Breathing (part 2 of 4)

2 July, 2010 by: colinparker

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Welcome back to more pearls on assessing breathing difficulty in children. In this episode we cover clinical tips to help distinguish different causes of respiratory signs, tachypnea, and respiratory failure: there are FOUR groups now!
B is for Breathing

Outline of this PEMcast:

ALL: Clinically distinguishing:
Croup vs asthma, crasthma
Bronchiolitis vs CCF

CP: Causes of tachypnea

  • RS
    • LRTI
    • Obstructive: asthma, bronchiolitis, (FB/UAWO)
  • CVS
    • CCF (blockages, holes, bad plumbing)
    • Shock
    • hypoxia
  • metabolic
    • fever
    • metabolic acidosis (AG vs non-AG)
  • other
    • pain, anxiety
    • brainstem disease
    • drugs: salicylate poisoning (stimulation respiratory centre), sympathomimetics

DA: Causes of Respiratory failure
Type 1: Acute Hypoxic (airway flooding): air hunger; no response to supplemental oxygen
Type 2: Hypercapnoeic (inadequate alveolar ventilation): central, neuromuscular, chest wall, restrictive lung disease; supplemental oxygen improves oxygenation
Type 3: Peri-operative (atelectasis)
Type 4: Shock (inadequate lung perfusion)

Next time, I ask Kate about when to refer patients to the PICU for ventilatory support, and Dan tells us about basic ventilator settings and how to avoid VILI.  See you there!

Meanwhile, tell us what you think about the extra 2 types of respiratory failure – leave a comment below.

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2 Responses to “Breathing (part 2 of 4)”
  1. Tonks says:

    Hi Colin. I have some concerns about grouping extra thoracic and intrathoracic obstruction together as crasthma. This is not a diagnosis and is potentially confusing. Moreover they have totally different treatment and I have seen children approaching total airway obstruction secondary to junior staff treating asthma and not extra-thoracic stridor (croup/LTB/tracheitis). I would suggest you remove it and clarify the difference between stridor (a predominantly inspiratory noise due to extra thoracic lesions/narrowing etc) and wheeze (an expiratory noise exclusively and intra thoracic). It’s fine to talk about concurrent stridor with some suggestion of lower small airway obstruction, although in 15 years of paeds I have rarely seen ( actually I just haven’t seen this) the two co-exist.
    Otherwise your style is nice and fun. I would also suggest that the comment at the beginning that this is based on tradition and not science is deleted!! You are hanging yourselves guys and it comes across as unprofessional. How about stating this is based on clinical experience (you have loads) backed up with evidence where available as this is what you are doing!

  2. colinparker says:

    Thanks for your comment and support Tonks.
    Regarding ‘crasthma’, as you say this is not a real diagnosis, and I agree the extrathoracic stridor component is not to be confused with the intrathoracic (predominantly expiratory and polyphonic) wheeze. It may be that underestimating upper airway obstruction is more dangerous than underestimating wheeze. Down here in the ED, we do sometimes see croupers who have a touch of wheeze added in to the mix; often the pre-hospital crew will give bronchodilators, which does not fix the (predominant) upper airway component of their illness. I’ve never seen an asthmatic with a touch of stridor though! The croupers get better after oral steroids and go home; this may be why the inpatient teams don’t get to see croup with a smidgen of wheeze.
    I’m happy to admit to practising evidence-informed, experience-based, witchcraft…


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