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Approaches to a child with fast breathing

APPROACH TO A CHILD WITH FAST BREATHING

Fast respiration is the most common demonstration in children browsing a hospital emergency. These children possess the respiratory rate more than the normal upper limit for this age group; (see stand 1), with or without increased work of breathing in the form of torso indrawing, sinus flaring and brain nodding. It could also be associated with stridor or wheeze suggestive of upper and lower airway obstruction respectively. There's a need of urgent examination of airway patency and respiration whenever a child with fast breathing is first examined. Stabilization of vital parameters may require intubation, oronasal suctioning, use of air by hood/nose prongs, intravenous liquid boluses, modification of hypoglycaemia, nebulization with bronchodilator, intercostal pipe drainage, correction of hyperthermia/ hypothermia etc. Such original treatment in conjunction with a thorough record, physical evaluation and relevant investigations, is accompanied by creating a provisional examination and instituting appropriate empirical treatment in the disaster ward itself.

Table 1: The top limits of respiratory rate described by the WHO

Age group

Respiratory rate cut-off

Young infant (

>60/minute

Infant (2 mo-1yr)

>50/minute

Children (1-5yr)

>40/minute

School children (>5yr)

>30/ minute

Etiology of fast deep breathing:

Fast breathing may not always derive from a lung disease. It might be physiological e. g. , exercise induced, or pathological due to pulmonary or non-pulmonary triggers (desk 2)

Table 2: Causes of fast breathing in children

Upper respiratory tract involvement

  • Croup, acute epiglottitis, Ludwig's angina
  • Retropharyngeal abscess
  • Foreign body aspiration
  • Diphtheria
  • Laryngospasm

Lower respiratory system involvement

  • Pneumonia,
  • Bronchiolitis
  • Asthma
  • Pleural effusion or empyema and hemothorax
  • Pneumothorax
  • Atelectasis
  • Hypersensitivity pneumonitis

Non pulmonary causes

  • Congestive heart failure due to cardiovascular disease or severe anemia
  • CNS attacks, cerebral edema, tumor (raised ICT, compression of the brainstem), spinal-cord harm, Guillain Barre syndrome
  • Metabolic Acidosis as with Renal failing, Diabetic ketoacidosis, Renal tubular acidosis, etc.
  • Psychogenic Hyperventilation, stress, panic attacks

Clinical Features:

A child with fast respiration be may have increased work of deep breathing (suggested by use of accessory muscles), cyanosis and lethargy or changed sensorium. Alteration in sensorium (in the form of irritability, agitation, lethargy or coma) indicates brain hypoxia and is also one of the earliest signals of impending respiratory inability. While fast respiration is often associated with respiratory system diseases, it may also appear with fever, crying or metabolic acidosis. However, normal or reduced respiratory rate may be more ominous if it's associated with severe retractions (paradoxical breathing), cyanosis, grunting or transformed sensorium. Central cyanosis is a overdue sign but may not be discovered in presence of severe pallor (low Hb) and dark epidermis colour.

Stridor is a tough inspiratory audio that indicates top airway obstruction. Grunt is a loud noise produced by a forceful expiration against a shut down glottis. Grunt and wheeze (a musical audio) are suggestive of lower airway obstruction.

A complete history should show the onset, length of time, progression of dyspnea, the aggravating and relieving factors as well as the associated symptoms like fever, coughing, sore throat, breasts pain, choking shows, accidental ingestion of poisons etc. (table 3)

Table 3: Indication structured diagnostic clues

Fever, cough and fast breathing

Lower respiratory system microbe infections like Pneumonia, bronchiolitis and pathogen associated wheeze

Exercise induced dyspnea

Asthma, CHF, severe anemia

Nocturnal coughing, orthopnea and dyspnea

congestive heart and soul failure

Fever, sore throat, stridor

Acute epiglottitis

Severe chest pain with swift, shallow breathing, decreased air entry

Pneumonia, pneumothorax, pulmonary embolism

Persistent wheezing, recurrent vomiting, inability to thrive

Gastroesophageal reflux disease

Acute respiratory distress after unexpected choking, hyperinflated chest

Foreign body inhalation

Fever with altered sensorium, convulsions, fast breathing

Encephalitis concerning brain stem

Chest wall membrane retractions, paraplegia

Acute flaccid paralysis

Acute respiratory problems with vomiting, altered sensorium

Poisoning

Anuria, generalized edema, impact, anemia

Acute kidney injury/ chronic kidney disease with metabolic acidosis

Fast breathing, modified sensorium, polyuria, dehydration

Diabetic ketoacidosis

Clinical pearls:

 

Investigations:

Laboratory investigations help confirm the diagnosis however the immediate management of a patient should not be delayed pending the reviews of the investigations. Usage of non-invasive devices such as pulse oximeter and ET CO2 detector (built in the ventilator) decrease the necessity for repeated intrusive exams for monitoring of the kid. Desk 4 shows the relevant investigations to ascertain the reason for respiratory stress in a kid.

Table 4: Lab investiagations

Investigation

Suggested diagnosis

Complete blood matter with peripheral smear

Leucocytosis/leucopenia, toxic granules, switch to kept, anemia/polycythemia, eosinophilia-Pneumonia, sepsis, TPE

CRP, ESR

Raised-pneumonia, bronchiolitis

Blood culture

Sepsis with pneumonia

Kidney function tests

Acute/ chronic kidney disease

Arterial blood gas

Hypoxemia, hypercarbia, acidosis (metabolic/respiratory)-pneumothorax, AKI

Chest X ray, X ray very soft tissue neck

Pneumonia, pneumothorax, effusion, overseas body, serious epiglottitis, CHF

Bronchoscopy

Foreign body

Echocardiography

Cardiac disease

24 hr pH monitoring

GERD

Pleural tap

Pneumonia (bacterial, tubercular)

Lumbar puncture/ cranial CT scan

Pleocytosis, raised proteins and decreased sugar-Meningoencephalitis/increased ICT

Treatment: The management of a child with fast breathing includes supportive treatment in the form of stabilization of essential guidelines i. e. heat range, airway, deep breathing and circulation accompanied by definitive treatment by instituting appropriate respiratory support, antibiotics, breasts pipe drainage, decongestive options etc. Acute onset of fast breathing, esp following choking, and stridor signify foreign body, and warrants quick bronchoscopic search and removal of international body.

Algorithmic approach to management of fast breathing:

Conclusion:

It is essential to immediately triage children with impending respiratory failing and quickly institute supportive management, simultaneously searching for the etiology and planning a definitive treatment. The above mentioned approach will improve the outcome of children, especially the under-five ones, in whom respiratory microbe infections contribute to the best quantity of mortalities.

Suggested reading:

  1. Kilham H, Gillis J, Benjamin B. Severe top airway obstruction. Pediatr Clin North Am 1987; 34: 1-14.
  2. Mathew JL, Singhi SC. Method of a kid with respiration difficulty. Indian J Pediatr 2011 Sep;78(9):1118-26.
  3. Fallot A. Respiratory distress. Pediatr Ann. 2005;34:885-91.
  4. Singh V, Tiwari S. Respiratory problems. In: Gupta P, editor. Textbook of Pediatrics, editition 1. India: CBS publishers;2013, pp 335-368.
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