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Amalina Aminuddin 0820121000 67A Child with Breathing Difficulties

Contents Introduction Etiology ApproachInvestigations Congestive heart failure

Introduction Aka Shortness of breath, breathlessness, dyspnea

Abnormally uncomfortable awareness of breathing Harrison's Principles of Internal Medicine, 16th Edition

A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensityAmerican Thoracic Society

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Etiologies

Respiratory Parenchyma Pulmonary embolismBronchiolitisBronchial asthma PneumoniaPulmonary hypertension

AirwayForeign body aspirationCroupEpiglotitis

); chronic bronchitis or emphysema

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Respiratory: Newborn

Cause Time of onset Meconium aspiration syndrome First few hours of life Respiratory distress syndromeFirst 6 hours of life Transient tachypnea of newborn First 6 hours of lifePersistent pulmonary hypertension Any age Congenital malformationsAny age

Tracheoesophygeal fistula, diap hernia

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Cardiac Others Congestive heart failure Congenital heart diseaseAllergies High altitudeEmotional distress (anxiety, stress, panic attack)Obesity

Myocarditis, arrYthmia, pul hypertensio, rheumatic fever,7

Approach Assess severity Evaluate history and physical examinationDistinguish between respiratory and cardiac causes

i) Grading

Grading of dyspnea NYHA MRC ATS Borg Yale Minnesota9

i) Grading

Dyspnea, palpitation, fatigue grading due to cardiac cause 10

ii) Red flag signs Sudden onset Dyspnea at restDecreased level of consciousness Accessory muscle use Tightness in the throat or barking crouping coughChest painWheezing

Sternomastoid, scaleneus ant, pec major n minor, ser ant, lat dorsiCan compromise airway patencyMost likely cardiac origin11

History Onset, duration, course, severity , exacerbating factors (allergen exposure, cold, exertion, supine position)Any other associated symptomschest pain or pressure (pulmonary embolism, myocardial ischemia, pneumonia)dependent edema, orthopnea, and paroxysmal nocturnal dyspnea (heart failure) fever, chills, cough, and sputum production (pneumonia)weight loss or night sweats (cancer or chronic lung infection)Past history: asthma, heart disease, TB, pneumonia

Physical examination

VitalsExamination focuses on the cardiovascular and pulmonary systems.

fever, tachycardia, and tachypneaadequacy of air entry and exit, symmetry of breath sounds, and presence of crackles, rhonchi, stridor, and wheezing. Signs of consolidation (eg, egophony, dullness to percussion) . The cervical, supraclavicular, and inguinal areas for lymphadenopathy.Neck veins , pitting edema (both suggesting heart failure).Heart sounds should be auscultated with notation of any extra heart sounds, muffled heart sounds, or murmurConjunctiva should be examined for pallor. Rectal examination and stool guaiac testing should be done.

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DistinguishesRespiratory CardiovascularCough with expectorant Fever Seasonal variation Abnormal breath sounds

PND and orthopnea Associated syncope, palpitation, anginal pain Distended neck vein, edema

Pulse oximetryChest X RayECGABGEchocardiographyBronchoscopy

Initial studiesInvestigations

O2 saturation, distinguish rs n cvs prob , abg developing any acid base imbalance , echo n broncho to locate any structural deformity

Advantages of VBG include less pain to the patient and ability to draw concurrently with other labsA normal venous pH, pCO2, and HCO3 rules out severe acid base abnormalitiesA venous pH of > 7.25 predicts an arterial pH of > 7.2 in 98% of cases(Conversely, a venous pH of < 7 predicts an arterial pH of < 7.2 in 98% of cases)

A venous pCO2 of > 45 mm Hg is predictive of an arterial pCO2 of > 50 mm Hb Venous blood gasses do not allow adequate determination of the arterial concentration of oxgyen (paO2) and is not as useful to quantify oxygen delivery to target tissues 15

Causes: foreign body, tissue edema, trauma, viral infection, intubation, tongue movement to posterior pharynx with decreased consciousnessSymptomsPartial obstruction: noisy inspiration (stridor), choking, gagging or vocal changes Complete obstruction: no audible speech, cry or coughManagementRapidly decide if advanced airway is neededAvoid agitationSuction only if blood or debris are presentReduce airway swellingInhaled epinephrineCorticosteroidsCroup and anaphylaxis require additional managementUpper Airway Obstruction

CroupSymptoms:barking cough stridor retractionsTreatment:Oral or IM dexamethasoneOxygenKeep NPONebulized racemic epinephrine with observation for at least 2 hours after treatment

Anaphylaxis Symptoms: Stridor or wheezingDizzinessVomiting or diarrheaHives or facial swellingTreatment:IM/IV epinephrineAlbuterol (if bronchospasm is present)Treat hypotensionDiphenhydramineRanitidineMethylprednisolone

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BronchiolitisSymptoms: copious nasal secretions, wheezes and crackles in child less than 2 yearsManagementOral or nasal suctioningViral studies, CXR, ABG/VBGTrial of nebulized albuterolAsthmaSymptoms: wheezing, tachypnea, hypoxiaManagementMild-moderate: oxygen, albuterol, oral corticosteroidsModerate to severe: oxygen, albuterol-ipratropium (Duo-Neb), corticosteroids (IV), magnesium sulfateImpending respiratory failure: oxygen, albuterol-ipratropium, corticosteroids, assisted ventilation (bag-mask ventilation, BiPAP, intubation), adjunctive agents (terbutaline, magnesium sulfate), helioxLower Airway Obstruction

Assisted ventilation for patients with lower airway obstruction should be at a slow rate with adequate expiratory time to decrease the risk of air trapping and complications with high airway pressure including pneumothorax, gastric distension, regurgitation and aspiration. 17

Etiologies of lung tissue diseaseInfectious pneumoniaAspiration pneumonitisNon-cardiogenic pulmonary edema (ARDS)Cardiogenic pulmonary edema (ARDS)Consider positive expiratory pressure (CPAP, BiPAP or mechanical ventilation with PEEP) if hypoxemia is refractory to high concentrations of oxygen

Lung Tissue Disease

For more information regarding specific etiologies of lung tissue disease:Infectious pneumoniaSymptoms: fever, tachypnea, hypoxemia, increased work of breathing, crackles or decreased breath soundsManagement:Ancillary testing: ABG/VBG, CXR, viral studies, CBC, BCxAntibiotics to treat gram + organisms, consider macrolide coverageAlbuterol if wheezingReduce temperature if febrileAspiration pneumoniaSymptoms: coughing or gagging associated with feeding, more common in children with abnormal neurologic statusManagementRespiratory support and antibiotics if infiltrate is present on CXRNon-cardiogenic pulmonary edema (ARDS) Symptoms: pulmonary or systemic insult to the alveolar-capillary unit with release of inflammatory mediators ManagementCorrection of hypoxemia Intubate if hypoxemia is refractory to high inspired oxygen concentrationsCardiogenic pulmonary edemaSymptoms: fluid accumulation in the lung interstitium due to elevated pulmonary capillary pressureManagementVentilatory supportSupport cardiovascular function

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Abnormal respiratory pattern produces inadequate minute ventilationAltered level of consciousnessElevated intracranial pressureCushings triad Poisoning or drug overdoseAdminister specific antidote if availableHyperammonemiaMetabolic acidosis Neuromuscular diseaseRestrictive lung disease => atelectasis, chronic pulmonary insufficiency, respiratory failureSupport oxygenation and ventilation while treating the underlying problemDisordered Control of Breathing

Disordered control of breathing can be due to elevation of intracranial pressure or depressed level of consciousness due to CNS infection, seizures, metabolic disorders, poisoning or drug overdose.

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Congestive Cardiac Failure

Most important cause of breathing difficulties due to cardiac problems

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Inability of the heart to maintain output (systolic failure)Inability to receive blood into ventricles at low pressure during diastole (diastolic failure)

Etiology Infants Children Congenital heart disease Myocarditis and primary myocardial diseaseTachyarrhythmias and bradyarrythmias Pulmonary hypertension Miscellaneous causes : Anemia, hypoglycemia, infections, hypocalcemia, neonatal asphyxiaRF, RHDCHD complicated with anemia, infection, endocarditisSystemic hypertensionMyocarditis, primary myocardial diseasePulmonary hypertension

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Systolic dysfunctionDiastolic dysfunctionMyocarditisValvular lesions causing stenosis or regurgitationCADMyocardial ischemiaCardiomyopathyDrugs and toxic agentsMitral or tricuspid stenosisConstrictive pericarditisRestrictive cardiomyopathyMyocardial ischemiaMarked ventricular hypertrophyDilated cardiomyopathy

Onset of Congestive Heart Failure Age Lesion Birth 1 week Congenital mitral and tricuspid regurgitation, neonatal Ebstein anomaly1 4 weeksPDA in preterms, VSD with coarctation, persistent truncus arteriosus, transposition with large VSD or PDA, severe coarctation, congenital mitral or aortic stenosis1 2 monthsTransposition with VSD or PDA, VSD, PDA, endocardial cushion defect, severe coarctation2 6 monthsVSD, PDA, endocardial cushion defect

Clinical features Poor weight gainFacial puffiness, pedal edemaPoor feederIrritability, excessive perspiration and restlessnessBreathes too fast ; breathes better when held against shoulder

Small feed: easy fatigue, excessive calorie loss due to inc work of breathing, Unusual weight gainBaby does not take more than 2 ounces of milk at a time, hungry within a few minutesPersisting hunger due to small feedsEquivalent to orthopnea in older childrenSigns of left ventricular failure

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Common feature to left n right failure r cardiac enlargement, poor peri pulse w/wo cyanosis26

Investigations Chest X-ray ECG ECHO Blood culture Hemoglobin for anaemiaArterial blood gas

: to differentiate between cardiac and respiratory disease: changes will give clue about diagnosis vegetations suggestive of infective endocarditis (IE27

Treatment

Duct dep systemic circulation ( AS, interrupted aortic arch ,coA) prostaglandin28

1) Reduce Cardiac WorkRestrict activityTreat fever, anemia, infectionNeonate: Incubator ,inclined position with oxygenRestless child: Morphine sulfate 0.05mg/kg SC Midazolam VasodilatorsNitrates, hydralazine, ACE inhibitors

PRBC 10-20ml/kg if severe anemiaTemp 36-37 minimal met need, humidified O2 40-50%Dec catecholamine ,anxietyphys activityCatecholamine- mediated :Arterial constrction inc Syst vascular resistantce inc work of heart veno const inc venous return inc venous returnCough .Captopril,enalapril: cause cough, may need ARB (losartan) Vasodilator indication: acute A/M regurgitation, ventr dysfunction, 29

2) Inotropic AgentsDigoxin :Initial in 6-8 hr

Cathecolamines inotropes : dopamine, dobutamine and adrenalinePDE inhibitor : milrinone, amrinone

Age Dose (mg.kg)Maintainance Premature/ neonates 0.04 mg/kg , 1/4

1 month 1 year 0.08 mg/kg, 1/3 to 1/4

1-3 year :0.06 mg/kg, 1/3 to 1/4

Above 3 year :0.04 mg/kg, 1/3

Rapid onset, quick elimination, in next 6-8 hrBefore 3rd dose, ECG must be donIno + peri vsdi30

3) Reduce preload Diuretics Frusemide 1-3mg/kg/d oral Spirinolactone 1 mg/kg orally every 12 hoursRestrict sodium intake

Pot sparing : triamterene, spririno, amiloride .reduce arrythmiaDiff to implement, avoid salt rich food- chips,pickle31

Prognosis High mortalityPrognosis depend on underlying cause

Reference Vinod, Arvind, Ghai Essential Pediatrics ,8th editionKliegman, Stanton, St Geme, Schor, Nelson Textbook of Pediatric, 1st south asian editionN. K. Burki, MD, PHD, acute dyspnea: is the cause cardiac or pulmonaryor both?,November 16, 2012Cardinal symptoms in cardiology... an analysis Dr S Venkatesan.MD,DM Madras Medical college SIMS March 4 th 2016http://www.msdmanuals.com/professional/pulmonary-disorders/symptoms-of-pulmonary-disorders/dyspnea#false