Emergency Medicine

Paediatric Emergencies 349

BREATHLESS CHILD

(iii) Persistent hypoxaemia.

(iv) Circulatory collapse.

(v) Requires continuous salbutamol nebulizers for >1 h.

(vi) Discuss with ICU staff the administration of i.v. salbutamol,

aminophylline and i.v. or nebulized magnesium.

Bronchiolitis

DIAGNOSIS

1 This is a viral lower respiratory tract infection, which occurs in seasonal
epidemics and usually affects children <1 year of age.

2 The most common infecting organism is the respiratory syncytial virus
(RSV). Although other viruses are implicated, a routine nasopharyngeal
aspirate (NPA) is not necessary in infants with a typical picture. However,
NPA can be useful for cohorting admitted patients.

3 It starts with fever and snuff les, but progresses rapidly to cough, f luid
refusal, irritability, wheeze, chest hyperinf lation and marked tachypnoea.
The illness usually peaks at day 2–3 and the wheeze and tachypnoea resolve
by day 7. The cough may persist for weeks.

4 Listen for expiratory rhonchi and fine crepitations. In severe cases, cyanosis
develops with a raised respiratory rate and intercostal recession, or recurrent
apnoeic episodes occur.

5 Request a CXR. Hyperinf lation, parahilar peribronchial thickening and
patchy areas of atelectasis and collapse are common abnormalities seen.

MANAGEMENT

1 Attach a pulse oximeter and give the child oxygen to maintain saturations
above 90%.

2 Treat mild cases where the child is well perfused, feeding well and has oxygen
saturations above 90% expectantly, and discharge for GP review the next
day.

3 Admit moderate to severe cases with signs of lethargy, poor feeding, cyano-
sis, oxygen saturation less than 90%, or marked respiratory distress under
the paediatric team.
(i) Include any infant with recurrent apnoea, pre-existing lung
disease, congenital heart disease or immunodeficiency, who are
at highest risk of respiratory failure.
(ii) Continue oxygen, and commence oral, nasogastric or i.v. fluid
rehydration at 75% of maintenance requirement to reduce the
risk of syndrome of inappropriate antidiuretic hormone secretion
(SIADH).