Podcast – Shortness of Breath in Children

Welcome to the St. Emlins induction podcast. I’m Iain Beardsell, and I’m Natalie May. In this podcast, we’re going to discuss something that can be quite intimidating, especially for those new to Emergency Medicine: the child who presents with shortness of breath. This situation can be concerning and challenging, even for experienced practitioners.

As regular readers of the blog will know, Natalie is our resident St. Emlins pediatric expert, so there’s no one better to get her hints and tips on how to look after these children. So, Natalie, if it’s all right, I’ll give you a case description, and maybe you can tell us how you would approach this patient. From there, we can cover some of the typical causes of shortness of breath in children.

Imagine it’s winter, and you’re in a busy pediatric emergency department. The triage nurse brings in a two-year-old child who’s short of breath. She’s brought them straight through because she’s a bit worried about the child. How do you suggest we approach these children to ensure a safe and effective evaluation?

That’s a great case and exactly the sort of child we would see in the winter when more kids come into the emergency department with shortness of breath. The first thing I would say is: don’t panic. You’ve got plenty of skills from your adult practice in assessing patients who are short of breath, and you can use those in the pediatric emergency department as well. Take your systematic approach to a short-of-breath patient and apply it to a child.

The first thing to do is assess the child’s level of consciousness, decide if the child needs resuscitation, and get help if you’re really worried. If things are okay from that point of view, you can go on to do a structured assessment of the effort they’re putting into breathing. Look for signs such as the use of accessory muscles, intercostal and subcostal recession, tracheal tug, or head bobbing in small babies. Then, assess the effectiveness and efficacy of that breathing effort. Check if they’re getting air into the chest and listen for any extra sounds that might indicate the pathology driving their breathing problems. Also, evaluate the effectiveness of oxygen delivery and gas exchange by checking the child’s level of consciousness, oxygen saturation, and effects on other systems like their heart rate.

For a child who is short of breath, do you think it’s a good idea to give them oxygen as soon as they come in?

Yes, it’s unlikely to cause any big problem, so it’s a great place to start. If you don’t know what else to do, give them oxygen; you can always stop it later. Oxygen doesn’t really cause children much harm, so it’s a good initial step.

Our decision on how to treat the child depends on what we find during our assessment. You’ll want to take a history from the parents about the chronology of events, how long the child has been short of breath, if there are any pre-existing lung problems, and any other presenting features like fever or cough. Don’t forget that toddlers might have inhaled a foreign body, so if the onset is very sudden, always consider that. This history can help decide if the child will respond quickly to therapy and which therapy to give, or if they will need to stay in the hospital.

One thing I’ve noticed is that viral infections are often the culprit behind these issues. Can you talk about the different viruses and how they affect treatment?

Yes, different viruses can cause different problems. For example, bronchiolitis is something we tend to see in the winter months. It’s on a continuum with what we call viral-induced wheeze and is caused by a virus, often the respiratory syncytial virus (RSV). It typically presents in children under six months old who are working hard with their breathing, showing lots of recession and tracheal tug, sometimes with low oxygen saturation and a wheezy chest. Older children can get similar symptoms from cold viruses, often when someone else in the family has a runny nose or other cold symptoms.

We need to differentiate between bronchiolitis and viral wheeze, particularly in children under two. Although 90% of children under two will have had an episode of bronchiolitis, not all need to come into the hospital. Our decision to admit a child depends on how well they are coping with the illness. If a child is very early in the course of the disease and already struggling with low oxygen saturation, they will need to be admitted. Children with low oxygen saturation on air, not feeding well, or with reduced urine output are also candidates for hospital admission.

How about the use of bronchodilators and steroids in these cases?

For bronchodilators, we can try salbutamol through a spacer if the child’s oxygen saturation is okay or a nebulizer if it’s low. If it helps, great; if not, no harm done. Steroids are more controversial. For children under five, recent studies suggest no benefit from giving steroids for viral wheeze, so I tend to avoid them unless the child has a formal diagnosis of asthma.

Let’s move on to another common cause: croup. How do you approach a child with croup?

Croup is related to viral infections and tends to present with a characteristic seal-like cough and inspiratory stridor. The first step is to stay calm and not distress the child. Try to stay back and not upset them, as anxiety can worsen their symptoms. For treatment, a single dose of dexamethasone usually works wonders. It reduces swelling around the vocal cords and makes breathing easier. We observe the child for two hours after administering dexamethasone and use a croup score to decide if they can go home.

Are there other causes of shortness of breath we should consider?

Yes, bacterial chest infections like pneumonia are another possibility. These children may not work as hard with their breathing as those with viral illnesses but often have a fever, decreased oxygen saturation, and a bit of recession. If you suspect pneumonia, a chest x-ray might be warranted, although we try to avoid unnecessary radiation.

In summary, the key points are to stay calm, use a systematic approach to assess the child’s breathing, and provide oxygen when needed. Most cases will be viral, requiring supportive therapy. Only a few children will need further investigations like a chest x-ray. Always consider the possibility of an inhaled foreign body if things don’t add up. Remember, there’s always someone more senior to ask for help if needed.

We hope this general approach helps you feel more comfortable on your first shift in the pediatric emergency department. Thank you for listening, and we look forward to speaking to you again on the St. Emlins podcast soon. Take care, everybody. Bye.