Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

1. 7
Lower respiratory
tract conditions
lower respiratory tract usually present with
Objectives one or more signs of breathing difficulty.
When you have completed this unit you Lower respiratory tract disorders usually present
should be able to: with one or more signs of breathing difficulty.
• Give the signs of breathing difficulty
and respiratory distress.
• List the important lower respiratory 7-2 What are the signs of breathing
tract conditions. difficulty?
• Diagnose these conditions. The major signs are :
• Understand the causes and possible
prevention of these conditions. • stridor
• Provide primary management of these • indrawing of the lower chest wall
conditions. (recession)
• Describe a syndromic approach to a • wheeze
child with a cough. • fast breathing (tachypnoea)
• shortness of breath with grunting, nasal
flaring, head nodding and refusal to feed.
INTRODUCTION These signs of breathing difficulty suggest that
the child’s breathing difficulty is becoming
progressively more severe and could lead to
7-1 What is the lower respiratory tract? respiratory distress.
The lower respiratory tract consists of:
7-3 What are the signs of respiratory
• Larynx and trachea distress?
• Bronchi
• Bronchioles Respiratory distress is the clinical condition
• Alveoli (lungs) where the respiratory difficulty has become so
severe that the child is likely to die unless given
Therefore, the respiratory tract from the larynx respiratory support (e.g. oxygen or ventilation).
down is called the lower respiratory tract while
the respiratory tract above the larynx is called • Central cyanosis (or a low oxygen
the upper respiratory tract. Disorders of the saturation)
• Drowsiness, lethargy or unconsciousness

2. LOWER RESPIRATOR Y TRACT INFECTIONS 123
• Restlessness Always look for central cyanosis if a child has
• Apnoea peripheral cyanosis.
7-4 What is stridor? Pulse oximetry is a very useful method of
assessing the oxygen saturation (the amount
Stridor is a crowing sound made in the throat, of oxygen being carried in the red cells of
most commonly during inspiration. Any the blood). The normal oxygen saturation is
narrowing of the airway in the region of the above 95% (above 92 % in newborn infants).
larynx may result in stridor. Narrowing of the An oxygen saturation below 90% is abnormal
airway above (e.g. epiglottis) or below (e.g. and an indicator for oxygen therapy. A pulse
trachea) the larynx may also cause stridor. oximeter (or oxygen saturation monitor) is
used for measuring the oxygen saturation. The
7-5 What is chest indrawing? probe is clipped onto the child’s finger, hand or
With chest indrawing, the lower ribs on both foot and the device displays the heart rate and
sides of the chest are pulled in when the child oxygen saturation.
breathes in. This is very abnormal as the As central cyanosis is an important sign of
lower chest normally moves out when a child respiratory failure, measuring the oxygen
breathes in. When resting, children should saturation is very useful.
never have chest indrawing.
7-6 What is a wheeze? VIRAL CROUP
This is a noise made during expiration due to
narrowing of the lower airways.
7-9 What is viral croup?
7-7 How can you tell when a child is This is an acute viral infection of the
breathing too fast? larynx, trachea and bronchi (acute viral
laryngotracheobronchitis). With croup the
Rapid respiration (tachypnoea) is one of the area around the vocal cords is swollen as is
most important signs of pneumonia. A child the area just below the cords. Viral croup
at rest is breathing too fast when the following typically presents in children around 2 years
rates are exceeded: of age (between 6 months and 6 years),
• 60 breaths or more per minute in an infant especially in autumn. Viral croup is usually
of 2 months or less mild and the signs of croup usually clear
• 50 breaths or more per minute in children in a few days but may recur. Some children
2 months to 1 year develop viral croup whenever they have a
• 40 breaths or more per minute in children common cold or pharyngitis.
older than 1 year The most common cause of viral croup is an
The normal respiratory rate decreases with age. infection with parainfluenza virus.
By the age of 12 years healthy children should NOTE Other viruses, such as the respiratory syncytial
not breathe faster than 20 breaths per minute. virus, metapneumovirus, measles, adenovirus and
Herpes simplex, can also cause croup.
7-8 What is central cyanosis?
7-10 What are the presenting signs of viral
A blue colour of the tongue. The lips may
croup?
also appear blue instead of the normal pink.
Central cyanosis is a very important and The characteristic signs of viral croup are:
dangerous sign which indicates that the
• The infection often starts with a common
cells are not receiving enough oxygen. Cold
cold or pharyngitis.
hands and feet may show peripheral cyanosis.

3. 124 LOWER RESPIRATOR Y TRACT INFECTIONS
• A mild fever obstruction. Stridor becomes softer with severe
• A typical ‘barking’ cough obstruction.
• Inspiratory stridor is often, but not always,
present. It is usually worse at night and 7-12 What is the correct management of
then much better in the morning. viral croup?
• Hoarseness of the voice is a less common
1. The degree of airways obstruction must be
sign in viral croup.
continually observed.
Viral croup typically presents at night with 2. Keep the child comfortable and calm as
inspiratory stridor and a barking cough. crying worsens the airways obstruction.
NOTE Stridor can also be cause by an inhaled
3. Keeping the room warm helps.
foreign body, retropharyngeal abscess, epiglottitis Humidifying the air may also help. Do not
or, rarely, by diphtheria. accidently burn the child with steam from
a kettle. Cold mist does not help.
7-11 How is the degree of stridor assessed? 4. If the child has fever above 38 °C give
paracetamol.
The degree of respiratory obstruction is diffi- 5. Continue to give frequent, small amounts
cult to assess as it may vary from moment to of oral fluid unless the airway obstruction
moment. Stridor usually becomes worse if is severe. Continue breastfeeding if the
the child cries or becomes agitated. Therefore child is not distressed.
stridor in a quiet child should be regarded as 6. The child can be closely observed at home
severe. if the airways obstruction is mild and
1. Inspiratory stridor only, without lower chest the home circumstances are adequate.
wall indrawing (recession or retraction) Communication and transport to the
suggests mild airway obstruction. These nearest health facility are needed if the
children usually only have stridor when child is to be managed at home.
they are upset or crying. There is no stridor 7. Oral dexamethasone 0.5 mg/kg as a single
when they are sleeping or at rest. dose (not if measles or herpes is the cause
2. The addition of lower chest wall indrawing of the stridor). If no improvement, repeat
or stridor during both inspiration and after 24 hours. Steroids are the most
expiration are very important clinical important treatment in severe viral croup.
signs as they indicate worsening airways 8. There is no indication for antibiotics or
obstruction. Therefore, expiratory stridor bronchodilators in viral croup.
is a sign of severe airway obstruction. 9. Move to hospital if the airways obstruction
Stridor at rest in a quiet child also suggests becomes worse, especially if there is both
severe stridor. inspiratory and expiratory stridor. It is best
3. The obvious use of chest and abdominal to move the child to hospital if there is
muscles during expiration (active stridor when the child is at rest. If possible,
expiration, restlessness or fast breathing give oxygen during transport.
(tachypnea) are signs of dangerous airway 10. Nebulised adrenaline (1:1000 solution)
obstruction obstruction. in hospital is the treatment of choice for
worsening or severe airways obstruction.
It will often provide temporary relief. If the
Expiratory stridor is a sign of worsening airway child responds to the nebulised adrenaline
obstruction. admit the child to hospital for 24 hours to
observe for rebound airway obstruction
NOTE Disappearance or weakening of the as the effect of adrenaline usually last only
peripheral pulse on light palpation during about 2 hours.
inspiration (pulsus paradoxis), marked recession, 11. Intubation or tracheotomy under general
apathy and cyanosis are signs of severe airway anaesthetic is only needed if respiratory

4. LOWER RESPIRATOR Y TRACT INFECTIONS 125
failure develops (cyanosis, restlessness, green secretions indicates a secondary
severe chest wall indrawing or inadequate bacterial infection.
oxygen saturation in room air). Intubation • There may be chest pain with excessive
must be seriously considered if the child coughing.
has expiratory stridor and uses the chest • Mild fever
and abdominal muscles during expiration. • Wheezing may occasionally occur in an
12. Oxygen should only be given in cases of older child. This should always suggest
severe airway obstruction as the method asthma.
of delivering (e.g. nasal prongs) could
Acute bronchitis in children is very different
make the child frightened and agitated and
from chronic bronchitis in adults.
worsen the airway obstruction.
NOTE Loose crackles are heard, especially on
NOTE Mix 1 ml of 1:1000 adrenaline with 1 ml auscultation (with a stethoscope). These noises
saline. Nebulise the entire volume with oxygen. clear with coughing.
Repeat every 15 minutes until the expiratory
obstruction has resolved. Observe the child very
carefully for signs of deterioration. Laryngoscopy 7-15 What is the management of acute
to look for other causes of stridor is important in bronchitis?
children who require intubation.
1. Make sure the child drinks enough fluid.
Often there is a loss of appetite.
2. Inhaling warm, moist air may relieve the
BRONCHITIS cough. Warm drinks may also help.
3. Cough mixtures are of little help, but
salbutamol syrup may relieve the cough.
7-13 What is bronchitis?
4. Give paracetamol for the fever.
Bronchitis is an inflammation of the lining on 5. Oral antibiotics should only be given if the
the large airways of the lung (the large bronchi). mucus becomes yellow-green.
The inflammation is usually due to a viral
It is important to observe for signs of
infection, but there may also be a secondary
pneumonia, especially in small children. A
bacterial infection. Bronchitis usually follows
wheeze suggests asthma or bronchiolitis. Bouts
an upper respiratory infection (common cold,
of severe coughing with an inspiratory whoop,
pharyngitis or influenza). With inflammation
apnoea or vomiting suggest whooping cough.
of the bronchi, the glands in the walls of the
large airways produce excessive secretions
(mucus or phlegm) with a ‘productive cough’.
These secretions may partially block the BRONCHIOLITIS
airways. Children with bronchitis do not
have breathing difficulties (the only lower
7-16 What is bronchiolitis?
respiratory tract infection that does not cause
breathing difficulties in children). Bronchitis in Bronchiolitis is an acute viral infection of the
children is usually acute and recovers in 1 to 2 small airways of the lungs (the bronchioles).
weeks. Bronchitis is more common in a smoky It typically presents with airways obstruction.
environment (cigarette smoke or an open fire in Bronchiolitis is usually caused by the
the home) and is usually seen in older children. respiratory syncytial virus (RSV) and occurs
commonly in children under one year of
7-14 What are the symptoms and signs of age. When severe it can be life threatening.
acute bronchitis? Bronchiolitis usually occurs in winter
and follows a few days after the onset of a
• A persistent cough. At first the cough is common cold. The small airways become
dry, but it may later become loose and
produce clear, sticky secretions. Yellow-

5. 126 LOWER RESPIRATOR Y TRACT INFECTIONS
inflamed and narrowed. Secondary bacterial inability to feed, tachycardia or low oxygen
infection may occur. saturation.
3. Oxygen therapy with nasal prongs (flow 1
to 2 litres/minute) is indicated if there are
Bronchiolitis causes serious narrowing of the signs of respiratory distress or the oxygen
small airways in young infants. saturation is low (below 90%).
4. Bronchodilators usually do not help in
7-17 What are the signs of bronchiolitis? bronchiolitis.
5. Steroids are of little help.
• Recession (indrawing of the lower chest)
6. Ensure an adequate fluid intake. If the
and a hyperinflated chest (over expanded
child will not drink give nasogastric fluid.
due to air trapping).
Intravenous fluid should only be given with
• Wheezing is usually present and is not
great caution as overhydration is dangerous.
relieved by an inhaled bronchodilator.
7. Antibiotics are usually not given unless
Occasionally wheeze may be absent.
there are also signs of pneumonia or the
• Rapid breathing and breathlessness
child is less than 3 months. If pneumonia is
(difficulty breathing)
suspected give amoxycillin.
• Prolonged expiration
8. If the child has a fever give paracetamol.
• A dry coughing
9. Physiotherapy is contraindicated and can
• Reluctance or difficulty in feeding
be dangerous.
• Mild fever
10. Careful observation is important for signs
Cyanosis, decreased level of consciousness, of respiratory failure or apnoea.
inability to feed or persistent vomiting and 11. Intubation and ventilation for respiratory
a marked tachycardia (fast heart rate) are all failure
dangerous signs and indicates respiratory
failure. Apnoea is common in infants less than
Oxygen is the treatment for severe bronchiolitis.
3 months. Bronchiolitis takes about a week to
recover.
NOTE Bronchodilators by nebulisation, e.g.
Repeated bronchiolitis, especially in an older salbutamol, are sometimes used in severe
child, suggest asthma. bronchiolitis with variable results. Children with
a history of 2 or more attacks of bronchiolitis and
NOTE There is poor air entry over both lungs
respond to inhaled bronchodilators probably
on auscultation. Fine crackles may be present. have early asthma. Do not use aminophylline as it
A chest X-ray shows air trapping due to small is dangerous.
airway narrowing without signs of consolidation
(pneumonia). Pneumothorax is an uncommon
complication of bronchiolitis. 7-19 When should children with
bronchiolitis be referred to hospital?
7-18 What is the correct management of Bronchiolitis is a serious condition which
bronchiolitis? can suddenly deteriorate. Therefore, only the
1. Children with mild bronchiolitis may mildest cases should be managed at home or
be managed at home provided they are at a primary care clinic. The following children
carefully observed, they take adequate should be referred to hospital:
fluids, the home circumstances are good • Children with signs of respiratory failure
and that communication and transport are (e.g. cyanosis or depressed level of
available if needed. consciousness)
2. All other children with bronchiolitis • If there is no improvement
must be admitted to hospital, especially if • Signs of pneumonia
they are under 3 months, or if there is an

6. LOWER RESPIRATOR Y TRACT INFECTIONS 127
• Oxygen saturation below 90% with examination and chest X-ray. Often pneumonia
oximetry (saturation monitor) is due to bacteria complicating a viral infection.
PNEUMONIA 7-22 What are the symptoms and signs of
pneumonia?
• The child is generally unwell.
7-20 What is pneumonia? • Fever, often high fever
Pneumonia is an inflammation of the small • Cough
air sacs of the lungs (alveoli), usually due to • Breathlessness (difficulty breathing). The
a viral or bacterial infection. Pneumonia is breathing is usually fast and shallow.
often a complication of an upper respiratory • Chest wall indrawing (recession or
tract infection. It may involve only part of retraction)
one lung or be more extensive and even • Refusal to eat or drink due to shortness of
involve both lungs. The common causes breath
of pneumonia depends on the child’s age. • The infant may become cyanosed (with a
Breastfeeding and avoiding cigarette smoke low oxygen saturation).
helps to prevent pneumonia. • Chest pain may be present.
7-21 What are the causes of pneumonia? Fast breathing is the most important sign of
• Pneumonia in newborn infants is usually pneumonia.
due to a bacterial infection such as Group
B Streptococcus and Gram negative bacilli There are some causes of fast breathing, other
(e.g. Klebsiella). than lung conditions, such as a high fever or
• Viruses especially the respiratory syncytial a metabolic acidosis (seen in diarrhoea with
virus, cause most pneumonias in infancy. severe dehydration). It is best to look for fast
• In young children Mycoplasma is a breathing when the child is calm and the fever
common cause of pneumonia. has been lowered.
• Pneumonia in older children is usually
due to bacteria such as Pneumococcus, A normal breathing rate usually excludes
Haemophilus and Staphylococcus.
pneumonia.
Pneumococcus is the most common cause
of community-acquired pneumonia in
NOTE Nothing abnormal may be heard on
children.
auscultation with a stethoscope as the classical
• Tuberculosis is an important cause of chest signs of pneumonia (dullness, bronchial
pneumonia in poor communities. breathing, crepitations) are often not present in
• Pneumocystis is an important cause children with pneumonia.
of pneumonia in HIV infected infants
between 2 and 6 months of age. This is 7-23 Should all children with pneumonia
a very unusual cause of pneumonia in have chest X-rays?
children who do not have AIDS.
• Gram negative organisms such as Klebsiella A routine chest X-ray need not be taken in
and E. coli are also an important cause of all children suspected of having pneumonia.
severe pneumonia in children with HIV However, if facilities are available, it should be
infection. done where:
NOTE Chlamydia can cause pneumonia in infants. • Complications are expected (e.g.
pneumothorax).
It is difficult to decide whether the pneumonia
• The diagnosis of tuberculosis is suspected.
is due to a virus, bacteria or TB on both clinical

7. 128 LOWER RESPIRATOR Y TRACT INFECTIONS
• The pneumonia is severe or does not 3. Give oxygen by nasal prongs (or catheter)
respond to treatment after 2 days. or face mask for severe pneumonia.
Monitor with the use of a saturation
monitor and give oxygen if saturations are
The diagnosis of pneumonia in a child is usually below 90%.
made on general examination rather than by 4. Give an appropriate antibiotic. While
listening to the chest. oral antibiotics can be used with mild
pneumonia, intramuscular or intravenous
NOTE Bronchopneumonia is common in small antibiotics must be used with more severe
children while lobar pneumonia is often seen in cases. All children with pneumonia must
older children. Always look for a pleural effusion receive an antibiotic as it is difficult to tell
or other signs of tuberculosis.
whether the pneumonia is due to a virus
or bacteria.
7-24 Is pneumonia a serious infection? 5. If a wheeze is present give an inhaled
Yes. Pneumonia is a common reason for bronchodilator.
hospital admission and a major cause of 6. Give paracetamol to lower the fever.
death in children, especially in developing 7. Remove thick secretion from the nose by
countries, such as South Africa, and in gentle suctioning.
children with AIDS. Pneumonia acquired in 8. Encourage breastfeeding. If the child does
hospital is particularly dangerous. not take fluids by mouth, give nasogastric
feeds or start an intravenous infusion.
9. Physiotherapy may be helpful.
Pneumonia is a major cause of death in children. 10. All children with signs of severe
pneumonia must be urgently referred to
7-25 How can you recognise severe hospital. Give the first dose of antibiotic
pneumonia? before referring the child.
11. In very severe cases of pneumonia,
Any of the following clinical signs suggest that intubation and ventilation may be needed.
the child has severe pneumonia:
• Chest wall indrawing (recession) Oxygen and antibiotics are the main form of
• Cyanosis (needs oxygen to keep the oxygen
treatment for pneumonia.
saturation above 90%)
• Depressed level of consciousness
• Refusal to eat or drink due to shortness of 7-27 What antibiotics are used in
breath pneumonia?
These are danger signs which mean that the 1. Amoxycillin 30 mg/kg orally 3 times
child needs urgent treatment and then referral a day for 5 days in children with mild
to hospital. community-acquired pneumonia that is
treated at home.
7-26 What is the correct management of 2. Intramuscular ampicillin 20 mg/kg before
pneumonia? referring a child with severe pneumonia.
In hospital, ampicillin and gentamicin,
1. If possible, all children with pneumonia or cefotaxime (or ceftriaxone) are usually
should be admitted to hospital. Only mild used. The choice of antibiotic may change
cases should be managed at home or in a when the sputum and blood cultures and
primary care clinic. sensitivities are received.
2. Observe the child carefully. Monitoring the 3. Cloxacillin 50 mg/kg/dose orally 6 hourly
oxygen saturation is very important. Look is given if Staphylococcus is suspected.
for signs of severe pneumonia.

8. LOWER RESPIRATOR Y TRACT INFECTIONS 129
4. Hospital-acquired pneumonia may be due • Difficulty breathing (breathlessness or
to organisms resistant to many antibiotics. shortness of breath or a ‘tight chest’)
5. Search for tuberculosis if there is no
Most, but not all, children with asthma
response to antibiotics.
have wheezing. Some children present with
NOTE Erythromycin or co-trimoxazole are the coughing only, especially at night. Both the
antibiotics of choice if Mycoplasma pneumonia wheezing and coughing are worse at night and
is suspected in older children (5 years or older). often wake the child. Asthma is usually seen in
Additional co-trimoxazole 6 hourly in high
children of one year or older.
doses is used to treat suspected Pneumocystis
pneumonia in HIV infected children.
Always think of asthma when a child presents
with wheezing.
ASTHMA
7-31 What are the clinical signs of asthma?
7-28 What is asthma? The clinical signs of asthma on examination are:
Asthma is a chronic inflammatory condition • A generalised, expiratory wheeze,
with repeated episodes (or attacks) of especially on forced expiration.
reversible narrowing of the small airways • The chest may appear full (hyperexpanded
(bronchi) of the lung that respond to due to air trapping) with prolonged
bronchodilators. Children with asthma have expiration.
‘hyperactive airways’, i.e. their small airways • There may be lower chest wall indrawing.
become narrow in response to a number of • The use of muscles in the abdomen or neck
factors. Asthma usually presents as repeated during expiration suggests severe airways
acute attacks. Each attack lasts hours to days. obstruction.
While some children only have a few attacks • Cyanosis, drowsiness or panic are signs of
a year others are rarely free from asthma. If respiratory failure.
acute asthma is not controlled, the asthma • Usually there is no fever.
may become persistent. • Long standing, poorly controlled asthma
may result in chest deformity and poor
growth.
Asthma presents with repeated episodes of
• Between acute attacks the chest
airway narrowing.
examination is usually normal.
NOTE Asthma is an inflammatory disease. The The sudden onset of wheezing during play in
inflammation leads to airway narrowing. To control a well child with no history of asthma suggests
asthma the inflammation must be treated. the inhalation of a foreign body.
7-29 How common is asthma? 7-32 What is the cause of asthma?
Asthma occurs in about 10% of children in Asthma results from a combination of
South Africa, especially children living in towns inherited and trigger factors which cause
and cities. Asthma is becoming more common inflammation of the bronchi. Most, but not all,
as more rural families move into town. children with asthma have a family history of
allergic conditions (asthma, eczema, or allergic
7-30 What are the symptoms of asthma? rhinitis). Children with asthma often have
other allergic conditions.
Children with asthma complain of :
Inflammation of the bronchi results in:
• Expiratory wheezing
• Cough

9. 130 LOWER RESPIRATOR Y TRACT INFECTIONS
1. Mucosal oedema (swelling of the linings of NOTE In allergic people the body responds
the bronchi) abnormally to foreign proteins by producing IgE
2. Bronchospasm (contraction of the smooth rather than IgG (atopy).
muscle in the bronchi)
3. Increased secretion of sticky mucus 7-35 What trigger factors may start an
attack of asthma?
These factors cause narrowing of the bronchi,
especially in small children who normally have A wide range of trigger factors may start an
narrower bronchi than do older children. acute attack of asthma. They include:
NOTE The causes of asthma are multifactorial and • Upper respiratory tract infections
result in airway hyperresponsiveness. • Allergens in the environment
• Active or passive smoking
7-33 How do inherited factors increase the • Exercise, especially running
risk of asthma? • A sudden drop in environmental
temperature (cold air)
There may be a history of asthma on either the
• Emotion (sadness, anger or excitement)
mother’s or father’s side of the family. Often a
• Irritants in the environment, e.g. paint
parent or sibling has an allergic condition. The
fumes
tendency to have asthma is, therefore, passed
from one generation to the next and close
family members with asthma are an important 7-36 How is asthma diagnosed?
risk factor for children to develop the condition. Asthma is mainly a clinical diagnosis based on
a history of repeated acute attacks of wheezing,
coughing and breathlessness, often with a
Children with asthma usually have a family
positive family history of allergy.
history of allergies.
NOTE A high risk of allergic conditions is inherited Asthma is mainly a clinical diagnosis based on the
as an autosomal dominant with variable past and family history.
inheritance.
The most useful special investigations are:
7-34 What is allergy?
1. Lung function tests: Children over the
Allergy (or atopy) is an abnormal or age of 5 years can use a peak flow meter to
exaggerated reaction by the body to certain measure their peak expiratory flow rate.
foreign proteins. In these allergic people the They take a deep breath and then blow as
body produces an inflammatory response to hard as they can into the peak flow meter,
these proteins which are called allergens. This which measures how fast they can blow
abnormal inflammatory response is present air out of their lungs (like blowing out a
in all common allergic conditions. Allergens candle). Children with asthma have a lower
do not produce an inflammatory response in peak flow rate than normal due to their
people who are not allergic. narrow airways.
Common allergens are: 2. Skin tests: Skin tests are done by placing
a drop of a specific allergen on the child’s
• House dust mite forearms. The underlying skin is then
• Foods, e.g. cows milk protein, eggs, wheat, pricked with a special lancet through
peanuts, fish and soya the drop of allergic testing solution. The
• Pollens, e.g. grass or tree pollen test site is examined after 15 minutes. A
• Dog and cat hair swelling (wheal) at the test site indicates
• Fungus (mould) spores that the person is allergic to that allergen.
Skin tests are simple to perform, cheap

10. LOWER RESPIRATOR Y TRACT INFECTIONS 131
and accurate. A blood test (RAST) can 2. Control the acute attack
also be used to identify a response to 3. Prevent recurrent attacks
specific allergens. The child should not be 4. Avoid trigger factors
on an antihistamine for 48 hours before 5. Education and support
performing a skin prick test. Skin tests are
used as supportive evidence for asthma as 7-39 How is the severity of acute asthma
they diagnose allergies only. assessed?
3. Response to a short acting bronchodilator: The following are features of severe asthma:
A good clinical and peak flow rate response
to a dose of inhaled bronchodilator is the • Previous history of severe acute asthma
best way to confirm the clinical diagnosis indicates that any further attack should be
acute asthma. In preschool children the regarded as severe.
diagnosis usually depends on a clinical • Lack of response to bronchodilator therapy
response to treatment while in older • Inability to speak or cry or feed due to
children an improvement in the peak flow severe respiratory distress
is important. • Cyanosis
• Oxygen saturation below 90%
NOTE A silent chest when examined with a
Asthma presents with repeated episodes of stethoscope or peak expiratory flow rate below
wheezing, coughing or shortness of breath that 60% indicates severe asthma.
respond to bronchodilators.
7-40 How should acute asthma be treated?
7-37 How is the severity of asthma graded? The aim of treating acute asthma (whether
With intermittent asthma there are only intermittent or persistent) is to relieve the
occasional episodes of wheezing or coughing airway narrowing (bronchospasm) as soon
(less than once a month). Most children with as possible and make sure that the patient is
asthma only have intermittent asthma. The getting adequate oxygen.
symptoms of intermittent asthma are usually 1. Nebulised or inhaled short acting
easily controlled and do not affect the quality bronchodilators (beta 2 agonists),
of life. e.g. salbutamol (Ventolin) or
With persistent asthma the episodes are more fenoterol (Berotec). Oral short acting
frequent (at least once a month). Persistent bronchodilators are rarely used as the
asthma may be: inhaled drugs are better and safer.
2. Antibiotics are usually not needed.
• Mild: Episodes of coughing or wheezing 3. Sedatives and antihistamines must be
occur once or twice a week avoided.
• Moderate: Episodes of coughing or 4. Oral theophylline is only rarely used.
wheezing at least 4 times a week Rectal and intravenous theophylline, and
• Severe: They have daily symptoms which subcutaneous adrenaline, are dangerous
interfere with sleep and schooling and should not be used.
NOTE With intermittent or mild persistent asthma
Acute intermittent asthma is usually mild and
the peak expiratory flow is usually 80% or more
of predicted. This falls to 60–80% with moderate can be treated at home. ‘Reliever’ treatment
and less than 60% with severe asthma. can be given at home with inhaled short acting
bronchodilators using a spacer (e.g. 1 or 2
puffs of salbutamol or fenoterol, i.e. 100–200
7-38 What is the correct management of
μg). This can be repeated after an hour if
asthma?
needed. The child must be carefully observed
1. Assess the of severity of the asthma and moved to hospital if the wheeze gets

11. 132 LOWER RESPIRATOR Y TRACT INFECTIONS
worse. An inhaled short acting bronchodilator Specially designed commercial spacers are
can also be taken before exercise to prevent available but they are expensive. A face mask
wheezing or cough. is needed in young children. Older children
should use a mouthpiece.
7-41 What should you do if there is no Metered dose inhalers can be used in children
response? of 8 years or more when they are able to co-
If there is no clinical response within 20 operate and use the inhalers correctly. Spacers
minutes of giving an inhaled bronchodilator, are used for younger children.
repeat the dose, give a dose of oral steroids Nebulisers can be used in hospital to very
and refer the child to hospital for further efficiently give inhaled drugs. The drug in
treatment. Also consider transfer to hospital liquid form is added to the nebuliser which
if the child refuses fluids, becomes restless or produces a fine mist. The dose is usually 1 ml
lethargic, or becomes cyanosed. Give oxygen of drug with 1 ml of saline.
during transfer.
The management of acute asthma in hospital 7-43 How can repeated attacks of asthma
consists of: be prevented?
1. Nebulised or inhaled bronchodilators If the child has persistent asthma (more than
every hour. one episode a month) or severe attacks of
2. A short course of oral steroids for 7 days asthma (requiring admission to hospital) the
(e.g. oral prednisone 2 mg/kg daily). aim of management should be to prevent
3. Reassess hourly. If no response consider these acute attacks. These children should
admission for intensive care. be referred to an asthma clinic for chronic
maintenance management if possible. The
7-42 How should inhaled and nebulised aim of treatment is to allow the child to have
drugs be given? a good quality of life, i.e. play sport, attend
school normally and sleep well. Treatment
Inhaled medication (e.g. bronchodilators requires the use of both anti-inflammatory
and anti-inflammatory drugs) are safer and and bronchodilator drugs.
more effective than oral drugs. They are best
given to children using a spacer. A spacer is a The treatment of persistent asthma:
container that is placed between the metered 1. In mild persistent asthma (with repeated
dose inhaler (MDI or ‘puffer’) and the patient’s mild episodes of cough and wheezing which
mouth. This allows the drug to mix well with occur once or twice a week) a low daily
the air in the container before it is inhaled. In dose of inhaled corticosteroid (‘prevention’
this way the drugs are better absorbed through therapy e.g. beclomethasone 100–200 μg)
the linings of the airway. should be given in addition to the short
The inhaler is pushed through a hole made in acting bronchodilator. Inhaled steroids are
the bottom end of a 500 ml cooldrink bottle very effective and safer than oral steroids.
while a face mask is attached to the mouth Inhaled steroids should be used with a
of the bottle. This home-made spacer works spacer. Rinse out the mouth after inhaling
well and is much better than a small plastic or the steroid to avoid excessive absorption.
polystyrene cup. 2. Moderate persistent asthma requires
higher doses of daily inhaled steroids (e.g.
For older children the child places her mouth beclomethasone 200–400 μg).
directly over the top of the bottle rather than 3. In severe persistent asthma, oral steroids
using a face mask. The child then breathes may be needed. These patients should
normally into the bottle. be management by an asthma clinic at a
regional or tertiary health centre.

12. LOWER RESPIRATOR Y TRACT INFECTIONS 133
4. Short acting inhaled bronchodilators are AN APPROACH TO LOWER
needed in all patients with asthma and
should be used when necessary. Use a RESPIRATORY TRACT
spacer whenever possible. CONDITIONS
Exercise-induced asthma can be prevented
by inhaling a short acting bronchodilator 10
minutes before starting the exercise. 7-46 What is the syndromic approach to
acute respiratory tract disorders?
In severe or repeated attacks of asthma, daily This is a simple way of using important
clinical signs to classify and manage acute
treatment is needed to give the child as normal a
respiratory tract disorders. It is based on
quality of life as possible. what you and the mother observe (see and
hear) in the child. In the older child, the
NOTE A long acting bronchodilator (beta 2
history (symptoms) given by the child is
agonist) such as salmeterol, or sustained release
also important. This is the method used by
oral theophylline, or a leukotriene antagonist may
be added as a steroid sparing agent.
IMCI (Integrated Management of Childhood
Illness) for primary care management.
7-44 How can trigger factors be avoided? The two main signs of lower respiratory tract
disorders are:
1. No one should smoke in the house.
2. Avoid contact with people who have upper • Cough
respiratory tract infections, especially • Difficulty breathing
common colds.
3. Avoids cats and dogs if allergic to them. 7-47 What are the important causes of a
Ban pets from the bedroom. cough?
4. Reduce house dust mites, especially in
Most children become ill and cough a number
the child’s bedroom. Cover the pillow and
of times a year:
mattress with plastic sheeting, vacuum the
carpet daily, wash the sheets and covers 1. Usually a cough is due to a mild upper
frequently in hot water and dry them in respiratory tract infection (cold,
the sun. Synthetic bedding is best. pharyngitis or sinusitis) due to a virus and
does not last more than 3 weeks.
7-45 What education and support is useful 2. A cough may be due to a lower respiratory
in asthma? tract infection (pneumonia, croup,
bronchitis, bronchiolitis and asthma). It
Asthma is frightening to the child and parents. is, therefore, important to look for signs of
They should understand the causes, symptoms these conditions.
and treatment of the condition. Children 3. A cough lasting more than 3 weeks ( 21
should be encouraged to manage their own days) may be a sign of tuberculosis (TB).
use of bronchodilators. 4. Think of whooping cough if a bout of
Parents can be reassured that asthma tends to couching leads to vomiting.
improve with age. 5. Think of asthma if the cough is worse at
night or after exercise. In bronchiolitis the
cough is also worse at night. Asthmatics
usually have a recurrent wheezy cough.
6. A cough that starts soon after lying down
suggests a post-nasal drip in acute sinusitis.

13. 134 LOWER RESPIRATOR Y TRACT INFECTIONS
7. The sudden onset of coughing after a If any of these signs are present, the child
choking episode suggests an inhaled should be carefully examined and considered
foreign body. for urgent transfer to hospital.
8. A barking cough is suggestive of croup.
7-50 When and how should oxygen be
7-48 What is the management of a cough? given?
1. If the child has a cough but no signs of Children with rapid breathing, indrawing of
breathing difficulty, the cause is usually an the chest, expiratory stridor or cyanosis, restless
upper respiratory tract viral infection. They and saturations less than 90% should be given
do not need an antibiotic but something to oxygen. Usually 1 to 2 litres per minute of 100%
soothe the throat (warm water or tea with oxygen is given by nasal prongs or 3 to 4 litres
honey or sugar). Cough mixtures usually via face mask. Measuring the oxygen saturation
only help by soothing the throat. Therefore, is very helpful.
use a simple cough linctus.
2. The cough should get better by 3 weeks.
If not, think of TB, asthma or whooping CASE STUDY 1
cough. These children should be referred
for further investigation and management. During the early evening a 2-year-old child
Always think of tuberculosis in a child develops a strange cough and a crowing noise
with a chronic cough and weight loss. when she breathes in. She had a mild fever and
3. If the child has signs of breathing difficulty, a runny nose during the day. When the child
refer for management of the underlying cries, the noise during inspiration becomes
condition. worse. The mother became anxious and
NOTE There is no scientific evidence that cough brought the child to the casualty department
suppressants, expectorants or mucolytics are of the local hospital.
effective for an acute cough cause by a viral
infection.
1. What is the crowing sound during
inspiration called?
7-49 What signs of breathing difficulty
suggest specific diagnoses? Stridor. The sound is caused by breathing in
through swollen vocal cords. Mild stridor only
These signs must be assessed when the child is occurs during inspiration and is usually only
calm and not crying: heard when the child cries.
1. Stridor is usually due to viral croup.
2. Indrawing of the lower chest wall may 2. What is the most likely cause?
occur with most severe lower respiratory
Viral croup. This is an acute viral infection
tract problems, i.e. pneumonia, stridor,
of the larynx, trachea and bronchi
bronchiolitis or asthma.
(laryngotracheobronchitis). It usually follows
3. Wheezing suggests bronchiolitis (in an
the start of a common cold or pharyngitis.
infant) or asthma (in an older child).
4. Fast breathing suggests pneumonia,
bronchiolitis or asthma. 3. What other sign is common with this
condition?
Older children with a severe lower respiratory
tract problem may complain of shortness of A ‘barking’ cough.
breath. Always look for danger signs in any
child with breathing difficulty.
The sudden onset of stridor or wheeze in a
well child suggests a foreign body.

14. LOWER RESPIRATOR Y TRACT INFECTIONS 135
4. What signs would suggest that the 3. What is the cause?
stridor is becoming worse?
Probably the respiratory syncytial virus
Both inspiratory and expiratory stridor, which can start as a common cold. Infection
especially if present at rest, and indrawing of with the respiratory syncytial virus is
the lower ribs during inspiration. The obvious commoner in winter.
use of chest and abdominal muscles during
expiration, restlessness or fast breathing are 4. What is the correct management?
signs of dangerous airway obstruction.
Bronchiolitis is best managed in hospital where
humidified oxygen can be given if necessary.
5. What is the main treatment of severe
stridor?
5. Should antibiotics be given?
Nebulised adrenaline. A single dose of steroids
helps. There is no indication for bronchodilators Usually not, except in infants under 3 months
or antibiotics. If respiratory failure develops, and where pneumonia is difficult to exclude.
intubation or a tracheotomy may be needed to
bypass the laryngeal narrowing. 6. What are danger signs with bronchiolitis?
Cyanosis, refusal to drink, apnoea, a marked
6. What diagnosis should you consider with tachycardia, restlessness or a depressed level
the sudden onset of stridor in a well child? of consciousness. An oxygen saturation below
An inhaled foreign body. 90% is cause for great concern. This child does
not have any of these danger signs.
CASE STUDY 2
CASE STUDY 3
An infant of 6 months develops fast breathing
and recession 3 days after the start of a common A 5-year-old child develops a cough and
cold. On inspection the chest appears over blocked nose. The next day his mother notices
expanded and a wheeze is heard. There is a mild that he is breathing fast and has a fever. On
fever and the child does not appear seriously examination he has a respiratory rate of 45
ill. He takes his bottle well and has no cyanosis. with chest indrawing. He refuses to drink and
There is no family history of asthma and this is has mild central cyanosis.
the first time the child has been ill.
1. Why is this child breathing fast?
1. What is the most likely diagnosis? He probably has pneumonia.
Bronchiolitis. This is an acute inflammation and
narrowing of the small airways of the lungs. 2. What is the definition of fast breathing?
It depends on the child’s age as younger
2. Why is this unlikely to be asthma? children normally breathe faster than older
The infant is young for asthma, this is the first children. A respiratory rate above 40 breaths
episode of wheezing and there is no family per minute is abnormally fast in any child
history of asthma. No other features of allergy older that one year.
are mentioned.
3. What is the likely cause?
Probably viral as he has an upper respiratory
tract infection. However the cause of the
pneumonia may be bacterial.

15. 136 LOWER RESPIRATOR Y TRACT INFECTIONS
4. What is chest indrawing? 2. What is this clinical condition?
Chest indrawing (recession or retractions) is Asthma is a chronic condition that presents
a clinical sign where there is indrawing of the with repeated attacks of airway narrowing.
lower chest when the child breathes in. It is
seen with pneumonia as well as a number of 3. What is the cause?
other lower respiratory tract conditions.
Asthma is caused by a combination of an
inherited factor (i.e. allergy) plus trigger
5. How severe is the pneumonia in this
factors.
child?
It is severe as he has 3 signs of severe 4. What are common trigger factors?
pneumonia (chest indrawing, refusal to drink
and cyanosis). These are danger signs. Viral infections, exercise, exposure to allergens
or irritants (e.g. smoke), cold air and emotion.
In this child the trigger factor was a viral
6. What management is needed?
upper respiratory airway infection.
1. Give oxygen to keep the child pink.
2. Start antibiotics. 5. Can you name a few common allergens?
3. Try to get the child to take oral fluids.
Otherwise start an intravenous infusion. House dust mite, pollens, cat or dog hair, some
4. Urgently transfer the child to hospital. foods and fungus spores.
7. What antibiotic would you choose? 6. How is a clinical diagnosis of asthma
confirmed?
Intramuscular ampicillin. It can be given
intravenously if an intravenous infusion (a drip) By lung function tests for airway narrowing
is started. In hospital gentamicin may be added. and response to an inhaled bronchodilator. A
skin prick test provides supportive evidence
for allergies.
8. What is the value of measuring the
oxygen saturation?
7. How should his acute attack be treated?
This is a very useful method of assessing
whether there is enough oxygen in the blood. He will probably respond well to an inhaled
short acting bronchodilator. If not, he should
be referred to hospital for assessment and
CASE STUDY 4 further treatment
8. Can acute attacks be prevented?
A 7-year-old child has a history of repeated
attacks of coughing and wheezing, especially at Yes. Every attempt should be made to prevent
night and during sport at school. He now has acute attacks by identifying and removing
wheezing for the past few hours, complicating trigger factors. In children with persistent
a common cold. There is a strong family asthma, steroids should be added to the
history of allergies. regular use of an inhaled bronchodilator.
1. Why is this child coughing and
wheezing?
He has an acute attack of asthma.