7 Lower respiratory tract conditions
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- Viral croup
- An approach to lower respiratory tract conditions
- Case studies
When you have completed this chapter you should be able to:
- Give the signs of breathing difficulty and respiratory distress.
- List the important lower respiratory tract conditions.
- Diagnose these conditions.
- Understand the causes and possible prevention of these conditions.
- Provide primary management of these conditions.
- Describe a syndromic approach to a child with a cough.
7-1 What is the lower respiratory tract?
The lower respiratory tract consists of:
- Larynx and trachea
- Alveoli (lungs)
Therefore, the respiratory tract from the larynx down is called the lower respiratory tract while the respiratory tract above the larynx is called the upper respiratory tract. Disorders of the lower respiratory tract usually present with one or more signs of breathing difficulty.
Lower respiratory tract disorders usually present with one or more signs of breathing difficulty.
7-2 What are the signs of breathing difficulty?
The major signs are:
- Indrawing of the lower chest wall (recession)
- Fast breathing (tachypnoea)
- Shortness of breath with grunting, nasal flaring, head nodding and refusal to feed
These signs of breathing difficulty suggest that the child’s breathing difficulty is becoming progressively more severe and could lead to respiratory distress.
7-3 What are the signs of respiratory distress?
Respiratory distress is the clinical condition where the respiratory difficulty has become so severe that the child is likely to die unless given respiratory support (e.g. oxygen or ventilation).
- Central cyanosis (or a low oxygen saturation)
- Drowsiness, lethargy or unconsciousness
7-4 What is stridor?
Stridor is a crowing sound made in the throat, most commonly during inspiration. Any narrowing of the airway in the region of the larynx may result in stridor. Narrowing of the airway above (e.g. epiglottis) or below (e.g. trachea) the larynx may also cause stridor.
7-5 What is chest indrawing?
With chest indrawing, the lower ribs on both sides of the chest are pulled in when the child breathes in. This is very abnormal as the lower chest normally moves out when a child breathes in. When resting, children should never have chest indrawing.
7-6 What is a wheeze?
This is a noise made during expiration due to narrowing of the lower airways.
7-7 How can you tell when a child is breathing too fast?
Rapid respiration (tachypnoea) is one of the most important signs of pneumonia. A child at rest is breathing too fast when the following rates are exceeded:
- 60 breaths or more per minute in an infant of 2 months or less
- 50 breaths or more per minute in children 2 months to 1 year
- 40 breaths or more per minute in children older than 1 year
The normal respiratory rate decreases with age. By the age of 12 years healthy children should not breathe faster than 20 breaths per minute.
7-8 What is central cyanosis?
A blue colour of the tongue. The lips may also appear blue instead of the normal pink. Central cyanosis is a very important and dangerous sign which indicates that the cells are not receiving enough oxygen. Cold hands and feet may show peripheral cyanosis. Always look for central cyanosis if a child has peripheral cyanosis.
Pulse oximetry is a very useful method of assessing the oxygen saturation (the amount of oxygen being carried in the red cells of the blood). The normal oxygen saturation is above 95% (above 92% in newborn infants). An oxygen saturation below 90% is abnormal and an indicator for oxygen therapy. A pulse oximeter (or oxygen saturation monitor) is used for measuring the oxygen saturation. The probe is clipped onto the child’s finger, hand or foot and the device displays the heart rate and oxygen saturation.
As central cyanosis is an important sign of respiratory failure, measuring the oxygen saturation is very useful.
7-9 What is viral croup?
This is an acute viral infection of the larynx, trachea and bronchi (acute viral laryngotracheobronchitis). With croup the area around the vocal cords is swollen as is the area just below the cords. Viral croup typically presents in children around 2 years of age (between 6 months and 6 years), especially in autumn. Viral croup is usually mild and the signs of croup usually clear in a few days but may recur. Some children develop viral croup whenever they have a common cold or pharyngitis.
The most common cause of viral croup is an infection with parainfluenza virus.
- Other viruses, such as the respiratory syncytial virus, metapneumovirus, measles, adenovirus and Herpes simplex, can also cause croup.
7-10 What are the presenting signs of viral croup?
The characteristic signs of viral croup are:
- The infection often starts with a common cold or pharyngitis.
- A mild fever
- A typical ‘barking’ cough
- Inspiratory stridor is often, but not always, present. It is usually worse at night and then much better in the morning.
- Hoarseness of the voice is a less common sign in viral croup.
Viral croup typically presents at night with inspiratory stridor and a barking cough.
- Stridor can also be cause by an inhaled foreign body, retropharyngeal abscess, epiglottitis or, rarely, by diphtheria.
7-11 How is the degree of stridor assessed?
The degree of respiratory obstruction is difficult to assess as it may vary from moment to moment. Stridor usually becomes worse if the child cries or becomes agitated. Therefore stridor in a quiet child should be regarded as severe.
- Inspiratory stridor only, without lower chest wall indrawing (recession or retraction) suggests mild airway obstruction. These children usually only have stridor when they are upset or crying. There is no stridor when they are sleeping or at rest.
- The addition of lower chest wall indrawing or stridor during both inspiration and expiration are very important clinical signs as they indicate worsening airways obstruction. Therefore, expiratory stridor is a sign of severe airway obstruction. Stridor at rest in a quiet child also suggests severe stridor.
- The obvious use of chest and abdominal muscles during expiration (active expiration, restlessness or fast breathing (tachypnea) are signs of dangerous airway obstruction.
Expiratory stridor is a sign of worsening airway obstruction.
- Disappearance or weakening of the peripheral pulse on light palpation during inspiration (pulsus paradoxus), marked recession, apathy and cyanosis are signs of severe airway obstruction. Stridor becomes softer with severe obstruction.
7-12 What is the correct management of viral croup?
- The degree of airways obstruction must be continually observed.
- Keep the child comfortable and calm as crying worsens the airways obstruction.
- Keeping the room warm helps. Humidifying the air may also help. Do not accidently burn the child with steam from a kettle. Cold mist does not help.
- If the child has fever above 38 °C give paracetamol.
- Continue to give frequent, small amounts of oral fluid unless the airway obstruction is severe. Continue breastfeeding if the child is not distressed.
- The child can be closely observed at home if the airways obstruction is mild and the home circumstances are adequate. Communication and transport to the nearest health facility are needed if the child is to be managed at home.
- Oral dexamethasone 0.5 mg/kg as a single dose (not if measles or herpes is the cause of the stridor). If no improvement, repeat after 24 hours. Steroids are the most important treatment in severe viral croup.
- There is no indication for antibiotics or bronchodilators in viral croup.
- Move to hospital if the airways obstruction becomes worse, especially if there is both inspiratory and expiratory stridor. It is best to move the child to hospital if there is stridor when the child is at rest. If possible, give oxygen during transport.
- Nebulised adrenaline (1:1000 solution) in hospital is the treatment of choice for worsening or severe airways obstruction. It will often provide temporary relief. If the child responds to the nebulised adrenaline admit the child to hospital for 24 hours to observe for rebound airway obstruction as the effect of adrenaline usually last only about 2 hours.
- Intubation or tracheotomy under general anaesthetic is only needed if respiratory failure develops (cyanosis, restlessness, severe chest wall indrawing or inadequate oxygen saturation in room air). Intubation must be seriously considered if the child has expiratory stridor and uses the chest and abdominal muscles during expiration.
- Oxygen should only be given in cases of severe airway obstruction as the method of delivering (e.g. nasal prongs) could make the child frightened and agitated and worsen the airway obstruction.
- Mix 1 ml of 1:1000 adrenaline with 1 ml saline. Nebulise the entire volume with oxygen. Repeat every 15 minutes until the expiratory obstruction has resolved. Observe the child very carefully for signs of deterioration. Laryngoscopy to look for other causes of stridor is important in children who require intubation.
7-13 What is bronchitis?
Bronchitis is an inflammation of the lining on the large airways of the lung (the large bronchi). The inflammation is usually due to a viral infection, but there may also be a secondary bacterial infection. Bronchitis usually follows an upper respiratory infection (common cold, pharyngitis or influenza). With inflammation of the bronchi, the glands in the walls of the large airways produce excessive secretions (mucus or phlegm) with a ‘productive cough’. These secretions may partially block the airways. Children with bronchitis do not have breathing difficulties (the only lower respiratory tract infection that does not cause breathing difficulties in children). Bronchitis in children is usually acute and recovers in 1 to 2 weeks. Bronchitis is more common in a smoky environment (cigarette smoke or an open fire in the home) and is usually seen in older children.
7-14 What are the symptoms and signs of acute bronchitis?
- A persistent cough. At first the cough is dry, but it may later become loose and produce clear, sticky secretions. Yellow-green secretions indicates a secondary bacterial infection.
- There may be chest pain with excessive coughing.
- Mild fever
- Wheezing may occasionally occur in an older child. This should always suggest asthma.
Acute bronchitis in children is very different from chronic bronchitis in adults.
- Loose crackles are heard, especially on auscultation (with a stethoscope). These noises clear with coughing.
7-15 What is the management of acute bronchitis?
- Make sure the child drinks enough fluid. Often there is a loss of appetite.
- Inhaling warm, moist air may relieve the cough. Warm drinks may also help.
- Cough mixtures are of little help, but salbutamol syrup may relieve the cough.
- Give paracetamol for the fever.
- Oral antibiotics should only be given if the mucus becomes yellow-green.
It is important to observe for signs of pneumonia, especially in small children. A wheeze suggests asthma or bronchiolitis. Bouts of severe coughing with an inspiratory whoop, apnoea or vomiting suggest whooping cough.
7-16 What is bronchiolitis?
Bronchiolitis is an acute viral infection of the small airways of the lungs (the bronchioles). It typically presents with airways obstruction. Bronchiolitis is usually caused by the respiratory syncytial virus (RSV) and occurs commonly in children under one year of age. When severe it can be life threatening. Bronchiolitis usually occurs in winter and follows a few days after the onset of a common cold. The small airways become inflamed and narrowed. Secondary bacterial infection may occur.
Bronchiolitis causes serious narrowing of the small airways in young infants.
7-17 What are the signs of bronchiolitis?
- Recession (indrawing of the lower chest) and a hyperinflated chest (over expanded due to air trapping).
- Wheezing is usually present and is not relieved by an inhaled bronchodilator. Occasionally wheeze may be absent.
- Rapid breathing and breathlessness (difficulty breathing)
- Prolonged expiration
- A dry coughing
- Reluctance or difficulty in feeding
- Mild fever
Cyanosis, decreased level of consciousness, inability to feed or persistent vomiting and a marked tachycardia (fast heart rate) are all dangerous signs and indicates respiratory failure. Apnoea is common in infants less than 3 months. Bronchiolitis takes about a week to recover.
Repeated bronchiolitis, especially in an older child, suggest asthma.
- There is poor air entry over both lungs on auscultation. Fine crackles may be present. A chest X-ray shows air trapping due to small airway narrowing without signs of consolidation (pneumonia). Pneumothorax is an uncommon complication of bronchiolitis.
7-18 What is the correct management of bronchiolitis?
- Children with mild bronchiolitis may be managed at home provided they are carefully observed, they take adequate fluids, the home circumstances are good and that communication and transport are available if needed.
- All other children with bronchiolitis must be admitted to hospital, especially if they are under 3 months, or if there is an inability to feed, tachycardia or low oxygen saturation.
- Oxygen therapy with nasal prongs (flow 1 to 2 litres/minute) is indicated if there are signs of respiratory distress or the oxygen saturation is low (below 90%).
- Bronchodilators usually do not help in bronchiolitis.
- Steroids are of little help.
- Ensure an adequate fluid intake. If the child will not drink give nasogastric fluid. Intravenous fluid should only be given with great caution as overhydration is dangerous.
- Antibiotics are usually not given unless there are also signs of pneumonia or the child is less than 3 months. If pneumonia is suspected give amoxycillin.
- If the child has a fever give paracetamol.
- Physiotherapy is contraindicated and can be dangerous.
- Careful observation is important for signs of respiratory failure or apnoea.
- Intubation and ventilation for respiratory failure
Oxygen is the treatment for severe bronchiolitis.
- Bronchodilators by nebulisation, e.g. salbutamol, are sometimes used in severe bronchiolitis with variable results. Children with a history of 2 or more attacks of bronchiolitis and respond to inhaled bronchodilators probably have early asthma. Do not use aminophylline as it is dangerous.
7-19 When should children with bronchiolitis be referred to hospital?
Bronchiolitis is a serious condition which can suddenly deteriorate. Therefore, only the mildest cases should be managed at home or at a primary care clinic. The following children should be referred to hospital:
- Children with signs of respiratory failure (e.g. cyanosis or depressed level of consciousness)
- If there is no improvement
- Signs of pneumonia
- Oxygen saturation below 90% with oximetry (saturation monitor)
7-20 What is pneumonia?
Pneumonia is an inflammation of the small air sacs of the lungs (alveoli), usually due to a viral or bacterial infection. Pneumonia is often a complication of an upper respiratory tract infection. It may involve only part of one lung or be more extensive and even involve both lungs. The common causes of pneumonia depends on the child’s age. Breastfeeding and avoiding cigarette smoke helps to prevent pneumonia.
7-21 What are the causes of pneumonia?
- Pneumonia in newborn infants is usually due to a bacterial infection such as Group B Streptococcus and Gram negative bacilli (e.g. Klebsiella).
- Viruses especially the respiratory syncytial virus, cause most pneumonias in infancy.
- In young children Mycoplasma is a common cause of pneumonia.
- Pneumonia in older children is usually due to bacteria such as Pneumococcus, Haemophilus and Staphylococcus. Pneumococcus is the most common cause of community-acquired pneumonia in children.
- Tuberculosis is an important cause of pneumonia in poor communities.
- Pneumocystis is an important cause of pneumonia in HIV infected infants between 2 and 6 months of age. This is a very unusual cause of pneumonia in children who do not have AIDS.
- Gram negative organisms such as Klebsiella and E. coli are also an important cause of severe pneumonia in children with HIV infection.
- Chlamydia can cause pneumonia in infants.
It is difficult to decide whether the pneumonia is due to a virus, bacteria or TB on both clinical examination and chest X-ray. Often pneumonia is due to bacteria complicating a viral infection.
7-22 What are the symptoms and signs of pneumonia?
- The child is generally unwell.
- Fever, often high fever
- Breathlessness (difficulty breathing). The breathing is usually fast and shallow.
- Chest wall indrawing (recession or retraction)
- Refusal to eat or drink due to shortness of breath
- The infant may become cyanosed (with a low oxygen saturation).
- Chest pain may be present.
Fast breathing is the most important sign of pneumonia.
There are some causes of fast breathing, other than lung conditions, such as a high fever or a metabolic acidosis (seen in diarrhoea with severe dehydration). It is best to look for fast breathing when the child is calm and the fever has been lowered.
A normal breathing rate usually excludes pneumonia.
- Nothing abnormal may be heard on auscultation with a stethoscope as the classical chest signs of pneumonia (dullness, bronchial breathing, crepitations) are often not present in children with pneumonia.
7-23 Should all children with pneumonia have chest X-rays?
A routine chest X-ray need not be taken in all children suspected of having pneumonia. However, if facilities are available, it should be done where:
- Complications are expected (e.g. pneumothorax).
- The diagnosis of tuberculosis is suspected.
- The pneumonia is severe or does not respond to treatment after 2 days.
The diagnosis of pneumonia in a child is usually made on general examination rather than by listening to the chest.
- Bronchopneumonia is common in small children while lobar pneumonia is often seen in older children. Always look for a pleural effusion or other signs of tuberculosis.
7-24 Is pneumonia a serious infection?
Yes. Pneumonia is a common reason for hospital admission and a major cause of death in children, especially in developing countries, such as South Africa, and in children with AIDS. Pneumonia acquired in hospital is particularly dangerous.
Pneumonia is a major cause of death in children.
7-25 How can you recognise severe pneumonia?
Any of the following clinical signs suggest that the child has severe pneumonia:
- Chest wall indrawing (recession)
- Cyanosis (needs oxygen to keep the oxygen saturation above 90%)
- Depressed level of consciousness
- Refusal to eat or drink due to shortness of breath
These are danger signs which mean that the child needs urgent treatment and then referral to hospital.
7-26 What is the correct management of pneumonia?
- If possible, all children with pneumonia should be admitted to hospital. Only mild cases should be managed at home or in a primary care clinic.
- Observe the child carefully. Monitoring the oxygen saturation is very important. Look for signs of severe pneumonia.
- Give oxygen by nasal prongs (or catheter) or face mask for severe pneumonia. Monitor with the use of a saturation monitor and give oxygen if saturations are below 90%.
- Give an appropriate antibiotic. While oral antibiotics can be used with mild pneumonia, intramuscular or intravenous antibiotics must be used with more severe cases. All children with pneumonia must receive an antibiotic as it is difficult to tell whether the pneumonia is due to a virus or bacteria.
- If a wheeze is present give an inhaled bronchodilator.
- Give paracetamol to lower the fever.
- Remove thick secretion from the nose by gentle suctioning.
- Encourage breastfeeding. If the child does not take fluids by mouth, give nasogastric feeds or start an intravenous infusion.
- Physiotherapy may be helpful.
- All children with signs of severe pneumonia must be urgently referred to hospital. Give the first dose of antibiotic before referring the child.
- In very severe cases of pneumonia, intubation and ventilation may be needed.
Oxygen and antibiotics are the main form of treatment for pneumonia.
7-27 What antibiotics are used in pneumonia?
- Amoxycillin 30 mg/kg orally 3 times a day for 5 days in children with mild community-acquired pneumonia that is treated at home.
- Intramuscular ampicillin 20 mg/kg before referring a child with severe pneumonia. In hospital, ampicillin and gentamicin, or cefotaxime (or ceftriaxone) are usually used. The choice of antibiotic may change when the sputum and blood cultures and sensitivities are received.
- Cloxacillin 50 mg/kg/dose orally 6 hourly is given if Staphylococcus is suspected.
- Hospital-acquired pneumonia may be due to organisms resistant to many antibiotics.
- Search for tuberculosis if there is no response to antibiotics.
- Erythromycin or co-trimoxazole are the antibiotics of choice if Mycoplasma pneumonia is suspected in older children (5 years or older). Additional co-trimoxazole 6 hourly in high doses is used to treat suspected Pneumocystis pneumonia in HIV infected children.
7-28 What is asthma?
Asthma is a chronic inflammatory condition with repeated episodes (or attacks) of reversible narrowing of the small airways (bronchi) of the lung that respond to bronchodilators. Children with asthma have ‘hyperactive airways’, i.e. their small airways become narrow in response to a number of factors. Asthma usually presents as repeated acute attacks. Each attack lasts hours to days. While some children only have a few attacks a year others are rarely free from asthma. If acute asthma is not controlled, the asthma may become persistent.
Asthma presents with repeated episodes of airway narrowing.
- Asthma is an inflammatory disease. The inflammation leads to airway narrowing. To control asthma the inflammation must be treated.
7-29 How common is asthma?
Asthma occurs in about 10% of children in South Africa, especially children living in towns and cities. Asthma is becoming more common as more rural families move into town.
7-30 What are the symptoms of asthma?
Children with asthma complain of :
- Expiratory wheezing
- Difficulty breathing (breathlessness or shortness of breath or a ‘tight chest’)
Most, but not all, children with asthma have wheezing. Some children present with coughing only, especially at night. Both the wheezing and coughing are worse at night and often wake the child. Asthma is usually seen in children of one year or older.
Always think of asthma when a child presents with wheezing.
7-31 What are the clinical signs of asthma?
The clinical signs of asthma on examination are:
- A generalised, expiratory wheeze, especially on forced expiration.
- The chest may appear full (hyperexpanded due to air trapping) with prolonged expiration.
- There may be lower chest wall indrawing.
- The use of muscles in the abdomen or neck during expiration suggests severe airways obstruction.
- Cyanosis, drowsiness or panic are signs of respiratory failure.
- Usually there is no fever.
- Long standing, poorly controlled asthma may result in chest deformity and poor growth.
- Between acute attacks the chest examination is usually normal.
The sudden onset of wheezing during play in a well child with no history of asthma suggests the inhalation of a foreign body.
7-32 What is the cause of asthma?
Asthma results from a combination of inherited and trigger factors which cause inflammation of the bronchi. Most, but not all, children with asthma have a family history of allergic conditions (asthma, eczema, or allergic rhinitis). Children with asthma often have other allergic conditions.
Inflammation of the bronchi results in:
- Mucosal oedema (swelling of the linings of the bronchi)
- Bronchospasm (contraction of the smooth muscle in the bronchi)
- Increased secretion of sticky mucus
These factors cause narrowing of the bronchi, especially in small children who normally have narrower bronchi than do older children.
- The causes of asthma are multifactorial and result in airway hyperresponsiveness.
7-33 How do inherited factors increase the risk of asthma?
There may be a history of asthma on either the mother’s or father’s side of the family. Often a parent or sibling has an allergic condition. The tendency to have asthma is, therefore, passed from one generation to the next and close family members with asthma are an important risk factor for children to develop the condition.
Children with asthma usually have a family history of allergies.
- A high risk of allergic conditions is inherited as an autosomal dominant with variable inheritance.
7-34 What is allergy?
Allergy (or atopy) is an abnormal or exaggerated reaction by the body to certain foreign proteins. In these allergic people the body produces an inflammatory response to these proteins which are called allergens. This abnormal inflammatory response is present in all common allergic conditions. Allergens do not produce an inflammatory response in people who are not allergic.
Common allergens are:
- House dust mite
- Foods, e.g. cows milk protein, eggs, wheat, peanuts, fish and soya
- Pollens, e.g. grass or tree pollen
- Dog and cat hair
- Fungus (mould) spores
- In allergic people the body responds abnormally to foreign proteins by producing IgE rather than IgG (atopy).
7-35 What trigger factors may start an attack of asthma?
A wide range of trigger factors may start an acute attack of asthma. They include:
- Upper respiratory tract infections
- Allergens in the environment
- Active or passive smoking
- Exercise, especially running
- A sudden drop in environmental temperature (cold air)
- Emotion (sadness, anger or excitement)
- Irritants in the environment, e.g. paint fumes
7-36 How is asthma diagnosed?
Asthma is mainly a clinical diagnosis based on a history of repeated acute attacks of wheezing, coughing and breathlessness, often with a positive family history of allergy.
Asthma is mainly a clinical diagnosis based on the past and family history.
The most useful special investigations are:
- Lung function tests: Children over the age of 5 years can use a peak flow meter to measure their peak expiratory flow rate. They take a deep breath and then blow as hard as they can into the peak flow meter, which measures how fast they can blow air out of their lungs (like blowing out a candle). Children with asthma have a lower peak flow rate than normal due to their narrow airways.
- Skin tests: Skin tests are done by placing a drop of a specific allergen on the child’s forearms. The underlying skin is then pricked with a special lancet through the drop of allergic testing solution. The test site is examined after 15 minutes. A swelling (wheal) at the test site indicates that the person is allergic to that allergen. Skin tests are simple to perform, cheap and accurate. A blood test (RAST) can also be used to identify a response to specific allergens. The child should not be on an antihistamine for 48 hours before performing a skin prick test. Skin tests are used as supportive evidence for asthma as they diagnose allergies only.
- Response to a short acting bronchodilator: A good clinical and peak flow rate response to a dose of inhaled bronchodilator is the best way to confirm the clinical diagnosis acute asthma. In preschool children the diagnosis usually depends on a clinical response to treatment while in older children an improvement in the peak flow is important.
Asthma presents with repeated episodes of wheezing, coughing or shortness of breath that respond to bronchodilators.
7-37 How is the severity of asthma graded?
With intermittent asthma there are only occasional episodes of wheezing or coughing (less than once a month). Most children with asthma only have intermittent asthma. The symptoms of intermittent asthma are usually easily controlled and do not affect the quality of life.
With persistent asthma the episodes are more frequent (at least once a month). Persistent asthma may be:
- Mild: Episodes of coughing or wheezing occur once or twice a week
- Moderate: Episodes of coughing or wheezing at least 4 times a week
- Severe: They have daily symptoms which interfere with sleep and schooling
- With intermittent or mild persistent asthma the peak expiratory flow is usually 80% or more of predicted. This falls to 60–80% with moderate and less than 60% with severe asthma.
7-38 What is the correct management of asthma?
- Assess the of severity of the asthma
- Control the acute attack
- Prevent recurrent attacks
- Avoid trigger factors
- Education and support
7-39 How is the severity of acute asthma assessed?
The following are features of severe asthma:
- Previous history of severe acute asthma indicates that any further attack should be regarded as severe.
- Lack of response to bronchodilator therapy
- Inability to speak or cry or feed due to severe respiratory distress
- Oxygen saturation below 90%
- A silent chest when examined with a stethoscope or peak expiratory flow rate below 60% indicates severe asthma.
7-40 How should acute asthma be treated?
The aim of treating acute asthma (whether intermittent or persistent) is to relieve the airway narrowing (bronchospasm) as soon as possible and make sure that the patient is getting adequate oxygen.
- Nebulised or inhaled short acting bronchodilators (beta 2 agonists), e.g. salbutamol (Ventolin) or fenoterol (Berotec). Oral short acting bronchodilators are rarely used as the inhaled drugs are better and safer.
- Antibiotics are usually not needed.
- Sedatives and antihistamines must be avoided.
- Oral theophylline is only rarely used. Rectal and intravenous theophylline, and subcutaneous adrenaline, are dangerous and should not be used.
Acute intermittent asthma is usually mild and can be treated at home. ‘Reliever’ treatment can be given at home with inhaled short acting bronchodilators using a spacer (e.g. 1 or 2 puffs of salbutamol or fenoterol, i.e. 100–200 µg). This can be repeated after an hour if needed. The child must be carefully observed and moved to hospital if the wheeze gets worse. An inhaled short acting bronchodilator can also be taken before exercise to prevent wheezing or cough.
7-41 What should you do if there is no response?
If there is no clinical response within 20 minutes of giving an inhaled bronchodilator, repeat the dose, give a dose of oral steroids and refer the child to hospital for further treatment. Also consider transfer to hospital if the child refuses fluids, becomes restless or lethargic, or becomes cyanosed. Give oxygen during transfer.
The management of acute asthma in hospital consists of:
- Nebulised or inhaled bronchodilators every hour.
- A short course of oral steroids for 7 days (e.g. oral prednisone 2 mg/kg daily).
- Reassess hourly. If no response consider admission for intensive care.
7-42 How should inhaled and nebulised drugs be given?
Inhaled medication (e.g. bronchodilators and anti-inflammatory drugs) are safer and more effective than oral drugs. They are best given to children using a spacer. A spacer is a container that is placed between the metered dose inhaler (MDI or ‘puffer’) and the patient’s mouth. This allows the drug to mix well with the air in the container before it is inhaled. In this way the drugs are better absorbed through the linings of the airway.
The inhaler is pushed through a hole made in the bottom end of a 500 ml cooldrink bottle while a face mask is attached to the mouth of the bottle. This home-made spacer works well and is much better than a small plastic or polystyrene cup.
For older children the child places her mouth directly over the top of the bottle rather than using a face mask. The child then breathes normally into the bottle.
Specially designed commercial spacers are available but they are expensive. A face mask is needed in young children. Older children should use a mouthpiece.
Metered dose inhalers can be used in children of 8 years or more when they are able to co-operate and use the inhalers correctly. Spacers are used for younger children.
Nebulisers can be used in hospital to very efficiently give inhaled drugs. The drug in liquid form is added to the nebuliser which produces a fine mist. The dose is usually 1 ml of drug with 1 ml of saline.
7-43 How can repeated attacks of asthma be prevented?
If the child has persistent asthma (more than one episode a month) or severe attacks of asthma (requiring admission to hospital) the aim of management should be to prevent these acute attacks. These children should be referred to an asthma clinic for chronic maintenance management if possible. The aim of treatment is to allow the child to have a good quality of life, i.e. play sport, attend school normally and sleep well. Treatment requires the use of both anti-inflammatory and bronchodilator drugs.
The treatment of persistent asthma:
- In mild persistent asthma (with repeated mild episodes of cough and wheezing which occur once or twice a week) a low daily dose of inhaled corticosteroid (‘prevention’ therapy e.g. beclomethasone 100–200 µg) should be given in addition to the short acting bronchodilator. Inhaled steroids are very effective and safer than oral steroids. Inhaled steroids should be used with a spacer. Rinse out the mouth after inhaling the steroid to avoid excessive absorption.
- Moderate persistent asthma requires higher doses of daily inhaled steroids (e.g. beclomethasone 200–400 µg).
- In severe persistent asthma, oral steroids may be needed. These patients should be management by an asthma clinic at a regional or tertiary health centre.
- Short acting inhaled bronchodilators are needed in all patients with asthma and should be used when necessary. Use a spacer whenever possible.
Exercise-induced asthma can be prevented by inhaling a short acting bronchodilator 10 minutes before starting the exercise.
In severe or repeated attacks of asthma, daily treatment is needed to give the child as normal a quality of life as possible.
- A long acting bronchodilator (beta 2 agonist) such as salmeterol, or sustained release oral theophylline, or a leukotriene antagonist may be added as a steroid sparing agent.
7-44 How can trigger factors be avoided?
- No one should smoke in the house.
- Avoid contact with people who have upper respiratory tract infections, especially common colds.
- Avoids cats and dogs if allergic to them. Ban pets from the bedroom.
- Reduce house dust mites, especially in the child’s bedroom. Cover the pillow and mattress with plastic sheeting, vacuum the carpet daily, wash the sheets and covers frequently in hot water and dry them in the sun. Synthetic bedding is best.
7-45 What education and support is useful in asthma?
Asthma is frightening to the child and parents. They should understand the causes, symptoms and treatment of the condition. Children should be encouraged to manage their own use of bronchodilators.
Parents can be reassured that asthma tends to improve with age.
An approach to lower respiratory tract conditions
7-46 What is the syndromic approach to acute respiratory tract disorders?
This is a simple way of using important clinical signs to classify and manage acute respiratory tract disorders. It is based on what you and the mother observe (see and hear) in the child. In the older child, the history (symptoms) given by the child is also important. This is the method used by IMCI (Integrated Management of Childhood Illness) for primary care management.
The two main signs of lower respiratory tract disorders are:
- Difficulty breathing
7-47 What are the important causes of a cough?
Most children become ill and cough a number of times a year:
- Usually a cough is due to a mild upper respiratory tract infection (cold, pharyngitis or sinusitis) due to a virus and does not last more than 3 weeks.
- A cough may be due to a lower respiratory tract infection (pneumonia, croup, bronchitis, bronchiolitis and asthma). It is, therefore, important to look for signs of these conditions.
- A cough lasting more than 3 weeks ( 21 days) may be a sign of tuberculosis (TB).
- Think of whooping cough if a bout of couching leads to vomiting.
- Think of asthma if the cough is worse at night or after exercise. In bronchiolitis the cough is also worse at night. Asthmatics usually have a recurrent wheezy cough.
- A cough that starts soon after lying down suggests a post-nasal drip in acute sinusitis.
- The sudden onset of coughing after a choking episode suggests an inhaled foreign body.
- A barking cough is suggestive of croup.
7-48 What is the management of a cough?
- If the child has a cough but no signs of breathing difficulty, the cause is usually an upper respiratory tract viral infection. They do not need an antibiotic but something to soothe the throat (warm water or tea with honey or sugar). Cough mixtures usually only help by soothing the throat. Therefore, use a simple cough linctus.
- The cough should get better by 3 weeks. If not, think of TB, asthma or whooping cough. These children should be referred for further investigation and management. Always think of tuberculosis in a child with a chronic cough and weight loss.
- If the child has signs of breathing difficulty, refer for management of the underlying condition.
- There is no scientific evidence that cough suppressants, expectorants or mucolytics are effective for an acute cough cause by a viral infection.
7-49 What signs of breathing difficulty suggest specific diagnoses?
These signs must be assessed when the child is calm and not crying:
- Stridor is usually due to viral croup.
- Indrawing of the lower chest wall may occur with most severe lower respiratory tract problems, i.e. pneumonia, stridor, bronchiolitis or asthma.
- Wheezing suggests bronchiolitis (in an infant) or asthma (in an older child).
- Fast breathing suggests pneumonia, bronchiolitis or asthma.
Older children with a severe lower respiratory tract problem may complain of shortness of breath. Always look for danger signs in any child with breathing difficulty.
The sudden onset of stridor or wheeze in a well child suggests a foreign body.
If any of these signs are present, the child should be carefully examined and considered for urgent transfer to hospital.
7-50 When and how should oxygen be given?
Children with rapid breathing, indrawing of the chest, expiratory stridor or cyanosis, restless and saturations less than 90% should be given oxygen. Usually 1 to 2 litres per minute of 100% oxygen is given by nasal prongs or 3 to 4 litres via face mask. Measuring the oxygen saturation is very helpful.
Case study 1
During the early evening a 2-year-old child develops a strange cough and a crowing noise when she breathes in. She had a mild fever and a runny nose during the day. When the child cries, the noise during inspiration becomes worse. The mother became anxious and brought the child to the casualty department of the local hospital.
1. What is the crowing sound during inspiration called?
Stridor. The sound is caused by breathing in through swollen vocal cords. Mild stridor only occurs during inspiration and is usually only heard when the child cries.
2. What is the most likely cause?
Viral croup. This is an acute viral infection of the larynx, trachea and bronchi (laryngotracheobronchitis). It usually follows the start of a common cold or pharyngitis.
3. What other sign is common with this condition?
A ‘barking’ cough.
4. What signs would suggest that the stridor is becoming worse?
Both inspiratory and expiratory stridor, especially if present at rest, and indrawing of the lower ribs during inspiration. The obvious use of chest and abdominal muscles during expiration, restlessness or fast breathing are signs of dangerous airway obstruction.
5. What is the main treatment of severe stridor?
Nebulised adrenaline. A single dose of steroids helps. There is no indication for bronchodilators or antibiotics. If respiratory failure develops, intubation or a tracheotomy may be needed to bypass the laryngeal narrowing.
6. What diagnosis should you consider with the sudden onset of stridor in a well child?
An inhaled foreign body.
Case study 2
An infant of 6 months develops fast breathing and recession 3 days after the start of a common cold. On inspection the chest appears over expanded and a wheeze is heard. There is a mild fever and the child does not appear seriously ill. He takes his bottle well and has no cyanosis. There is no family history of asthma and this is the first time the child has been ill.
1. What is the most likely diagnosis?
Bronchiolitis. This is an acute inflammation and narrowing of the small airways of the lungs.
2. Why is this unlikely to be asthma?
The infant is young for asthma, this is the first episode of wheezing and there is no family history of asthma. No other features of allergy are mentioned.
3. What is the cause?
Probably the respiratory syncytial virus which can start as a common cold. Infection with the respiratory syncytial virus is commoner in winter.
4. What is the correct management?
Bronchiolitis is best managed in hospital where humidified oxygen can be given if necessary.
5. Should antibiotics be given?
Usually not, except in infants under 3 months and where pneumonia is difficult to exclude.
6. What are danger signs with bronchiolitis?
Cyanosis, refusal to drink, apnoea, a marked tachycardia, restlessness or a depressed level of consciousness. An oxygen saturation below 90% is cause for great concern. This child does not have any of these danger signs.
Case study 3
A 5-year-old child develops a cough and blocked nose. The next day his mother notices that he is breathing fast and has a fever. On examination he has a respiratory rate of 45 with chest indrawing. He refuses to drink and has mild central cyanosis.
1. Why is this child breathing fast?
He probably has pneumonia.
2. What is the definition of fast breathing?
It depends on the child’s age as younger children normally breathe faster than older children. A respiratory rate above 40 breaths per minute is abnormally fast in any child older that one year.
3. What is the likely cause?
Probably viral as he has an upper respiratory tract infection. However the cause of the pneumonia may be bacterial.
4. What is chest indrawing?
Chest indrawing (recession or retractions) is a clinical sign where there is indrawing of the lower chest when the child breathes in. It is seen with pneumonia as well as a number of other lower respiratory tract conditions.
5. How severe is the pneumonia in this child?
It is severe as he has 3 signs of severe pneumonia (chest indrawing, refusal to drink and cyanosis). These are danger signs.
6. What management is needed?
- Give oxygen to keep the child pink.
- Start antibiotics.
- Try to get the child to take oral fluids. Otherwise start an intravenous infusion.
- Urgently transfer the child to hospital.
7. What antibiotic would you choose?
Intramuscular ampicillin. It can be given intravenously if an intravenous infusion (a drip) is started. In hospital gentamicin may be added.
8. What is the value of measuring the oxygen saturation?
This is a very useful method of assessing whether there is enough oxygen in the blood.
Case study 4
A 7-year-old child has a history of repeated attacks of coughing and wheezing, especially at night and during sport at school. He now has wheezing for the past few hours, complicating a common cold. There is a strong family history of allergies.
1. Why is this child coughing and wheezing?
He has an acute attack of asthma.
2. What is this clinical condition?
Asthma is a chronic condition that presents with repeated attacks of airway narrowing.
3. What is the cause?
Asthma is caused by a combination of an inherited factor (i.e. allergy) plus trigger factors.
4. What are common trigger factors?
Viral infections, exercise, exposure to allergens or irritants (e.g. smoke), cold air and emotion. In this child the trigger factor was a viral upper respiratory airway infection.
5. Can you name a few common allergens?
House dust mite, pollens, cat or dog hair, some foods and fungus spores.
6. How is a clinical diagnosis of asthma confirmed?
By lung function tests for airway narrowing and response to an inhaled bronchodilator. A skin prick test provides supportive evidence for allergies.
7. How should his acute attack be treated?
He will probably respond well to an inhaled short acting bronchodilator. If not, he should be referred to hospital for assessment and further treatment
8. Can acute attacks be prevented?
Yes. Every attempt should be made to prevent acute attacks by identifying and removing trigger factors. In children with persistent asthma, steroids should be added to the regular use of an inhaled bronchodilator.