Pediatrics Respiratory Emergencies

#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 Large head, small mandible, small neck Large, posteriorly- placed tongue High glottis opening Small airways Presence of tonsils, adenoids

Pediatric Respiratory System Poor accessory muscle development Less rigid thoracic cage Horizontal ribs, primarily diaphragm breathers Increased metabolic rate, increased O2 consumption

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

Respiratory Distress

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

Respiratory Emergencies CroupEpiglottitisAsthmaBronchiolitis Foreign body aspiration

Laryngotracheobronchitis Croup

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

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

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

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

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

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

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

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

Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis

Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction

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

Asthma

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

Asthma: Signs/Symptoms Coughing Expiratory wheezing TachypneaCyanosis

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

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

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

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

Asthma SILENT CHEST= DANGER OF RESPIRATORY FAILURE

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

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

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

Asthma: Management Obtain medication history –Overdose –Arrhythmias

Asthma: Management Nebulized Beta-2 agents –Albuterol

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

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

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

Status Asthmaticus Asthma attack unresponsive to  -2 adrenergic agents

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

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

Bronchiolitis

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

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

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

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

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

Foreign Body Airway Obstruction FBAO

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

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

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

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

Otitis Media It is an infection of the middle ear Acute Otitis media Chronic Otitis media

Etiology: Suppurative Otitis media: Bacteriologic: Hemophilus influenza, Beta hemolytic streptococci or pneumococci. Secondary: common cold, measles or scarlet fever. Nonsuppurative Otitis media: Allergy. Auditory canal dysfunction (obstruction or abnormal patency).

Predisposing factors: Auditory canal in children is shorter. more accessible to invasion of microorganism. Anatomic immaturity of tubal muscles and cartilage in children under two years of age. Certain craniofacial congenital defects e.g. cleft palate and down syndrome

Clinical manifestations: History of common cold for several dates. Fever. Older child: pain in the affected ear, headache, vomiting and/or impaired hearing. Infant: may rub ear, anorexia, turn head from side to side and/or diarrhea. Decreased hearing.

Complications: Chronic otitis media. Mastoditis.Septicemia. Meningitis and brain damage. Deafness.

Diagnostic evaluation: Pneumatic otoscope: bulging, red eardrum, rupture drum may be obscured by secretions. Culture and sensitivity: for secretions of ruptured eardrum or by myringotomy Tampanometery-to measure change in airpressure Acoustic reflectometery: measure sound trasmission

Nursing intervention Administer medications and treatments as prescribed. Wash hands prior to any treatment or contact with ear. Provide physical comfort: Local heat. Encourage fluid intake to maintain hydration. Give soft diet,. Observe for signs of complications Provide emotional and psychological support

Treatment: Identify the etiology Antibiotic according to culture Antibiotic according to culture Analgesic and antipyretic Antihistaminic and decongestant Follow up hearing tests Surgical

pneumonia Definition: is inflammation of the pulmonary parenchyma occur as primary disease or as a complication of some other illness

Etiology 1-Labor pneumonia: all or large segment of one or more pulmonary lobe is involved 2-Brocho-pneumonia: called lobular pneumonia start in the terminal brochioles 3-Interstial pneumonia:- combined with the alveolar walls (interstitial) and peribronchial tissue

Causes of pneumonia 1-Viral:- affact all age groups good prognosis good prognosis 2-Primary typical pneumonia: affect 10%- 20% of hospitalized children (myeoplasma pnu.) 3-Bacterial pnu.

Management Can be treared at home Hospitalization for pleural effusion’ empyema, staphylococcal pneumonia IV fluild O2 therapy AntiboiticSupportiverest

Clinical Sign FeverMalaise Rapid shalow resp. Chest pain Abdomenal pain Pleural effusion

Complication 1-empyema2-pyopneumothorax 3-tension nuemothorax 4-pleural effusion

Prognosis Prognosis generally good for pneumococal infection resolve spontaneously. The course of treatment is generally prolong. Early detection and treatment is effective

Nursing consideration 1-Isolation according to hospital policy 2-Bedrest is encourage 3-Fluid to prevent dehydration 4-oral fluid is given 5-oxygen Sitting position 7-monitor vital sign 8-observe complication 9- suction 10- reduce stress

Aspiration pneumonia More common in children who has difficulty with swallowing or is unable to swallow because of paralysis,weakness,congenital abnormalities

Nursing management 1-same as pneumonia 2-prevention 3-proper feeding techniques 4- family and health education 5-treat the cause

Cystic Fibrosis Is the most common serious pulmonary and gastric It is multisystem disorder mainly affect the exocrine gland Cystic fibrosis is inherited as autosomal recessive trait defect in chromosome number (7)

Pathophysiology The basic biochemical defect in CF is unknown

Clinical Feature Increase viscosity of mucus gland secretion Increase sweat electrolytes Increase enzymatic and saliva Mechanical obstruction of secretion Meconium ileus which is the first sign Thick secretion block the duct of the pancreas Rectal prolapsed Bronchial obstruction result in hypoxia & acidsis

The result of pancreas blockage Cystic dilation of small lobe and gland that prevent essential pancreatic enzymes from reaching the duodenum result in impair digestion Disturbed GI function result in bulky stool, foul smell from undigested fat Biliary obstrucion

Diagnosis of CF History of the disease Absence of pancreatic enzymes Increase electrolyte concentration of sweat Chronic pulmonary involvement Salty taste skin Chloride concentration more than 60 meq/l which consider as confirm diagnosis of CF

Management of CF General goal of treatment: 1- promote normal life for the child 2- maintain good nutrient 3- prevent respiratory infection 4-psychological adjustment

Management of CF Pulmonary treatment: Postal drainage Chest physiotherapy Oxygen therapy

Management of CF GI therapy: Replacement of pancreatic enzymes with meals and snakes. Provide coated enzymes to prevent from neutralization by gastric acid Provide high calories No restriction of fat

Prognosis of CF Early diagnosis and treatment prolong life expectancy (God Knows) According to the severity of S&S Good progress with lung transplantation

Complication of CF Meconium ileus Rectal prolapsed

Nursing consideration Take brief history Assessment for resp.&GI Observe S&S Teach the family Support Medication awareness Teach about complication