RESPIRATORY INSUFFICIENCY

IN CHILDREN
 Case 1
• Girl, 6 months
• Previous healthy

• History
– Start with coryza since 2 days
– Now since 1 day cough and wheeze
 Physical exam
• Body weight 6 kg
• Temp: 38.2 °C, Respiratory rate 50-60/min
• No chest indrawing
• No nasal flaring
• Auscultation
– Some crackles
– Expiratory wheezing
 Question
The most likely diagnosis is

3. Bronchiolitis due to Respiratory Syncytial Virus

4. Bacterial pneumonia
5. Secondary pneumonia after viral infection
6. Asthma
Semin Pediatr Infect Dis 2005;16:84-92
 Question
A. Expiratory wheezing indicates a lower (intra-thoracal)
airway obstruction (i.e. the bronchioli)
B. Inspiratory stridor indicates a higher (extra-thoracal)
airway obstruction (i.e. the trachea)

5. Only A is true
6. Only B is true
7. A and B are true
8. A and B are false
 Intra-thoracal obstruction

+
+ + + +
- + + +
- Ptr < Ppl
- - - +
- + +
- Ptr > Ppl
+
Ptr > Ppl
- -
- Expiration
-
-

Inspiration
 Extra-thoracal obstruction
+ Ptr > Patm

- Ptr < Patm

+ +

-
- +
- +
+ +

- -
Expiration
-
-

Inspiration
 Question
A. Expiratory wheezing indicates a lower intra-thoracal
airway obstruction.
Asthma, bronchiolitis

• Inspiratory stridor indicates a higher extra-thoracal

airway obstruction (i.e. the trachea).
Laryngitis subglottica, corpus alienum

• Only A is true
• Only B is true
• A and B are true
• A and B are false
 Case 2
• Boy, 4 yrs old

• Always healthy, no chronic diseases

• History: since 2 days fever and cough
 Physical exam
• Temperature 39.5 °C
• Respiratory rate: 55/min, pulse rate 120/min
• Nasal flaring
• Chest indrawing

• Auscultation: crepitations right hemithorax

 Question
A. Chest indrawing represent accessory respiratory
muscles use

B. Chest indrawing is more common in children than

in adults

5. A is true
6. B is true
7. A and B are true
8. A and B are false
 Question
A. Respiratory rate of 55/min is normal in children

B. Pulse rate of 120/min is to high in children

5. A is true
6. B is true
7. A and B are true
8. A and B are false
Normal values vital signs children
Age Pulse rate Bloodpressure Resp. rate

Newborn 120-160 60/40 40-50

1 month -2 year 80-140 85/55 30-40

2-5 year 70-115 90/60 20-30

5-8 year 70-115 100/65 15-25
>8 year 70-110 110/70 12-20

Note 1: normal pulse rate in case of fever: for every degree temperature
above 37.5 increase pulse rate with 10/min

Note 2: Rule of thumb for bloodpressure: systolic bloodpressure=

(2*age)+85
 Case continued

• Differential diagnosis

– Bronchitis
– Bronchiolitis
– Pneumonia

• Treatment
– Amoxicillin 125mg tds
 Question
Among the most frequent bacterial causes
of acute respiratory tract infections in
children are:

1. Streptococcus pneumoniae
2. Haemophilus Influenzae
3. Staphylococcus Aureus
4. All of the above
Semin Pediatr Infect Dis 2005;16:84-92
MSFH Guidelines respiratory tract
infection
Chest indrawing

No Yes

Respiratory rate increased Severe pneumonia

No Yes

No pneumonia < 2 m: >60/min

2 m-1y: >50/min
1-5 y: >40/min
Pneumonia
 Question
A. Mortality rate due to pneumonia decreases when
antibiotics are given promptly

B. Malnutrition is a risk factor for mortality due to

pneumonia

7. A is true
8. B is true
9. A and B are true
10. A and B are false
Meta-analysis of intervention trials on case-management of
pneumonia in community settings
Sazawal et al. Lancet 1992; 340: 528 33

• Meta analysis of 6 intervention trials

• Intervention: active case management (including

antibiotics) by community health workers based
on simple algorythm

• Results:
35% reduction in mortality rate <5 years of life.
 Case continued
History/
Mother returns to the clinic with the boy after
one day because of no improvement

Physical Exam/
Temp 39 °C, resp rate: 50/min, pulse rate 150/min
Chest retractions
Lips and tongue cyanotic
 Question
There are 2 forms of cyanosis:
central cyanosis and peripheral cyanosis

What is the pathophysiological difference?

 Cyanosis
• Central cyanosis: arterial oxygen desaturation
– Alarm sign!
– Sign of severe respiratory insufficiency!

• Peripheral cyanosis: venous oxygen desaturation

– Not necessarily alarm
– Centralisation of bloodflow
 Question
What could have been the reason for
treatment failure?

4. Micro-organism resistant
5. Not taking amoxicillin appropriately
6. Dosage of amoxicillin
• Streptococcal resistance against β-lactam
antibiotics occurs through β-lactamase production

• It makes sense to increase the dose of β-lactam

antibiotics in case of suspicion of H Influenza
resistance

6. A is true
7. B is true
8. A and B are true
9. A and B are false
Resistance against β-lactam antibiotics
• Streptococci:
– change in Penicillin Binding Protein
– In general this is dose dependent

• H Influenzae
– β-lactamase production
Drug resistance among S pneumoniae in
SE Asia

• Most studies: penicillin resistance patterns

• Prevalence of SP Penicillin resistance up to 40%

• Critchley 2002, Reechaipichitkul 2006, Watanabe 2003

• Penicillin resistant SP: variable sensitivity to

amino-penicillin (i.e. amoxicillin) : 50-95%
• Critchley 2002, Srifeungfung S 2005, Reechaipichitkul 2006
 Drug resistance among H Influenzae in
SE Asia

• Prevalence of beta-lactamase producing H.I.

highly variable: 20-57%
– Phan 2006, Critchley 2002, Larson 2000

• Amoxicillin-clavulanic acid potential alternative

Circulatory insufficiency in
children
Recognition and first treatment
 Case 1
• Boy, 2 year

– Previous history no abnormalities

– Since 3 days severe diarrhoea, with more
than 5 watery stools/day
– Poor drinking
 Physical exam
• Alert
• Pulse rate: 180/min
• Bloodpressure: 90/45 mm Hg
• Respiratory rate: 25/min
• Poor turgor, capillary refill > 3 sec
• Cold extremities
 Is this patient in shock?

A. Yes, pulse rate is high, skin turgor is

poor and capillary refill is prolonged

C. No the bloodpressure is still ok

 Case 2

• Girl, 3 yrs
• Previous healthy
• Since 4 days coryza and skin rash

• Since 1 day more sick and high fever

 Physical exam
• Not alert
• Temperature: 38.5 °C
• Pulse rate: 150 /min
• Bloodpressure: 60/40 mm Hg
• Respiratory rate: 55/min
• Skin lesions with secundary infection
 Is this patient in shock?

A. Yes, organ perfusion and thus function is

decreased

B. No, the diastolic bloodpressure is still ok

 What is shock?
A. Shock is a situation in which perfusion of
the organs is acutely decreased and
oxygen supply can not fulfill oxygen
demand

C. Shock is a situation of increased pulse

rate and low diastolic bloodpressure
 Shock
Pathophysiology
• Cardiogenic shock

• Distributive shock

• Hypovolaemic shock
 Imminent shock
compensation mechanisms
1. Increase of cardiac output:
Increase of pulse rate in children

4. Centralisation of the bloodflow

Cold hands and feet

3. Increase of oxygen extraction

Peripheral cyanosis
 Shock
Compensation mechanisms insufficient
• Bloodpressure decreases
– bloodpressure is a late (preterminal) sign

• Perfusion of organs to low:

– Brain: decreased consciousness
– Kidney: decreased urine output
– Lungs: increased respiratory rate
 Back to the 2 patients

Case 1, ♂ 2 y Case 2, ♀ 3 y

• Alert • Not alert

• Pulse rate: 180/min
• Bloodpressure: 90/45 mm Hg
• Respiratory rate: 25/min
• Poor turgor
• capillary refill > 3 sec
• Cold extremities
• Temperature: 38.5 °C
• Pulse rate: 150 /min
• Bloodpressure: 60/40 mm Hg
• Respiratory rate: 55/min
• Skin lesions with secundary
infection
Why so much attention to this?
 Treatment of shock in children

• Early goal directed therapy!

• The first hours are most important

• Early antibiotics: better survival

• Goal of the study:
– Does Early Goal Directed treatment make sense?

• Intervention
– ‘Aggressive’ early volume expansion vs ‘normal’ volume expansion
 Early goal directed therapy
consequences for MSFH setting
Before sending to hospital:

• If possible: give iv line and start iv fluid bolus

• Give first dose of parenteral broad spectrum

antibiotics

• If possible: accompagny patient to hospital

How much fluid for the child in shock?

1. 20 ml/kg in 30 minutes

2. 5 ml/kg in 2 h