1. Respiratory Emergencies
in the
Pediatric Population

2. CASE 1 16 month old boy with wheeze Initial Vitals: HR 160 RR 60
BP 88/50
Temp 38
O2sat on RA 89%

3. You do your pediatric assessment triangle:
Appearance Crying, distressed, looking
around, moving all 4 limbs
Breathing (work of) Laboured, chest caving in,
+++indrawing
Circulation Colour OK, N cap refill

4. What would you like to do now?
Oxygen by mask applied, IV attempt started and
pt now on cardiac monitor
Airway No stridor audible, no obvious secretions
Breathing +++ wheeze with little air entry bilat
(inspiratory AND expiratory)
Circulation Warm extrem, PPP, cap refill 2 secs

5. What would you like to do now?
Oxygen
Ventolin
Atrovent
IV Access established – orders?
CXR done / pending
Blood work Doctor?
Venous Gas pH
pCO2 38 pO

6. History: Has had a “cold” for almost 2 days now
(mild fever, decreased energy / appetite with cough
and runny nose)
Started getting wheezy this morning
No history of exposure to allergens, inhalants
or FB aspiration
Family History of Asthma / no smokers / no pets
Otherwise healthy with no known allergies

7. Continuous Ventolin for 15 mins has little effect
Still indrawing
RR 65
Still alert and looking around, crying
Additional treatment?
IV steroids Solucortef 1 mg/kg IV / IM
Continue Ventolin
Consider racemic Epinephrine (0.5 mls)

8. Repeat Venous Gas about 30 mins later pH 7.15 pCO2 55 pO2 120
Eyes rolling back, little crying now …
What do you want to do?
Drugs? Tube Size?
Ketamine 1-2 mg/kg IV
Atropine mg/kg IV (min 0.1 mg)
Succinyl 1 mg/kg IV
4 – 4.5 tube

9. Other Options IV Magnesium 25 mg/kg (max 2 gm) IV Epinephrine
IV Ventolin
Inhalational Anesthetics
Methylxanthines
Heli - Ox

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

11. 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

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

13. 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)

14. CAEP Pediatric Asthma Guidelines
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
Symptoms
Pre - Treat
Treatment

15. CASE 2 18 mo Girl with 24 hr Hx of coughing with drooling
Hx: Has had an URTI for about a week and was
getting mildly better until yesterday. She
developed a fever and the cough got harsher.
Still drinking but not interested in solids
Vomited once last night
Started drooling this morning

16. Physical Exam T39.1 degrees rectally, P170, R28, BP 100/66
Appearance alert, awake, not toxic, in no acute distress
Did not appear to prefer upright or a forward leaning position
EENT Moist MM, slight erythema of oropharynx,
nasal crusting, N TMs, no rash / petechiae,
no drooling
Supple neck
Chest Clear when resting
Mild inspiratory stridor with crying
Rest of the exam N

17. DDx? 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

18. Soft tissue lateral
neck radiograph

19. Retropharyngeal Abscess
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

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

21. Typically … 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

22. On Exam … Nasopharynx Bulging forward of the soft palate and
nasal obstruction
Oropharynx Bulging of posterior phyaryngeal wall or
Not visualized
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

23. Complications 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.

24. Treatment Clindamycin 20-30 mg/kg/day divided Q8H
(if pre-fluctuant phase)
Decadron 0.6 mg/kg
Airway management
Surgical decompression

25. CASE 3 17 month old male with a one-hour history
of noisy and abnormal breathing
Normal now but at the time, parents thought he was
quite distressed.
Now, he is able to speak and drink fluids without difficulty

26. What would you like to do now???
VS T36.8, P200 (crying), R28 (crying), O2 sat 99%
Alert with no signs of respiratory distress
Able to speak, had no cyanosis, no drooling,
no dyspnea
H+N No obvious swelling, bleeding, FB seen
Chest Mild wheezing with ? mild inspiratory stridor
What would you like to do now???

27. Soft Tissue
Neck View

28. CXR (PA)

29. Next?
Expiratory
CXR

30. Inspiratory View
Expiratory View

31. Right
Decub
View

32. 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)

33. 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

34. Investigations Xrays Lateral neck
Chest – inspiratory, expiratory, decubitus views
Expiratory views
Overinflation (partial obstruction with inspiratory flow)
Volume loss with mediastinal shift towards obstructed
side (partial obstruction with expiratory flow)
Atelectasis (complete obstruction)

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

36. CASE 4 2 yo Boy with Barky Cough for 2 days
Runny nose, decreased appetite
Not himself
No PMHx / FHx of significance
Shots UTD
Other sibs with similar URTIs

37. On Exam … Temp 38.9 HR 140 O2 sat 98% (drops to 90% when he crys)
RR 40 (mild indrawing)
Irritable, crying, good colour
H & N sl erythema of throat, no pus
N TMs, small cervical nodes
Chest Barky cough, inspiratory stridor
No wheeze noted

38. Diagnosis? Re – Assess in 30 minutes What would you like to do now?
Racemic Epinephrine ml dose
? Dexamethasone now or later
Re – Assess in 30 minutes
No improvement with 1st dose of epinephrine
What would you like to do now?

39. Re – Examine Ongoing Inspiratory Stridor
Cries when trachea is examined
IV Cefuroxime PLUS Cloxacillin
Consult Pediatric ICU / Pulmonary
for Bronch / Intubation

40. Bacterial tracheitis
An acute bacterial infection of the upper airway capable
of causing life-threatening airway obstruction
Staph aureus most commonly
(parainfluenza, 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

41. CLINICAL MANIFESTATIONS
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)

42. Treatment Antibiotics (good Staph coverage)
Intubation or tracheostomy is usually necessary
? Decadron

43. Pediatric Pneumonia Neonate Bacteria more frequent
E. coli, Grp B strep, Listeria, Kleb
1 – 3 mo Chlamydia trachomatis (unique)
Commonly viral (RSV, etc.)
B. Pertussis
1 – 24 mo S. pneumonia, Chlamydia pneum
Mycoplasma pneumonia
2 – 5 yrs RSV
Strep pneumonia, Mycoplasma, Chlam

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

45. 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

46. Physical Exam Tachypnea is the best single indicator of pneumonia
Age in months Upper limit of Normal RR
<
>

47. 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)