not a good marker of severity. • Biphasic wheeze or less apparent wheeze with a quiet chest can both indicate severe obstruction. • Most reliable parameters for assessing severity are often best achieved without even touching the patient • With exception of pulse oximetry!

10. Parameters for assessing severity: • General appearance • Degree of agitation • Conscious level • Respiratory rate • Respiratory effort (accessory muscle use/chest wall recession) • Heart rate • Pulse oximetry [Peak expiratory flow (PEF)]

11. Effort of breathing signs in younger children: • Always expose the whole torso • Increase abdominal >>> chest wall movement • Subcostal >>> scalene muscle use • Watch for forced expiration – abdominal muscle use • Beware the grunting or tiring child! • The only time a ‘seesaw’ is not a fun thing!

13. Acute wheeze Initial management strategies

17. Transfer to hospital based services

18. Depends on what you can offer locally • If severe/life-threatening – liaise with local Paediatric services / Scotstar AFTER initiating therapy. • Hypoxic children (SpO2<92%) need oxygen. • Ambulance transfer not parent transport! • Ensure all necessary therapies are continued on route to the hospital.