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Introduction to Breathing Difficulties

This step gives an overview of breathing difficulties in paediatric patients.

Disorders of the respiratory tract are the most common illnesses of childhood. They are also the most frequent reason for children to be seen by their general practitioner.

Kate Mackay, a Consultant in Paediatric Emergency Medicine, will guide you through this topic. For all those non-medics out there, parts of this topic are quite technical. You may find it easier to first download the Parent Information Leaflet attached to the bottom of this page. This is written in plain English and avoids technical jargon.

At the end of this session you should be able to:

  1. Understand the differences between paediatric and adult airways
  2. Understand how paediatric patients present with respiratory distress
  3. Understand the features and management of acute severe asthma

There is a wide range of problems that may cause apparent difficulties in breathing in children. This table shows you some of the most common causes of breathing difficulty in children:

Abnormality Causes
Upper airway obstruction Croup/Epiglottitis; Foreign body
Lower airway obstruction Tracheitis; Asthma; Bronchiolitis
Disorders affecting lungs Pneumonia; Pulmonary oedema (e.g. in cardiac disease)
Disorders around the lungs Pneumothorax; Empyema; Rib fractures
Disorders of the respiratory muscles Neuromuscular disorders
Disorders below the diaphragm Peritonitis; Abdominal distension
Increased respiratory drive Diabetic Ketoacidosis; Shock; Poisoning (e.g. salicylate); Anxiety attack and hyperventilation
Decreased respiratory drive Coma; Convulsions; Raised intracranial pressure; Poisoning

Most children with breathing difficulties will have an upper or lower respiratory tract illness. These are the commonest causes of acute benign conditions in children but are also the most likely causes of life-threatening illness, especially in the very young. However, there are disorders outside the respiratory system that may cause apparent breathing difficulties, such as cardiac disease, poisoning and metabolic and neurological disorders.

Let’s explore some breathing difficulty facts:

  • Respiratory tract infections account for 30-40% of acute medical admissions.
  • In 1998, in England 300 deaths between the ages of 4 weeks and 14 years.
  • In 2002, this dropped to 167 and 65 were between ages 1 month- 1 year (ONS 2004).
  • Most respiratory illnesses are self limiting minor infection, but a few are life threatening.

Severe respiratory illness may result in the development of respiratory failure, defined as an inability of physiological compensatory mechanisms to ensure adequate oxygenation and carbon dioxide clearance, resulting in either arterial hypoxia, or hypercapnia, or both. In other words, when the lungs fail it becomes difficult to get oxygen into the body and clear waste products such as carbon dioxide. This leads to low levels of oxygen and high levels of carbon dioxide in the blood – which is bad news.

Young children and infants may develop respiratory failure more readily than older children and adults, reflecting important differences in the immune status, and the structure and function of the lungs and the chest wall of children and adults.

It is important to be aware that respiratory conditions in children do not always present with respiratory symptoms. The following table gives some examples of how they can present.

Respiratory Non-Respiratory
Breathlessness Poor feeding
Cough Abdominal Pain
Chest pain Changes in tone: hypotonic
  Change in colour or conscious level

Noisy breathing may be normal or pathological; parents and carers commonly understand different meanings from those understood by doctors and nurses for the terms used to describe breathing noises, or they may have their own terms. Useful historical features include relieving or aggravating factors (e.g. sleep, crying, feeding, position) and whether the voice or usual vocalisations are normal.

Stridor is usually a high pitched sound on inspiration from obstruction of the larynx or trachea and should be distinguished from stertor or snoring, which are lower pitched inspiratory noises suggestive of poor airway positioning or pharyngeal obstruction.

Bubbly or gurgly noises suggest pharyngeal secretions often seen in the child with cerebral palsy, who may have noises permanently from poor airway control and inability to spontaneously clear secretions.

Wheeze is a predominantly expiratory noise from lower airway obstruction, but may be termed a variety of other names by parents. An expiratory grunt suggests pneumonia. More on this in the next step.

Chest pain is an unusual symptom in children, and does not usually reflect cardiac disease, as it so often does in adults. While parents are usually alert to breathing difficulties in toddlers and older children, abnormal respiration may be more difficult for them to detect in infants.

  • So what do you look out for when faced with a child in respiratory distress? Add your comments below and discuss.
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Emergency and Urgent Care for Children: a Survival Guide

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