Respiratory Emergencies in the Pediatric Population Respiratory Emergencies in the Pediatric Population

Common upper airway obstruction including :- Croup Epiglottises Retropharyngeal Abscess F.B.A Bacterial Tracheaitis Pneumonia Lower airway obstruction(ASTHMA), OBJECTIVES

What is the difference between peds and adult airways? The tongue is larger, easily displaced, and the most common cause of airway obstruction in the obtunded child. The narrowest portion of the pediatric airway is at the cricoid ring, making obstruction with subglottic pathology more likely than adults.

Croup Also called laryngotracheobronchitis Most common cause of infectious acute upper airway obstruction. Approx. 10% of children seen with croup require admission, 1-5% require intubation, and 10 cases are seen for each case of epiglottitis.

Croup Viral etiologies include parainfluenza virus type1, influenza, respiratory syncytial virus (RSV),rhinoviruses and measles. Mean age of affected patients is 18 months, with a slight male predominance, and there is a seasonal increase in cases in autumn and early winter.

Croup May have elevated temperature. Drooling is uncommon. May have mild expiratory wheezing Inspiratory stridor at rest with nasal flaring, suprasternal and intercostal retractions. Poor air entry Lethargy + agitation = HYPOXIA Dehydration

Treatment of Croup Racemic epinephrine Steroids(dexamethasone)

Epiglottitis Also known as supraglottitis First described in 1878, was thought to be disease of adults. “angina epiglottidea anterior” 60% male dominance

Epiglottitis Occurs in children from 3-7 yrs in age with only 4% under the age of 1. Hemophilus influenzae (bacterial infection) is the most common etiology. (some viruses, allergic reactions and physical and thermal injuries can play a part also) 1985 – vaccine….but things mutate.

Epiglottis Signs and symptoms Very sudden onset and progresses rapidly Muffled voice or cry (in croup it is more hoarse) Minimal cough Sore throat, fever, hoarseness Drooling caused by difficulty swallowing saliva Intercostal muscle retractions Noisy, high-pitched, squeaky inhalations Purple skin and nails Odd head posture. (sniffing position), tripod position

Why do children with epiglottitis have airway obstruction? Fatigue Laryngospasm Progressive swelling of the supraglottic structures Pooled secretions

Treatment of epiglottitis DO NOT AGITATE THE CHILD IN ANY WAY Airway mgmt. Done in OR Administer high flow humidified oxygen in order to obtain maximal alveoli oxygen saturation. If there is an obstruction – BVM ventilation. Position of comfort Run like hell………………

Review Croup Voice – hoarse Cough – barking Fever – yes Saliva – minimal Neck swelling – little Begins – slowly Season – autumn Time – evening/night Epiglottitis Voice – muffled Cough – usually none Fever – yes Saliva – lots Neck swelling – lots Begins – suddenly Season – all year Time – all day

Croup Epiglottitis Bacterial tracheitis RetroPharygeal abcess Foreign Body aspiration Other things on DDx of Inspiratory Stridor Laryngeal Web TEF Diptheria Airway thermal injury Subglottic stenosis Peritonsillar abcess GERD Esophageal FB Laryngeal fracture Laryngeal cyst Lymphoma Upper airway obstruction

Lymph nodes between the posterior pharyngeal wall and the prevertebral fascia gone by 3 – 4 yrs of life drain portions of the nasopharynx and the posterior nasal passages may become infected and progress to breakdown of the nodes and to suppuration Retropharyngeal Abscess

ETIOLOGY Retropharyngeal absces Complication of bacterial pharyngitis Less frequently - extension of infection from vertebral osteomyelitis Group A hemolytic streptococci, oral anaerobes, and S. aureus

Recent or current history of an acute URTI Abrupt onset:  High fever with difficulty in swallowing  Refusal of feeding  Severe distress with throat pain  Hyperextension of the head  Noisy, often gurgling respirations  Drooling Typically …Retropharyngeal absces

Soft Tissue Neck Film Patient position – MILD EXTENSION Positive Film - Retropharyngeal soft tissue > ½ the width of the adjacent vertebral body - may see air in the retropharynx On Exam Retropharyngeal absces Nasopharynx Bulging forward of the soft palate and nasal obstruction OropharynxBulging of posterior phyaryngeal wall or Not visualized

Complications of Retroph.absces Abscess rupture - aspiration of pus. Lateral extension - present externally on the side of the neck Dissection along fascial planes into the mediastinum Death may occur with aspiration, airway obstruction, erosion into major blood vessels, or mediastinitis.

Treatment of Retroph.absces Clindamycin mg/kg/day divided Q8H (if pre-fluctuant phase) Decadron 0.6 mg/kg Airway management Surgical decompression

Foreign Body Aspiration More common with food than toys Highest risk between 1 and 3 years old (immature dentition – no molars, poor food control) Common foods = peanuts, grapes, hard candies Some foods swell with prolonged aspiration (may even sprout)

Clinical Manifestations Typically … Acute respiratory distress (now resolved or ongoing) Witnessed choking period Uncommonly … Cyanosis and resp arrest Symptoms: cough, gag, stridor, wheeze, drool, muffled voice

Investigations Xrays  Lateral neck  Chest – inspiratory, expiratory, decubitus views Expiratory views Overinflation (partial obstruction with inspiratory flow) with mediastinal shift towards opposite obstructed side (partial obstruction with expiratory flow) Atelectasis (complete obstruction) with mediastinal shift towerds obstructed side

Decubitus views Normal Smaller volumes and elevated diaphragm on side down AbnormalHyperinflation or “normal” volumes in decub position If suspected …fluoroscopy …then… Need a bronchoscope to rule out or remove Foreign Body

Bacterial tracheitis An acute bacterial infection of the upper airway capable of causing life-threatening airway obstruction Staph aureus most commonly ( Moraxella catarrhalis, H. influenzae, anearobes) Most pts less than 3 years old Usually follows an URTI (esp laryngotracheitis) Mucosal swelling at the level of the cricoid cartilage, complicated by copious thick, purulent secretions

Brassy cough High fever “Toxicity" with respiratory distress (may occur immediately or after a few days of apparent improvement) Failed response to CROUP TREATMENT (mist, intravenous fluid, racemic epinephrine) CLINICAL MANIFESTATIONS

Antibiotics (good Staph coverage) Intubation or tracheostomy is usually necessary Dexamethasone? Treatment

Pediatric Pneumonia NeonateBacteria more frequent E. coli, Grp B strep, Listeria, Kleb 1 – 3 moChlamydia trachomatis ( unique ) Commonly viral (RSV, etc.) B. Pertussis 1 – 24 moS. pneumonia, Chlamydia pneum Mycoplasma pneumonia 2 – 5 yrsRSV Strep pneumonia, Mycoplasma, Chlam

Severe Pneumonia: Staph aureus Strep pneumonia Grp. A strep HIB Mycoplasma pneumonia Pseudomonas if recently hospitalized

History: Infants < 3 months Tachypnea, cough, retractions, grunting, isolated fever or hypothermia, vomiting, poor feeding, irritability, or lethargy As age increases, symptoms are more specific Fever and chills, headache Cough or wheezing Chest pain, abdominal distress, neck pain and stiffness pallor and leukocytosis

Physical Exam Tachypnea is the best single indicator of pneumonia Age in monthsUpper limit of Normal RR <

Treatment Neonates Ampicillin + Gentamycin / Cefotaxime 1 – 3 mo Erythromycin 10 mg/kg IV Q6H 1 – 24 mo Cefuroxime 50 mg/kg IV Q8H (not ICU) Ceftriaxone mg/kg IV Q24H and Cloxacillin 50 mg/kg IV Q6H (ICU) 3 mo – 5 yrs Cefuroxime / Erythro IV (admitted) Clarithro / Azithro (outpt Tx)

Differential Diagnosis of Wheezing H + N Vocal cord dysfunction Chest Asthma Bronchiolitis Foreign Body Aspiration CVS Congestive Heart Failure Vascular Rings

CAEP Pediatric Asthma Guidelines MILD Nocturnal cough Exertional SOB Increased Ventolin use Good response to Ventolin O2 sat > 95% PEF > 75% (predicted / personal best) ± O2 Ventolin Consider po Steroids Symptoms Pre - Treat Treatment

MODERATE Normal mental status Abbreviated speech SOB at rest Partial relief with Ventolin and required > than q 4h O2 sat 92%-95% PEF 50-75% (predicted / personal best) O2 100% Ventolin Systemic corticosteroids Consider anticholinergic Symptoms Pre - Treat Treatment CAEP Pediatric Asthma Guidelines

SEVERE Altered mental status Difficulty speaking Laboured respirations Persistant tachycardia No prehospital relief with usual dose Ventolin O2 saturation <92% PEF, FEV1 <50% 100% O2 Continuous or frequent b-agonists Systemic corticosteroids & magnesium sulfate Consider anticholinergic & / or methylxanthines Symptoms Pre - Treat Treatment (consider RSI)

CAEP Pediatric Asthma Guidelines Symptoms Pre - Treat Treatment NEAR DEATH Exhausted, Confused Diaphoretic Cyanotic, Decreased respiratory effort, APNEA Falling heart rate O2 saturation <80% (spirometry not indicated) As above PLUS RSI IV Ventolin Inhalational anesthetic, aminophylline Epinephrine