Difficulty breathing in infants and young children:
Dyspnoea seen only with activity is usually managed at home, as prompt relief is obtained with inhaled bronchodilators (+/- the use of inhaled corticosteroids to dampen the inflammatory process).
LIMITS ACTIVITY (40-70% PEF) → OFFICE / ED
- frequent SABAs + oral steroids
- spacer > nebuliser
- oral steroids > inhaled corticosteroids (ICS)
- small volume spacer > large volume spacer – i.e. reserve large-volume spacers for those > 8 years old
- other:
- Turbuhaler: fast, deep breath and hold for 10 seconds
- Accuhaler: slow, deep breath and hold for 10 seconds
- other:
AT REST / INTERFERES WITH CONVERSATION (< 40% PEF) → ADMIT
- high-dose SABAs + Ipratropium q 20 min (or cont. for 1 hour)
- oral steroids
- +/- oxygen (O2 Saturation > 90%)
UNABLE TO SPEAK → ICU
- Oxygen (NRBM)
- Inhaled SABAs & Ipratropium: minimal relief despite frequent / continuous
- IV Corticosteroids: hydrocortisone or methylprednisone
- MgSO4: 1.2 – 2 g IVI over 20 minutes
- +/- IV Aminophylline
- +/- Bi-PAP
- +/- IV salbutamol (albuterol)
- +/- intubation
Beware the silent chest. This is a child who is having a life-threatening attack but, paradoxically, has little/no wheeze — only because they are moving very little air! They can give the (unsettling) impression of a “still-life” image. This is the child (who may still be a good colour) that when you listen to their chest you think: “gee, where are their breath sounds? … … …”
| Under 4 Years | Over 4 Years |
| 4 – 8 puffs salbutamol: spacer + mask prn | 8 – 12 puffs salbutamol: spacer prn |
| Prednisolone: 1 mg / kg PO | Prednisolone: 1 mg / kg PO |
| 4 – 8 puffs ipratropium: spacer + mask prn (0.25 mg nebs) | 4 – 8 puffs ipratropium: spacer prn (0.5 mg nebs) |
| Inhaled Mg SO4 (IMI) | Inhaled MgSO4 (IMI) |
| Theophylline PO | Theophylline PO |
| Adrenaline nebs | Adrenaline nebs |
| Salbutamol IMI or IV infusion | Salbutamol IMI or IV infusion |
| Adrenaline IM | Adrenaline IM |
References
- AAP/ACEP. APLS: The Pediatric Emergency Medicine Resource. 5th Edition. Jones & Bartlett, 2011 (Burlington, MA)
- Pain, M. Basic Tests of Respiratory Function. Aust Prescr 2000;23:10-2
- Australian Asthma Handbook, Quick Reference Guide – Version 1.0. Available at http://www.asthmahandbook.org.au/uploads/555143d72c3e3.pdf as at June 25, 2016
PEF (peak expiratory flow) reflects airflow in the larger airways, while asthma predominantly affects the small and midsized airways. That is why mean flow rates over the middle 50% of the vital capacity (maximal mid-expiratory flow, or MMEF) is a more sensitive indicator of airflow obstruction in children. This requires a spirometer, which today come in hand-held devices. Regardless, the guide above is a clinical one and requires no specialised equipment. If you’re out making house calls, for instance, a pulse oximeter is handy but not necessary and need also for supplementary oxygen can usually wait until an ambulance arrives.
