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Respiratory Emergencies Interact! • Respiratory distress / Impending or overt respiratory failure is the most frequent reason for admission in a PICU • Which is the most frequent anatomical abnormality in the respiratory tract causing distress/failure? Airway / Parenchyma / Interstitium / Pleura
Airway Obstruction is the Most Frequent, Parenchymal is Followed by Pleural Disease
Case 1 • 3 year old boy brought with noisy breathing from 3 days • He has been nebulized for this kind of breathing in the past • He wakes up at night due to this and coughs
Case 1 Interact!
Remember the 6 noises and the site of lesion • • • Snuffles Snoring Stridor Rattle Wheeze Grunt • • • Nasopharynx Oropharynx Larynx & trachea Carina Bronchial Tree Parenchyma/Pleura
Case 2 - 15 month old with noisy breathing Interact!
All these Children have Airway Obstruction • How do you triage such children? • Triage of these children will depend on 1. 2. The severity of obstruction The cause of obstruction which will give clue to the rate of narrowing
Principles of Stabilizing a Child with Airway Obstruction • Keep the child comfortable on the mothers lap • Do not stress the child, throat evaluation should be done only when facilities for providing airway access is available • Supplemental Humidified oxygen in a non threatening way
Croup--When do you call it mild? Looks Fine Barking cough Stridor on crying No accessory muscle use • No tachypnea • Saturations Normal • • • Symptomatic treatment +/- single dose of oral steroids • Parental education on symptoms and signs of worsening even at night
Moderate Croup Irritable Increased crying Barking cough Stridor at rest 1 -2 accessory muscle use • Tachypnea • Saturations Normal • • • Steroids • Nebulised adrenaline • Close monitoring
Severe Croup • • Irritable/Occ Drowsy Increased crying Barking cough Loud Stridor at rest >2 accessory muscle use Tachypnea Saturations may be low • Dexamethasone 0. 6 mg/kg oral, iv, IM / Budesonide 2 mg/2 ml • Adrenaline Nebulised 0. 5 ml/kg upto a maximum of 5 ml of a 1: 1000 dilution, Can be repeated every 20 -30 minutes for a maximum of 3 nebulisations
Treatment of Severe Croup • • • Oxygen Rapid transfer Steroids Nebulize adrenaline as frequently as needed Intubate if there is impending respiratory failure Use a tube half size smaller than optimal
Case 3 Interact!
3 Year Old Boy • Acute episode of cough with wheeze • Multiple episodes in the past
Pulmonary severity score ATM -IAP Score Resp Rate /Minute <6 years Resp Rate /Minute >6 years Wheeze Accessory Muscle use 0 <30 <20 None No apparent activity 1 30 -40 21 -35 Terminal expiration with stethoscope Questionable increase 2 41 -50 36 -50 Entire expiration Increase with stethoscope apparent 3 >50 During inspiration and expiration without stethoscope Interpretation 0 -3 mild 4 -6 moderate >6 Severe Maximum activity
Pulse Oximetry Please Note • Children with SPO 2 of < 92% at presentation were significantly more likely to require admission and multiple nebulizations. Br J Gen Pract. 2005 July 1; 55(516): 501– 502.
How do you Stabilize? Interact! • Aerosol Therapy with MDI with spacer is better than nebulizer in office setting Agree / Disagree ?
Salbutamol • MDI 4 - 8 puffs every 20 minutes in the first hour • After 1 st hr. 4 - 8 puffs every 1 -4 hrs as needed. • Nebulizer Dose is 0. 15 mg/kg (minimum 2. 5 mg and maximum 5 mg per dose )every 20 min for three doses Or 0. 3 mg/kg/hour
Glucocorticoids • If there is no/inadequate response to the first aerosol treatment • Administer Glucocorticoids • Oral is preferred to parenteral • Prednisolone 1 mg/kg (3 -5 days)or Dexamethasone (Oral or parenteral) 0. 6 mg/kg(1 -2 doses 24 hrs apart)
Ipratropium • Useful in moderate and severe attacks as an add on • Can be nebulized or given by a MDI with spacer • Dose is 250 mcg < 20 kg and 500 mcg > 20 kg for 3 doses every 20 min then as needed • MDI dose is lower 18 mcg/puff 4 -8 puffs repeated every 20 minutes then as needed
Parenteral Beta 2 Agonists • Where the patient is not improving on aerosol therapy • Intramuscular terbutaline 0. 01 mg/kg (subcutanous is an alternate) • Adrenaline 0. 01 mg/kg 1/1000 solution sc or im is an alternative but has more side effects (maximum 0. 5 mg)
Magnesium Sulphate • In patients who have received salbutamol, ipratropium and glucocorticoids and who are still significantly symptomatic • IV magnesium sulphate 50 mg/kg administered over 20 minutes with cardiorespiratory monitoring
Key Issues in Transport in Severe Exacerbations • • • Oxygen Airway Vascular access Nebulisation/MDI with aerosol Position Communication For Transport details Refer SOS-HOPE APP
Case 4 Interact!
Case 4 • S - an 8 month old infant presented with fever cough and breathlessness of 1 day • On examination he is febrile , toxic resp rate is 65, moderate intercostal and subcostal retractions, has significant grunt, HR is 140/min cap refill is < 2 secs and his saturation is 92%
Clinical Criteria for Pneumonia • Fever • Cough • Tachypnea Respiratory distress • Chest or abdominal Pain • Signs of Consolidation • Signs of Hypoxemia Complicated Pneumonia Effusions Empyema Necrotizing pneumonia Pneumatocoeles/Pneu mothorax • Abscess • • •
Respiratory Rates • <2 months >60/Min • 2 months-12 months >50/min • 12 months-5 years > 40/min
Severity of Community Acquired Pneumonia Severe Pneumonia • Only Tachypnea • No retractions • Tachypnea + Retractions • Any Pneumonia <3/12 is severe Very Severe Pneumonia • • • Not able to drink , Convulsions, Abnormally sleepy or difficult to wake up, Grunt in a calm child, Severe malnutrition
Key Issues in Transport of very Severe Pneumonia • • • Oxygenation Perfusion Communication Rarely may need airway Administer 1 st dose of antibiotic – Ceftriaxone for Severe or Very Severe Pneumonia is an appropriate emergency choice.
Case 5 Interact!
Foreign Body Picture of Aluminium foil stuck in Cricopharynx
Foreign Body • • Suspect choking caused by a foreign body if : The onset was very sudden There are no other signs of illness There are clues to alert the rescuer, for example a history of eating or playing with small items immediately prior to the onset of symptoms
Algorithm Pediatric Choking Treatment Algorithm Assess severity Ineffective Cough Unconscious Open Airways 5 Breaths Start CPR Conscious < 1 year – 5 back blows and 5 chest thrusts > 1 year – abdominal thrusts – Heimlich Manoeuvre Effective Cough Encourage Cough Continue to check for deterioration to ineffective cough or until obstruction relieved
Infants • Back Blows for Infants • Chest thrusts for Infants
Summary • Clinical evaluation should be with a focused history and clinical examination • Carefully count the respiratory rate for 1 minute, watch for breathing, respiratory sounds, and examine the chest • Measure the oxygen saturation, always have a pulse oximeter • Stabilise all patients with oxygen, airway and ensure they are breathing adequately
Summary • Keep a watch for subtle signs of hypoxia and deterioration • Make arrangements to shift optimally • Keep your office adequately stocked everyday, make sure the equipment is well maintained • Staff should be trained in triage, communication, maintaining equipment and medication and helping in an emergency