Related Subjects:Sick Neonate
|APGAR Scoring
|Approach to Assessing Sick Child
|Sick Child with Acute Gastroenteritis
|Sick Child with Respiratory Distress
|Sick child Diabetes Mellitus Type 1 and DKA
👶 Introduction
- When a child presents with difficulty breathing, first establish the site of disease:
upper airways (oropharynx, nasopharynx, larynx), lower airways (trachea, bronchi, bronchioles), lung parenchyma, central control, or a combination.
- Respiratory failure occurs when ventilation is inadequate to maintain oxygenation and CO₂ clearance.
- 💔 In paediatrics, most cardiac arrests are secondary to progressive respiratory failure - early recognition and intervention saves lives.
- ⚠️ Clinical signs of distress:
- Abnormal rate/effort: tachypnoea, bradypnoea, nasal flaring, retractions, accessory muscle use.
- Airway sounds: stridor, wheezing, grunting.
- Colour changes: pallor, cool peripheries, cyanosis.
- Consciousness: agitation, irritability, drowsiness.
📊 Key Differential Diagnosis of Stridor
| Criteria |
Mild Croup |
Bacterial Tracheitis |
Epiglottitis |
| Prevalence |
Common |
Uncommon |
Rare (post-HiB vaccine) |
| Age Group |
6 mo – 6 y |
6 mo – 14 y |
2 – 7 y |
| Onset |
Gradual, over days |
Viral prodrome 2–5 d → sudden deterioration |
Sudden, rapid |
| Symptoms |
- Stridor only when upset
- Harsh barking cough
- Swallows secretions
- Hoarse voice
- Apyrexial or low-grade fever
|
- Continuous (often biphasic) stridor
- Barking cough + toxic appearance
- Hoarse, weak voice
- Moderate–high fever
- Swallows secretions
|
- Continuous stridor (softer, snoring quality)
- Drooling (unable to swallow)
- Muffled “hot-potato” voice
- Toxic, high fever (>39 °C)
- No barking cough
|
🛠️ General Management Principles
- Keep child in position of comfort; avoid unnecessary handling.
- Airway: head tilt–chin lift; if C-spine injury suspected, use jaw thrust.
- Suction if secretions present.
- Give humidified oxygen (headbox for infants, non-rebreather for older children).
- Continuous monitoring: HR, RR, BP, SpO₂.
- Secure IV/IO access if feasible.
🎯 Specific Management
- Croup (NB: SpO₂ not reliable marker of severity):
- Mild: Barking cough, no stridor at rest → reassure parents, explain red flags.
- Moderate: Stridor at rest, retractions → Nebulised Adrenaline 0.5 ml/kg (1:1000, max 5 ml), Oral/IV/IM Dexamethasone 0.3 mg/kg (or Prednisolone 1 mg/kg). Observe ≥4h.
- Severe: Marked distress, restless/irritable → urgent transfer to PICU.
- Bronchiolitis (common in <1 y):
- Mild: SpO₂ >95% RA, feeding well → home with nasal saline drops.
- Moderate: SpO₂ 90–95%, feeding <50% normal → admit; humidified O₂, NG feeds, nebulised hypertonic saline/adrenaline.
- Severe: SpO₂ <90%, apnoeas, exhaustion → high-flow nasal cannula, CPAP, or intubation in PICU.
- Asthma:
- Mild: SpO₂ >95%, little distress → Salbutamol MDI + spacer, inhaled steroids, discharge with plan.
- Moderate: SpO₂ 90–94%, phrases only, tachycardia → admit; O₂, Salbutamol (6–12 puffs via spacer), ± Ipratropium, Oral Prednisolone.
- Severe: SpO₂ <90%, single words, confusion → urgent PICU transfer; Nebulised Salbutamol + Ipratropium, IV steroids, NIV/CPAP.
💡 Paediatric Emergency Pearls
- Rapid breathing may also reflect cardiac failure, metabolic acidosis, or neurological disease.
- ❌ Do not use bronchodilators in infants <6 mo with bronchiolitis.
- Refer urgently if: tachypnoea, retractions, cyanosis, severe cough, feeding difficulties, or altered mental status.
🌟 Teaching pearl: In children, respiratory distress is often reversible if treated early. Always prioritise airway, breathing, and minimising agitation - a distressed child handled roughly can deteriorate into complete obstruction.
📈 Normal Paediatric Vital Signs (approx.)
| Age | HR (bpm) | RR (/min) | SBP (mmHg) | SpO₂ |
|---|
| Neonate | 100–180 | 40–60 | > 60 | > 94% |
| Infant (1–12 mo) | 100–160 | 30–50 | > 70 | > 94% |
| Toddler (1–3 y) | 90–150 | 25–40 | > 75 | > 94% |
| Child (4–6 y) | 80–140 | 20–30 | > 80 | > 94% |
| School age (7–12 y) | 75–120 | 18–25 | > 85 | > 94% |
| Adolescent | 60–100 | 12–20 | > 90 | > 94% |
🚨 Red Flags in Stridor
- Drooling, tripod posture, muffled voice → think epiglottitis (do not attempt throat exam, call anaesthetics/ENT immediately).
- Sudden onset during play/eating → suspect foreign body aspiration.
- Toxic appearance, high fever, worsening stridor → bacterial tracheitis.
🧠 Mnemonic: Causes of Stridor (“CUTE BATS”)
- Croup
- Upper airway foreign body
- Tracheitis (bacterial)
- Epiglottitis
- Bacterial abscess (retropharyngeal/parapharyngeal)
- Airway trauma or anaphylaxis
- Tumour / congenital anomaly
- Subglottic stenosis
🛑 Management Flow (Simplified)
- Stable child: Minimal handling, oxygen, steroids (if croup/asthma), supportive care, observe.
- Unstable child: Call senior/anaesthetics early, prepare advanced airway, consider adrenaline nebs, escalate to PICU.
🌟 Teaching Pearl:
In children, respiratory arrest usually follows progressive obstruction/fatigue.
If you see exhaustion, apnoeas, or bradycardia - act immediately: this is a peri-arrest state.
