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Vianca Shah SOB in a childCONTENT 1. Breathlessness in a child 2. History taking 3. Examination 4. DDx 1: Bronchiolitis 5. Quiz 1 6. DDx 2 : VIW 7. DDx 3 : Pneumonia 8. Quiz 2What is the presentation?Elsa is a 1-year- old girl presentingwith acute onset shortness of breathDifferentialsAcute SOB causes Upper airway causes? • Croup • Epiglottis • Foreign body inhalation • Anaphylaxis • Retropharyngeal abscessAcute SOB causes Lower airway causes? • Asthma • Bronchiolitis • Pneumonia • ARDSOther acute SOB causes Cardiac causes • Acute HF (background of congenital) Metabolic causes • DKA, anaemia Neuromuscular • Muscular dystrophy PsychiatricChronic SOB causes Respiratory causes • CF • Asthma • Primary ciliary dyskinesia • Consequence of bronchopulmonary dysplasia • Chronic aspiration / GORD Neuromuscular • Muscular dystrophy DMD/SMA • Kyphoscoliosis Cardiac • CHD Haematological causes / other • Anaemia • Mitochondrial diseaseHistory Taking History of presenting complaint Past medical history Drug history Don’t forget to ICE! Family history Social historyHPC • Onset • Exertional? • Worse at night? Seasonal / diurnal • If using an inhaler how often? • Respiratory symptoms associated : wheeze, cough, stridor, cyanosis • Other associated symptoms: palpitations • Constitutional symptoms – fever • Appetite / behaviournappiesHPC Onset – started last 2 days ago Associated cough and fever breastfeeding)te - <50% of milk intake (currently Fewer wet nappies Seems lethargicPMH Hospital admissions Visits to PICU and number Birth history Respiratory pathology Weight at birth Type of delivery (C-section vs vaginal) Any NICU stay Immunisation historyPMH Born 39 weeks - vaginal delivery, nil complicationsDHx Including allergies – and the impact Consider OTC / herbalDHx NKDA Nil DHx Imms: Up to dateSHx • Any other people unwell at home • SafeguardingSHx • Older brother goes to nursery is always picking up ‘some kind of bug’ • Lives with mum and dad • Does not yet attend nursery • No safeguarding concernsFHx • Atopic conditions (asthma/allergic)FHx • Brother has asthma and dad has eczemaRED FLAGSRed flags: Grunting RR > 60 Moderate/severe chest indrawingEXAMINATION • RR 45 • Nasal flaring • O2 sats 90% on air • Widespread wheeze and inspiratory crackles • WOB • Look out for chest recessions, accessory muscle use, tracheal tug, head bobbing in infantsInvestigations O2 sats Obs Bedside – peak flow/spirometry, ABG (asthma) Bloods – baseline + CRP (pneumonia), tryptase (anaphylaxis) Imaging – CXR / otherDIFFERENTIAL 1What is it? BronchiolitisCauses/risk factors • RF: previous bronchiolitis, age < 1 (most common at 5-6 months), NICU/neonatal respiratory pathology • More serious with: congenital heart disease, bronchopulmonary dysplasia (prematurity), CFSymptoms and signs Cough / coryzal symptoms SOB Wheeze Mild fever Feeding difficulties – often cause of hospital admissionInvestigations • As before: CXR etc • Consider viral swab (note immunofluorescence for RSV is not common)Treatment Supportive - optiflow (humidified O2), suction NG tube if feeding difficultyComplications • Respiratory distressQuestion 1 A 3-year-old child presents with sudden onset of respiratory distress, inspiratory stridor, and a barking cough. The child has a low-grade fever most likely diagnosis?rest but has mild intercostal recession. What is the B) Foreign body aspiration C) Croup D) AsthmaQuestion 1 A 3-year-old child presents with sudden onset of respiratory distress, inspiratory stridor, and a barking cough. The child has a low-grade fever most likely diagnosis?rest but has mild intercostal recession. What is the B) Foreign body aspiration C) Croup D) AsthmaQuestion 2 A 6-month-old infant presents with a 2-day history of cough, nasal congestion, and increasing difficulty in breathing. On examination, the infant has a wheezing. What is the most likely causative organism?recessions, and B) Respiratory syncytial virus (RSV) C) Haemophilus influenzae type B D) Bordetella pertussisQuestion 2 A 6-month-old infant presents with a 2-day history of cough, nasal congestion, and increasing difficulty in breathing. On examination, the infant has a wheezing. What is the most likely causative organism?recessions, and B) Respiratory syncytial virus (RSV) C) Haemophilus influenzae type B D) Bordetella pertussisQuestion 3 A 4-month-old infant is brought to the emergency department with a 3-day history of cough, poor feeding, and increasing respiratory distress. Examination reveals nasal flaring, subcostal of 65 breaths per minute, and no focal lung signs. A chest X-ray is performed and showsatory rate hyperinflation but no focal consolidation. Which of the following would NOT be routinely recommended in the management of this infant? A) Supplemental oxygen B) Nebulised hypertonic saline C) Oral dexamethasone D) Nasogastric feeding if oral intake is inadequateQuestion 3 A 4-month-old infant is brought to the emergency department with a 3-day history of cough, poor feeding, and increasing respiratory distress. Examination reveals nasal flaring, subcostal of 65 breaths per minute, and no focal lung signs. A chest X-ray is performed and showsatory rate hyperinflation but no focal consolidation. Which of the following would NOT be routinely recommended in the management of this infant? A) Supplemental oxygen B) Nebulised hypertonic saline C) Oral dexamethasone D) Nasogastric feeding if oral intake is inadequateDIFFERENTIAL 2 : VIWWhat is it? • In children < 5 asthma is difficult to diagnose • Wheeze linked to respiratory virusesCauses/risk factorsSymptoms and signs • Wheeze • Coryzal symptomsInvestigations • Basic respiratoryManagement Nebulised salbutamol O2 Episodic – 1st - SABA / anticholinergic via spacer, 2nd - + LTRA / and intermittent ICS Multiple trigger – trial inhaled ICS / LTRAComplications • Future asthma increased risk • Respiratory failureDIFFERENTIAL 3What is it?Causes/risk factors Viralrial Rarely – fungalSymptoms and signs Cough - sputum producing, green/yellow Fever Pleuritic chest painInvestigations CURB-65 As for all resp CXRTreatment CAP : amoxicillin Add macrolide if atypical If influenza + pneumonia – co- amoxiclav Severe : IVComplications Pleural effusions / empyema Respiratory failure Sepsis Abscess ARDSQuestion 4 A 2-year-old child presents to the emergency department with a 2-day history of cough, wheezing, and increased work of breathing. There is no history of atopy or previous wheezing episodes. Examination reveals a respiratory rate of 50 breaths per minute, mild subcostal recessions, widespread expiratory wheeze, and SpO₂ of 95% on air. Which of the following is the most appropriate initial management? A) Nebulised adrenaline B) Oral prednisolone C) Inhaled salbutamol via a spacer D) Intravenous magnesium sulfateQuestion 4 A 2-year-old child presents to the emergency department with a 2-day history of cough, wheezing, and increased work of breathing. There is no history of atopy or previous wheezing episodes. Examination reveals a respiratory rate of 50 breaths per minute, mild subcostal recessions, widespread expiratory wheeze, and SpO₂ of 95% on air. Which of the following is the most appropriate initial management? A) Nebulised adrenaline B) Oral prednisolone C) Inhaled salbutamol via a spacer D) Intravenous magnesium sulfateQuestion 5 A breathlessness. The child was playing and eating peanuts when they suddenly startedre coughing and became dyspnoeic. On examination, the child has a respiratory rate of 45 breaths per minute, decreased air entry on the right side, and a mild wheeze. There is no appropriate next step in management? A chest X-ray shows as follows. What is the most A)B) Oral prednisolonel C) Rigid bronchoscopy D) Chest physiotherapyQuestion 5 A breathlessness. The child was playing and eating peanuts when they suddenly startedre coughing and became dyspnoeic. On examination, the child has a respiratory rate of 45 breaths per minute, decreased air entry on the right side, and a mild wheeze. There is no appropriate next step in management? A chest X-ray shows as follows. What is the most B) Oral prednisolonemol C) Rigid bronchoscopy D) Chest physiotherapyQuestion 6 An 8-year-old child presents with a 5-day history of fever, malaise, and progressively worsening cough. The cough is dry at first but has become productive. The child has a mild headache and complains of pleuritic chest pain. Examination reveals a respiratory rate of 35 breaths per minute, crackles and reduced air entry on consolidation. The child is otherwise well and tolerating oral intake.shows bilateral patchy infiltrates without Which of the following is the most likely causative organism, and what is the most appropriate treatment? A) B) Mycoplasma pneumoniae – Clarithromycin C) Haemophilus influenzae – Co-amoxiclav D) Respiratory syncytial virus (RSV) – Supportive careQuestion 6 An 8-year-old child presents with a 5-day history of fever, malaise, and progressively worsening cough. The chest pain. Examination reveals a respiratory rate of 35 breaths per minute, crackles and reduced air entry on the left side, but no significant dullness to percussion. Chest X-ray shows bilateral patchy infiltrates without consolidation. The child is otherwise well and tolerating oral intake. Which of the following is the most likely causative organism, and what is the most appropriate treatment? A) Streptococcus pneumoniae – Amoxicillin B) Mycoplasma pneumoniae – Clarithromycin – this is suggestive of an atypical infection (dry cough, bilateral patchy infiltrates) D) Respiratory syncytial virus (RSV) – Supportive careSUMMARY 1. What is limb weakness? 2. History taking 3. Examination 4. DDx 1 5. Quiz 1 6. DDx 2 7. DDx 3 8. Quiz 2Please fill out the feedback form Thank you!References