Pediatrics Respiratory Emergencies

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

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

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

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

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

Respiratory Distress

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

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

Laryngotracheobronchitis Croup

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

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

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

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

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

Epiglottitis

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

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

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

Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis

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

Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction

Asthma

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

Asthma: Pathophysiology Bronchospasm Bronchial EdemaIncreased Mucus Production

Asthma: Pathophysiology

Cast of airway produced by asthmatic mucus plugs

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

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

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

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

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

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

Asthma n SILENT CHEST= DANGER OF RESPIRATORY FAILURE

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

Asthma: Management n Airway n Breathing – Sitting position – Humidified O2 by NRB mask n Dry O2 dries mucus, worsens plugs – Encourage coughing – Consider intubation, assisted ventilation

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

Asthma: Management n Obtain medication history – Overdose – Arrhythmias

Asthma: Management n Nebulized Beta-2 agents – Albuterol

POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE Asthma: Management n Subcutaneous beta agents – Epinephrine 1: to 0.3 mg SQ

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

Asthma: Management n Avoid – Sedatives n Depress respiratory drive – Antihistamines n Decrease LOC, dry secretions – Aspirin n High incidence of allergy

Status Asthmaticus Asthma attack unresponsive to  -2 adrenergic agents

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

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

Bronchiolitis

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

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

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

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

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

Foreign Body Airway Obstruction FBAO

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

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

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

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