2. Respiratory Emergencies

3. Respiratory distress / Impending or overt respiratory failure is the most frequent reason for admission in a PICU Which is the most frequent anatomical abnormality in the respiratory tract causing distress/failure? Airway / Parenchyma / Interstitium / Pleura Interact!

4. Airway Obstruction is the Most Frequent, Parenchymal is Followed by Pleural Disease

5. Case 1 3 year old boy brought with noisy breathing from 3 days He has been nebulized for this kind of breathing in the past He wakes up at night due to this and coughs

6. Case 1 Interact!

7. Remember the 6 noises and the site of lesion Snuffles Snoring Stridor Rattle Wheeze Grunt Nasopharynx Oropharynx Larynx & trachea Carina Bronchial Tree Parenchyma/Pleura

8. Case 2 - 15 month old with noisy breathing Interact!

9. All these Children have Airway Obstruction How do you triage such children? Triage of these children will depend on 1. The severity of obstruction 2. The cause of obstruction which will give clue to the rate of narrowing

10. Principles of Stabilizing a Child with Airway Obstruction Keep the child comfortable on the mothers lap Do not stress the child, throat evaluation should be done only when facilities for providing airway access is available Supplemental Humidified oxygen in a non threatening way

11. Croup--When do you call it mild? Looks Fine Barking cough Stridor on crying No accessory muscle use No tachypnea Saturations Normal Symptomatic treatment +/- single dose of oral steroids Parental education on symptoms and signs of worsening even at night

12. Moderate Croup Steroids Nebulised adrenaline Close monitoring Irritable Increased crying Barking cough Stridor at rest 1-2 accessory muscle use Tachypnea Saturations Normal

13. Severe Croup Dexamethasone 0.6 mg/kg oral, iv, IM / Budesonide 2 mg/2 ml Adrenaline Nebulised 0.5 ml/kg upto a maximum of 5 ml of a 1:1000 dilution, Can be repeated every 20-30 minutes for a maximum of 3 nebulisations Irritable/Occ Drowsy Increased crying Barking cough Loud Stridor at rest >2accessory muscle use Tachypnea Saturations may be low

14. Treatment of Severe Croup Oxygen Rapid transfer Steroids Nebulize adrenaline as frequently as needed Intubate if there is impending respiratory failure Use a tube half size smaller than optimal

15. Case 3 Interact!

16. 3 Year Old Boy Acute episode of cough with wheeze Multiple episodes in the past

17. Pulmonary severity score ATM -IAP ScoreResp Rate /Minute <6 years Resp Rate /Minute >6 years WheezeAccessory Muscle use 0<30<20NoneNo apparent activity 130-4021-35Terminal expiration with stethoscope Questionable increase 241-5036-50Entire expiration with stethoscope Increase apparent 3>50 During inspiration and expiration without stethoscope Maximum activity Interpretation 0-3 mild 4-6 moderate >6 Severe

18. Pulse Oximetry Please Note Children with SPO 2 of < 92% at presentation were significantly more likely to require admission and multiple nebulizations. Br J Gen Pract. 2005 July 1; 55(516): 501–502.

19. How do you Stabilize? Aerosol Therapy with MDI with spacer is better than nebulizer in office setting Agree / Disagree ? Interact!

20. Salbutamol MDI 4 - 8 puffs every 20 minutes in the first hour After 1 st hr. 4- 8 puffs every 1-4 hrs as needed. Nebulizer Dose is 0.15 mg/kg (minimum 2.5 mg and maximum 5 mg per dose )every 20 min for three doses Or 0.3 mg/kg/hour

21. Glucocorticoids If there is no/inadequate response to the first aerosol treatment Administer Glucocorticoids Oral is preferred to parenteral Prednisolone 1 mg/kg (3-5 days)or Dexamethasone (Oral or parenteral) 0.6 mg/kg(1-2 doses 24 hrs apart)

22. Ipratropium Useful in moderate and severe attacks as an add on Can be nebulized or given by a MDI with spacer Dose is 250 mcg 20 kg for 3 doses every 20 min then as needed MDI dose is lower 18 mcg/puff 4-8 puffs repeated every 20 minutes then as needed

23. Parenteral Beta 2 Agonists Where the patient is not improving on aerosol therapy Intramuscular terbutaline 0.01mg/kg (subcutanous is an alternate) Adrenaline 0.01mg/kg 1/1000 solution sc or im is an alternative but has more side effects (maximum 0.5 mg)

24. Magnesium Sulphate In patients who have received salbutamol, ipratropium and glucocorticoids and who are still significantly symptomatic IV magnesium sulphate 50mg/kg administered over 20 minutes with cardiorespiratory monitoring

25. Key Issues in Transport in Severe Exacerbations Oxygen Airway Vascular access Nebulisation/MDI with aerosol Position Communication For Transport details Refer SOS-HOPE APP For Transport details Refer SOS-HOPE APP

26. Case 4 Interact!

27. Case 4 S - an 8 month old infant presented with fever cough and breathlessness of 1 day On examination he is febrile,toxic resp rate is 65, moderate intercostal and subcostal retractions, has significant grunt, HR is 140/min cap refill is < 2 secs and his saturation is 92%

28. Clinical Criteria for Pneumonia Fever Cough Tachypnea Respiratory distress Chest or abdominal Pain Signs of Consolidation Signs of Hypoxemia Complicated Pneumonia Effusions Empyema Necrotizing pneumonia Pneumatocoeles/Pneu mothorax Abscess

29. Respiratory Rates 60/Min 2months-12 months >50/min 12months-5 years > 40/min

30. Severity of Community Acquired Pneumonia Pneumonia Only Tachypnea No retractions Severe Pneumonia Tachypnea + Retractions Any Pneumonia <3/12 is severe Very Severe Pneumonia Not able to drink, Convulsions, Abnormally sleepy or difficult to wake up, Grunt in a calm child, Severe malnutrition

31. Key Issues in Transport of very Severe Pneumonia Oxygenation Perfusion Communication Rarely may need airway Administer 1st dose of antibiotic – Ceftriaxone for Severe or Very Severe Pneumonia is an appropriate emergency choice.

32. Case 5 Interact!

33. Foreign Body Picture of Aluminium foil stuck in Cricopharynx

34. Foreign Body Suspect choking caused by a foreign body if : The onset was very sudden There are no other signs of illness There are clues to alert the rescuer, for example a history of eating or playing with small items immediately prior to the onset of symptoms

35. Algorithm Pediatric Choking Treatment Algorithm Assess severity Ineffective Cough Effective Cough Unconscious Open Airways 5 Breaths Start CPR Unconscious Open Airways 5 Breaths Start CPR Conscious < 1year – 5 back blows and 5 chest thrusts > 1year – abdominal thrusts – Heimlich Manoeuvre Conscious < 1year – 5 back blows and 5 chest thrusts > 1year – abdominal thrusts – Heimlich Manoeuvre Encourage Cough Continue to check for deterioration to ineffective cough or until obstruction relieved Encourage Cough Continue to check for deterioration to ineffective cough or until obstruction relieved

36. Infants Back Blows for Infants Chest thrusts for Infants

37. Heimlich Manoeuvre

38. Summary Clinical evaluation should be with a focused history and clinical examination Carefully count the respiratory rate for 1 minute, watch for breathing, respiratory sounds, and examine the chest Measure the oxygen saturation, always have a pulse oximeter Stabilise all patients with oxygen, airway and ensure they are breathing adequately

39. Summary Keep a watch for subtle signs of hypoxia and deterioration Make arrangements to shift optimally Keep your office adequately stocked everyday, make sure the equipment is well maintained Staff should be trained in triage, communication, maintaining equipment and medication and helping in an emergency

40. Your Opinion