Approaches to a child with fast breathing

Approaches to a child with profligate breathingAPPROACH TO A CHILD WITH FAST BREATHING luxuriant breathing is the most common presentation in children visiting a hospital emergency. These children hold in the respiratory rate more than the normal tightness limit for that age group (see table 1), with or without increased run away of breathing in the variance of chest indrawing, nasal flaring and learning ability nodding. It may also be associated with stridor or wheeze suggestive of upper berth and glare airway obstruction respectively. There is a need of urgent assessment of airway patency and breathing when a child with prodigal breathing is first evaluated. Stabilization of vital parameters may require intubation, oronasal suctioning, phthisis of oxygen by hood/nasal prongs, intravenous fluid boluses, castigation of hypoglycaemia, nebulization with bronchodilator, intercostal tube drainage, correction of hyperthermia/ hypothermia etc. Such initial word coupled with a thorough history, physical examination and pertinent investigations, is followed by establishing a provisional diagnosis and instituting appropriate empirical treatment in the emergency ward itself. parry 1 The upper limits of respiratory rate defined by the WHOEtiology of fast breathing riotous breathing may not always result from a lung disease. It may be physiological e.g., exercise induced, or pathological due to pneumonic 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 cardinal of the earliest indicators of impending respiratory ill. While fast breathing is normally associated with respiratory diseases, it may also occur with fever, crying or metabolic acidosis. H owever, normal or decreased respiratory rate may be more ominous if it is associated with severe retractions (paradoxical breathing), cyanosis, grunting or altered sensorium. Central cyanosis is a late sign scarcely may not be detect 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 reveal the tone-beginning, duration, progression of dyspnea, the aggravating and relieving factors as well as the associated symptoms like fever, cough, sore throat, chest pain, throttling episodes, accidental ingestion of poisons etc. (table 3)Table 3 Symptom ground diagnostic cluesClinical pearlsInvestigationsLaboratory investigations help to confirm the diagnosis but the immediate management of a patient should not be detain pen ding the reports of the investigations. Use of non-invasive devices such as pulse 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 su pportive management, simultaneously searching for the etiology and prep a definitive treatment. The above mentioned approach will improve the ending of children, especially the under-five ones, in whom respiratory infections contribute to the highest number of mortalities.Suggested 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 kinfolk78(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.