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This is a short video on how to use the anaesthetic circuit. As justified in the video - bag valve mask is good for ventilation but not in a breathing child who is needing PEEP +/- oxygen!

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A quick guide on how to set up the vapotherm

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"Healthier together" assessment tool of babies with Bronchiolitis

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"Healthier together" assessment tool of babies with Bronchiolitis

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This is written for GPs but is still applicable in the ED. Consider going through these risk factors with parents

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Infographic on Discharging Babies with Bronchiolitis

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Infographic on Discharging Babies with Bronchiolitis

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Updated Critical care guidance, whereby we use Chapter 5 for our guidance on the use of High Flow

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YH PCC ODN Clinical Guidelines 2021 July v3.1

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e-learning package aimed largely at Junior Docs new to paediatrics. From chapter 2 of e-LFH. Should take 15-20 minutes

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An OpenAthens account allows you to access a range of quality information online. If you have an OpenAthens account and wish to access e-LfH please click or tap the button.

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Useful for those new to triaging children. Part of chapter 1

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This post accompanies the talk I was asked to give to a fantastic group of Ambulance Victoria paramedics. I was given the title "Everything you NEED to know about paediatrics" but given that I don't know everything I need to know yet I thought I would drill down and focus on doing one thing well.

One of the biggest challenges is identifying the difference between sick and not sick. In the prehospital environment you don't have the luxury of time and observation. All you can go on is what is in front of you. So how can you distil years of training and exposure? Perhaps what we call gut feeling is really a synthesis of the paediatric assessment triangle - a decision based on one snapshot in time.

The basics

The American Academy of Pediatrics introduced the Pediatric Assessment Triangle - PAT - ( Editors note: I'm going to call it the PAediatric Assessment Triangle throughout this post as I just cannot bring myself to spell it that way. Sorry, Tim) in 2000 in the Pediatric Education for Pre-hospital Providers course. It was an effort to make it easier for pre-hospital providers to triage children into sick or not-sick, and perhaps to help them determine the cause of illness too.

Appearance

So what does that child actually look like? What do we take in at first glance that might make us concerned. Consider this mnemonic.

Tone

Are they unusually floppy, like a ragdoll, unable to hold themselves upright? By six months of age nearly all children should be able to sit up and support their own heads.

Interactiveness

To a newborn child the world is an amazing place, full of strange sights and sounds and smells. Babies have learnt to smile by about two months of age and by a year or so they are following objects around the room with their gaze. If they do not appear to be interested in what is going on in the world around them then it is time to be a little more concerned.

Consolabilty

Children cry - all of the time. They cry because you want to brush their hair, they cry because you don't want to brush their hair, they cry because you have looked at them. But they are also consolable. If they can't be consoled, despite the best efforts of their mother, then something is amiss.

Look/gaze

Whilst staring off into the distance may be normal for a teenager it is probably not normal for a three year old (unless they are very hungry).

Speech/cry

Crying, generally, is good especially of it is someone else's child and not your own, as long as they are consolable (see above). But that high pitched squealing cry, that means something different entirely.

All of these things help make up our clinical gestalt. They are something that we are often not even aware that we are aware of. Taking a look at their breathing may require a little more attention.

Breathing

Assessing their work of breathing does not require an eidetic memory of age-based norms, but once again is a snapshot taken in seconds. Problems can occur at any point of the respiratory tree from snotty nostrils through tightened tracheas and blocked bronchioles. Assessing this is a matter of looking AND listening.

Here are some of the things we are looking for...

But we can take in just as much information through our ears as we can through out eyes.

As air passes through the nostrils on its way to pulmonary alveoli it can be subject to smooth, laminar flow, or the chaotic eddies of turbulent flow. Any point of narrowing in an already small airway can make a sound. I liken it to my my 2 year old trying to breath through a recorder. If I want silence I need to remove the narrow mouthpiece, the part that starts the noise.

As it passes inwards through a narrowed larynx (for whatever reason) we may hear stridor and as it gets to the narrowed bronchial tree of an asthmatic (for example) we may hear a wheeze. If the air hunger is great enough we don't need a stethoscope to hear these noises, you can hear them from the end of the bed. These noises, coupled with the grunt of a child trying to generate enough PEEP to keep their alveoli from collapsing, are the sounds of respiratory distress. In the pre-verbal child, then, there seem to be a number of overlaps with veterinary science.

Circulation

Embarrassment of the circulatory system is much harder to spot.

Often the child needs to be undressed to make these changes a little more obvious. You might want to rely on the capillary refill time too but this is not part of the assessment triangle. It is a strictly no-touch technique.

Once we have a basic snapshot of appearance, breathing and circulation we can combine the elements to help determine both how unwell the child is and what could be wrong with them.

So does it actually work?

Even after 20 years in practice I cannot remember the age-based norms for vital signs (and there is some evidence that the ones we have may not be accurate anyway). I like to think of patients as either sick or not sick, in the first instance. If I feel they are sick then the next question is nearly always why? Does the Paediatric Assessment Triangle framework actually work in real life?

One group from UCLA examined how accurate triage nurses were at using the tool. In their prospective observational cohort they provided a multimedia training package then asked nurses to fill in a PAT card for every child that came through the door that met inclusion criteria. The investigators then performed a structured chart review to assess just how good the PAT was. They found that it did a great job of identifying stable patients ( LR 0.12) but an even better job of determining their pathophysiology.

A similar study was done with EMS providers and had similar results. Paramedics were very good at detecting stability and instability using the tool. Both groups have a degree of medical knowledge and it would be hard to determine how that might bias their assessment. Could non-medics be trained to use the tool? Could a computer?

Limitations

Most of the data only applies to children under 14 years of age and those with what could be termed a normal baseline. It is much less useful in children with developmental delay, those with congenital abnormalities or those reliant on technology to keep them alive.

For an aural version of some of the things covered in this talk you could not do better than listening to Tim Horeczko.

If you enjoyed this post, why not check out our online courses at DFTB Digital

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This post accompanies the talk I was asked to give to a fantastic group of Ambulance Victoria paramedics. I was given the title "Everything you NEED to know about paediatrics " but given that I don't know everything I need to know yet I thought I would drill down and focus on doing one thing well.

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a nearby 8 minute video on how to set up vapotherm in the ED

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Different to APLS as takes median weight rather than calculated weight. This is the most updated version and can be used

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Remember ABC and get the most senior staff around to assist. Don't forget you can phone a friend!

Useful numbers:

1. Paediatric registrar - bleep 488
2. Anaesthetics - bleep 606
3. Crash call will get you both quickly! call 2222
4. Paediatric consultant - through switchboard
5. EMBRACE - 0114 268 8180. Even if the patient does not need intubation they can still offer advice

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Takes up to 60 minutes

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See the PARIS Paper

This is the biggest and most robust trial yet done to assess the value of high-flow in bronchiolitis. The primary outcome shows that there is a role for high-flow in the non-ICU management of this disease. Importantly PARIS has shown in a large cohort of children that high-flow, when used within the parameters of the trial protocol, does not lead to an increase in adverse events which in-turn suggests the increased patient:nurse ratios for kids on high-flow that are often mandated by hospital policies may not be necessary (depending on the severity of disease of course). Some caution must be used around the potential for erroneous use of the high-flow circuits themselves and the interpretation of early warning scores in the context of high-flow use.

PARIS was supported with significant nursing education resources potentially reducing errors to a level that were below what could be expected with the standard resourcing of mixed EDs and other environments where high-flow use in children may be infrequent. As with many grey areas in medicine protocols as to how we use high-flow vary by institution with little more than opinion to guide them.

Though neither the intention nor the conclusion of this paper in showing the progress of such a large number of children on high-flow, this trial also provides a basis for more robust decision making around how we use high-flow itself.

Give fluids by nasogastric or orogastric tube in children with bronchiolitis if they cannot take enough fluid by mouth.

Give intravenous isotonic fluids (see the NICE guideline on intravenous fluids therapy in children) to children who: do not tolerate nasogastric or orogastric fluids; or have impending respiratory failure.

How do you manage them?

What has been the onset of symptoms? Progressive over days is most consistent with bronchiolitis. Onset of wheeze and respiratory distress over hours is most consistent with bronchospasm (viral induced wheeze).

What has been the pattern of their work of breathing?

How significant is the work of breathing?

What are the auscultation findings - is there presence of focal findings? Wheeze? Crackles?

Is this affecting the child functionally with feeding or sleeping difficulties?

If auscultation is suggestive of possible viral induced wheeze or at least, a component of wheeze that may be responsive to bronchodilators (If wheeze is present and no crackles or focal findings) and presuming the child has more than just mild work of breathing -then we suggest this may be a possible candidate for viral induced wheeze.

(Note - This is a good opportunity to survey your team and colleagues to see what the practice is at your local department).

Regarding this grey area question, in Australian practice, some clinicians will trial salbutamol for potential viral induced wheeze if the child is 12 months or older. Other doctors may wish to trial if the child is slightly younger (e.g. from 10 months) if they have a strong family history of asthma and atopy or if they have had previous ventolin use reported by their family with good effect. The younger the child is, the less likely that the story and case is to fit viral induced wheeze.

It would be prudent to give 6 puffs (or do you use another number?) and reassess following to see if there is any improvement or change.

What are your next steps?

Consider revisiting history, respiratory examination and consider adjuncts to assessment such as a capillary or venous blood gas.

For example, Do they have an NG tube on free drainage, are they nil by mouth and on IV fluid support at ⅔ maintenance

Are their family actually compliant with this or have also been feeding them via a bottle?

Are they working harder to breathe because they are getting "hangry" and might actually tolerate a continuous NG or comfort feed?

Consider whether the HFNP has led to no change, improvement and then deterioration or simple worsening of symptoms due to patient distress.

If no improvement was observed on commencement - it may be worth de-escalating them - ie. lower flow rates or low flow nasal prongs

Consider your confidence of whether you have the right diagnosis or if there is need to assess for a secondary pathology such as pneumonia, foreign body, cardiac contribution? Do you need to further investigate with bloods, CXR? Do you need to append your management and provide antibiotic coverage? Do you need to assess for a complication from treatment e.g. pneumothorax.

Have you sought a senior review/notified the admitting paediatrician?

Do you need an ICU consult, NETS consult or retrieval to a tertiary centre?

How long are you comfortable to wait to see if there is a response to high flow?

What settings would you start on?

Where could you move up to (in terms of peep, FiO2)

How soon would you reassess - what are you looking for?

How would you determine this?

Who should be involved in the conversation? Who should perform the intubation?

What sedation would you use?

What equipment would you use?

What settings would you use?

In bronchiolitis, children do not respond to salbutamol because:

A: They don't have beta receptors until they are older.

B: The beta receptors are immature and do not begin functioning correctly until the child is older.

C: The large amount of secretions interfere with it and prevent it binding to the receptors

D: There is no bronchospasm for the salbutamol to act on.

The correct answer is D.

All humans have beta receptors. Foetuses develop them from around 15 weeks gestation and are therefore born with them. Developing beta receptors after 1 year of age is a common paediatric myth! In fact, in bronchiolitis, there is no bronchospasm in the same way as there is in viral induced wheeze. Bronchiolitis is a illness developing gradually over 4 days and then slowly improving. Patients have increased mucous rather than bronchospasm, which does not respond to a bronchodilator.

A 3 month old baby presents to ED with coryza, cough, and poor feeding. Breastfeeding is going ok, but the baby is feeding for shorter periods, more frequently than usual. She is having wet nappies as normal. Saturations are 93% on room air, RR is 62, and there is moderate subcostal recession with some nasal flaring. Which of the following is an indication to admit this baby to hospital?

A: The reduced breastfeeding

B: The oxygen sats

C: The work of breathing

D: The age of the baby

The correct answer is C.

The criteria for admission usually are:

feeding less than half of usual, or less wet nappies

saturations less than 92% on air

increased WOB

apnoeic episodes

Risk factors such as:

Ex-prem

Age less than 12 weeks or less than 37 weeks CGA

history of lung disease or congenital heart disease or neurological problems

smoke exposure

In clinical practice, you would use your judgement to assess if hospitalisation was necessary. Social concerns should always be considered.

In this case, the baby is maintaining good urine output and the feeds, although shorter, are more frequent. The age alone is not an indication for admission. Obviously, an O2 requirement would be an indication for admission but most units would consider sats of 92% or less as reduced. There is significantly increased work of breathing with recession and nasal flaring, however, so this would be the main indication for admission.

You have a 10 month old baby with bronchiolitis who is to be commenced on high flow. Which of the following is false?

A: Nasal prongs size should be estimated based on the width of the patient's nostrils.

B: Patients can be NG fed immediately once on high flow.

C: High flow improves the functional residual capacity.

D: The humidified oxygen help clearing mucous secretions.

The correct answer is B.

Patients on high flow will likely need an NG inserted due to abdominal distention, but should usually not be fed for the first couple of hours on high flow. The aim of high flow is to provide humidified, high flow to improve clearance of secretions and to increase the functional residual capacity. Together this should reduce the work of breathing.

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See the PARIS Paper This is the biggest and most robust trial yet done to assess the value of high-flow in bronchiolitis. The primary outcome shows that there is a role for high-flow in the non-ICU management of this disease.

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Brief review on the review of a sick child

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Brief review on the review of a sick child

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10 minute video - links into chapter 1 of e-LFH respsurge

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Re-ACT Talks: Deterioration: How to Spot the Sick Child