Makindo Medical Notes

👶 Introduction

• When a child presents with difficulty breathing, first establish the site of disease: upper airways (oropharynx, nasopharynx, larynx), lower airways (trachea, bronchi, bronchioles), lung parenchyma, central control, or a combination.
• Respiratory failure occurs when ventilation is inadequate to maintain oxygenation and CO₂ clearance.
• 💔 In paediatrics, most cardiac arrests are secondary to progressive respiratory failure — early recognition and intervention saves lives.
• ⚠️ Clinical signs of distress:
  • Abnormal rate/effort: tachypnoea, bradypnoea, nasal flaring, retractions, accessory muscle use.
  • Airway sounds: stridor, wheezing, grunting.
  • Colour changes: pallor, cool peripheries, cyanosis.
  • Consciousness: agitation, irritability, drowsiness.

📊 Key Differential Diagnosis of Stridor

Criteria	Mild Croup	Bacterial Tracheitis	Epiglottitis
Prevalence	Common	Uncommon	Rare (post-HiB vaccine)
Age Group	6 mo – 6 y	6 mo – 14 y	2 – 7 y
Onset	Gradual, over days	Viral prodrome 2–5 d → sudden deterioration	Sudden, rapid
Symptoms	Stridor only when upset Harsh barking cough Swallows secretions Hoarse voice Apyrexial or low-grade fever	Continuous (often biphasic) stridor Barking cough + toxic appearance Hoarse, weak voice Moderate–high fever Swallows secretions	Continuous stridor (softer, snoring quality) Drooling (unable to swallow) Muffled “hot-potato” voice Toxic, high fever (>39 °C) No barking cough

🛠️ General Management Principles

• Keep child in position of comfort; avoid unnecessary handling.
• Airway: head tilt–chin lift; if C-spine injury suspected, use jaw thrust.
• Suction if secretions present.
• Give humidified oxygen (headbox for infants, non-rebreather for older children).
• Continuous monitoring: HR, RR, BP, SpO₂.
• Secure IV/IO access if feasible.

🎯 Specific Management

• Croup (NB: SpO₂ not reliable marker of severity):
  • Mild: Barking cough, no stridor at rest → reassure parents, explain red flags.
  • Moderate: Stridor at rest, retractions → Nebulised Adrenaline 0.5 ml/kg (1:1000, max 5 ml), Oral/IV/IM Dexamethasone 0.3 mg/kg (or Prednisolone 1 mg/kg). Observe ≥4h.
  • Severe: Marked distress, restless/irritable → urgent transfer to PICU.
• Bronchiolitis (common in <1 y):
  • Mild: SpO₂ >95% RA, feeding well → home with nasal saline drops.
  • Moderate: SpO₂ 90–95%, feeding <50% normal → admit; humidified O₂, NG feeds, nebulised hypertonic saline/adrenaline.
  • Severe: SpO₂ <90%, apnoeas, exhaustion → high-flow nasal cannula, CPAP, or intubation in PICU.
• Asthma:
  • Mild: SpO₂ >95%, little distress → Salbutamol MDI + spacer, inhaled steroids, discharge with plan.
  • Moderate: SpO₂ 90–94%, phrases only, tachycardia → admit; O₂, Salbutamol (6–12 puffs via spacer), ± Ipratropium, Oral Prednisolone.
  • Severe: SpO₂ <90%, single words, confusion → urgent PICU transfer; Nebulised Salbutamol + Ipratropium, IV steroids, NIV/CPAP.

💡 Paediatric Emergency Pearls

• Rapid breathing may also reflect cardiac failure, metabolic acidosis, or neurological disease.
• ❌ Do not use bronchodilators in infants <6 mo with bronchiolitis.
• Refer urgently if: tachypnoea, retractions, cyanosis, severe cough, feeding difficulties, or altered mental status.

🌟 Teaching pearl: In children, respiratory distress is often reversible if treated early. Always prioritise airway, breathing, and minimising agitation — a distressed child handled roughly can deteriorate into complete obstruction.

📈 Normal Paediatric Vital Signs (approx.)

Age	HR (bpm)	RR (/min)	SBP (mmHg)	SpO₂
Neonate	100–180	40–60	> 60	> 94%
Infant (1–12 mo)	100–160	30–50	> 70	> 94%
Toddler (1–3 y)	90–150	25–40	> 75	> 94%
Child (4–6 y)	80–140	20–30	> 80	> 94%
School age (7–12 y)	75–120	18–25	> 85	> 94%
Adolescent	60–100	12–20	> 90	> 94%

🚨 Red Flags in Stridor

• Drooling, tripod posture, muffled voice → think epiglottitis (do not attempt throat exam, call anaesthetics/ENT immediately).
• Sudden onset during play/eating → suspect foreign body aspiration.
• Toxic appearance, high fever, worsening stridor → bacterial tracheitis.

🧠 Mnemonic: Causes of Stridor (“CUTE BATS”)

• Croup
• Upper airway foreign body
• Tracheitis (bacterial)
• Epiglottitis
• Bacterial abscess (retropharyngeal/parapharyngeal)
• Airway trauma or anaphylaxis
• Tumour / congenital anomaly
• Subglottic stenosis

🛑 Management Flow (Simplified)

• Stable child: Minimal handling, oxygen, steroids (if croup/asthma), supportive care, observe.
• Unstable child: Call senior/anaesthetics early, prepare advanced airway, consider adrenaline nebs, escalate to PICU.

🌟 Teaching Pearl: In children, respiratory arrest usually follows progressive obstruction/fatigue. If you see exhaustion, apnoeas, or bradycardia — act immediately: this is a peri-arrest state.