Respiratory

Respiratory distress in a child — bronchiolitis vs asthma differential

Intermediate

Pediatric · 8yr · female

Patient Information

Dispatch	You are called to the First Aid Post at the Perth Royal Show where a parent has brought in an 8-year-old girl (Mia Cartwright) who is struggling to breathe. Mum states she has had a cold for the past three days and has gotten worse this afternoon.
Patient	Mia Cartwright — 8yr (25kg)
Incident History	Mia has had a runny nose and mild cough for three days. This afternoon she became increasingly short of breath and her mum noticed she was breathing harder than usual. No known trigger. No recent exertion. Mum brought her directly to the FAP.
Emergency Contact	Rachael Cartwright (Mother) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil foreign body. Nil stridor. Mild audible wheeze on expiration.
Breathing	Increased work of breathing. Subcostal and intercostal recession visible. Expiratory wheeze audible bilaterally. RR elevated. Unable to complete full sentences without pausing.
Circulation	Radial pulse present, regular, slightly elevated. Skin warm and pink centrally. CRT <2s.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious but co-operative.
Exposure	No rashes. No urticaria. No angioedema. Nil visible injuries. Mild nasal congestion noted.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Moderate	32	118	96/62	<2s	15	4 4 ++	37.8	–	3
10 mins	96% (O2 NRB 10L/min)	Mild	24	108	98/64	<2s	15	4 4 ++	37.8	–	2

History Taking

Treatment Response

Diagnosis

This patient is suffering from an acute viral-induced wheeze / lower respiratory tract illness presenting with moderate respiratory distress. At 8 years of age, this presentation is at the upper boundary of bronchiolitis (typically <2 years); the correct clinical classification is viral-induced wheeze or reactive airways disease in the context of a current URTI. EHS scope does not include salbutamol administration (Intermediate Care and above per Asthma CPG); the key EHS actions are recognition of moderate respiratory distress, appropriate oxygen titration, correct patient positioning, and urgent transport with pre-notification. The trainee must NOT administer salbutamol — this is outside EHS scope for asthma.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not apply oxygen within 3 minutes of initial assessment, SpO2 drops to 88% and Mia becomes more distressed and stops speaking in phrases — mum becomes increasingly anxious.)
! (If the trainee attempts to administer salbutamol MDI via spacer, facilitator reminds them to check their scope of practice — salbutamol for asthma/bronchospasm is Intermediate Care and above per the Asthma CPG. EHS may only assist the patient to use their OWN inhaler if clinically indicated and the patient has a prescribed device.)
! (If the trainee does not recognise the moderate severity classification — accessory muscle use, unable to complete sentences, SpO2 90–94% — escalate urgency: Mia says 'I can't breathe properly' and Mum states 'she's getting worse'.)
! (If oxygen is not titrated and instead administered at maximum flow without assessment, the facilitator notes SpO2 is 99% on NRB — prompt trainee to titrate to target ≥95% for paediatrics and reduce flow accordingly.)
! (If BGL is not considered and primary survey is incomplete, Mia briefly appears slightly drowsy — prompt trainee to complete disability assessment and consider BGL.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — identify patent airway, moderate respiratory distress with expiratory wheeze and subcostal/intercostal recession, SpO2 91% on room air.
3. Position Mia upright or in a position of comfort — do NOT force posture change if child has adopted a preferred position.
4. Apply oxygen therapy — commence non-rebreather mask at 10–15 L/min; titrate to achieve SpO2 ≥95% for paediatric patient as per Oxygen CPG.
5. Conduct Vital Sign Survey — RR, SpO2, HR, BP, temperature, GCS, pain score.
6. Assess respiratory distress severity using clinical features — Mia has moderate distress (accessory muscle use, audible wheeze, unable to complete sentences, SpO2 90–94% on RA).
7. Recognise that salbutamol administration is OUTSIDE EHS scope for asthma exacerbation (Intermediate Care and above) — do NOT administer salbutamol independently.
8. If Mia has her own prescribed salbutamol MDI and spacer with her, EHS may assist her to use her own medication as per the Asthma CPG — confirm she does NOT have a prescribed device with her at this event.
9. Reassure Mia and her mother continuously throughout assessment and treatment.
10. Monitor full observations every 10 minutes — record RR, SpO2, HR, BP, GCS, pain score, respiratory distress severity.
11. Prepare for rapid deterioration — have BVM and suction available at bedside.
12. Contact State Operations Centre to request Priority 1 ambulance — Mia is a paediatric patient with moderate respiratory distress and SpO2 91% on RA.
13. Pre-notify receiving facility (Perth Children's Hospital) — paediatric patient, 8 years, 25 kg, moderate respiratory distress, expiratory wheeze, SpO2 91% RA improving to 96% on O2.
14. Reassess 10-minute vitals — SpO2 96% on O2 10L NRB, RR 24, HR 108, reduced work of breathing. Continue oxygen and monitoring.
15. Maintain oxygen therapy during transport — do not cease oxygen.
16. Scenario ends on arrival of ambulance and IMISTAMBO handover.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Asthma exacerbation · Dyspnoea & Respiratory Distress · Oxygen

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Signs/Symptoms	Shortness of breath, expiratory wheeze, subcostal and intercostal recession, mild cough, increased work of breathing.
Allergies	Nil known drug or food allergies.
Medications	Nil regular medications. No salbutamol puffer at home. No inhaled corticosteroids.
Pertinent History	No prior hospital admissions for respiratory illness. No previous asthma diagnosis. No history of eczema or hay fever. Mum reports Mia has had three similar episodes of wheeze with colds in the past two years, all resolved at home. No family history of asthma formally diagnosed. Mia is fully vaccinated.
Last Oral Intake	Lunch approximately 3 hours ago — sandwich and water.
Events Leading	Mia was watching show animals with her mum when her breathing worsened. Mum noticed increased work of breathing and brought her to the FAP.
Treatment Prior	Mum gave Mia one puff of an old salbutamol MDI found at home (no spacer used) approximately 30 minutes ago with minimal effect.

Onset	Gradual onset over three days following viral URTI. Worsened significantly this afternoon over the past two hours.
Pain	Mild chest tightness rated 3/10. No pleuritic pain.
Quality	Tight, wheezy breathing. Difficulty speaking in full sentences.
Radiates	Nil
Severity	3/10 chest tightness