1. Common Paediatric Respiratory conditions
Corrine Balit

2. Outline Respiratory Distress : Signs and Treatment
Respiratory Supports
High Flow Nasal prong
CPAP/ BIPAP
Ventilation
Bronchiolitis
Pertussis
Asthma

3. Case 1: 6 week old E.L.
6 week old infant presents with severe respiratory distress
Taken to resuscitation bay on arrival
Call from ED doctor asking for help

4. Resp CVS Neuro RR 90 Tracheal tug Intercostal and subcostal recession
Grunting
Head bobbing, nasal flaring
CVS
HR 200
Cap refill 3 seconds
Mottled
Neuro
Agitated,
Unsettled,

5. Respiratory Distress/ Failure
One of most common reason ICU will need to review a patient
Hard to determine which patients will need to come to ICU
Clinical assessment and reassessment is most important
May need to start some basic measures and then reassess again.

6. Increased work of breathing
Malformations of chest wall
Evidence of hypoxemia/hypercarbia
Tachypnea
Large A diameter (barrel chest)
Agitation
Nasal Flaring
Narrow AP diameter
Confusion
Chest wall retractions
Somnolence
Paradoxical breathing
Cyanosis
Grunting
Accessory muscle use

9. Investigations Venous Blood Gas Oximetry Chest x-ray
Carbon dioxide and pH
Lactate
Oximetry
Chest x-ray
Other investigations to support underlying cause.

10. Who needs to come to ICU Clear cut ones that do and don’t
In-between that is the hardest.
Indications
Mod- Severe respiratory distress despite basic treatment
Recurrent apnoeas
Respiratory acidosis (pH < 7.2)
Increasing oxygen requirements
Change in mental state
Needing airway protection

11. Treatment of Respiratory Failure
Administration of supplemental oxygen + consider humidification
Evaluation of airway patency
Clear secretions / Airway toileting to maintain airway patency
Appropriate adjuncts
Salbutamol +/- ipratropium
Steroids if indicated

12. Respiratory Distress
RR < 60
Mild-Mod Work of breathing
Oxygen requirement < 2L
Not irritable/agitated
RR >60
Mod-severe work of breathing
Increasing oxygen requirement
Irritable/agitated
Basic Measures
Nil by mouth
Cannula + IVF
Humidified oxygen total flow of 2-3L
Adjuncts appropriate to condition e.g. salbutamol, steroids

13. Mod-Severe Respiratory Distress
IV Cannula
Oxygen + humidification
Salbutamol, ipratropium, steroids
Indications for ICU
Ongoing mod-severe respiratory distress despite above
Apnoeas
Respiratory Acidosis
Fatigue

14. Treatment of Respiratory Distress
Specific treatment for conditions
Non-invasive support
High Flow nasal prong oxygen
CPAP
BIPAP
Mechanical ventilation
IPPV
HFOV
ECMO

15. Treatment of Respiratory Distress
Fluid Management
Generally restricted if receiving ventilatory support
Two- thirds maintenance
Normal saline or Hartmann's as fluid for severe resp distress
Watch EUC
Feeds
Feed once stable and improving
Can feed while receiving NIV support

16. High Flow Nasal Prong oxygen
Delivered via nasal prong and using Fisher and Paykel System
Rational is two fold:
High flows provide positive distending pressure to the airway improving functional residual capacity
Use of humidification
Humidification improves mucocillary clearance
Advantages:
Tolerated better by children
Avoid some of CPAP complication like nasal mucosal injury

17. High Flow Nasal Prong oxygen
Flow rates currently recommended up to 8L/Min
Prospective study in Brisbane where the used flow rates between 1 and 8 L/min were used and they used electrical impedance tomography and oesophageal pressures measured.
Found that using 8L/min flow rate delivered on average a CPAP effect of 4 cm H20 in infants with viral bronchiolitis
Definition of High flow nasal prong cannula
1L/kg/min
Current cannula for paediatrics up to 8L flow.

18. High Flow- Indications
Respiratory distress with hypoxemia
Bronchiolitis
Pneumonia
Post extubation respiratory support
Facilitation of weaning from CPAP
Post operative respiratory failure

19. High Flow- Contraindications
Nasal obstruction
Choanal atresia
Large polyps
Foreign body aspiration
Children requiring airway protection
Severe life threatening hypoxia (not a replacement for intubation

20. Non-Invasive Ventilation
CPAP versus bi-level NIV
Difficulties is with appropriate size mask
Bubble CPAP good for infants (<10kg)
PEEP 5-10cm
Contraindications
If airway protection is needed
Decreased level of consciousness
Nasal obstruction

21. Invasive Ventilation Conventional Ventilation
High Frequency Ventilation
If intubating patient for severe respiratory distress suggest always using cuffed tube.
Cuff doesn’t need to go up but there if you need it

22. Bronchiolitis

23. Bronchiolitis- aeitology
Respiratory Syncytial Virus
Para influenza virus
Adenovirus
Influenza virus
Rhinoviruses
Human metapneumovirus

24. Bronchiolitis- Pathology
Loss of epithelial cells
Cellular infiltration
Oedema around airway
Plugging of airway with mucus
Can get complete and partial plugging of airways resulting in localised atelectasis and over distention in other areas.
Imbalance of ventilation and perfusion leads to hypoxemia.

25. Bronchiolitis – Clinical Features
Coryzal symptoms
Wheezing
Pneumonia
Aponea
Hyponatremia
Seizures
Encephalopathy
Myocarditis

26. Investigations NPA Blood Gas CXR Septic workup if severe or very young
FBC, EUC

27. Bronchiolitis- Indications for ICU admission
Recurrent Apnoea
Slow irregular breathing
Decreased level of consciousness
Shock
Exhaustion
Hypoxia
Respiratory acidosis

28. Bronchiolitis- Management
Supportive Care
Oxygen
Suction
Fluids / Feeding
Always Nil by mouth if moderate- severe
IV fluids : 2/3 maintenance if moderate- Severe
NG Tube
Decompression of stomach
Feeds once more stable
Infection Control

29. Bronchiolitis – Specific Treatments
Bronchodilators
Surfactant
Corticosteroids
Ribavirin
RSV Immunoglobulin
Palivizumab
Antibiotics

30. Bronchiolitis – Specific Treatments
Bronchodilators
B- agonists
Meta analysis: modest short term improvement in clinical scores, without changes in oxygen saturation, rate of hospitilisation or length of hospital stay
Adrenaline
RCT comparing adrenaline nebulised with placebo
No difference in length of hospital stay and no short term or long term clinical improvement

31. Bronchiolitis – Specific Treatments
Corticosteroids
Controversial, conflicting studies
Cochrane review: no benefits in either length of stay or clinical course in infants
Surfactant
Promising as RSV affects endogenous surfactant production
given to mechanically ventilated infants with RSV – shortened time on mechanical ventilation,
Individual case reports and series.
Limited evidence, very expensive

32. Bronchiolitis – Specific Treatments
Ribavirin
Antiviral
Inhibits RSV replication
Evidence supports aerolised use, IV can be given
Early trials showed it to be effective
No convincing benefit on clinical outcomes expect to patients post BMT with RSV

33. Bronchiolitis – Specific Treatments
RSV- IG IV
No improvement on clinical outcome
Palivizumab
Monoclonal antibody
For prophylaxis for high risk infants
Expensive
50% decrease in need for hospitlisation in high risk infants

34. Bronchiolitis – Specific Treatments
Ipratropium bromide
Not been demonstrated to be efficacious
Heliox
Helium-oxygen gas
Prospective study looking at 70% helium, 30% oxygen mixture- improved tachypnoea and tachycardia and shorter stay in PICU
Nitric oxide
Case reports only

35. Bronchiolitis: Antibiotics
Used for secondary bacterial infection
Traditionally risk of secondary infection with RSV thought to be low but theses studies based on children not admitted to PICU.
Recent studies: PCCM 2010
Secondary pneumonia in patients in PICU with RSV reported to be as high as 20-50%
If child is unwell enough to be admitted to PICU with bronchiolitis, cultures should be taken and antibiotics started

36. Levin et al PCCM 2010
Prospective study looking at patients admitted with RSV bronchiolitis with progressive respiratory failure
Excluded patients who had pre-existing conditions
Found 39% had probable pneumonia by tracheal aspirate
Concluded that due to high rate of possible secondary bacterial pneumonia, empirical antibiotics for hrs pending cultures may be justified in those sick enough to come to PICU

37. Bronchiolitis- Ventilation
High Flow Nasal Prongs
CPAP
Mechanical Ventilation
IPPV
HFOV
ECMO

38. My Approach – to moderate-severe bronchiolitis
Suction and clear airway esp nasal passages
Application of oxygen with humidification if possible
Nil by mouth
IV cannula + 2/3 maintaince IVF
Obtain venous blood gas (BC + FBC/EUC at time of IVC)
Decide on level of respiratory support
High flow Nasal prong Cannula to 8L/min (not available in ED)
Bubble CPAP

39. OG or NG if on respiratory support Constant reassessment, looking for
Decreasing respiratory rate
Decrease in work of breathing
Heart rate improving
If not responding to above to be intubated and ventilated
If sick enough with bronchiolitis to need ventilatory support I do blood culture and sputum culture and cover with antibiotics.
Need to monitor Sodium

40. Pertussis

41. Pertussis - Pathology Bordetella Pertussis
Toxin damages respiratory epithelium and can produce systemic toxicity
Severe, Prolonged Coughing
Aponea in young infants
Whoop- loud stridor on inspiration after a paroxysm

42. Pertussis- Severe Complications
Pneumonia
Pulmonary Hypertension
Encephalopathy
Seizures
Global Myocardial dysfunction

43. Pertussis Mortality highest in Indications for ICU Very young infants
WCC >
Presenting with pneumonia
Need for circulatory support
Indications for ICU
Apnoeas
Seizure
Severe respiratory failure

44. Pertussis - Investigations
PCR on NPA
CXR
WCC
ECHO if severe

45. Pertussis- Management
Suction
Oxygen
Respiratory support
High flow nasal o2
CPAP
Ventilation
Antimicrobials
Azithromycin

46. Pertussis- Other Management
If leukocytosis (esp neutrophilia)
Exchange transfusions or aphaeresis to remove white cells
With high white cell count can get leukocyte aggregates in pulmonary vessels
If Pulmonary Hypertension present
Consider inhaled nitric oxide or sildenafil
If Severe respiratory failure
ECMO
Treat contacts

47. PCCM 2007 Retrospective study from RCH Melbourne
Median age at admission was 6 weeks
94% of patients were unimmunised at time of admission
Infants presenting with pneumonia had raised white cell count
38% needing intubation died
All patients who needed ECMO died

48. Asthma

49. Asthma – Management Oxygen B-adrenergic agonists Corticosteroids
Anticholinergic
Magnesium Sulphate
Theophylline/ Aminophylline
Inhalational anaesthetics

50. Asthma- Management Helium-Oxygen Non-invasive ventilation Ventilation
Ketamine
Adrenaline

51. B-adrenergic agonists
Salbutamol first line bronchodilator of choice
MDI with spacer as effective as nebulisation
When giving nebulisation, continuous nebulization is superior to intermittent doses (Cochrane Review 2009)
Provides sustained stimulation of B-receptors
Promotes progressive bronchodilatation
Improves drug delivery in distal airway

52. IV salbutamol
Considered in patients unresponsive to treatment with continuous nebulisation.
RCT in children 2002:
IV salbutamol as a bolus , atrovent or IV salbutamol +atrovent
In severe asthma, IV salbutamol as a bolus lead to more rapid recovery

53. Ipratropium bromide
Leads to bronchodilatation by decreasing parasympathetic-mediated cholinergic bronchomotor tone
Cochrane review 2009:
Adding multiple doses of anticholinergic to B2 agonists appears safe and improves lung function
Would avoid hospital admission in 1 of 12 such patients
No studies in critically ill children admitted to PICU
Because safe, considered reasonable to use

54. Magnesium Sulphate
Acts as calcium antagonist leading to smooth muscle relaxation
5 x RCT looking at IV magnesium in children
4 of these studies showed improvement in respiratory function and decrease in hospital admissions
1 study showed no significant difference between magnesium and placebo group
2 x meta analysis that showed adding magnesium provided additional benefit to children

55. Methylxanthines Theophylline and Aminophylline
Role is in severe asthma who have failed other treatment
Meta analysis of RCT in paeds found no benefit in mild or moderate asthma
RCT in 163 children with status asthmaticus
Aminophylline improved oxygen sats and pulmonary function
No difference in length of stay