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VarpuElenius
TuomasJartti
MikaMäkelä

Difficulty Breathing in a Child

Essentials

  • In children, two types of obstructive breathing http://www.dynamed.com/approach-to/wheezing-in-children-approach-to-the-patient#INCIDENCE_PREVALENCE difficulties exist.
    • Difficulty in inspiration occurs in laryngitis, epiglottitis, laryngotracheitis and bacterial tracheitis.
    • Difficulty in expiration occurs in bronchiolitis, obstructive bronchitis and asthma.
  • Identify the following conditions requiring immediate treatment (the child should be treated in a hospital):
    • Imminent exhaustion of the child due to hypoxia and/or increased respiratory workload in association with breathing difficulty of any cause
      • If oxygen saturation is below 95 %, administer supplemental oxygen; saturation below 90 % signifies a severe case.
  • Assess breathing difficulty by observing the patient's general appearance and work of breathing
    • Check oxygen saturation, pulse rate, respiratory rate and use of accessory respiratory muscles.
  • Perform auscultation
    • Inspiratory stridor is associated with obstruction of the larynx and trachea (laryngitis, epiglottitis, tracheitis),
    • The wheezing heard in patients with expiratory difficulty may be polyphonic (various frequencies may be heard), which is due to obstruction of several bronchi of different sizes (bronchiolitis, obstructive bronchitis, asthma).
    • Monophonic expiratory wheezing suggests obstruction of a single airway (foreign body, mucous plug)

Laryngitis

Epiglottitis

  • Epiglottitis should be suspected if a child has drooling, dysphagia, high fever and difficulty in inspiration http://www.dynamed.com/condition/acute-epiglottitis#CHIEF_CONCERN__CC_. Epiglottitis is not associated with barking cough.
  • Refer the child immediately to hospital care. Ensure adequate oxygenation during transport.
  • Hib vaccination, which is part of the Finnish national vaccination programme, has reduced the incidence of epiglottitis in children born in Finland to virtually non-existent (1-2 cases per year). Check whether the child has been immunized.

Obstructive bronchitis

  • Acute and recurrent expiratory difficulty
  • See article Management of acute expiratory airflow obstruction and exacerbation of asthma in children Management of Acute Expiratory Airflow Obstruction and Exacerbation of Asthma in Children.
  • In Finland, expiratory difficulty triggered by an acute viral infection usually in a child aged 12 to 36 months is called obstructive bronchitis (ICD 10: J20.5-J20.9).
  • Expiratory difficulty triggered by an infection occurs in as many as 1 child in 3 below the age of 3 years http://www.dynamed.com/approach-to/wheezing-in-children-approach-to-the-patient#INCIDENCE_PREVALENCE.
  • The border between obstructive bronchitis, bronchiolitis and childhood asthma is indistinct.
  • The diagnosis is not difficult: there is a coughing child with rapid and noisy expiration.
  • On auscultation of the lungs, the expirium is typically prolonged and wheezing can usually be heard. Due to the constriction of bronchi of various sizes, wheezing may be polyphonic, i.e. wheezing of various frequencies may be heard.
  • However, wheezing is not always heard; auscultation findings may consist only of coarse rales associated with the presence of mucus, predominantly in expiration.
  • In severe obstruction, auscultation findings may even be interpreted as normal or reduced because of shallow breathing. However, the respiratory rate is nearly invariably increased. It is essential to assess the work of breathing comprehensively by inspection and auscultation.
  • PEF can usually be successfully measured even in a child of about 6 years, and it should be done also in emergency cases.
  • Mild obstruction does not always cause visible breathing difficulty but only prolonged expiration or mucus-related rales.
    • The disease may be interpreted as "incipient bronchitis", and the child may receive a course of antimicrobials, when he/she would actually need a bronchodilator.
  • It is important to identify those children who are prone to develop symptoms in association with viral infections.
  • Expiratory difficulty observed by a physician repeatedly (more than 3 times per year) or frequently (2 attacks within 6 weeks) in association with viral infections in a child below school age is an indication for referral for assessment by a paediatrician in specialized care, where the risk factors for asthma are assessed and the start and further follow-up of anti-inflammatory medication planned.

BronchiolitisEpinephrine for Bronchiolitis, Glucocorticoids for Acute Viral Bronchiolitis in Infants and Young Children, Steam Inhalation or Humidified Oxygen for Acute Bronchiolitis in Children, Bronchodilators for Bronchiolitis, Antibiotics for Bronchiolitis in Children

  • Bronchiolitis denotes the first episode of expiratory breathing difficulty in an infant less than one year of age. RS virus is the most common causative agent http://www.dynamed.com/condition/bronchiolitis#CAUSES. Viruses such as rhino- and metapneumovirus can also cause a similar clinical picture.
  • Bronchiolitis is an infection of the most peripheral bronchi (bronchioles) and, as the virus also occurs in the surrounding lung tissue, the disease shows features of viral pneumonia. There may be copious mucus.
  • A typical patient with bronchiolitis is a small infant with respiratory difficulty; on auscultation, crepitation/crackles and possibly slight expiratory wheezing can be heard. Feeding often becomes more difficult and the child gets easily exhausted. The auscultatory finding may be normal. Increased respiratory rate (> 50/min.) is a significant symptom.
  • Patients below the age of 3 months should usually be referred for follow-up at hospital because of the risk of apnoea and respiratory insufficiency. High-risk patients include the youngest infants, premature babies and those with a cardiac disorder http://www.dynamed.com/condition/bronchiolitis#MISC8.
  • Treatment is symptomatic. In the hospital it consists of monitoring the patient's general condition and taking care of adequate oxygenation, nutrition and clearing of mucus. Warmed and humidified oxygen-air mixture may be administered at a high rate (high flow mask), which may decrease the need for intubation http://www.dynamed.com/condition/bronchiolitis#MISC8.
  • Inhaled salbutamol, racemic adrenaline, hypertonic saline or glucocorticoids do not, according to studies, alleviate the symptoms or decrease the need for hospital treatment of infants with bronchiolitis http://www.dynamed.com/condition/bronchiolitis#MISC8.

Cough associated with viral infection Honey for Acute Cough in Children, Antibiotics for Preventing Complications from Acute Respiratory Infections in Children, Antibiotics for Prolonged Moist Cough in Children

Cough associated with a foreign body

References

Evidence Summaries