1. Pediatric Respiratory Emergencies
Amy Gutman MD
EMS Medical Director Tobey Hospital

2. Conflicts of Interest
Sadly, I have no corporate sponsorships or private funding to declare
Employed by Tobey Emergency Associates, a private EM group staffing Tobey Hospital Emergency Department (Southcoast Hospitals Group)
Medical Director for a bevy of awesome Fire & EMS Departments & training programs for which I am paid an enormous amount of money (ahem)

3. Overview
Review critical aspects of prehospital care of pediatric respiratory emergencies
Epidemiology
Anatomy
Specific disease processes
Emphasizing children have unique pathophysiology & respond differently to respiratory illness than adults
Most importantly:
How to recognize “sick”
Management strategies for respiratory distress
Timely recognition of respiratory distress & appropriate intervention key to preventing progression to cardiac arrest

4. Sick or Not Sick?

5. Pediatric Epidemiology
26% US population, 10% EMS calls
Respiratory distress #1 cause of admissions & death during 1st year except for congenital abnormalities
Most pediatric cardiac arrests begin as respiratory failure
Minimal training, few ill pediatric patients makes it difficult to obtain & maintain skills
Multiple sized pts, equipment sizes & drug dosages confusing in stressful situations

6. “External” Airway Anatomy
Large head, large tongue, small mandible
Narrowest at subglottic / cricoid area
Relatively straight cervical spine
Less rigid thoracic cage with poor accessory muscle development
Horizontal ribs, diaphragm breathers
Increased metabolic rate, increased O2 consumption, limited O2 reserves

7. Smaller “Internal” Airway
Epiglottis floppy, U shaped & anterior
Larynx anterior
Short floppy trachea
Small soft airways in obligate nasal breathers
Nose = 50% airway resistance
Large tonsils, adenoids rapidly swell
Pliable / floppy trachea collapses easily (Poiseuille’s Law)
Adult: 1 mm edema = 81% size
Pedi: 1 mm edema = 44% size

8. Patient Needs Fear of separation, being hurt & the unknown
Allow family to be with patient as long as it does not distract you
Never lie!
Always explain your plan to the child
Position at eye level, remain calm, speak slowly

9. CUPS: Critical, Unstable, Potentially Unstable, Stable
Assessment
Appearance
Skin Circulation
Pre-arrival preparation & scene size-up
General assessment (Pediatric Assessment Triangle)
“Sick” vs “Not Sick” vs “Could Rapidly Become Sick”
Clinical indicators reflect CV, respiratory & neurological status
ABCDE & transport decision
Ongoing assessment including more thorough history & exam
Work of Breathing
CUPS: Critical, Unstable, Potentially Unstable, Stable

10. HPI & Exam HPI PMH Exam How fast deteriorating? Fever?
Noisy breathing?
What has been done so far?
PMH
Prematurity, hospitalizations, Illnesses, intubations, immunizations?
Allergies?
Medications?
Exam
Sick or Not Sick?
Rate?
Noisy?
Position?
Color?
Symmetric?

11. “Normal” Vitals AGE HR SBP DBP AGE HR SB 0-3 mo 140 60-90 20-60
3 mo–2 yrs –
2 yrs–5 yrs –
6yrs–10 yrs –
>10 yrs –

12. Appearance Alertness Distractibility Consolability Eye contact
Speech/cry
Spontaneous motor activity
Color

13. Abnormal Breathing Sounds
Stridor
High pitched sound heard on inspiration
Indicates upper airway obstruction
Grunting
Short, low pitched sound heard in expiration
Auto-PEEP to keep small airways open as progresses towards respiratory failure
Wheezing
High-pitched whistling sound heard expiration > inspiration
Indicates lower airway obstruction
Crackles
Crackling sounds heard on inspiration
Associated with cardio-vascular disease, lung disease, infection

14. Respiratory Distress vs Failure
Maintain oxygenation only by increasing work of breathing
Failure
Cannot compensate for inadequate oxygenation despite extra respiratory effort & rate
Circulatory & respiratory system collapse
Distress Failure Arrest
Bradypnea
Inefficient respirations
Cyanosis / Grey
No air movement
Tachypnea
Nasal Flaring / Pursed Lips
Stridor / Wheezing
AMS / Agitation
Agitation
Tachycardia
Delayed Capillary Refill
Pale
RR > 60
Retractions
Grunting
Mottling
Head Bobbing
Severe Air Hunger
Bradycardia
Hypotension

15. Management Strategies
Treat the symptoms, not the disease
Every child with respiratory distress needs oxygenation as uncorrected respiratory distress deteriorates to bradycardia & cardiac arrest
Priority is to support breathing effort
Remember the basics!
If pulse remains low or breathing inadequate, re-evaluate airway, ventilations, O2 & tubing

17. Airway Management
Use pediatric assessment triangle to determine oxygenation status & O2 delivery device
Neutral “sniffing” head position
Towel under shoulders; do not flex head which collapses trachea
Head-tilt chin lift or jaw-thrust
<5 seconds to look, listen & feel
Suction airway
Appropriate ventilation volume & rate (4-6 mg/kg)
Maintain optimal cardiac output, venous return, cerebral blood flow & coronary perfusion
Limits regurgitation & aspiration

18. 7 Ps…Not Just For RSI 1. Preparation 2. Pre-oxygenation
3. Premedication
4. Paralyze
5. Pass tube
6. Placement proof
7. Post-intubation care

19. Endotracheal Intubation
EMS adult success rate: 85%–95% EMS pediatric success rate: 50%–80%
2005 AHA:
Cuffed ETT effective & safe for all ages, but un-cuffed ETT recommended in neonates
Rapidly deoxygenate & decompensate
Prepare to start compressions
“Hail Mary” plan

20. ETT & Resuscitation Smartphone apps: Traditional Calculations:
RapiTube, Difficult Airway, PediStat , PediSafe
Traditional Calculations:
Un-cuffed = (Age / 4) + 4
Cuffed = (Age / 4) + 3
General = Age + 16/4
[6yo + 16]/4 = 22; 22/4 = 5.5 ETT
Ready ETT 0.5 mm smaller & larger
Use blade you like:
In very young Miller directly lifts floppy epiglottis
In older children Macintosh slides into vallecula & indirectly lifts epiglottis

21. Alternative Airways Supraglottic, LMA, videoscope
Supraglottics & LMAs placed blindly with insertion times approximately 5 secs even during compressions
Confirm BL lung sounds, ETCO2, tube fog, rising O2 sat & HR

22. Secure The Tube!
Secure The Baby!

23. Upper vs Lower Airway Diseases
Upper Airway
Foreign Body Obstruction
Retropharyngeal Abscess
Bacterial Tracheitis
Epiglottitis
Croup
Lower Airway
RSV / Bronchiolitis
Asthma
Bronchitis / Pneumonia

24. Apparent Life Threatening Events (ALTE)
Lifeless, pulseless or unresponsive infant recovering spontaneously & “looks normal”
1-2% infants
Most common at 2-3 mo, uncommon >2 yrs
All require transport & admission
DDX:
Arrythmias
Congenital heart disease
Abuse / Trauma
GERD
Infectious / Metabolic / Neurological disorders
Respiratory compromise
Munchausen’s

25. Foreign Body Aspiration / Obstruction (FBAO)
>90% respiratory deaths in <5 yo; 65% infant deaths from respiratory causes
Suspect in sudden respiratory distress, choking / coughing, stridor or wheezing
DDX: seizure, syncope, arrhythmia or overdose
Large objects lodge in upper airway & trachea
20% FBAO
Acute dyspnea, drooling, stridor & cyanosis
Small objects lodge in bronchus / terminal airway

26. Even If obstruction clears prior to your arrival, still transport
Choking / FBAO
Able to talk or minimal distress, rapidly transport in position of comfort
Responsive but significant distress:
Child: abdominal thrusts or Heimlich
Infant: chest thrusts, back blows
Unresponsive, open airway & only remove object if visible / accessible
Begin CPR with airway check
Look for FB prior to starting each ventilation; if visible attempt removal with Magill’s
Airway management via PPV or advanced airway attempt
Rapid transport & notify receiving hospital
Medical Control for needle cricothyroidotomy if unable to clear obstruction, unable to intubate or ventilate
Even If obstruction clears prior to your arrival, still transport

27. Retropharyngeal Abscess
URI complication
Lymph nodes between posterior pharynx & pre-vertebral fascia
Soft palate bulging obstructs nose
Posterior pharynx bulging obstructs trachea
Abrupt fever, severe distress, painful swallowing
Head hyperextension
Noisy respirations, drooling

28. Epiglottitis (H. Influenza)
4-6 yo most common
10 X decrease since H. flu vaccinations
10% are vaccinated, but exposed to virulent strain
High fever, sore throat, stridor, drooling, tripoding & severe respiratory distress
Supraglottic edema completely obstructs airway
DO NOT attempt to visualize (“Sniff Test”)
Manage according to severity of condition but rapidly transport in upright position with humidified O2
Respiratory Distress + Sore Throat + Drooling

29. Croup (Viral Parainfluenza)
Nightly recurring fever, hoarseness, “barking seal” cough from laryngeal & tracheal edema
6 mo to 4 yr
Males > Females
Fall, early winter
Management:
Reassurance
Humidified, cool air
Steroids
Racemic epinephrine
Rare advanced airway management; consider alternative diagnoses

30. Bacterial Tracheitis Post URI
Purulent sputum, high fever, pseudomembrane
Toxic appearance + stridor
Croup-like symptoms responding poorly to croup management

31. Bronchiolitis (RSV) Viral bronchiolar edema from air trapping
>80% < 1 yo
Epidemics January - May
Recent URI with gradual onset of SOB
Expiratory wheezing, tachypnea, cyanosis
Management
Humidified oxygen
Bronchodilators
Advanced airway as needed

32. Asthma
Lower airway hypersensitivity causing bronchospasm, edema & mucus production
Varying degrees of respiratory distress
All that wheezes is not asthma
Non-wheezers often in severe respiratory distress
Important History
Prior ICU admission / intubations
>3 ED visits or >2 admissions in past yr
>1 MDI used in past mo or every 4 hrs
Symptom progression despite aggressive treatment
Management is aggressive airway, pharmacology & fluid resuscitation
Position of comfort, humidified O2
Beta-2 agents (Albuterol)
Anticholinergics (Atropine, Ipatropium)
Subcutaneous beta agents (Epinephrine 1:1000, 0.1 to 0.3 mg SQ)

33. Bronchitis / Pneumonia
Viral or bacterial
Neonates: GBS, enterics
3 mo-3yr: Streptococcus pneumonia
4mo- Preschool: RSV / viral
Fever, cyanosis + tachypnea, cough, nasal flaring, retractions, rales, decreased breath sounds
Aggressive airway management

34. Acute Respiratory Distress (ARDS)
Severe lung inflammation rapidly resulting in hypoxia & respiratory failure
Frequency: 2-12/100,000
Mortality: 15%
Management:
Aggressive airway control
PEEP
Fluid & cardiovascular resuscitation

35. Anaphylaxis Acute & life-threatening
Release of inflammatory mediators after a trigger
MEWS: Milk, eggs, wheat, soy
Peanuts & shellfish most potent
Others: preservatives, medications, insect venom, blood products, environmental, animal, exercise
Symptoms progress over minutes to days resulting in respiratory failure, shock, multiorgan system failure & DIC
5-20% experience recurrence of anaphylaxis >12 hrs
Symptoms can last 3 days despite treatment

36. Anaphylaxis Management
Airway
Oxygen + adjuncts including CPAP
Make early aggressive choices including advanced airway
Medications:
Diphenhydramine
Histamine blocker (pepcid, zantac)
Nebulized or MDI albuterol (2.5-5 mg/dose)
Epinephrine 1:1000 IM
Anaphylactic Shock:
Beware of “compensated shock”
Trandelenburg position
20 mL/kg crystalloid bolus; repeat to mL/kg as necessary
Vasopressors:
Epinephrine (0.1-1 mcg/kg/min IV)
Dopamine (2-20 mcg/kg/min IV)
Norepinephrine (0.1-2 mcg/kg/min IV)

37. Pediatric Bronchospasm / Respiratory Distress
Activate ALS intercept; rapidly transport without ALS if necessary
Mild Distress
If not taken max dose of prescribed MDI, encourage or assist patient to self-administer
Med Control for 2nd MDI dose if max not administered. MDI contraindicated if max dose administered, pt cannot physically use device, device not prescribed for patient
ALS:
IV, O2, Monitor
If not improving with O2, consider albuterol / atrovent nebulizer or MDI
Medical Control:
Epinephrine mg IM autoinjector
Magnesium Sulfate 25 mg/kg IV over 5 min
Treat for shock as needed
Notify receiving hospital

38. Special Patients
Tracheostomy tubes, apnea monitors, ventilators are common home-care devices
Most common are trach-related emergencies
Obstruction
Tube dislodgement
Stoma bleeding
Tube reinsertion “false track”
Infection
If ineffective ventilation/oxygenation:
Wipe stoma, suction tube
Remove tube if necessary
Once airway open, begin PPV
Attempt intubation if cannot oxygenate
Med Control may order tube re-insertion

39. References
Emergency Care & Transportation of the Sick and Injured, 9th ED
Massachusetts OEMS (
Alameda County EMS
Premier Health Care Services
Continuing Education and Training
Pediatric Advanced Life Support (PALS)
Pediatric Education for the Prehospital Provider (PEPP)
Pediatric Emergency Assessment, Recognition & Stabilization (PEARS)
NAEMT Emergency pediatric Care
E Humphreys PA-C, EMT-I “Pediatric Respiratory Emergencies” (2009)
J Reynolds MD “Pediatric Respiratory Emergencies” (2012)
S Villanueva MD, FACEP “Pediatric Respiratory Emergencies”
“Management of acute lung injury & ARDS in children”. Critical Care

40. Summary Find me: Nights at Tobey ED
Pre-arrival preparation important
Standardized approach to assessment & management
Knowledge of normal child development and age-specific physiology important
“Sick/not sick” determination is paramount in treatment & transport decisions
Find me: Nights at Tobey ED
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