Station 9.1: Acute bronchiolitis
You are a junior doctor in the emergency department. A 6-month-old baby, Sara Smith, is brought in with a 3-day history of cough, runny nose and red eyes. Today she has become very breathless, and is not feeding. Please assess the baby and instigate appropriate management.
‘The airway is patent, with no obstruction. No apnoeas or cyanotic spells are seen or reported.’
No additional airway support is required, though CPAP or intubation might be considered if the baby deteriorates.
In significant respiratory distress, feeding is usually affected. Assess fluid intake. If breast-feeding, assess length of breast-feeds, and enquire about quality of latching and sucking. If bottle-feeding, assess total volume taken each feed
‘RR 70/min, oxygen saturations are 90%, with intercostal recession, tracheal tug, nasal flaring, and abdominal breathing. Crackles are heard throughout the lung fields bilaterally, with occasional wheeze, and reduced air entry at the lung bases. Mum is breast-feeding, and normally feeds for 15 minutes every 3 hours, but today has only managed to feed for 5 minutes in 6 hours.’
Given the above, you give supplementary nasal cannulae oxygen (since saturations are below 94%), and you prescribe a hypertonic sodium chloride nebulizer. A trial of salbutamol may be considered in older babies but this should not be continued if the initial trial is ineffective.
Assess hydration status by looking at mucous membranes, skin turgor, feeling if the anterior fontanelle is sunken, and looking to see if the eyes are sunken. Ask about the number of wet nappies today and if there has been any change
Perform a cardiovascular exam to exclude evidence of heart failure. In a baby you would pay attention to gallop rhythm, a heart murmur, hepatomegaly, peripheral oedema and ascites. Crackles in the lung may not be bronchiolitis; they may be a sign of left heart failure
‘HR 180 bpm, BP 60/40 mmHg, CRT 4 seconds centrally, 6 seconds peripherally. Anterior fontanelle is slightly sunken, as are the eyes, and the mucous membranes are dry. Sara has only had one wet nappy today, when usually she would have three by this time. Cardiovascular exam shows normal heart sounds with no murmurs or hepatomegaly.’
The baby has signs of dehydration, and will require IV access and a fluid bolus, given as 20 mL/kg 0.9% sodium chloride, followed by reassessment. Bloods and a blood gas can be sent at the same time.
‘The baby is alert, and has blood sugar of 6.5 mmol/L.’
‘Temperature is 37.5°C, and examination is otherwise normal.’
Capillary blood gas: An acute respiratory acidosis is indicated by a low pH, a raised PaCO2, and a normal bicarbonate/base excess. A raised lactate or a reduction in the base excess indicates a metabolic acidosis, possibly secondary to infection or hypoperfusion. Note: PaO2 is of little use on a capillary gas
Nasopharyngeal aspirate (or combined nose and throat swabs): Used to detect respiratory syncytial virus (RSV), a common cause of bronchiolitis. A patient with confirmed RSV should be isolated in a side room
CXR: Will potentially show patchy changes consistent with bronchiolitis or pneumonia (though these are difficult to differentiate radiologically). Other respiratory pathology such as pneumothorax can be ruled out. The cardiac shadow may be suggestive of congenital heart disease (such as cardiomegaly or a boot-shaped heart in tetralogy of Fallot), which is an important differential. A CXR is not always required and is best reserved for severe cases or if the diagnosis is in doubt
‘Capillary blood gas shows a respiratory acidosis, with no metabolic compensation. pH 7.28, PaCO2of 7.5 kPa, HCO322 mmol/L, BE−0.5 mmol/L. Hb is 145 g/L, WCC 15×109/L, neutrophils 8×109/L, lymphocytes 4.5×109/L. Na 131 mmol/L, urea 9.3 mmol/L, creatinine 45 µmol/L. CRP is 20 mg/L. NPA is positive for RSV. CXR shows diffuse patchy changes in both lung fields. Weight is 6 kg.’
|Parameter||Value||Normal range (Units for 6 month olds)|
|Haemoglobin||145 g/L||105–150 (g/L)|
|CRP||20 mg/L||0.8–11.2 (mg/L)|
|Urea||9.3 mmol/L||1.8–6.4 (mmol/L)|
|Creatinine||45 μmol/L||2.65–44.2 (μmol/L)|
|Sodium||131 mmol/L||134–144 (mmol/L)|
|Potassium||4.0 mmol/L||3.5–5.6 (mmol/L)|
|PaCO2||7.5 kPa||4.7–6.0 (kPa)|
|HCO3||22 mmol/L||22–26 (mmol/L)|
|BE||−0.5 mmol/L||±2 mmol/L|
Initial Management 
Hypertonic sodium chloride: 4 mL 3% sodium chloride can be given through a nebulizer if the child has ongoing respiratory distress. This helps loosen and mobilize thick secretions and relieves mucus plugging. It can cause bronchospasm and is therefore occasionally given immediately after a bronchodilator
Ipratropium bromide and/or salbutamol: Some babies may respond to bronchodilator therapy, but generally speaking, those under 12 months are unlikely to show improvement. This is because the underlying pathophysiology is of small airway obstruction secondary to inflammation and secretions rather than bronchospasm, and as such is not reversible
Fluid support: This baby required a fluid bolus as she was significantly dehydrated. Moderate to severe respiratory distress will impair normal feeding. Depending on the degree of respiratory distress, feeding support may take one of two forms. Nasogastric feeds allow milk to be put in the stomach with less interruption in breathing than breast or bottle feeds. Smaller feed volumes can be given to minimize gastric distension by increasing feed frequency; ensuring total daily volume is the same. If the baby is too unwell to tolerate NG feeds, IV fluids can be given
Feed requirements would need to be calculated based on weight. For a weight of 6 kg, 600 mL/day is required for maintenance fluid (6×100 mL/kg/day). Syndrome of inappropriate antidiuretic hormone (SiADH) may develop in children with acute respiratory problems, indicated by low serum sodium as in this case. Giving full maintenance fluids may cause the sodium to fall dangerously. Therefore, two-thirds maintenance fluid of 0.9% NaCl with 5% glucose would be given rather than full maintenance fluid:
‘Sara looks significantly improved. Her airway is patent. RR 55/min, oxygen saturations are 95%, on 2 L of nasal cannula oxygen, with mild intercostal recession, and nasal flaring. Crackles are heard throughout the lung fields bilaterally, but air entry is much improved. HR 140 bpm, BP 90/60 mmHg, CRT 1 second centrally, 2 seconds peripherally. Anterior fontanelle is normal, eyeballs are not sunken, and the mucous membranes are moist. It is worth noting that the salbutamol did not result in any improvement and should be discontinued.’
Handing over the Patient
‘Baby Smith is a 6 month old with RSV positive bronchiolitis.
She presented with significant respiratory distress and poor feeding following a 3-day history of coryzal symptoms. From a respiratory point of view, she has required supplementary oxygen and hypertonic sodium chloride, given with ipratropium. In terms of circulation, she was significantly dehydrated requiring a fluid bolus to which she responded well. RR 55/min, oxygen saturations are 95% on 2 L of nasal cannula oxygen, with only mild respiratory distress. She is haemodynamically stable and well hydrated.
Investigations show an initial respiratory acidosis, with a pH 7.28, PaCO2 7.5 kPa, BE−0.5 mmol/L on capillary gas. She initially was hyponatraemic with a Na+ of 131 mmol/L, and dehydrated (urea 9.3 mmol/L, creatinine 45 µmol/L). CRP 20 mg/L. CXR shows diffuse patchy changes in both lung fields, consistent with bronchiolitis.
The plan is to transfer to the ward in a cubicle, NBM on two-thirds maintenance fluids IV and 6-hourly hypertonic sodium chloride with ipratropium. She will need a repeat capillary gas, U&Es and blood sugar later this evening. Supplementary oxygen should be continued to keep saturations above 94%.’
Station 9.2: Respiratory distress in the newborn
You are a junior doctor working on a postnatal ward. You are called to assess a baby (male infant Jones) who is 12 hours old with a rapid respiratory rate. He was born by emergency C-section for failure to progress. Mum had antibiotics during labour due to fever. The baby was born in good condition, with no resuscitation required.
‘The airway is patent, and the baby can cry. There is no evidence of meconium staining.’
The baby does not require any airway support.
Observe the baby for signs of respiratory distress, including grunting, nasal flaring, tracheal tug, intercostal and subcostal recession. Assess colour as evidence of oxygen saturations and request oxygen saturation monitoring
‘The baby is pink, but has increased work of breathing with grunting, nasal flaring, tracheal tug and subcostal/intercostal recession. Air entry is good throughout the chest with no added sounds. His respiratory rate is 70/min, and his oxygen saturations are 92%. The baby has been unable to latch to the breast for the last 6 hours.’
Given the above, the baby is in need of respiratory support and further investigation. He will need admission to the special care baby unit (SCBU) and supplemental oxygen.
‘HR 160 bpm, CRT 2 seconds centrally, 2 seconds peripherally. The apex is felt at fifth intercostal space, mid-clavicular line. The heart sounds are normal with no audible murmurs. Both femoral pulses are palpable.’
‘The baby is not alert and responds only to handling. He has a blood sugar of 1.7 mmol/L.’
The baby will require a bolus of glucose, given as 2.5 mL/kg of 10% glucose.
Expose the baby, and look for clues towards other possible causes of respiratory distress, including other congenital problems that may be associated with underlying lung pathology. Measure his temperature, as newborns can get cold very quickly, especially if unwell or hypoglycaemic
A brief antenatal history is important including abnormal antenatal scan results, gestation, and maternal factors such as gestational diabetes or medication. A birth history may elucidate risk factors for infection such as maternal pyrexia or known colonization with Group B Streptococcus
‘The antenatal history was unremarkable. His mother had pyrexia in labour and had prolonged rupture of membranes. Temperature is 36.2°C, and extended examination is otherwise normal.’
Capillary blood gas: An acute respiratory acidosis is indicated by a low pH, a raised PaCO2, and a normal bicarbonate/base excess. A raised lactate and/or reduced base excess indicates a metabolic acidosis, which may be secondary to sepsis or reduced perfusion
Bloods: FBC, U&Es, CRP and blood culture, looking for evidence of infection. The blood culture should be taken before starting antibiotics. Neonatal jaundice may be more pronounced in unwell newborns so a baseline serum bilirubin (SBR) should be taken. Group and save is normally taken early, so as to minimize delays should this baby develop sepsis and require transfusion of packed red cells or platelets
CXR: May show focal consolidation due to congenital pneumonia (secondary to maternal chorioamnionitis). Patchy shadowing with evidence of air trapping may indicate meconium aspiration. Hyperexpansion with a ground glass appearance is typical of surfactant deficiency (respiratory distress syndrome), while plethoric lung fields with cardiomegaly may be due to underlying congenital heart disease. Spontaneous pneumothorax should be excluded
‘Capillary blood gas shows a pH 7.22, PaCO2 of 8.2 kPa, HCO318 mmol/L, BE−4 mmol/L. Hb is 190 g/L, WCC 36×109/L, neutrophils 22×109/L. CRP is 75 mg/L. Bilirubin is 95 mg/dL, which plots below the threshold for phototherapy. CXR shows lobar left-sided consolidation consistent with congenital pneumonia. The weight is 3.5 kg, which plots on the fiftieth centile.’
|Parameter||Value||Normal range (Units)|
|Haemoglobin||190 g/L||150–240 (g/L)|
|CRP||75 mg/L||0.8–15.8 (mg/L)|
|Urea||4 mmol/L||1.1–4.3 (mmol/L)|
|Creatinine||40 μmol/L||2.65–44.2 (μmol/L)|
|Sodium||131 mmol/L||133–146 (mmol/L)|
|Potassium||4.0 mmol/L||3.5–5.5 (mmol/L)|
|Bilirubin||95 mg/dL||<150 (phototherapy)<200 (exchange transfusion) (mg/dL)|
|PaCO2||8.2 kPa||4.7–6.0 (kPa)|
|HCO3||18 mmol/L||22–26 (mmol/L)|
|BE||−4 mmol/L||±2 (mmol/L)|
Initial Management 
Supplementary oxygen: If saturations<94%. The child will be kept in an incubator to keep him warm while wearing a nappy only. This allows his work of breathing to be closely observed by all staff. He is placed prone as this reduces his work of breathing
Antibiotics: Broad-spectrum antibiotics are given intravenously to cover most likely pathogens. Benzylpenicillin and gentamicin is a combination favoured by many neonatal units. You may have local guidelines for this
Gentamicin requires regular monitoring of trough levels to avoid dose-dependent toxicity such as renal impairment (temporary) and ototoxicity causing sensorineural hearing loss (permanent). Trough levels are usually taken before the third dose
Vitamin K: All newborns are given IM vitamin K at birth to prevent haemorrhagic disease of the newborn, which can otherwise present with significant and potentially catastrophic bleeding in the first few months of life
Lumbar puncture: In babies where there is clinical suspicion of meningitis, or the CRP is significantly raised (threshholds will vary between units, but>10–20 mg/L is typical) a lumbar puncture should be considered.
‘The baby looks more alert, and the airway remains patent. RR 65/min, oxygen saturations are 97% in ambient incubator oxygen of 28%. The grunting has stopped but the work of breathing remains high. HR 160 bpm, BP 62/28 mmHg, CRT 1 second centrally, 2 seconds peripherally. Glucose is now 3.6 mmol/L, and the temperature is 37.0°C.’
Handing over the Patient
‘Baby Smith is a term newborn, currently 18 hours old, being treated for congenital pneumonia.
He was born by emergency caesarean for maternal chorioamnionitis. There were no other antenatal concerns. He developed respiratory distress over the first 12 hours of life, and required admission to SCBU.
From a respiratory point of view, he is in 28% ambient oxygen. His initial gas showed a mixed acidosis. His CXR shows congenital pneumonia. Cardiovascularly, he remains stable on monitoring. He initially required a glucose bolus for hypoglycaemia, and now remains NBM on 60 mL/kg/day 10% glucose with stable sugars. His bloods are also suggestive of infection and he is on benzylpenicillin and gentamicin. His bilirubin is well below the treatment line. He has received IM vitamin K. Mum has been updated.
The plan is to wean oxygen as tolerated, repeat a capillary gas, continue antibiotics for 5 days, chase blood cultures and repeat FBC U&Es, SBR and CRP in the morning. He will require a lumbar puncture now that he is stable in view of his raised CRP. Gentamicin levels are due to be taken before the third dose.’
Station 9.3: Viral-induced wheeze
You are a junior doctor in the emergency department. A 6-year-old named Emily is brought in with a 3-day history of runny nose and worsening wheeze. This is her first wheezing episode. Today she is becoming progressively more breathless. Please assess Emily and instigate appropriate management.
‘The airway is patent, with no obstruction. There is obvious wheeze and no stridor.’
‘RR 50/min, oxygen saturations are 88%, with marked intercostal and subcostal recession, tracheal tug and abdominal breathing. The chest is hyperexpanded with increased anteroposterior diameter. On auscultation, there is minimal wheeze and reduced air entry throughout, with a very long expiratory phase. The child is not able to talk in sentences and can count to two only.’
Given the above features consistent with severe to life-threatening wheeze, you give facemask oxygen and nebulized salbutamol and ipratropium bromide (Atrovent®).
‘HR 120 bpm, BP 110/65 mmHg, CRT 1 second. Cardiovascular examination is normal.’
Emily is cardiovascularly stable. Given the severity of the asthma attack it is worth siting IV access early for a blood gas and in case IV medication is required.
Assess the patient’s level of consciousness using AVPU (is the patient Alert? If not, do they respond to Verbal or Painful stimuli? Or are they Unresponsive?). Check glucose levels, it may be high due to stress associated with respiratory distress