Pediatrics

Respiratory EmergenciesRespiratory Emergencies

(adapted from pediatric .com)(adapted from pediatric .com)

Respiratory Emergencies

#1 cause of #1 cause of Pediatric hospital admissionsPediatric hospital admissions Death during first year of life except for Death during first year of life except for

congenital abnormalitiescongenital abnormalities

Respiratory Emergencies

Most pediatric cardiac arrest Most pediatric cardiac arrest begins as respiratory failure or begins as respiratory failure or

respiratory arrestrespiratory arrest

Pediatric Respiratory System

Large head, small Large head, small mandible, small neckmandible, small neck

Large, posteriorly-Large, posteriorly-placed tongueplaced tongue

High glottic openingHigh glottic opening Small airwaysSmall airways Presence of tonsils, Presence of tonsils,

adenoidsadenoids

Pediatric Respiratory System

Poor accessory muscle developmentPoor accessory muscle development Less rigid thoracic cageLess rigid thoracic cage Horizontal ribs, primarily diaphragm Horizontal ribs, primarily diaphragm

breathersbreathers Increased metabolic rate, increased OIncreased metabolic rate, increased O22

consumptionconsumption

Pediatric Respiratory System

Decrease respiratory reserve + Decrease respiratory reserve + Increased OIncreased O22 demand = demand =

Increased respiratory failure riskIncreased respiratory failure risk

Respiratory Distress

Respiratory Distress

Tachycardia (May be bradycardia in neonate)Tachycardia (May be bradycardia in neonate) Head bobbing, stridor, prolonged expirationHead bobbing, stridor, prolonged expiration Abdominal breathingAbdominal breathing Grunting--creates CPAPGrunting--creates CPAP

Respiratory Emergencies

CroupCroup EpiglottitisEpiglottitis AsthmaAsthma BronchiolitisBronchiolitis Foreign body aspirationForeign body aspiration Bronchopulmonary dysplasiaBronchopulmonary dysplasia

Laryngotracheobronchitis

CroupCroup

Croup: Pathophysiology

Viral infection (parainfluenza)Viral infection (parainfluenza) Affects larynx, tracheaAffects larynx, trachea Subglottic edema; Air flow obstructionSubglottic edema; Air flow obstruction

Croup: Incidence

6 months to 4 years6 months to 4 years Males > FemalesMales > Females Fall, early winterFall, early winter

Croup: Signs/Symptoms

““Cold” progressing to hoarseness, coughCold” progressing to hoarseness, cough Low grade feverLow grade fever Night-time increase in edema with:Night-time increase in edema with:

StridorStridor ““Seal bark” coughSeal bark” cough Respiratory distressRespiratory distress CyanosisCyanosis

Recurs on several nightsRecurs on several nights

Croup: Management

Mild CroupMild Croup ReassuranceReassurance Moist, cool airMoist, cool air

Croup: Management

Severe CroupSevere Croup Humidified high concentration oxygenHumidified high concentration oxygen Monitor EKGMonitor EKG IV tko IV tko ifif toleratedtolerated Nebulized racemic epinephrineNebulized racemic epinephrine Anticipate need to intubate, assist Anticipate need to intubate, assist

ventilationsventilations

Epiglottitis

Epiglottitis: Pathophysiology

Bacterial infection (Hemophilus influenza)Bacterial infection (Hemophilus influenza) Affects epiglottis, adjacent pharyngeal tissueAffects epiglottis, adjacent pharyngeal tissue Supraglottic edemaSupraglottic edema

Complete Airway Obstruction

Epiglottitis: Incidence

Children > 4 years oldChildren > 4 years old Common in ages 4 - 7Common in ages 4 - 7 Pedi incidence falling due to HiB vaccinationPedi incidence falling due to HiB vaccination Can occur in adults, particularly elderlyCan occur in adults, particularly elderly Incidence in adults is increasingIncidence in adults is increasing

Epiglottitis: Signs/Symptoms

Rapid onset, severe distress in hoursRapid onset, severe distress in hours High feverHigh fever Intense sore throat, difficulty swallowingIntense sore throat, difficulty swallowing DroolingDrooling StridorStridor Sits up, leans forward, extends neck slightlySits up, leans forward, extends neck slightly One-third present unconscious, in shockOne-third present unconscious, in shock

Epiglottitis

Respiratory distress+ Respiratory distress+ Sore throat+Drooling = Sore throat+Drooling =

EpiglottitisEpiglottitis

Epiglottitis: Management

High concentration oxygenHigh concentration oxygen IV tko, IV tko, ifif possiblepossible Rapid transportRapid transport Do Do notnot attempt to visualize airway attempt to visualize airway

Epiglottitis

Immediate Life ThreatImmediate Life Threat

Possible Complete Airway Possible Complete Airway ObstructionObstruction

Asthma

Asthma: Pathophysiology

Lower airway hypersensitivity to:Lower airway hypersensitivity to: AllergiesAllergies InfectionInfection IrritantsIrritants Emotional stressEmotional stress ColdCold ExerciseExercise

Asthma: Pathophysiology

Bronchospasm

Bronchial Edema Increased MucusProduction

Asthma: Pathophysiology

Asthma: Pathophysiology

Cast of airway produced by

asthmatic mucus plugs

Asthma: Signs/Symptoms

DyspneaDyspnea Signs of respiratory distressSigns of respiratory distress

Nasal flaringNasal flaring Tracheal tuggingTracheal tugging Accessory muscle useAccessory muscle use Suprasternal, intercostal, epigastric Suprasternal, intercostal, epigastric

retractionsretractions

Asthma: Signs/Symptoms

CoughingCoughing Expiratory wheezingExpiratory wheezing TachypneaTachypnea CyanosisCyanosis

Asthma: Prolonged Attacks

Increase in respiratory water lossIncrease in respiratory water loss Decreased fluid intakeDecreased fluid intake DehydrationDehydration

Asthma: History

How long has patient been wheezing?How long has patient been wheezing? How much fluid has patient had?How much fluid has patient had? Recent respiratory tract infection?Recent respiratory tract infection? Medications? When? How much?Medications? When? How much? Allergies?Allergies? Previous hospitalizations?Previous hospitalizations?

Asthma: Physical Exam

Patient position?Patient position? Drowsy or stuporous?Drowsy or stuporous? Signs/symptoms of dehydration?Signs/symptoms of dehydration? Chest movement? Chest movement? Quality of breath sounds?Quality of breath sounds?

Asthma: Risk Assessment

Prior ICU admissionsPrior ICU admissions Prior intubationPrior intubation >3 emergency department visits in past year>3 emergency department visits in past year >2 hospital admissions in past year>2 hospital admissions in past year >1 bronchodilator canister used in past month>1 bronchodilator canister used in past month Use of bronchodilators > every 4 hoursUse of bronchodilators > every 4 hours Chronic use of steroidsChronic use of steroids Progressive symptoms in spite of aggressive RxProgressive symptoms in spite of aggressive Rx

Asthma

Silent Chest Silent Chest equals equals

Danger Danger

Golden Rule

Pulmonary edemaPulmonary edema Allergic reactionsAllergic reactions PneumoniaPneumonia Foreign body aspirationForeign body aspiration

ALL THAT WHEEZES IS NOT ASTHMA

Asthma: Management

AirwayAirway BreathingBreathing

Sitting positionSitting position Humidified O2 by NRB maskHumidified O2 by NRB mask

Dry O2 dries mucus, worsens plugsDry O2 dries mucus, worsens plugs Encourage coughingEncourage coughing Consider intubation, assisted ventilationConsider intubation, assisted ventilation

Asthma: Management

CirculationCirculation IV TKOIV TKO Assess for dehydrationAssess for dehydration Titrate fluid administration to severity of Titrate fluid administration to severity of

dehydrationdehydration Monitor ECGMonitor ECG

Asthma: Management

Obtain medication historyObtain medication history OverdoseOverdose ArrhythmiasArrhythmias

Asthma: Management

Nebulized Beta-2 agentsNebulized Beta-2 agents AlbuterolAlbuterol TerbutalineTerbutaline MetaproterenolMetaproterenol IsoetharineIsoetharine

Asthma: Management

Nebulized anticholinergicsNebulized anticholinergics AtropineAtropine IpatropiumIpatropium

POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE

Asthma: Management

Subcutaneous beta agentsSubcutaneous beta agents Epinephrine 1:1000--0.1 to 0.3 mg SQEpinephrine 1:1000--0.1 to 0.3 mg SQ Terbutaline--0.25 mg SQTerbutaline--0.25 mg SQ

Asthma: Management

Use EXTREME caution in giving two Use EXTREME caution in giving two sympathomimetics to same patientsympathomimetics to same patient

Monitor ECGMonitor ECG

Asthma: Management

AvoidAvoid SedativesSedatives

Depress respiratory driveDepress respiratory drive AntihistaminesAntihistamines

Decrease LOC, dry secretionsDecrease LOC, dry secretions AspirinAspirin

High incidence of allergyHigh incidence of allergy

Status Asthmaticus

Asthma attack unresponsive to Asthma attack unresponsive to -2 -2 adrenergic agentsadrenergic agents

Status Asthmaticus

Humidified oxygenHumidified oxygen RehydrationRehydration Continuous nebulized beta-2 agentsContinuous nebulized beta-2 agents AtroventAtrovent CorticosteroidsCorticosteroids Aminophylline (controversial)Aminophylline (controversial) Magnesium sulfate (controversial)Magnesium sulfate (controversial)

Status Asthmaticus

IntubationIntubation Mechanical ventilationMechanical ventilation

Large tidal volumes (18-24 ml/kg)Large tidal volumes (18-24 ml/kg) Long expiratory timesLong expiratory times

Intravenous TerbutalineIntravenous Terbutaline Continuous infusionContinuous infusion 3 to 6 mcg/kg/min3 to 6 mcg/kg/min

Bronchiolitis

Bronchiolitis: Pathophysiology

Viral infection (RSV)Viral infection (RSV) Inflammatory bronchiolar edemaInflammatory bronchiolar edema Air trappingAir trapping

Bronchiolitis: Incidence

Children < 2 years oldChildren < 2 years old 80% of patients < 1 year old80% of patients < 1 year old Epidemics January through MayEpidemics January through May

Bronchiolitis: Signs/Symptoms

Infant < 1 year oldInfant < 1 year old Recent upper respiratory infection exposureRecent upper respiratory infection exposure Gradual onset of respiratory distressGradual onset of respiratory distress Expiratory wheezingExpiratory wheezing Extreme tachypnea (60 - 100+/min)Extreme tachypnea (60 - 100+/min) CyanosisCyanosis

Asthma vs Bronchiolitis

AsthmaAsthma Age - > 2 yearsAge - > 2 years Fever - usually normalFever - usually normal Family Hx - positiveFamily Hx - positive Hx of allergies - positiveHx of allergies - positive Response to Epi - positiveResponse to Epi - positive

BronchiolitisBronchiolitis Age - < 2 yearsAge - < 2 years Fever - positiveFever - positive Family Hx - negativeFamily Hx - negative Hx of allergies - negativeHx of allergies - negative Response to Epi - negativeResponse to Epi - negative

Bronchiolitis: Management

Humidified oxygen by NRB maskHumidified oxygen by NRB mask Monitor EKGMonitor EKG IV tkoIV tko Anticipate order for bronchodilatorsAnticipate order for bronchodilators Anticipate need to intubate, assist Anticipate need to intubate, assist

ventilationsventilations

Foreign Body Airway Obstruction

FBAOFBAO

FBAO: High Risk Groups

> 90% of deaths: children < 5 years old> 90% of deaths: children < 5 years old 65% of deaths: infants65% of deaths: infants

FBAO: Signs/Symptoms

Suspect in any previously well, afebrile Suspect in any previously well, afebrile child with sudden onset of:child with sudden onset of: Respiratory distressRespiratory distress ChokingChoking CoughingCoughing StridorStridor WheezingWheezing

FBAO: Management

Minimize intervention if child conscious, Minimize intervention if child conscious, maintaining own airwaymaintaining own airway

100% oxygen as tolerated100% oxygen as tolerated No blind sweeps of oral cavityNo blind sweeps of oral cavity WheezingWheezing

Object in small airwayObject in small airway Avoid trying to dislodge in fieldAvoid trying to dislodge in field

FBAO: Management

Inadequate ventilationInadequate ventilation Infant: 5 back blows/5 chest thrustsInfant: 5 back blows/5 chest thrusts Child: Abdominal thrustsChild: Abdominal thrusts

Bronchopulmonary Dysplasia

BPDBPD

BPD: Pathophysiology

Complication of infant respiratory distress Complication of infant respiratory distress syndromesyndrome

Seen in premature infantsSeen in premature infants Results from prolonged exposure to high Results from prolonged exposure to high

concentration Oconcentration O2 2 , mechanical ventilation, mechanical ventilation

BPD: Signs/Symptoms

Require supplemental O2 to prevent cyanosisRequire supplemental O2 to prevent cyanosis Chronic respiratory distressChronic respiratory distress RetractionsRetractions RalesRales WheezingWheezing Possible cor pulmonale with peripheral edemaPossible cor pulmonale with peripheral edema

BPD: Prognosis

Medically fragile, decompensate quicklyMedically fragile, decompensate quickly Prone to recurrent respiratory infectionsProne to recurrent respiratory infections About 2/3 gradually recoverAbout 2/3 gradually recover

BPD: Treatment

Supplemental O2 Supplemental O2 Assisted ventilations, as neededAssisted ventilations, as needed Diuretic therapy, as neededDiuretic therapy, as needed