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Pediatrics
Respiratory Emergencies
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Respiratory Emergencies
#1 cause of – Pediatric hospital admissions– Death during first year of life except for
congenital abnormalities
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Respiratory Emergencies
Most pediatric cardiac arrest begins as respiratory failure or respiratory
arrest
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Pediatric Respiratory System
Large head, small mandible, small neck
Large, posteriorly-placed tongue
High glottic opening Small airways Presence of tonsils,
adenoids
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Pediatric Respiratory System
Poor accessory muscle development Less rigid thoracic cage Horizontal ribs, primarily diaphragm
breathers Increased metabolic rate, increased O2
consumption
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Pediatric Respiratory System
Decrease respiratory reserve + Increased O2 demand = Increased
respiratory failure risk
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Respiratory Distress
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Respiratory Distress
Tachycardia (May be bradycardia in neonate) Head bobbing, stridor, prolonged expiration Abdominal breathing Grunting--creates CPAP
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Respiratory Emergencies
Croup Epiglottitis Asthma Bronchiolitis Foreign body aspiration
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Laryngotracheobronchitis
Croup
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Croup: Pathophysiology
Viral infection (parainfluenza) Affects larynx, trachea Subglottic edema; Air flow obstruction
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Croup: Incidence
6 months to 4 years Males > Females Fall, early winter
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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
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Croup: Management
Mild Croup– Reassurance– Moist, cool air
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Croup: Management
Severe Croup– Humidified high concentration oxygen– Monitor EKG– IV tko if tolerated– Nebulized racemic epinephrine– Anticipate need to intubate, assist ventilations
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Epiglottitis
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Epiglottitis: Pathophysiology
Bacterial infection (Hemophilus influenza) Affects epiglottis, adjacent pharyngeal
tissue Supraglottic edema
Complete Airway Obstruction
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Epiglottitis: Incidence
Children > 4 years old Common in ages 4 - 7 Pedi incidence falling due to HiB vaccination Can occur in adults, particularly elderly Incidence in adults is increasing
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Epiglottitis: Signs/Symptoms
Rapid onset, severe distress in hours High fever Intense sore throat, difficulty swallowing Drooling Stridor Sits up, leans forward, extends neck slightly One-third present unconscious, in shock
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Epiglottitis
Respiratory distress+ Sore throat+Drooling =
Epiglottitis
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Epiglottitis: Management
High concentration oxygen IV tko, if possible Rapid transport Do not attempt to visualize airway
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Epiglottitis
Immediate Life Threat
Possible Complete Airway Obstruction
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Asthma
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Asthma: Pathophysiology
Lower airway hypersensitivity to:– Allergies– Infection– Irritants– Emotional stress– Cold– Exercise
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Asthma: Pathophysiology
Bronchospasm
Bronchial Edema Increased MucusProduction
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Asthma: Pathophysiology
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Asthma: Pathophysiology
Cast of airway produced by
asthmatic mucus plugs
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Asthma: Signs/Symptoms
Dyspnea Signs of respiratory distress
– Nasal flaring– Tracheal tugging– Accessory muscle use– Suprasternal, intercostal, epigastric retractions
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Asthma: Signs/Symptoms
Coughing Expiratory wheezing Tachypnea Cyanosis
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Asthma: Prolonged Attacks
Increase in respiratory water loss Decreased fluid intake Dehydration
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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?
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Asthma: Physical Exam
Patient position? Drowsy or stuporous? Signs/symptoms of dehydration? Chest movement? Quality of breath sounds?
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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
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Asthma
SILENT CHEST= DANGER OF RESPIRATORY FAILURE
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Golden Rule
Pulmonary edema Allergic reactions Pneumonia Foreign body aspiration
ALL THAT WHEEZES IS NOT ASTHMA
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Asthma: Management
Airway Breathing
– Sitting position– Humidified O2 by NRB mask
Dry O2 dries mucus, worsens plugs
– Encourage coughing– Consider intubation, assisted ventilation
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Asthma: Management
Circulation– IV TKO– Assess for dehydration– Titrate fluid administration to severity of
dehydration– Monitor ECG
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Asthma: Management
Obtain medication history– Overdose– Arrhythmias
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Asthma: Management
Nebulized Beta-2 agents– Albuterol
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POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE
Asthma: Management
Subcutaneous beta agents– Epinephrine 1:1000--0.1 to 0.3 mg SQ
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Asthma: Management
Use EXTREME caution in giving two sympathomimetics to same patient
Monitor ECG
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Asthma: Management
Avoid– Sedatives
Depress respiratory drive
– Antihistamines Decrease LOC, dry secretions
– Aspirin High incidence of allergy
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Status Asthmaticus
Asthma attack unresponsive to -2 adrenergic agents
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Status Asthmaticus
Humidified oxygen Rehydration Continuous nebulized beta-2 agents Atrovent Corticosteroids Aminophylline (controversial) Magnesium sulfate (controversial)
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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
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Bronchiolitis
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Bronchiolitis: Pathophysiology
Viral infection (RSV) Inflammatory bronchiolar edema Air trapping
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Bronchiolitis: Incidence
Children < 2 years old 80% of patients < 1 year old Epidemics January through May
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Bronchiolitis: Signs/Symptoms
Infant < 1 year old Recent upper respiratory infection exposure Gradual onset of respiratory distress Expiratory wheezing Extreme tachypnea (60 - 100+/min) Cyanosis
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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
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Bronchiolitis: Management
Humidified oxygen by NRB mask Monitor EKG IV tko Anticipate order for bronchodilators Anticipate need to intubate, assist
ventilations
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Foreign Body Airway Obstruction
FBAO
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FBAO: High Risk Groups
> 90% of deaths: children < 5 years old 65% of deaths: infants
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FBAO: Signs/Symptoms
Suspect in any previously well, afebrile child with sudden onset of:– Respiratory distress– Choking– Coughing– Stridor– Wheezing
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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
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FBAO: Management
Inadequate ventilation– Infant: 5 back blows/5 chest thrusts– Child: Abdominal thrusts