1. Pediatric Airway Emergencies
LMHER – February 28, 2017
Preparred by Shane Barclay

2. Goals and Objectives
Recognize the child with acute respiratory distress.
Know the causes of pediatric acute respiratory distress.
Be aware of the anatomic differences with pediatric airways.
Know how to manage pediatric acute respiratory distress.

3. Goals and Objectives
Recognize the child with acute respiratory distress.
Know the causes of pediatric acute respiratory distress.
Be aware of the anatomic differences with pediatric airways
Know how to manage pediatric acute respiratory distress.

4. Recognizing an Acute airway problem in pediatrics
Two most common features of pediatric respiratory distress:
Tachypnea
Retractions
With time Tachypnea will be replaced by bradypnea as fatigue sets in.
Remember, the most common cause of Cardiac Arrest in children is Respiratory Arrest.

5. Recognizing an Acute airway problem in pediatrics
The Initial Evaluation includes:
Determining the severity.
Trying to localize the cause.
Determining the need for emergent intervention.

6. Determining Severity of pediatric emergencies
There are 3 simple Observational assessment tools that can quickly evaluate a sick child:
Appearance
Breathing
Circulatory status

7. Determining Severity of pediatric emergencies
Appearance - “TICLS” mnemonic
T – Tone. Seriously ill children tend to appear limp and have decreased muscle tone.
I – Instructiveness. Sick children will often not interact or will be indifferent to distractions.
C – Consolability. Sick children will often not be consolable however very sick children may be unresponsive.
L – Look. Sick children will often stare or be unresponsive.
S- Speech. Sick children will often have a weak cry.

8. Determining Severity of pediatric emergencies
2. Breathing Sounds – listen for abnormal sounds – Stridor, grunting, wheezing. Positioning – look for ‘sniffing position’ or ‘tripod’. Accessory muscles – supraclavicular, intercostal or substernal. Also head bobbing or nasal flaring.

9. Determining Severity of pediatric emergencies
3. Circulation Look for pallor or cyanosis. Capillary refill Cool skin

10. Recognizing an Acute airway problem in pediatrics
The Initial Evaluation includes:
Determining the severity.
Trying to localize the cause.
Determining the need for emergent intervention.

11. Localizing Respiratory distress
1. Upper airway 2. Lower airway 3. Cardiac 4. Central nervous system 5. Metabolic

12. Localizing Respiratory distress
Upper airway
Sniffing position
Nasal flaring
Prolonged inspiration
Retractions – supraclavicular, suprasternal
Stridor
Hoarseness or ‘hot potato voice’
Barking cough

13. Localizing Respiratory distress
2. Lower Airway Retractions – intercostal, subcostal Nasal flaring Prolonged expiration Wheezing Grunting Rales

14. Localizing Respiratory distress
3. Cardiac disease cardiac murmurs, rales, JVD, edema 4. Central nervous system Cheyne-Stokes breathing 5. Metabolic Kussmal breathing (deep and labored)

15. Recognizing an Acute airway problem in pediatrics
The Initial Evaluation includes:
Determining the severity.
Trying to localize the cause.
Determining the need for emergent intervention.

16. Determining need for emergent airway intervention
Upper airway foreign body or obstruction.
Respiratory Failure.
Tension pneumothorax.
Cardiac tamponade.
Epiglottitis.
Croup.
Tracheitis.
Retropharyngeal abscess.

17. Management Overview of common acute pediatric airway
These are short summaries, not complete reviews.
Asthma
Croup
Bronchiolitis
4. Anaphylaxis

18. Pulmonary Index Score (PIS)
Asthma
Treatment/Management: 1. Assess Severity 2. Reverse Airflow obstruction 2. Correct hypoxia and/or hypercapnia 4. Reduce likelihood of recurrence

19. Asthma Pulmonary Index Score
Pulmonary Index Score (PIS)
Asthma
Pulmonary Index Score
Score
Respiratory rate*
Wheezing¶
Inspiratory/expiratory ratio
Accessory muscle use
Oxygen saturation
≤30
None
2:1
99 to 100 1
31 to 45
End expiration
1:1 +
96 to 98 2
46 to 60
Entire expiration
1:2 ++
93 to 95 3
>60
Inspiration and expiration
1:3
+++
<93
< 7 = Mild, = Moderate, > 12 Severe

20. Asthma Treatment of moderate to severe cases.
Pulmonary Index Score (PIS)
Asthma
Treatment of moderate to severe cases.
1. Beta-agonists (salbutamol) – puffers as effective as nebulizers.
2. Prednisone 1 mg/kg PO, then mg/kg bid x 3-5 days
or Dexamethasone 0.6 mg/Kg PO/IM/IV
3. Oxygen for hypoxia
4. Epinephrine 0/01 mg/KG IM q 20 min prn x 3
5? Consider MgSO mg/Kg IV over 20 minutes.

21. Croup
= acute laryngotracheobronchitis = edema of laynx, trachea and bronchi.
Usually 6 mos to 2 yrs
Barking cough, hoarse, stridor, possible dysphagia

22. Croup
Treatment: Keep the child calm. Oxygen – for mild croup this may be all this is necessary. Dexamethasone 0.6 mg/Kg PO or Budesonide 2 mg via nebulizer. Nebulized Epinephrine 0.5 mg/kg to max 5 mg. Should improve within 30 minutes. Observe for 3-4 hours. If no need for repeat treatment and appear stable, can be discharged. If they require repeat treatment, consider admission.

23. Bronchiolitis
Usually < 2 yrs of age. URTI symptoms followed by LRT symptoms. Severity scores are inconsistent, but generally an SpO2 < 95% is considered severe.

24. Bronchiolitis
Treatment: If mild: 1. Ensure hydration and relieve nasal congestion. (decongestants and OTC of NO value)

25. Bronchiolitis Treatment: Severe:
A one time trial of salbutamol or epinephrine may be used, but clinical efficacy is questionable.
Hypertonic saline neb and steroids, NOT recommended.
IV fluids as needed.
Nasal suctioning.
Oxygen to maintain SpO2 > 90%
Non invasive ventilation/CPAP ie transfer/ICU

26. Anaphylaxis
A more complete review of anaphylaxis in general is available on the LMHER.com website.
In children the most common (80-90%) signs and symptoms are cutaneous (urticaria, angioedema, pruritus etc)
Warning signs: more than one organ system involved.
Signs of respiratory distress
Signs of impaired perfusion
Abdominal pain, vomiting, dysrhythmias.

27. Anaphylaxis Treatment:
Epinephrine 0.01 mg/kg IM in the thigh. Repeat q 5 min prn.
Place patient recumbent with legs elevated.
Normal saline bolus 20 ml/Kg
Ranitidine 1 mg/Kg IV for itch.
Methylprednisolone 1 mg/Kg IV
? Epinephrine infusion
? Vasopressor infusion
8. Call Pediatrics!

28. When you have to secure the airway
Main Anatomical Differences in Pediatrics and Adults
Small mandible and large head (towel under body and shoulders)
Large tongue
High larynx
Epiglottis is long and stiff
Narrowest area is the cricoid cartilage
Trachea is short and directly in line with Right Bronchus

29. Equipment
“Formulas” for blade, ETT size etc FORGET it, use a table or an app (ie palmPEDi etc)

30. Pediatric Airway management
The next slide is a video by Reuben Strayer on Pediatric airway management.