Children with Respiratory Difficulties

Children frequently present with respiratory problems which account for up to 50% of consultations with general practitioners in young children and about a third of presentations in older children. The importance of these conditions is further highlighted by the fact that they account for 20-35% of acute paediatric admissions and are the fifth most common cause of death in children between the age of one and 14 in the UK. This article focuses on identifying the sick child and suggests underlying diagnoses.

History

• What is the parent or carer worried about?
• What are the symptoms and how long have they been going on for?
• Specifically find out about recent activities suggesting foreign body ingestion, anaphylactic reaction
  

  Foreign body ingestion 4 Suggestive features: witnessed episode, sudden onset of coughing or choking, recent history of playing / eating small objects. Effective coughing suggested by: crying or verbal response to questions, able to take breath in before coughing, loud cough, fully responsive child. Ineffective coughing suggested by: inability to vocalise, quiet or silent cough, inability to breathe, cyanosis, decreasing level of consciousness.

• Specifically find out about past respiratory disease
  

  Past history of asthma 5 Previous severe asthma Previous hospitalisations Dependence on inhaled or systemic corticosteroids Non compliance with medications Labile asthma with pronounced diurnal obstruction Brittle asthma with unexpected sudden deterioration of airway function Chronic asthma with depressive symptoms / manipulative use of asthma

• Complete usual paediatric history. When enquiring about social history in young child, enquire about smokers in the house (relatives, frequent visitors).

Examination

• General observations
• Respiratory system

  Signs of respiratory Distress 3
  Sign	Comment
  Tachypnoea	Normal respiratory rates: < 1 year: 30-40 breaths per minute. 1-2 years: 25-35 breaths per minute. 2-5 years: 25-30 breaths per minute. 5-12 years: 20-25 breaths per minute. > 12 years: 15-20 breaths per minute.
  Intercostal and sternal resession	Intercostal and abdominal muscles are drawn in with each inspiration. This is seen more easily in very young children therefore if it is particularly significant if seen in the child over 6-7 years of age.
  Use of accessory muscles	Look for the head bobbing up and down in infants.
  Tripoding or anchoring	The child may sit forward and grasp their feet or hold onto the side of the bed.
  Nasal flaring	Particularly seen in infants.
  Inspiratory / expiratory noises	Stridor: high pitched inspiratory noise - sign of upper airway obstruction. Wheezing: tends to be louder on expiration - sign of smaller calibre lower airway obstruction. Grunting: exhalation against a partially closed glottis - sign of severe respiratory distress in infants.

  Assess chest expansion and auscultate: beware of the silent chest (this means that very little air is going in and out).

• Other systems - these need assessing to gauge to what extent the respiratory distress has affected them.
  • Cardiac system - tachycardia is generally seen. Bradycardia occurs in the presence of severe or prolonged hypoxia and is a pre-terminal sign.
  • Skin colour - pallor occurs initially. Cyanosis is a late and pre-terminal sign.
  • Agitation ± drowsiness. This may be difficult to assess and the parents will need to be consulted in the case of the very young child or baby.

• Laryngomalacia
• Foreign body
• Laryngeal oedema: anaphylaxis, inhalation injury
• Upper respiratory tract infection: epiglottitis, croup, retropharyngeal abscess
• Lower respiratory tract causes: asthma, bronchitis, acute respiratory distress syndrome.

This will be guided by the degree of respiratory distress and the underlying diagnosis. Life-threatening respiratory distress warrants immediate initiation of life support measures (see links below). Children with moderate to severe respiratory distress should be referred to the local paediatric team. Where the decision is made to treat the child at home, parental education and frequent reviews are mandatory.