Approaches to a child with fast breathing

APPROACH TO A CHILD WITH FAST BREATHING

Fast breathing is the most common presentation in children visiting a hospital emergency. These children have the respiratory rate more than the normal upper limit for that age group; (see table 1), with or without increased work of breathing in the form of chest indrawing, nasal flaring and head nodding. It may also be associated with stridor or wheeze suggestive of upper and lower airway obstruction respectively. There is a need of urgent assessment 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 relevant investigations, is followed by establishing a provisional diagnosis and instituting appropriate empirical treatment in the emergency ward itself.

Table 1: The upper limits of respiratory rate defined by the WHO

Etiology of fast breathing:

Fast breathing may not always result 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 children

Clinical Features:

A 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 ominous if it is associated with severe 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 reveal 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: Symptom based diagnostic clues

Clinical pearls:

Investigations:

Laboratory investigations help to confirm the diagnosis but the immediate management of a patient should not be delayed pending 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 investiagations

Treatment: 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 breathing:

Conclusion:

It is essential to promptly triage children with impending respiratory failure and quickly institute supportive management, simultaneously searching 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 reading:

1. Kilham H, Gillis J, Benjamin B. Severe upper airway obstruction. Pediatr Clin North Am 1987; 34: 1–14.
2. Mathew JL, Singhi SC. Approach to a child with breathing difficulty. Indian J Pediatr 2011 Sep;78(9):1118-26.
3. Fallot A. Respiratory distress. Pediatr Ann. 2005;34:885–91.
4. Singh V, Tiwari S. Respiratory problems. In: Gupta P,editor. Textbook of Pediatrics, editition 1. India: CBS publishers;2013, pp 335-368.