Approaches to a child with fast breathing

Approaches to a child with lush breathingAPPROACH TO A CHILD WITH immobile BREATHINGFast breathing is the most common presentation in children visiting a hospital emergency. These children have the respiratory rate more than the recipe upper limit for that age group (see table 1), with or without increased work of breathing in the form of bosom indrawing, nasal flaring and spot nodding. It may also be associated with stridor or wheeze suggestive of upper and lower airway obstruction respectively. There is a need of urgent sound judgment of airway patency and breathing when a child with fast breathing is first evaluated. Stabilization of vital parameters may require intubation, oronasal suctioning, use of oxygen by hood/nasal prongs, intravenous fluid boluses, correction of hypoglycaemia, nebulization with bronchodilator, intercostal tube drainage, correction of hyperthermia/ hypothermia etc. Such initial treatment coupled with a thorough history, physical examination and releva nt investigations, is followed by establishing a provisional diagnosis and instituting appropriate empirical treatment in the emergency ward itself. flurry 1 The upper limits of respiratory rate defined by the WHOEtiology of fast breathingFast breathing may not always leave from a lung disease. It may be physiological e.g., exercise induced, or pathological due to pulmonary or non-pulmonary causes (table 2)Table 2 Causes of fast breathing in childrenClinical FeaturesA child with fast breathing be may have increased work of breathing (suggested by use of accessory muscles), cyanosis and lethargy or altered sensorium. Alteration in sensorium (in the form of irritability, agitation, lethargy or coma) indicates brain hypoxia and is one of the earliest indicators of impending respiratory failure. While fast breathing is commonly associated with respiratory diseases, it may also occur with fever, crying or metabolic acidosis. However, normal or decreased respiratory rate may be more dou r if it is associated with pure(a) retractions (paradoxical breathing), cyanosis, grunting or altered sensorium. Central cyanosis is a late sign but may not be detected in presence of severe pallor (low Hb) and dark skin colour.Stridor is a harsh inspiratory sound that indicates upper airway obstruction. Grunt is a loud noise produced by a forceful expiration against a closed glottis. Grunt and wheeze (a musical sound) are suggestive of lower airway obstruction.A complete history should bust the onset, duration, progression of dyspnea, the aggravating and relieving factors as well as the associated symptoms like fever, cough, sore throat, chest pain, choking episodes, accidental ingestion of poisons etc. (table 3)Table 3 presage based diagnostic cluesClinical pearlsInvestigationsLaboratory investigations help to confirm the diagnosis but the immediate management of a patient should not be slow down pending the reports of the investigations. Use of non-invasive devices such as pu lse oximeter and ET CO2 detector (fitted in the ventilator) lessen the need for repeated invasive tests for monitoring of the child. Table 4 shows the relevant investigations to ascertain the cause of respiratory distress in a child.Table 4 Laboratory investiagationsTreatment The management of a child with fast breathing includes supportive treatment in the form of stabilization of vital parameters i.e. temperature, airway, breathing and circulation followed by definitive treatment by instituting appropriate respiratory support, antibiotics, chest tube drainage, decongestive measures etc. Acute onset of fast breathing, esp following choking, and stridor indicate foreign body, and warrants prompt bronchoscopic search and removal of foreign body.algorithmic approach to management of fast breathingConclusionIt is essential to promptly triage children with impending respiratory failure and quickly institute supportive management, simultaneously meddlesome 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 infections contribute to the highest number of mortalities.Suggested meter readingKilham H, Gillis J, Benjamin B. Severe upper airway obstruction. Pediatr Clin North Am 1987 34 114.Mathew JL, Singhi SC. Approach to a child with breathing difficulty. Indian J Pediatr 2011 phratry78(9)1118-26.Fallot A. Respiratory distress. Pediatr Ann. 20053488591.Singh V, Tiwari S. Respiratory problems. In Gupta P,editor. Textbook of Pediatrics, editition 1. India CBS publishers2013, pp 335-368.