Pediatric Respiratory Emergencies Amy Gutman MD EMS Medical Director Tobey Hospital prehospitalmd@gmail.com

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)

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

Sick or Not Sick?

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

“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

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

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

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

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?

“Normal” Vitals AGE HR SBP DBP AGE HR SB 0-3 mo 140 60-90 20-60 3 mo–2 yrs 140 90–105 55-65 2 yrs–5 yrs 90 95–105 55-65 6yrs–10 yrs 80 100–115 60-72 >10 yrs 75 115–125 65-85

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

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

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

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

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

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

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

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

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

Secure The Tube! Secure The Baby!

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

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

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

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

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

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

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

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

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

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)

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

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

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

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 60-80 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)

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 0.15-0.3 mg IM autoinjector Magnesium Sulfate 25 mg/kg IV over 5 min Treat for shock as needed Notify receiving hospital

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

References Emergency Care & Transportation of the Sick and Injured, 9th ED Massachusetts OEMS (www.dph.org) Alameda County EMS www.emsonline.com 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) healthtraining@inh.com NAEMT Emergency pediatric Care www.emsc.org E Humphreys PA-C, EMT-I “Pediatric Respiratory Emergencies” (2009) J Reynolds MD “Pediatric Respiratory Emergencies” (2012) S Villanueva MD, FACEP “Pediatric Respiratory Emergencies”. 2011. “Management of acute lung injury & ARDS in children”. Critical Care. 2009.

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 Email me: prehospitalmd@gmail.com / Website: www.TEAEMS.com Text me: 513-255-1353