Pediatrics Respiratory Emergencies Dr khaysy RASSAVONG Pediatric Department

Pediatrics Respiratory Emergencies Dr. khaysy RASSAVONG Pediatric Department Mahosot Hospital

Respiratory Emergencies n #1 cause of Pediatric hospital admissions u Death during first year of life except for congenital abnormalities u

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

Pediatric Respiratory System n n n Large head, small mandible, small neck Large, posteriorlyplaced tongue High glottic opening Small airways Presence of tonsils, adenoids

Pediatric Respiratory System n n Poor accessory muscle development Less rigid thoracic cage Horizontal ribs, primarily diaphragm breathers Increased metabolic rate, increased O 2 consumption

Pediatric Respiratory System Decrease respiratory reserve + Increased O 2 demand = Increased respiratory failure risk

Respiratory Distress

Respiratory Distress n n Tachycardia (May be bradycardia in neonate) Head bobbing, stridor, prolonged expiration Abdominal breathing Grunting--creates CPAP

Respiratory Emergencies n n n Croup Epiglottitis Asthma Bronchiolitis Foreign body aspiration Bronchopulmonary dysplasia

Laryngotracheobronchitis Croup

Croup: Pathophysiology n n n Viral infection (parainfluenza) Affects larynx, trachea Subglottic edema; Air flow obstruction

Croup: Incidence n n n 6 months to 4 years Males > Females Fall, early winter

Croup: Signs/Symptoms n n n “Cold” progressing to hoarseness, cough Low grade fever Night-time increase in edema with: u Stridor u “Seal bark” cough u Respiratory distress u Cyanosis n Recurs on several nights

Croup: Management n Mild Croup Reassurance u Moist, cool air u

Croup: Management n Severe Croup u Humidified high concentration oxygen u Monitor EKG u IV tko if tolerated u Nebulized racemic epinephrine u Anticipate need to intubate, assist ventilations

Epiglottitis

Epiglottitis: Pathophysiology n n n Bacterial infection (Hemophilus influenza) Affects epiglottis, adjacent pharyngeal tissue Supraglottic edema Complete Airway Obstruction

Epiglottitis: Incidence n n n Children > 4 years old Common in ages 4 - 7 Pedi incidence falling due to Hi. B vaccination Can occur in adults, particularly elderly Incidence in adults is increasing

Epiglottitis: Signs/Symptoms n n n n Rapid onset, severe distress in hours High fever Intense sore throat, difficulty swallowing Drooling Stridor Sits up, leans forward, extends neck slightly One-third present unconscious, in shock

Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis

Epiglottitis: Management n n High concentration oxygen IV tko, if possible Rapid transport Do not attempt to visualize airway

Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction

Asthma

Asthma: Pathophysiology n Lower airway hypersensitivity to: u Allergies u Infection u Irritants u Emotional stress u Cold u Exercise

Asthma: Pathophysiology Bronchospasm Bronchial Edema Increased Mucus Production

Asthma: Pathophysiology

Asthma: Pathophysiology Cast of airway produced by asthmatic mucus plugs

Asthma: Signs/Symptoms n n Dyspnea Signs of respiratory distress u Nasal flaring u Tracheal tugging u Accessory muscle use u Suprasternal, intercostal, epigastric retractions

Asthma: Signs/Symptoms n n Coughing Expiratory wheezing Tachypnea Cyanosis

Asthma: Prolonged Attacks n n n Increase in respiratory water loss Decreased fluid intake Dehydration

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

Asthma: Physical Exam n n n Patient position? Drowsy or stuporous? Signs/symptoms of dehydration? Chest movement? Quality of breath sounds?

Asthma: Risk Assessment n n n n Prior ICU admissions Prior intubation >3 emergency department visits in past year >2 hospital admissions in past year >1 bronchodilator canister used in past month Use of bronchodilators > every 4 hours Chronic use of steroids Progressive symptoms in spite of aggressive Rx

Asthma Silent Chest equals Danger

Golden Rule ALL THAT WHEEZES IS NOT ASTHMA n n Pulmonary edema Allergic reactions Pneumonia Foreign body aspiration

Asthma: Management n n Airway Breathing u Sitting position u Humidified O 2 by NRB mask FDry O 2 dries mucus, worsens plugs u Encourage coughing u Consider intubation, assisted ventilation

Asthma: Management n Circulation u IV TKO u Assess for dehydration u Titrate fluid administration to severity of dehydration u Monitor ECG

Asthma: Management n Obtain medication history u Overdose u Arrhythmias

Asthma: Management n Nebulized Beta-2 agents u Albuterol u Terbutaline u Metaproterenol u Isoetharine

Asthma: Management n Nebulized anticholinergics u Atropine u Ipatropium

Asthma: Management n Subcutaneous beta agents u Epinephrine 1: 1000 --0. 1 to 0. 3 mg SQ u Terbutaline--0. 25 mg SQ POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE

Asthma: Management n n Use EXTREME caution in giving two sympathomimetics to same patient Monitor ECG

Asthma: Management n Avoid u Sedatives FDepress respiratory drive u Antihistamines FDecrease LOC, dry secretions u Aspirin FHigh incidence of allergy

Status Asthmaticus Asthma attack unresponsive to -2 adrenergic agents

Status Asthmaticus n n n n Humidified oxygen Rehydration Continuous nebulized beta-2 agents Atrovent Corticosteroids Aminophylline (controversial) Magnesium sulfate (controversial)

Status Asthmaticus n n Intubation Mechanical ventilation u Large tidal volumes (18 -24 ml/kg) u Long expiratory times n Intravenous Terbutaline u Continuous infusion u 3 to 6 mcg/kg/min

Bronchiolitis

Bronchiolitis: Pathophysiology n n n Viral infection (RSV) Inflammatory bronchiolar edema Air trapping

Bronchiolitis: Incidence n n n Children < 2 years old 80% of patients < 1 year old Epidemics January through May

Bronchiolitis: Signs/Symptoms n n n Infant < 1 year old Recent upper respiratory infection exposure Gradual onset of respiratory distress Expiratory wheezing Extreme tachypnea (60 - 100+/min) Cyanosis

Asthma vs Bronchiolitis n Asthma u u u Age - > 2 years Fever - usually normal Family Hx - positive Hx of allergies - positive Response to Epi - positive n Bronchiolitis u u u Age - < 2 years Fever - positive Family Hx - negative Hx of allergies - negative Response to Epi - negative

Bronchiolitis: Management n n n Humidified oxygen by NRB mask Monitor EKG IV tko Anticipate order for bronchodilators Anticipate need to intubate, assist ventilations

Foreign Body Airway Obstruction FBAO

FBAO: High Risk Groups n n > 90% of deaths: children < 5 years old 65% of deaths: infants

FBAO: Signs/Symptoms n Suspect in any previously well, afebrile child with sudden onset of: u Respiratory distress u Choking u Coughing u Stridor u Wheezing

FBAO: Management n n Minimize intervention if child conscious, maintaining own airway 100% oxygen as tolerated No blind sweeps of oral cavity Wheezing u Object in small airway u Avoid trying to dislodge in field

FBAO: Management n Inadequate ventilation u Infant: 5 back blows/5 chest thrusts u Child: Abdominal thrusts

Bronchopulmonary Dysplasia BPD

BPD: Pathophysiology n n n Complication of infant respiratory distress syndrome Seen in premature infants Results from prolonged exposure to high concentration O 2 , mechanical ventilation

BPD: Signs/Symptoms n n n Require supplemental O 2 to prevent cyanosis Chronic respiratory distress Retractions Rales Wheezing Possible cor pulmonale with peripheral edema

BPD: Prognosis n n n Medically fragile, decompensate quickly Prone to recurrent respiratory infections About 2/3 gradually recover

BPD: Treatment n n n Supplemental O 2 Assisted ventilations, as needed Diuretic therapy, as needed