Author: Edward Snelson / Codes: PAP5 / Published: 12/09/2018
Children with noisy or difficult breathing often present to the Emergency Department (ED). The acuity of these patients varies, but any of the conditions that cause respiratory symptoms can be life threatening. This article will give key information about each presentation and condition, while signposting further information that you can read for more in depth learning.
LRTI vs URTI
Children with cough and fever are one of the most common presentations to the ED. The vast majority of these children do not have pneumonia. Clinical examination of children’s chests can be challenging because they may not cooperate and because transmitted sounds are very commonly heard in URTI. Thankfully, assessment of children is something that can be done more easily and often more safely from a distance. The appearance, behaviour and work of breathing of a child are all good discriminators between URTI and LRTI.
LRTI vs URTI – Key learning points
- Pneumonia in children is characterised by cough, fever, respiratory distress and a consistent reduction in activity.
- URTI in children is characterised by cough, fever, a fluctuating level of unwellness but absence of respiratory distress.
- Chest X-ray is not recommended as a way of diagnosing uncomplicated community acquired pneumonia.(BTS)
- Pneumonia is a clinical diagnosis. Blood tests and chest X-ray are not routinely required even if a child is being admitted. (BTS)
Most children with LRTI can be discharged from the ED with oral antibiotics and careful safety netting.
You should have local guidelines for when to refer children with LRTI. Usually they include the following criteria:
- Age below 1 year
- Low SaO2
- Moderate/ severe increased work of breathing
- Comorbidities (e.g. immunodeficiency etc)
- Poor oral intake or urine output (note possibility of AKI or SIADH)
- Signs of sepsis (Sepsis 6 and refer!)
The management of URTI is paradoxically often more complex. Children with sore throats, sore ears, runny noses or red eyes usually have a viral illness. The harsh reality is that even when tonsils are red or have exudate and when eardrums are red and bulging, the likelihood that antibiotics will help is very low. Even using a scoring system fails to give good odds. When you take into account the side effects that antibiotics cause to children, it is no surprise that NICE recommend a “no antibiotic or delayed antibiotic prescribing strategy.”
The most important aspects of managing URTI (including tonsillitis and otitis media) in children who present to the ED are:
- Good symptom control
- Ensure good hydration
- Rule out sepsis
- Rule out complications (peritonsillar abscess, mastoiditis etc.)
- Good safety netting advice
The evidence is against antibiotics being effective to reduce symptoms or complications so they should be prescribed mainly for prolonged or otherwise atypical cases of URTI in children.3
What about wheeze?
Now that we have dealt with respiratory infection, let’s cover wheeze. The vast majority of paediatric wheeze is caused by one of three things, bronchiolitis, viral wheeze or asthma. These three things tend to have recognisable patterns and tend to present at different ages. It can sometimes be difficult to tell the difference between them but most of the time it is possible. Getting the diagnosis right is important because each is managed differently.
Think of bronchiolitis as wet lungs. This cause of wheeze is usually seen under the age of 12 months. Typically, there is a slow gradual progression of cough, wheeze, feeding difficulty and then increased work of breathing over about 3-5 days. Symptoms often then plateau for a few more days and then finally begin to resolve. Many, many studies have looked for effective treatments for bronchiolitis and all have found that there are none. Nothing works apart from respiratory support and feeding support where needed. This means no inhaler, no steroids, no antibiotics and no nebulisers.
For infants presenting to the ED, the most important aspects of assessing bronchiolitis are:
- History any red flag symptoms such as blue, pale or floppy episodes?
- Feeding is the infant taking at least half of their normal feeds and having wet nappies?
- Comorbidities is this infant ex-premature? Do they have a known heart problem?
- Examination work of breathing, hydration, signs of an alternative diagnosis (see cardiac causes of wheeze below)
Like all things in life and clinical practice, bronchiolitis comes in three sizes. The severity of the presentation will determine how the child is managed:
Mild and moderate cases do not require chest X-ray or blood tests. The decision to admit or discharge is clinical.4 Chest X-rays often show a few streaks of white or a patch of uncertain significance which may lead to the prescription of unhelpful antibiotics.
*Your department will have a guideline which you should use. This is provided to give you an at-a-glance understanding of how things should go.
**There has been a recent increase in the number of centres using high flow nasal cannula oxygen as a treatment for moderate to severe bronchiolitis. There seems to be a measurable effect5 of this therapy in babies who are heading towards respiratory failure however it is not a substitute for assisted ventilation in those babies who have already properly failed.
Perplexing Cases 1: A wheezy 6 week old
A 6 week old baby presents with coryza, wheeze, poor feeding and increased work of breathing. While the obvious diagnosis should be bronchiolitis, this baby is excessively tachycardic (190 bpm) and has an unusually long prodrome for their symptoms, which started 7 days ago and are still getting worse.This is a case of cardiac failure, most likely due to a large ventricular septal defect. Other clues that might give the game away are a large liver and the presence of a murmur. It’s not easy to hear a murmur at 190bpm but early recognition of heart failure facilitates early treatment.
Viral wheeze is different from bronchiolitis. While bronchiolitis is wet lungs, viral wheeze is bronchospasm. So while both are caused by viruses, they present differently and respond differently to treatment. The reason for this difference is probably to do with the way that children’s immune systems develop over their first few years.6 This has an important effect on clinical practice because telling the difference between the two is important. Bronchiolitis is best NOT treated with bronchodilators but viral wheeze MUST be treated with bronchodilators. Viral wheeze is not a benign entity. Children have died from exacerbations of viral wheeze.
Bronchiolitis vs Viral Wheeze
The simplest way to tell the difference is by age. The reality is that a wheezy patient under the age of 12 months is highly likely to have bronchiolitis and a patient aged between 1 and 5 years old is highly likely to have viral wheeze.
There is inevitably some overlap, mostly in the children aged between 9 and 15 months. In this age bracket it is particularly worthwhile to pay attention to the history of the onset of symptoms, which tends to be days in bronchiolitis and hours in viral wheeze.
Telling the difference is important, because although a trial of inhalers is another way of discriminating between the two, giving inhalers to infants with bronchiolitis will potentially tire them out. It is all too easy to fall into the trap of trying inhalers for all wheezy babies. The trouble with that is that there is a potential for you to be misled into believing that the bronchodilator has worked. If a trial of inhalers is undertaken in an under 12 month old, the child should be reviewed shortly afterwards looking for strong evidence of benefit.
Treating Viral Wheeze
The treatment of a viral wheeze is all about one thing: -agonists. How that is done depends on the severity of the presentation.
*Your department will have a guideline which you should use. This is provided to give you an at-a-glance understanding of how things should go.
Inhaler via spacer is preferable to nebuliser in all situations other than the hypoxic child.
Chest X-ray is not usually helpful and should be avoided unless it is a severe episode or there is a specific indication.
Steroids are given for severe episodes but otherwise are not routinely used as the evidence does not support this practice.
Perplexing Cases 2: A not wheezy 3 year old
A 3 year old presents with increased work of breathing and a coryzal illness. They have a history of viral wheeze episodes but on auscultation there is no wheeze, and there is air entry throughout.
Odds are, this is still a case of viral wheeze. Although other diagnoses should be considered, one thing that you can try here is 10 puffs of salbutamol. If you are right, a wheeze might well appear as the bronchospasm improves slightly allowing a different musical note.
Viral Wheeze vs Asthma
There is a risk that multiple episodes of viral wheeze will lead to a misdiagnosis of asthma. Many children have several episodes of viral wheeze. Asthma is rare in the under five year old age group. If asthma is suspected in an under five year old it is usually on the basis of repeated episodes of wheeze that are not related to viral illnesses. Prolonged cough without wheeze is unlikely to be asthma.
Asthma in children should be treated as per BTS guidelines7. The important things to recognise are:
- Failure to respond to treatment is a very dangerous scenario
- If failing to respond to treatment, consider other diagnoses or comorbidities
- Cardiac causes (e.g. Myocarditis)
In most cases of failure to respond to treatment, what is needed is more treatment.
Perplexing Cases 3: A 2 year old with a cough for 2 months
A 2 year old presents with a cough that has gone on for two months. They had a particularly bad URTI at the beginning of the cough so bad that the child was vomiting after they coughed. Now that the cough has continued the parents think that their child might have asthma.
Prolonged cough without wheeze is rarely asthma and in a two year old the odds are massively against it. Post infective cough can take a long time to resolve and this case sounds like it could have been pertussis, which can lead to months of coughing. Very important: If a child has a daily (very important distinction from a cough that comes and goes) cough for 8 weeks, they should be referred for an outpatient assessment. Earlier referral through a more urgent route is indicated if there are red flags such as weight loss, haemoptysis or contact with TB.
Croup and other similar problems
The vast majority of children presenting with upper airways noises have croup. If a child goes from having a runny nose to having a barking cough, the diagnosis doesn’t need too much thought it’s going to be croup. While there are differential diagnoses for stridor, these alternatives usually stand out. If there has been a choking episode, then foreign body needs to be the presumed diagnosis. If the child is more unwell than expected for an uncomplicated viral infection, you should suspect epiglottitis, bacterial tracheitis or diphtheria.
Croup management depends on the severity of the episode. This is often categorised using the Westley croup score8.
* Your department will have a guideline which you should use. This is provided to give you an at-a-glance understanding of how things should go.
RCEMLearning has a blog on croup here.
Perplexing Cases 4: A squeaky 4 week old
A four week old baby presents because their parents have noticed noisy breathing, especially after feeds and when lying down. They are well, thriving and examine normally. The parents show you a video of the infant asleep and you can hear an inspiratory noise that sounds like a squeaky toy. This is very likely to be laryngomalacia a floppy larynx. The problem usually starts in the first few days after birth and may be exacerbated by reflux. In the majority of cases the problem resolves by itself as the child gets older. However, most ENT specialists recommend that all cases should be assessed by them in outpatients to exclude rarer causes of stridor in babies, such as haemangiomas and tracheal stenosis.
Respiratory tract problems are the most common paediatric presentation to the ED. Hopefully, this gives you a good overview and understanding of what you’re looking for and how to treat each condition. Here is a really basic and oversimplified summary of how to recognise the difference between them all:
*These conditions will also be seen outside of these age ranges, much less commonly.
And here are the key differences in evidence based treatment:
*There is a myth that ipratropium is the most appropriate inhaler under the age of 12 months.9,10 This myth leads to the use of ipratropium for children with bronchiolitis (where ipratropium has been shown to be ineffective4 and for children who have viral wheeze but are under the age of 12 months old. If the clinical picture is viral wheeze, salbutamol is the treatment of choice.
And if you’re not sure, there’s a great audiovisual guide to Winter Wheezes here.
Edward Snelson, Consultant in Paediatric emergency Medicine at Sheffield Children’s Hospital.
Massive thanks to Caroline Worsley for checking this through and adding the perspective of a trainee in Emergency Medicine.
- British Thoracic Society, Guidelines for the management of community acquired pneumonia in children: update 2011
- NICE, Respiratory tract infections antibiotic prescribing (NG69)
- The Trouble With Tonsils. St.Emlyn’s Blog
- NICE Bronchiolitis in children: diagnosis and management, NG9
- Franklin, D. et al, A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis, N Engl J Med. 2018 Mar 22;378(12):1121-1131.
- GPpaedsTips, Why Do Different Children Wheeze Differently?
- British guideline on the management of asthma 2016 Quick Reference Guide
- Yang et al. Westley score and clinical factors in predicting the outcome of croup in the pediatric emergency department, Paed Pulmonology.2017 October; 52(10):1329-1334
- GPpaedsTips, Why bronchiolitis doesn’t get better with inhalers
- Prendiville A, Green S, and Silverman M, Airway responsiveness in wheezy infants: evidence for functional beta adrenergic receptors, Thorax. 1987 Feb; 42(2): 100104.
- RCEMLearning. The Curious Incident of the Barking Cough in the Night time: Croup in the ED.