Post on 16-Jul-2015
RESPIRATORY EMERGENCIES IN
PAEDIATRIC PATIENTS 23/ 04/ 2015
Disorders of the respiratory tract are the most common forms of illnesses in
childhood. They are the most frequent reason for children to be seen by a
Doctor and account for 30> 40% of acute admissions to hospital.
Many respiratory illnesses are self- limiting minor infections but others present
as potentially life threatening emergencies. This small group is where accurate
diagnosis is essential to avoid unnecessary morbidity and mortality.
SUSCEPTIBILITY OF CHILDREN TO SEVERE RESPIRATORY ILLNESS.
The pattern of children suffering respiratory illness is different from adults as it
does involve the immune status, the structure and function of the lungs and
the chest wall of children and adults.
Children and particularly infants are susceptible to infection with many
organisms to which adults have acquired immunity to.
The upper and lower airways in children are smaller and are more easily
obstructed to swelling foreign body or mucosal secretions. It all centres
around the radius the 1mm reduction of a 5mm diameter trachea in a
child is much greater than the swelling of an adults trachea that is 10
mm in diameter.
The thoracic cage of a young child is much more compliant than that of
adults. When there is airway obstruction and increased respiratory
effort this increased compliance results in the efficiency of breathing.
Respiratory muscles of an infant or child are relatively inefficient. In infancy the
Diaphragm is the principle respiratory muscle and the intercostal and
accessory do not really make any contribution. Respiratory muscle fatigue can
develop rapidly and result in respiratory failure and apnoea.
ASSESSMENT OF RESPIRATORY EMERGENCIES IN CHILDHOOD
Respiratory illnesses that present most commonly as emergencies are as
follows
Upper airways obstruction
Lower airways obstruction
Pneumonia
Croup
Asthma / bronchiolitis
Epiglottitis
Although all these diseases result in respiratory distress, it is possible to
distinguish between them with careful history and clinical examination. As the
appropriate treatment for each of these disorders id quite specific, it is
imperative that the correct diagnosis of the distress is made.
HISTORY
Breathlessness ? At rest
? Walking up stairs
? When talking
? When sleeping (older children)
? When feeding (infants)
Cough Barking like a seal – like in Croup
Dry and wheezy in Bronchiolitis
Noisy Breathing Stridor, mainly inspiratory due to narrowing of trachea
Or larynx
Wheezy mainly expiratory, due to more distal obstruction
of the respiratory tree.
Hoarseness Vocal cord involvement
Drooling and unable to
Drink Epiglottitis
Abdominal pain sometimes present in Pneumonia
Meningism Sometimes present in Pneumonia (neck stiffness),
Photophobia, Headaches.
High fever, lethargy and anorexia are common in children
with respiratory infections.
Examination
Careful inspection of the Childs respiratory pattern, posture, and behaviour
pattern is often the most informative part of a physical examination. In
younger children you must straight away gain their trust, approach the child at
their level do not tower over them where possible let the parent or guardian
hold them as a comfort blanket if the child is very young. REMEMBER! That
diseases other than respiratory illnesses can produce many of these signs and
symptoms For example, deep rapid respirations may indicate metabolic
acidosis or salicylate poisoning, it can be difficult to distinguish between
respiratory disease and congenital heart disease in the young child.
Both give rise to tachypnoea, tachycardia, and cyanosis. Congenital heart
disease is more likely if there is evidence of heart failure such as Liver
enlargement cardiac murmurs or an irregular pulse may suggest primary heart
disease.
Further useful information will be from Oxygen saturation readings and blood
gasses done in hospital. In children over 5 years of age with asthma a peak flow
reading should be routine part of the assessment.
UPPER AIRWAY OBSTRUCTION.
Obstruction of the upper airway (Larynx / Trachea) is potentially life
threatening. As mentioned earlier the Childs airway is very small in diameter
and any blockage EG (coins, batteries, small toys, sweets, or small pieces of
food) or secretions is dangerous. Auscultation may reveal unilateral
wheezing or decreased air entry leading to possible collapsed lung.
Removal with Magill’s forceps may be lifesaving if that is your only answer if blockage can be visualised with the laryngoscope blade.
The cardinal feature of upper airway obstruction is STRIDOR! This is heard
predominantly on inspiration, but may be heard also on expiration. Like the
wheeze in asthma the intensity of the stridor does not indicate the severity of
the obstruction. Other signs such as hoarseness, swelling of the vocal cords,
barking seal like cough, sternal and subcostal recession, respiratory and heart
rate increase central cyanosis and agitation all indicate severe Hypoxemia and
a need for urgent intervention.
DIFFERENTIAL DIAGNOSIS OF ACUTE UPPER AIRWAY OBSTRUCTION.
Most cases of upper airway obstruction in children are a result of infection, but
other causes such as foreign body obstruction, house fire (Hot gasses)
Angioneurotic oedema and trauma can all result in such obstructions.
CROUP
Croup (or laryngotracheobronchitis) is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The
infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness. Fever in children < 38.5C. It
may produce mild, moderate, or severe symptoms, which often worsen at night. It is often treated with a single dose of oral steroids;
occasionally inhaled epinephrine is used in more severe cases. Hospitalization is rarely required.
Croup is diagnosed on clinical grounds, once potentially more severe causes of symptoms have been excluded (i.e. epiglottitis or an airway
foreign body). Further investigations—such as blood tests, X-rays, and cultures—are usually not needed. It is a relatively common condition that
affects about 15% of children at some point, most commonly between 6 months and 5–6 years of age. It is almost never seen in teenagers or adults.
SIGNS AND SYMPTOMS
Croup is characterized by a "barking" cough, stridor, hoarseness, and difficult breathing which usually worsens at night. The "barking"
cough is often described as resembling the call of a seal or sea lion. The stridor is worsened by agitation or crying, and if it can be heard at rest, it may indicate critical narrowing of the airways. As croup worsens, stridor
may decrease considerably.
Other symptoms include fever, coryza (symptoms typical of the common
cold), and chest wall in-drawing. Drooling or a very sick appearance indicate other medical conditions.
TREATMENT
Children with croup are generally kept as calm as possible. Steroids are given routinely, with epinephrine used in severe cases. Children with
oxygen saturations under 92% should receive oxygen (Humidified) if possible and those with severe croup may be hospitalized for observation. If oxygen is needed, "blow-by" administration (holding an
oxygen source near the child's face) is recommended, as it causes less agitation than use of a mask with treatment, less than 0.2% of people
require endotracheal intubation
Steroids
Corticosteroids, such as dexamethasone have been shown to improve outcomes in children with all severities of croup Significant relief is obtained as early as six hours after administration. While effective when
given orally, the oral route is preferred. A single dose is usually all that is required, and is generally considered to be quite safe. Dexamethasone
at doses stated in the JRCALC guidelines appear to be all equally effective.
PROGNOSIS
Viral croup is usually a self-limited disease with half of cases going away
in a day and 80% of cases in two days. It can very rarely result in death
from respiratory failure and/or cardiac arrest. Symptoms usually improve
within two days, but may last for up to seven days. Other uncommon
complications include bacterial tracheitis, pneumonia, and pulmonary Oedema.
ACUTE EPIGLOTTITIS
The epiglottis is a flap that is made of elastic cartilage tissue covered
with a mucous membrane, attached to the entrance of the larynx. It
projects obliquely upwards behind the tongue and the hyoid bone, pointing dorsally. There are taste buds on the epiglottis.
Inflammation of the epiglottis is known as epiglottitis. Epiglottitis is mainly caused by Haemophilus influenzae B. A person with epiglottitis
may have a fever, sore throat, difficulty swallowing, and difficulty
breathing. For this reason, in children, acute epiglottitis is considered a medical emergency, because of the risk of obstruction of the pharynx.
Epiglottitis is often managed with antibiotics and may require tracheal intubation or a tracheostomy if breathing is difficult.
Treatment
We should not try and examine the Childs airway as we do not want to induce choking or vomiting, the Epiglottis will be cherry red with the
inflammation and we should just encourage the parent or care provider to sit the child forward and let them drool into a paper towel and offer comfort. If the O2 saturation is showing <92% then we should encourage
oxygen therapy but wafting the oxygen over the patients face and nose to encourage an increase in the saturation levels. As a last resort Do-
not attempt intubation in the field unless acute airway obstruction is present. ET Tube to be one half to one size SMALLER for age and size of patient to accommodate the subglottic oedema, the event of
respiratory failure or obstruction, if emergency medical services (EMS) is unable to intubate, then cricothyroidotomy are the next lines of
treatment. (Speed to A&E is with ASHICE call is essential)!
LOWER AIRWAY OBSTRUCTION
Asthma
Acute exacerbation of asthma is the most common reason for a child to be
admitted to hospital. The classic features of acute asthma are cough, wheeze
and breathlessness an increase in these symptoms and difficulty in walking,
talking and sleeping. Upper respiratory tract infections are most common in
pre-school children. Ninety per cent are caused by viruses. Exercise induced
symptoms are more likely in the older child. Heat and water loss seem to be
the mechanism that induces bronchoconstriction.
ASSESSMENT OF SEVERITY
Except in a young infant it is rarely a problem diagnosing acute asthma, an
inhaled foreign body croup, epiglottitis or bronchiolitis should be considered as
alternative diagnosis. The peak expiratory flow is a reliable measure of severity
and should be routinely be part of the assessment.
Features of severe asthma
Too breathless to feed or talk
Recession / use of accessory muscles
Respiratory rate > 50breaths per min
Pulse rate > 140 bpm
Peak flow <50% expected best
Features of life life-threatening asthma
Conscious levels depressed / agitation
Exhaustion
Poor respiratory effort
Oxygen saturation <85% in air cyanosis
Silent chest
Peak flow <33% expected best.
Predicted values of peak expiratory flow rate in children
Height (cm) Peak flow (L/min)
110 150
120 200
130 250
140 300
150 350
160 400
170 450
Treatment
All treatment for this condition will be based around currant best practice
guidelines and the JRCALC drug administration protocols for Paediatrics.
Salbutamol, Ipratropium Bromide, Hydrocortisone, Epinephrine 1,1000
Nebulised drugs given by oxygen at all times,
If the child fails to improve they must be observed at all times ECG taken O2
saturation recorded the journey time will dictate how frequently you nebulise
but it can be continuously if needed.
BRONCHIOLITIS
This is the most common, serious, respiratory infection of childhood 2 -3% of
all infants are admitted to hospital with the disease each year. 1 to 9 months
age range it is rare after 1 year of age.
° Acute, infectious, inflammatory disease of the upper and
Lower respiratory tracts; major cause of respiratory disease
Worldwide. Obstruction of bronchioles from inflammation, oedema,
And debris leads to hyperinflation, increased airway resistance, and atelectasis.
Although wheezing is common, bronchoconstriction is not.
Most cases are mild and self-limiting; however, inpatient
Mortality can be as high as 5%.
Causes
Bronchiolitis is most often caused by respiratory
Syncytial virus (RSV)
Common in infants and during the autumn and winter time.
EMERGENCY TREATMENT
As there is no specified treatment for Bronchiolitis, management is supportive,
Humidified Oxygen is delivered into a head box in hospital. Sometimes IV fluids
or nasogastric fluids are commenced if needed. Pulse oximetry is helpful in
assessing the severity of hypoxemia. Because of the risk of Apnoea small
infants will be placed on monitors in hospital.
Pneumonia
This condition in children is still responsible for 150 deaths each year. Infants
and children with congenital abnormalities or chronic illnesses are at greater
risk. Viruses are the most common cause in younger children as they grow
older the bacteria is more frequent as part of the infection.
Fever, cough, dyspnoea, and lethargy following upper respiratory infection are
the usual presenting symptoms. The cough is often dry but then becomes
loose. Older children may produce purulent sputum, but those below the age
of 5 it is usually swallowed. It can produce pleuritic chest pains, neck stiffness
and abdominal pains if there is pleural inflammation. Classic signs of
consolidation such as impaired percussion decreased breath sounds and
bronchial breathing are often absent. Particularly in infants. A chest X-ray will
be needed. This may show the Dr Consolidation or widespread pneumonia.
EMERGENCY TREATMENT
As it’s not possible to differentiate between bacterial and viral infection
children should receive antibiotics, the antibiotic given is age dependant by the
Doctor. If over a period of time the child keeps getting reoccurring infections
then other tests need to be carried out to rule out conditions such as cystic
fibrosis or immunodeficiency problems.
(This Paper reflects what we as health care professionals may be able to care
for at our skill level out in the pre-hospital environment).
REFERENCES:-
WWW.WIKIPAEDIA.ORG
http://www.cs.amedd.army.mil/borden/FileDownloadpublic.
http://www.patient.co.uk/health/pneumonia-leaflet
http://image.slidesharecdn.com/emergenciesinchildren-140310043441-
phpapp02/95/otolaryngological-emergencies-in-neonateinfant-and-child-32-
638.jpg?cb=1394444149
Advanced Paediatric Life Support ISBN No 0-7279-1069-8
Clinical Practice Guidelines 2013 ISBN 978 185959 364 9
Emergency Care in the Streets 6th edition ISBN 13-978-7637-5057-2
Mark Dunkerley
HCPC Paramedic
PA00479.