CASE  Children’s Health – Breathless and noisy breathing

In module Child Health

The following case surrounds the presentation of a 2 year old girl brought into the Emergency Department with respiratory difficulties.

MAIN CASE

CASE COMPONENT

Guidance and Resources – Breathlessness and noisy breathing

In case Children’s Health – Breathless and noisy breathing

Guidance

By the end of Case 1 you will be able to:

1.    Apply knowledge of epidemiology, clinical presentations, assessment and the justification for the management of upper airway obstruction in childhood, recognising the impact of these conditions on individuals, and their families .

2.    Apply knowledge from the pre-module material regarding the recognition and immediate care in acutely unwell child

3.     Explain the key features you would look for when as sessing a child presenting with shortness of breath.

4.     Compare and contrast different causes of stridor in cluding their assessment and management.

5.    Apply knowledge of pharmacology and the principles of safe drug prescription in childhood

6.    Review the Planning and negotiation with the patient/ legal guardian appropriate evidence based management strategies

Resources

Overview of croup:

https://youtu.be/gxvtY2hUzWw

Paediatric Early Warning Score (PEWS) Chart

Saudi Growth Charts

Web Links

Croup – BMJ Best Practice (open through university library) WWW.elibrary.taibahu.edu.sa/taibah

Spotting the Sick Child (free access but need registration)

very helpful recourse: see symptoms videos and work through till you  reach the final test

Foreign body aspiration – BMJ Best Practice (open through university library) WWW.elibrary.taibahu.edu.sa/taibah

North West Paediatric Allergy Network

CASE COMPONENT

Case Introduction – Breathlessness and noisy breathing

In case Children’s Health – Breathless and noisy breathing

Ellie aged 2 has been brought into to Emergency Department by ambulance at 11pm. Her mum said that she had woken suddenly with a loud harsh cough and difficult noisy breathing and that she was very distressed.

Her parents report she had been well during the day although the whole family have had a mild cold. She is otherwise fit and well, fully immunised, and making good developmental progress.

Rapid clinical assessment in the emergency department resuscitation area reveals a frightened 2 year old girl who is visibly breathless with a high pitched noise heard on inspiration.

You need to decide how unwell Ellie is and what initial actions are required.

Please Revise the Early Warning Score (EW) used to identify unwell or deteriorating adults:

· Summary of EWS Policy – CMFT (can you use it in this child? why?

Ellie’s Observations and initial assessment:

Please view the video below representing Ellie’s initial examnitaion:

https://youtu.be/Qbn1Zw5CTbA

Additional Examination findings:

· SaO2 95% in air

· HR 180/min Capillary refill time 2 seconds

· You have NOT examined her ears nose and throat.

Use the mnemonic VITAMIN CDEF to assist you .

 Vascular

Haemangioma; consider a laryngeal capillary haemangioma if slowly progressive airway obstruction / stridor since birth, particularly if the child has other capillary haemangiomas (Strawberry Marks), as the natural course of these is to enlarge steadily over the first 12-24 months of life.

These images show the typical evolution, enlargement and start of resolution of the capillary haemangiomas (which should be eventually complete). They require specialist management if they are in sensitive areas particularly next to the eye or are very large.

 Infective

Please see Below; Viral or Bacterial

 Traumatic

Consider foreign body aspiration in the absence of direct trauma.

 Autoimmune

Allergic symptoms may present with upper airway signs.

 Metabolic

Abnormalities of the thyroid and neck are rare, and likely congenital although cystic lesions may appear to develop later, older children with rare metabolic diseases affecting the bones and soft tissues such as Mucopolysaccharidoses, may present with breathing difficulties; progressive symptoms and infants and children with neck swelling or dysmrophic features require specialist assessment.

 Inflammatory / Iatrogenic

Secondary upper airway inflammation and symptoms such as stridor and cough can occur due to gastro-oesophageal reflux disease. Please note that some infants with gastro-oesophageal reflux do not vomit but have ‘silent symptoms of intermittent distress commonly after feeds and on lying flat, intermittent breathing difficulty with symptoms including stridor, episodes of colour change and / or recurrent chest infections, and behavioural changes such as back arching. the following search terms may be helpful in finding source video materials; ‘infant, silent reflux, back arching’

Information regarding the identification, assessment and treatment of gastro oesophageal reflux disease:

Dyspepsia and gastro-oesophageal reflux disease overview – NICE Pathways

 Neoplastic

Airway neoplasms other than vascular malformations are very rare in childhood

 Congenital

Present since birth; for example; Laryngomalacia or floppy larynx, consider if present from birth, with soft stridor worsening with feeds due to the collapse of the very soft airway tissues with negative inspiratory pressure; infants with this condition should be well; the following search terms may be helpful in finding source video materials; ‘laryngomalacia infant stridor’.

Other congenital anomalies are rare; diagnosis of these, vascular anomalies and other causes of on-going stridor require specialist investigation in some circumstances, endoscopic viewing of the upper airway via tertiary ENT teams.

 Degenerative / Developmental

Children with delays in development and neuromuscular disorders may have difficulty clearing secretions, swallowing and coughing efficiently, a build up of secretions causes upper airway usually inspiratory noises, these sound very wet and are described as stertor. Similar symptoms can be found in children with enlargement of their adenoids and tonsils and may be severe enough to lead to sleep apnoea.

 Endocrine Functional / Environmental

Foreign body ingestion is discussed below. This should not cause upper airway symptoms in childhood, it must be remembered however that inconsistencies in the history and/ or unusual patterns of symptoms may be due to child abuse or neglect and a full assessment including looking for index features of inflicted injury such as a torn frenulum is indicated.

You assess that Ellie has croup.

The bacteriology profile of causes of upper airway obstruction is changing with epiglottitis becoming very uncommon due to HiB vaccination or due to staphylococcal or haemolytic streptococcal infection, with additional organisms implicated as in Bacterial Tracheitis (although anaerobic organisms are also implicated in this condition). Antibiotic choice once the airway has been secured is therefore broad spectrum.

Her parents are extremely worried and want to know the diagnosis, how she is and what you are going to do.

Progress

Ellie received single doses of dexamethasone and paracetamol, she was observed in the observation and assessment unit and she steadily improved.

After 3- 4 hours Review revealed:

Alert, playing with mum’s phone; stridor very quiet, only when excited, intermittent barking cough remains.

Respiratory Rate32/min no signs of respiratory distress; SaO2 98% in air.

Heart Rate 110/min, cap refill less than 2 seconds.

She was allowed home with instructions to seek medical attention should they notice a recurrence of her difficulty in breathing, as a safety net.

CASE COMPONENT

Further Case Information – Breathlessness and noisy breathing

In case Children’s Health – Breathless and noisy breathing

 Please revise and refresh your knowledge of acute allergy in childhood below

Anaphylaxis is thankfully rare but does occur in children occasionally. It must be considered in children presenting with signs of upper airway obstruction.

Surprisingly there is no international agreement on the definition of Anaphylaxis. This is not really that important in clinical practice. We need to assess whether there has been evidence of life threatening allergic reactions. In the above question the incorrect answers were all features of allergic reactions but would not in isolation constitute life threatening allergy. Angioedema often causes confusion. If it occurs in the airway it is clearly serious. If it occurs on the face and lips it looks very distressing but is not of itself a worrying sign. If it occurs on the tongue this is more difficult as it may cause airway compromise if severe enough.

When taking a history it is therefore necessary to assess the child for future risk of an anaphylactic reaction as this will guide your management. 

Most clinicians agree that a history of allergy in the presence of poorly controlled Asthma is a risk factor for anaphylaxis. There is some disagreement about whether the risk is increased if a child is taking a small dose of inhaled corticosteroid and they have well controlled Asthma as a result. This would therefore be a judgement that an experienced clinician would need to make.

In order for children to have reactions to foodstuffs or environmental allergens they would need to have encountered the allergen previously. This is the process of sensitization.

An understanding of the underlying physiological processes involved will help you when it comes to seeing patients with suspected allergy. The key thing to remember is that it is a Type I immediate Hypersensitivity. Knowing the actions of Histamine will also help you when deciding if the reaction described is suspicious of a food allergy.

So the first task is to assess the severity of previous reactions and the risk of future Anaphylaxis.

The next thing to consider is how easily avoidable an allergen is. Some things are more difficult to avoid such as nuts and some may be easier such as Kiwi fruit. This needs to be taken into consideration when prescribing treatment. The amount of allergen ingested to cause a reaction can be an indicator as well i.e. a relatively florid reaction to a tiny exposure would make one suspect a more severe reaction were they to eat a larger amount of allergen.

Adrenaline pen

https://www.youtube.com/watch?v=EN83hen4D-Y

In the absence of these risk factors and after discussion with parents it is often the case that children merely need to have an anti-histamine available. They must be informed what symptoms to look out for and what to do in the event of deterioration.

In addition realistic advice must be given regarding allergy avoidance ideally via a specialist dietician. Most paediatric Allergy units now give parents individualised management plans.

Regarding foreign Body Inhalation in a child

It is important for you to be able to recognise and manage a choking child; please see the following link:

· Management of the choking child – Resuscitation UK

CASE COMPONENT

Background Science – Breathlessness and noisy breathing

In case Children’s Health – Breathless and noisy breathing

Detailed review of allergy and hypersensitivity:

· Immune System Structure and Function

· Review of hypersensitivity reactions

CASE COMPONENT

Case Conclusion – Breathlessness and noisy breathing

In case Children’s Health – Breathless and noisy breathing

 Patient: Ellie Wilson – NHS No. 2434659876

Discharge summary: to GP Parents and Health Visitor;

Diagnosis: Moderate viral Croup

Ellie presented acutely with typical barking cough and sudden onset of stridor, and breathlessness following corhyza; assessment revealed a low grade fever, moderate upper airway obstruction requiring a single dose of nebulised adrenaline. She was observed overnight, responding well to oral dexamethasone treatment.

Advice given: to seek medical attention should her breathing difficulty recur.

Follow up: Nil

GP action: to review as needed only

Yours sincerely

Dr B Murphy GMC 9876543

FY1; Central Manchester Children’s Hospital

This is the ellie’s discharge summary letter

CASE COMPONENT

Formative Assessment – Breathlessness and noisy breathing

In a child with stridor which of the following statements is TRUE?

·          A cannula should be immediately sited in a child with severe stridor

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·          The airway team should only be called after the initial attending doctor has visualised the vocal cords

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·          Cyanosis is seen early

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·          A child with significant stridor is best managed in the mothers lap and distress kept to a minimum

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·          The loudness of the stridor indicates how unwell the child is