GEMC: Pediatric Respiratory Distress: Resident Training

Project: Ghana Emergency Medicine Collaborative Document Title: Pediatric Respiratory Distress Author(s): Stuart A Bradin (University of Michigan), DO, FAAP, FACEP, 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/

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2

Pediatric Respiratory Distress

Stuart A Bradin, DO, FAAP, FACEP Assistant Professor of Pediatrics and

Emergency Medicine 3

Objec3ves 1. Recognize differences between the pediatric and adult airway

2. Recognize the spectrum of diseases that can cause upper airway obstruction in children

3. Recognition of clinical presentations/ manifestations of upper airway obstruction in pediatric population

4. Manage acute airway obstruction in this population 5. Recognition and management of lower airway obstruction in the pediatric population

6. Recognize respiratory distress and impending respiratory failure in pediatric population

7. Recognize signs and symptoms of pneumonia 8. Management and care of common causes of pneumonia 9. Recognize and manage pediatric status asthmaticus 10. Recognize and treatment of bronchiolitis

4

Introduc3on

•  Infants and young kids have small airways compared to adults

•  Can quickly develop clinically significant upper airway obstruction

•  Acute upper airway obstruction-‐ whatever the etiology-‐ can be life threatening

•  Complete obstruction will lead to respiratory failure àprogress to cardiac arrest in minutes

•  Prompt recognition and management of airway compromise is critical to good outcome

5

Pathophysiology

•  Small caliber of airway makes it vulnerable for occlusion

•  Exponential rise in airway resistance and WOB with any process that narrows airway

•  Infant is nasal breather-‐ any obstruction of nasopharynx significantly increases WOB

•  Large tongue can occlude airway-‐ especially in increased ICP/ loss muscle tone due to decreased GCS

•  Cricoid ring is narrowest part upper airway-‐ often site occlusion in FB

6

Evalua3on

•  Begins with rapid assessment of respiratory status •  “Who needs resuscitation” ? •  Focus : upper airway patency degree respiratory effort efficiency of respiratory function •  History: onset of symptoms and presence of fever •  Context of Pediatric Assessment Triangle

7

The Pediatric Assessment Triangle

8

Circulation/ Skin Color

Pediatric Assessment Triangle

•  Observational assessment •  Formalizes the “general impression” •  Establishes the severity of illness or injury •  Determines the urgency of intervention •  Identifies general category of physiologic abnormality or state

•  SICK OR NOT SICK

9

Appearance

•  Level of consciousness –  Irritability –  Consolability – Distractibility –  Eye contact –  Agitation –  Lethargy – Quality of Cry –  Speech

•  Developmental considerations

10

Appearance

11

Clappstar (Flickr)

Randy Deuro (Flickr)

Breathing

•  Tachypnea •  Work of breathing •  Abnormal sounds •  Position of comfort

12

Retrac3ons

•  Suprasternal •  Supraclavicular •  Intercostal •  Subcostal •  Nasal flaring

Bobjgalindo (Wikimedia Commons)

14

•  Note exact location (important clue in cause/severity of respiratory distress

•  Ex) subcostal and substernal retractions usually result from lower respiratory tract disorders

•  Ex) suprasternal retractions from upper respiratory tract disorders

•  Mild intercostal retractions may be normal

•  Paired with subcostal and substernal retractions may indicate moderate respiratory distress

•  Deep suprasternal retractions indicate severe stress

Suptasternal retractions

Intercostal retractions

Substernal retractions

Subcostal retractions

Anatomography (Wikimedia Commons)

Abnormal Sounds

•  Grunting – Noted at end expiration –  Voluntary closure of glottis –  Physiologically generates PEEP – Worrisome sign

•  Stridor •  Audible wheezing

15

Stridor •  Musical , high pitched inspiratory sound •  Hallmark of partial airway obstruction •  Pattern can localize the lesion •  Supraglottic disease = inspiratory stridor lesion at or above the cords Inspiration: loose tissues collapse inward Expiration: airway enlarges, tissues move •  Subglottic disease = biphasic stridor lesion at or below vocal cords Inspiration: loose tissues move inward Expiration : fixed lumen size impedes air flow

16

Stridor •  Age of pt important Infants-‐ congenital problems Toddlers-‐ foreign body •  Older child = bigger airway à complete obstruction less likely

•  Fever implies infectious etiology •  Sudden onset suggests : some infections foreign body anaphylaxis/ allergic rxn •  Other non infectious causes: anaphylaxis trauma/ caustic ingestion burn/ thermal injury

17

Posi3on of Comfort

•  Lower airway disease – Upright posture, leaning forward and support of upper thorax by arms

–  Tripoding •  Upper airway disease

– Upright posture, leaning forward, self-‐generation of jaw thrust and chin lift

–  “Sniffing” position

18

Signs of Distress

•  Retractions •  Tachypnea •  Grunting •  Position of comfort •  Color •  Signs of respiratory distress: tripod position, nasal flaring

19 U.S. Navy photo by Journalist 1st Class Joshua Smith (Wikimedia Commons)

•  Signs of impending respiratory failure –  Increased respiratory rate or bradnypnea –  Nasal flaring –  Use of accessory muscles –  Cyanosis

20

Retraction

Limbs extended (poor muscle tone)

Nasal Flaring

Infant, Poor First Impression

Bobjgalindo (Wikimedia Commons)

Infant, Good First Impression

Alert, with good muscle tone

Alvin Smith (Flickr)

Circulation

•  Capillary refill •  Distal vs central pulses •  Temperature of extremities •  Color

—  Pink —  Pale —  Blue (central cyanosis vs acrocyanosis) —  Mottled

21

Capillary Refill

22 Aladaze (Flickr)

Respiratory Distress •  Defined as inability to

maintain gas exchange •  Multiple etiologies

leading to distress •  Signs/symptoms varied-

dependent on age •  Abnormal respirations •  Tachypnea •  Bradypnea •  Apnea

•  Retractions/ accessory muscle use •  Head bobbing, position of comfort •  Nasal flaring •  Grunting •  Color change- pale or cyanotic •  Poor aeration •  Altered mental status

23

Impending Respiratory Failure

•  Presence of acidosis •  PCO2 > 50 mm Hg •  PaO2 < 50 mm Hg •  “Normal “ blood gas in face of tachypnea and distress •  Diagnosis based primarily clinically •  Definitive airway should not be delayed waiting for

labs or xray

24

Case 1

•  4-‐year-‐old boy in good health

•  Sore throat, fever, no appetite

•  Trouble swallowing, stridor

•  Pulse 140, respirations 30 to 40

•  Anxious, drooling •  How sick is this child?

25

Ben McLeod (Flickr)

Differen3al Diagnoses of Upper Airway Obstruc3on

•  Epiglottitis •  Retropharyngeal abscess •  Peritonsillar abscess •  Croup •  Caustic ingestion •  Foreign body obstruction •  Bacterial tracheitis

What steps need to be taken immediately?

26

Immediate Steps

•  Reduce child’s anxiety •  Provide supplemental oxygen •  Minimize procedures •  Avoid oral examination •  Prepare airway equipment •  Alert OR, anesthesiologist, surgeon •  Prepare to move to OR, if needed

27

Acute SupragloH3s or EpigloH3s

•  Mild URI that progresses over a few hours to severe throat pain, drooling, and fever

•  Cellulitis of structures above the glottis

•  Although considered pediatric illness, historically disease of adults

•  Early 1980’s-‐ kid: adult 2.6 : 1 •  Mid 1990’s-‐ 1 adult case for every 0.4

pediatric case •  Current presentation-‐ older child or

young adult •  Severe sore throat and dysphagia •  H. influenza, parainfluenza •  Treatment

–  Intubation –  Empiric Abx-‐ 3RD generation Ceph.

28 Wikimedia Commons 2013

Source Undetermined

EpigloH3s

•  Newborn to adulthood •  Pre HIB vaccine

–  Age 1-‐7 years, mean 2 1/2-‐3 years –  H. influenzae type B

•  Post HIB vaccine-‐1991 •  Rates dramatically fallen-‐ from 3.47

cases/100,000 to 0.63/ 100,000 •  Seen rarely but can still occur despite

vaccination •  Group A Streptococcus most

common etiology today •  Strep pneumo, Staph Aureus,

Parainfluenza virus •  Concern immigrant population and

immunocompromised pt

29

Source Undetermined

Wikimedia Commons 2013

Presenta3on

•  Classic: acute fever, dysphagia, drooling •  Extremely rapid onset and progression •  Toxic appearing •  Difficulty tolerating secretions •  Cough not a prominent finding •  Resp distress •  Anterior neck pain/ tenderness •  Hoarseness •  Most telling-‐ child’s posture and behavior •  “If moving around, they do not have epiglottitis”-‐

Dr Anna Messner-‐ Pediatric ENT Stanford Univ 30

Clinical Findings of EpigloH3s in the Child

•  Drooling •  Dysphagia •  High fever •  Inspiratory stridor •  Muffled, “ hot potato” voice •  Rapid onset and progression symptoms •  Sore throat •  Toxic appearance •  Tripod positioning

31

EpigloH3s

32 Source Undetermined Med Chaos (Wikimedia Commons)

Description: Left column: Normal epiglottis. Right column: Epiglottitis.

EpigloH3s

33 Source Undetermined

Wikimedia Commons 2013

Management

•  Avoid agitation. Allow position of comfort

•  Provide supplemental oxygen in a non-‐threatening manner

•  Assemble equipment and consultants

•  Intubation in controlled setting

•  IV antibiotics cefotaxime, ceftriaxone

•  Delay imaging if suspect Epiglottitis

Marty Bahamonde (Wikimedia Commons)

Case 2 •  12 yr old female •  Fatigue, malaise, fevers 102+ x 3-‐4 days •  Sore throat, difficulty swallowing •  Pain “ so bad-‐ can’t drink” •  Feels dizzy when standing •  Denies sexual activity •  Mom thinks she “ talks funny”

•  Dry, pale, non toxic appearing •  Foul breath •  Muffled voice •  Large posterior chain nodes, tender to touch •  Neck decreased ROM due to pain •  HR 120’S, orthostatic •  Soft belly, ? Spleen tip palpable •  Appropriate, GCS 15 •  HCG -‐, WBC 17, 23% Atypical lymphs on

differential, no blasts platelets 127, lfts minimally elevated

35 James Heilman, MD (Wikimedia Commons)

What’s This Disease?

36

Grook Da Oger (Wikimedia Commons) Fateagued (Wikimedia Commons)

Infec3ous Mononucleosis •  Caused by Epstein-‐ Barr Virus (EBV) •  Transmitted via contact w/ oropharyngeal secretions •  Incubation period 4-‐6 weeks •  Typical presentation: Adolescent or young adult Fever Pharyngitis Lymphadenopathy Splenomegaly •  Other constitutional findings: h/a, anorexia, myalgias, chills, rash ( generalized

maculopapular), malaise •  Rare complications: myocarditis, myositis, transverse myelitis, encephalitis,

pancreatitis/ cholecystitis, glomerulonephritis •  Spontaneous splenic rupture 1-‐2 % •  Labs supportive of EBV: elevated transaminases relative lymphocytosis w/ > 10% atypical lymphs mild leukocytosis (12-‐20,000) mild thrombocytopenia elevated ESR or CRP

37

Mononucleosis

•  May cause upper airway obstruction in young children

•  Management Supportive: Admit for severe distress Fluids Steroids Pain control •  Get EBV Titers-‐ mono spot often false negative : kids < 10 yrs symptoms < 5 days •  Avoid contact sports for 3-‐4 weeks •  Close follow up w/ PCP

38

Case 3

•  18 mo presents to ED w/ difficulty breathing –  h/o rhinorrhea and fever for 3 days –  Awoke in middle of the night w/ barking cough and noisy breathing

–  Symptoms worsen when agitated •  VS: T 102.5, HR 160, RR 40, O2 Sat 95%

– Hoarse cry, Audible stridor, supraclavicular and suprasternal retractions

•  How sick is this child? •  What is causing his symptoms?

39

Donnie Ray Jones (Flickr)

Your First Clue: Croup

•  Prodromal symptoms mimic upper respiratory infection.

•  Fever is usually low grade (50%). •  Barky cough and stridor (90%) are common.

•  Hoarseness and retractions may also occur.

•  Caused by swelling of tissue around voice box and windpipe

40

Frank Gaillard (Wikimedia Commons)

Croup

•  Accounts for 90% of stridor with fever •  Children 1 to 3 years old •  Generally nontoxic presentation (38° to 40°C) •  Gradual onset of cough (barking) with varying degrees of stridor

•  Viral pathogens •  Seasonal and temporal variations •  Clinical diagnosis

41

Croup/ Laryngeotracheobronchi3s •  Most common cause for stridor in febrile infant •  Mostly kids < 2 yrs of age •  Affects 6 mths – 6 yrs

Incidence 3-‐5/100 children Male predominance 2:1 Peak in second year of life-‐ mean age 18 mths Seasonal: Occurs more late fall and early winter Viral etiology: Parainfluenza virus (60%) Influenza A-‐ severe disease RSV (“ croupiolitis-‐” wheeze and stridor) Adenovirus Coxsackievirus Mycoplasma pneumoniae

42

Croup

•  Acute viral infection •  Characterized by : Bark like cough Hoarseness Inspiratory stridor •  Symptoms worse at night-‐ typically last 4-‐7 days •  Spectrum of respiratory distress •  Mild to resp failure requiring intubation •  Disease most often self limited •  Rarely can lead to severe obstruction and death ( < 2%)

43

Croup Score

•  Westley croup score most common

•  Tool to describe severity of obstruction

•  Higher the score, the greater the risk for resp failure


Diagnos3c Studies

•  Croup is a clinical diagnosis.

•  Routine laboratory or radiological studies are not necessary.

•  Films may be done if diagnosis is uncertain

•  May see “ Steeple Sign”


Croup-‐ Management

•  Avoid agitation, allow position of comfort

•  Provide cool mist – if tolerated •  Aerosolized epinephrine

–  Racemic EPI 0.5 ml in 3 ml NS –  Stridor, retractions at rest

•  Steroids – Dexamethasone 0.6 mg/kg IM – Methylprednisolone 2 mg/kg PO

•  Prepare airway equipment in severe cases

•  Heliox may prevent intubation •  Airway radiographs not necessary

46

Management Croup

•  Minimize anxiety •  Oxygen •  Humidified mist: anecdotally effective literature shows no proven benefit can use if tolerated cool mist safer just as effective as warm mist

47

Steroids •  Faster improvement croup score •  Decrease need for intubation and PICU •  Decrease hospitalization rates •  Shorter hospital stay if admitted •  Multiple studies have proven benefit-‐ even mild cases ( Bjornson, et

al NEJM 2004) •  Dexamethasone or oral prednisolone both efficacious •  Dexamethasone-‐ better compliance usually only single dose required cheap, easy to administer IM = PO efficacy standard dose 0.6 mg/kg-‐ max 10 mg recent studies show that lower dose may be ok (0.15-‐ 0.3 mg/kg) •  Nebulized budesonide ( Pulmicort) better than placebo, not as good

as Dex or prednisolone ( Klassen, NEJM 1994) •  No added benefit if added to Dexamethasone

48

(Wikimedia Commons)

Racemic Epinephrine

•  Indications: stridor at rest retractions moderate – severe distress •  Duration 90-‐120 minutes •  “ Rebound effect”-‐ myth only •  Must observe 2-‐4 hrs after treatment •  Dosing:

0.5 mg in 2-‐3 cc NSS

49

Admission Criteria

•  Inability to drink •  Cyanosis •  Hypoxia •  Stridor at rest •  Poor response to or multiple racemic epinephrine treatments

•  Social concerns •  Lack of follow up •  Young age-‐ consider for < 1 yr given how small airway is

50

Differen3al Diagnosis: What Else Could it Be?

•  Epiglottitis (rare) •  Bacterial tracheitis •  Peritonsillar abscess •  Uvulitis •  Allergic reaction •  Foreign body aspiration •  Neoplasm

51

•  Can’t assume all stridor is croup-‐related

•  Could be epiglottitis •  Child may have aspirated a

foreign body that is causing acute stridor

•  Stridor may also be caused by psychological problems, hypocalcemia, or angioneurotic edema

Trachei3s/ Pseudomembranous Croup

•  Bacterial infection subglottic region •  Same age group as croup-‐ average 3 yrs •  High fevers •  Look toxic •  Mortality 4-‐20% •  Characterized: subglottic edema inflammation larynx, trachea, bronchi, lungs •  Copious purulent secretions •  Polymicrobial: Staph Aureus ( most likely) S. pneumoniae H. influenzae •  Distress severe, not responsive to croup tx •  Complications-‐ pneumonia, ARDS, Pulm

edema, subglottic stenosis

52

Source Undetermined

Bacterial Trachei3s

•  Complication of viral laryngotracheobronchitis •  Fever, white count, respiratory distress following a

complicated course of croup •  Staphylococcus aureus-‐ need appropriate antibiotic

coverage •  Diagnosis usually made by direct visualization when

intubating •  Require aggressive pulmonary toilet/ supportive care •  Rare-‐ has emerged as most common potentially life

threatening upper airway infection in children •  Hopkins, et al, Pediatric 2006: 3 x as likely to cause resp failure than croup and

epiglottitis combined

53

Case 4

•  16 yr old male with fever, sore throat, dysphagia

•  Decreased po, “muffled voice”

•  Sent in by PCP because of abnormal exam

•  What is wrong with this kid?

54

James Heilman, MD (Wikimedia Commons)

Peritonsillar Abscess

•  Most common deep infection of head and neck (30/100,000 people) •  Occurs primarily teenagers and young adults •  Pediatrics-‐ typically kids > 5 yrs of age •  Highest incidence Nov-‐ Dec and April-‐ May •  Coincides highest incidence Group A strep pharyngitis and tonsillitis •  Can occur after mononucleosis •  Polymicrobial-‐ Group A strep predominate organism •  Symptoms: fever, malaise, sore throat dysphagia, otalgia •  Physical findings: trismus muffled voice/ “ hot potato voice” •  Treatment: Drainage, antibiotics, pain control, hydration •  Steroids?-‐ (Ozbek, et al J Laryngol Otol. 2004, Jun:118)-‐ single high dose steroid prior to antibiotic more effective than antibiotic alone May be institutionally dependent-‐ ENT here seems to use •  Children have lower recurrence rate-‐> tonsillectomy not always needed

55

Peritonsillar Abscess

Physical Findings Deviation of tonsil Dysphagia Enlargement of tonsil Fever Fluctuance of soft tissue/palate “Hot potato” voice Severe pain Trismus ( 60%)

Complications Extension of abscess into neck

Hemorrhage due to erosion carotid artery

Septic thrombosis w/in internal jugular vein

Mediastinitis Sepsis

56

Retropharyngeal Abscess

•  Most common kids 2-‐4 yrs •  Symptoms related to pressure and

inflammation caused by abscess •  Intense dysphagia •  Drooling •  Respiratory distress-‐ stridor, tachypnea •  Usually febrile and fussy •  Unwilling to move neck Extension > Flexion •  Pt holds neck stiffly •  Mimic meningismus •  Group A strep, S. aureus, anaerobes •  CT will help define abscess •  Medical management successful 50% •  May require surgical drainage-‐ especially

if airway compromise 57

Source Undetermined

Retropharyngeal Abscess

Predisposing Factors: Recent infection Penetrating trauma/ FB

Crack cocaine use adults

Recent intubation


Diphtheria •  Toxic appearance •  “Bull neck”-‐ swelling

nodes and neck •  Gray adherent pharyngeal

membrane •  Croup like symptoms-‐ low grade fever hoarseness sore throat stridor •  Rare US-‐ extensive

immunization •  Can result in laryngeal

web •  If suspected, treat: diphtheria antitoxin Penicillin Erythromycin •  Early intubation/ trach

59

Dileepunnikri (Wikimedia Commons)

Non-‐infec3ous E3ologies for Upper Airway Obstruc3on

•  Caustic Ingestion •  Burns •  Anatomical •  Foreign Bodies •  Trauma/ bleeding •  Anaphylaxis

60

Case 5

•  18 mo sudden onset of cough and difficulty breathing

•  No fever, drooling •  Exam:

–  T 99, P 130, RR 40, O2 Sat 93% – Mild intercostal retractions, no stridor, exp wheezing on left side

How sick is this child? What do you think is going on? What is your next step?

61

Hubert K (Flickr)

Foreign Body Aspira3on

•  Foreign objects can be lodged in the upper or lower airway, or esophagus.

•  Differences in the pediatric airway make evaluation and management of foreign body aspiration challenging.

62

Source Undetermined

Dafuriousd (Flickr) 2007

Pediatric vs Adult Airway


Anatomy

•  Infant larynx: -‐More superior in neck -‐Epiglottis shorter, angled more over glottis -‐Vocal cords slanted: anterior commissure more inferior -‐ Vocal process 50% of length

-‐Larynx cone-‐shaped: narrowest at subglottic cricoid ring -‐Softer, more pliable: may be gently flexed or rotated anteriorly

•  Infant tongue is larger •  Head is naturally flexed

64

Susan Gilbert

Foreign Body

•  Seen in children <5 years old •  Symptoms variable; may be acute, subacute, or chronic

•  Upper or lower airway symptoms

•  Maintain a high degree of suspicion

•  Radiography useful for incomplete obstruction


Aspirated Foreign Bodies

•  Identification can be quite subtle •  FB aspiration relatively uncommon event •  Initial choking episode may be unwitnessed •  Delayed residual symptoms mimic other common conditions like asthma, URI, pneumonia

•  Initial diagnosis missed in 30% of patients •  High index of suspicion required •  “All that wheezes is not asthma”

66

Foreign Bodies

•  2-‐4year olds •  Acute episode of choking/gagging •  Triad of acute wheeze, cough and unilateral diminished sounds only in 50%

•  5-‐40% of patients manifest no obvious signs •  Think FB if persistent symptoms despite appropriate therapy

•  Think FB if acute onset cough, gagging •  Any child eating, running and acute onset distress = FOREIGN BODY

67

Fatal Aspira3ons

•  Require complete airway obstruction

•  Hot dogs •  Candy •  Nuts •  Grapes •  Balloons •  Balls (< 3cm) •  Meat •  Carrot •  Hard cookies/bisquits

68

Tim Shearer (Flickr) 2008

Derek Key (Flickr) 2012

Veggiefrog (Fickr) 2007

Arbyreed (Flickr) 2007

Epidemiology of Aspira3ons

•  Agent-‐ usually food, round, < 3cm •  Objects that stay in mouth for prolonged time increase risk-‐ gum, hard candy, sunflower seeds

•  Age 6 mths-‐ 5 years •  Underlying curiosity, oral phase of children •  Male: Female 2:1 •  Environment-‐ poor supervision availability small objects not sitting when eating inappropriate for age toys

69

FB Aspira3on Symptoms

•  Choking (22-‐86%) •  Coughing (22-‐77%) •  Dypsnea/ SOB (4-‐49%) •  Fever (12-‐37%) •  Wheezing (22-‐40%) •  Stridor (1-‐61%) •  Hemoptysis (1-‐11%) •  Asymptomatic (1-‐6%)

70

“Classic Triad”

•  Study by Oguz-‐ 2000 •  Findings associated with FB aspiration •  Cough (87%) •  Wheezing (45%) •  Asymmetrical breath sounds (53%) •  Only 23% have all 3 components

71

Radiologic Diagnosis •  Xrays can not rule out non-‐radiopaque FB aspiration

•  Majority aspirated FB radiolucent

•  AP, lateral chest films-‐ normal 25% aspirated FB

•  Inspiratory/Expiratory films require patient cooperation

•  Decubitus views-‐ “poor man’s” expiratory film

•  Down side is expiratory •  Most common findings : hyperinflation/airtrapping

atelectasis pneumonia


Management

•  Bronchoscopy-‐ diagnostic/therapeutic treatment of choice

•  Typically performed by Peds surgery, ENT, pulmonologist

•  Unsuccessful bronchoscopy requires need for thoracotomy to remove FB

•  Position of comfort •  Reduce agitation •  NPO •  Be prepared if partial obstruction progresses to complete airway obstruction

-‐ heimlich, back blows, Magill forceps, jet ventilation

73

Wikimedia Commons

Jason Eppink (Flickr) 2007

Foreign Body

•  Management –  Rigid Bronchoscopy

– Often based on clinical suspicion

– Negative xray does not rule out pulmonary FB

74

Philippa Willitts (Flickr) 2008

Tomblois (Flickr) 2006

Darwin Bell (Flickr) 2007

Chris_Hertel (Flickr) 2011

Caus3c Inges3on

75

Waldo Jaquith (Flickr) 2010

Ben McLeod (Flickr) 2005

Pharyngeal lye ingestion

76

Alex Avriette (Flickr) 2006

Thermal Injuries

77

•  Burns to the airway can cause swelling that

blocks the flow of air into the lungs

Joshua Bousel (Flickr) 2006

Congenital Disorders

•  Laryngomalacia-‐ young infants •  Web •  Hemangioma and vascular rings •  Polyp •  Vocal cord paralysis •  All will present with “ noisy breathing” •  URI will worsen stridor and increase respiratory distress •  Think anatomy in young infant : especially < 6 mths age recurrent “ croup”-‐ especially if no other infectious symptoms

78

SubgloHc Stenosis

•  Narrowing of airway below vocal cords

•  Congenital •  Acquired-‐ prolonged intubation

•  Treatment dependent on severity of stenosis

79

Joseph B. Sutcliffe III (Wikimedia Commons)

Laryngomalacia

•  Most common cause of stridor in newborns

•  Develops over 1st several mths of life

•  Gradually resolves by 12 mths-‐ 18 mths of age

•  Distinctive low pitched, coarse cryà “Turkey Gobble”

•  Stridor intermittent •  Worse during feeding/ sleeping •  Improves when crying •  Treatment dependent on

severity of symptoms/ wt gain •  Must treat GERD-‐ accompanies

100% •  Watch for aspiration •  Supraglottoplasty for FTT

80

Doctormichael (Wikimedia Commons)

Vocal Cord Paralysis

•  2nd most common cause stridor in kids

•  Treatment varies •  Dependent 1 or both cords affected

•  Severity of respiratory symptoms

•  At risk for aspiration and feeding difficulties

81

Dan Simpson (Flickr) 2005

Laryngeal Web

•  Well recognized cause for airway obstruction

•  Estimated 1 in 10,000 births •  Congenital webs present almost exclusively infancy

•  Acquired webs due to: -‐direct laryngeal trauma via intubation -‐ infection •  Most common agent: C.diphtheria

82

Rn cantab, Wikimedia Commons

Laryngeal Papilloma

•  Affects young children most commonly

•  Recurrence frequent •  HPV-‐ contracted by baby as passes

through vaginal canal •  300 infants/yr with virus due to

maternal transmission •  Laser ablation and interferon

combined results in longer remission (Poenaru, et al, 2005) •  Cidofovir-‐”lasting remission” 50% •  Goal of treatment: maintain airway maintain voice prevent spread

83

Source Undetermined

Anaphylaxis

•  Often under recognized •  Must treat aggressively •  Epinephrine is crucial (.01 cc/kg-‐ 1: 1000 SQ or IM) •  Adjunctive meds-‐ -‐ steroids -‐ fluids -‐ albuterol -‐ H1 and H2 blockers •  Must observe at least 8 hrs •  When d/c , do so with Epi pen x 2 and referral to allergy

84

Intropin (Flickr) 2010

Mikael Haggstrom (Wikimedia Commons) 2011

85

Could you save a life? Think F.A.S.T.

Face – itchiness, redness, swelling of the face and tongue

Airway- trouble breathing, swallowing, or speaking

Stomach- pain, vomiting, diarrhea

Total Body- rash, itchiness, swelling, weakness, paleness, sense of doom, loss of consciousness

Then ACT!

•  Give epinephrine •  Call 911

Case 6 •  1 yr old with URI symptoms x 1 week •  Now increased work of breathing •  Acute onset fever •  Increased cough •  Decreased appetite, decreased wet

diapers •  Vitals : P 188 RR 76 T 40.1 Sat 89% wt

10 kg •  Physical Exam: Pale, lying mom’s arms, coughing grunting

intermittenly Nares patent, flaring, copious green rhinitis Dry lips, dry mucosa Tachycardic, no murmur, cap refill 3+ secs, decreased femoral pulses Lungs rhonchorous and coarse, decreased breath sounds R, diffuse retractions, no wheeze Alert ,anxious, crying but consolable

What do you want to do? What more do you want to know? Context of Pediatric Assessment Triangle Sick or not sick?

86

Hubert K (Flickr) 2011

Interventions and Progression

•  100% O2 via face mask •  Cardiac monitor/ continuous pulse

ox •  IV access attempt •  Lab work- cbc, cx, basic, ? blood

gas (vbg) •  Chest Xray •  Antipyretics •  ? Albuterol treatment •  ? Empiric antibiotics •  Reassessment

Can’t get line HR 195 RR 36 Sat 94% on NRB, cap refill 4 sec “Sleeping” now per mom and “ looks more comfortable”

VBG 7.21, PCO2 54, base deficit -‐9 Becomes unresponsive, RR now 16 What do you want to do doctor?

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Uh Oh-‐ What do you see?


Interventions and Disposition?

•  IO placement •  BVM assisted breathing •  Intubation via RSI •  IVFP-‐ 20 cc/kg boluses •  Antibiotics •  PICU •  Remember your ABC’s

89

Michael Quinn Family (Flickr) 2009

Pneumonia

•  Acute respiratory tract infections commonly seen in pediatrics

•  Estimated that “healthy” kids have 10 or more resp infections/year early childhood

•  Pneumonia accounts for close 15% all respiratory infections

•  20% all pediatric hospital admissions •  Worldwide- 3 million children die annually •  Significant cause morbidity despite antibiotics

90

Definition

•  Acute infection/inflammation of lung parenchyma •  Infiltrates on chest xray •  WHO defined as: tachypnea (< 1yr, rr >50 , > 1 yr, rr > 40) retractions cyanosis •  Much overlap between viral and bacterial etiologies

91

Etiology

•  Multiple agents can cause pneumonia •  Most likely pathogen inferred by age, season,

clinical characteristics •  Strep pneumonia most common bacterial

cause pneumonia infants/children •  Mycoplasma more common with increasing age •  RSV most common viral etiology •  Mixed viral and bacterial infection common

92

Clinical Presentation- Neonate

•  Non specific signs •  Lethargy/ poor feeding/ irritibility/

emesis •  Respiratory distress •  Grunting/ retractions •  Apnea •  Fever or hypothermia •  Usually will not have usual signs/

symptoms such as cough or rales •  Deserve full sepsis evaluation •  Admission

94

John Arnold (Flickr) 2005

Clinical presentation- Infant •  Cough and rales often absent •  Non specific signs/symptoms seen as

with neonate •  Can present as “ sepsis” •  “Fever without source” •  Bachur, et al, 1999 146 kids fever > 39 wbc > 20 no source

26% had “ occult” pneumonia by Xray 95

Vgm8383 (Flickr) 2011

Clinical Presentation- Toddler/ Young Child

•  Fever •  Cough •  Vomiting •  Abdominal pain •  Anorexia •  Lower lobe infiltrate can mimic acute

abdomen •  Meningismus- upper lobe infiltrates

96

Lori Ann (Flickr) 2011

Radiologic Diagnosis: Classic Patterns on Chest Xray

•  Bacterial pneumonia: focal lobar consolidation •  Viral disease: diffuse peribronchial thickening, air

trapping, atelectasis •  Mycoplasma: focal or diffuse interstitial pattern •  Exceptions to classic pattern frequent •  Films can “ lag behind” clinical picture- especially

early in course or dehydrated

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Staphyloccocal Pneumonia

•  Rapidly progressive •  Fever, distress •  Significant morbidity •  71% pleural effusion •  Empyema •  Abcess •  Pneumothorax


Chlamydia trachomatis

•  2-19 weeks after birth •  Conjuctivitis •  Afebrile •  Staccato cough •  Tachypnea •  Crackles •  Eosinophilia •  B/l diffuse infiltrates •  Hyperinflation


Pneumococcal pneumonia

•  Unilobar infiltrate •  Round infiltrate •  Tachypnea •  Crackles •  Fever/ chills acutely •  GI symptoms •  No resp symptoms 28%

(Toikka, et al) •  40%- pleural effusion •  Greatest incidence< 2yrs •  Sickle cell disease •  Asplenia


Mycoplasma

•  Bilateral diffuse interstitial infiltrates

•  Film can be normal •  Rarely effusion (<20%) •  Gradual onset

symptoms •  Low grade fever •  Non productive cough •  Older child/ adolescent


Viral Pneumonia

•  Most common < 5yrs age

•  Diffuse interstitial infiltrate

•  Atelectasis •  Hyperinflation •  Peribronchial

thickening •  Hilar adenopathy •  RSV, Parainfluenza,

Adenovirus, Influenza

•  Wheezing


Laboratory Diagnosis- Blood Cultures

•  No role in evaluation routine outpatient pneumonia- ( Wubble, et al 1999)

•  Reserve for specific settings •  Clinical sepsis •  Immunocompromised host •  Hospitalized focal pneumonia (Byington, et al 2002-

11% bacteremia) •  Pneumonia with large effusion

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Treatment

•  Oxygen •  Pulmonary toilet/ suctioning •  IVF •  Pressors to support perfusion •  Intubation- severe distress, ventilatory failure, acidosis •  Chest tube/ thoracentesis large effusion or empyema •  Antibiotics- based on age most likely pathogen compliance strongly consider if child ill appearing

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Admission Criteria

•  Neonate •  Young infant < 6 mths of age •  Inability to tolerate po/ dehydration •  Failure outpatient therapy •  Concern re followup or compliance •  Comorbidity- CLD, SCD, immunosuppression •  Respiratory Distress •  Hypoxia •  Sepsis •  Complication of pneumonia- abscess, empyema •  Virulent pathogen- Staph aureus

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Case 7

•  3 mth old •  Ex 31 week premie, short NICU stay •  2 day hx cough, nasal congestion •  Breathing “ funny “ per mom •  Vitals hr 195 rr 80 T 38 Sat 93% r/a •  Wt 4 kg

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Physical Exam •  Pale, small, ill appearing •  Slightly sunken eyes, dry mouth •  No stridor, thick rhinorrhea and

congestion, and flaring •  Marked intercostal and subcostal

retractions •  Diffuse wheeze, rhonchi, and crackles •  Good aeration •  No murmur , tachycardic •  Cap refill 3 sec, cool skin, mottled •  Crying, anxious, consolable

Further history- mom states “baby turned blue , stopped crying, stopped breathing” twice past 3 hrs Lasted “ forever” but baby better after mom picked baby up and rubbed back “Is this important? “ mom asks Impression- sick or not sick? What do you want to do?

107 Tobay Bochan (Flickr) 2010

Interventions

•  ABC’s •  Oxygen •  Suction •  IV access, IVFP, check blood

sugar •  Initial trial albuterol •  Consider Racemic

Epinephrine •  Call for chest film •  Prepare for intubation


Case Progression

•  Little change with albuterol •  Called stat into room, baby “ not

breathing” and blue •  Apneic, HR 90, sats 74% •  Emergently intubated •  Transferred to PICU

109 Maria Mono (Flickr) 2004

Bronchiolitis •  Viral infection medium and small airways •  RSV 85% (parainfluenza, adenovirus,

influenza A, rhinovirus) •  Seasonal disease •  Peak: winter and early spring •  Most children infected by 3 yrs age •  10% of kids have clinical bronchiolitis w/in 1st

year of life •  Peak incidence 2-6 mths •  Majority mild illness, cough may persist for

weeks •  Highly contagious- WASH HANDS!

110

Jencu (Flickr) 2008

Clinical Manifestations

•  URI symptoms •  Gradual progression over 3-4 days •  Fever •  Tachypnea •  Wheezing •  Retractions/flaring •  Dehydration, secondary otitiis media, pneumonia •  Apnea- especially infants < 3 mths

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Risk Factors for Severe Disease

•  Age •  Prematurity •  Underlying Disease •  Most common complication = APNEA •  Occurs early in illness, may be presenting

symptom •  Most at risk- very young, premature, chronically

ill •  Smaller, more easily obstructed airway •  Decreased ability to clear secretions

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Bronchiolitis score score 3 or more higher risk for severe disease

0 1 2

age < 3 mths < 3 mths

gestation > 37 wks 34-36 wks < 34 wks

appearance

well ill toxic

Resp rate < 60 60-69 > 70

atelectasis absent present

Pulse ox > 97 95-96 < 95 113

Management

•  Supportive care •  Fluids •  Oxygen •  Monitoring •  Pulmonary toilet •  Ventilatory support •  Prevention- Respigam, Synagis

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Management Controversies

•  Efficacy of bronchodilators •  Benefits of steroids •  Risk SBI in bronchiolitic with fever

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Corticosteroids

•  Again, studies inconclusive, unclear benefit in bronchiolitis •  Recent meta- analysis Garrison , et al 2000- suggest

statistically significant improvement clinical symptoms, LOS, DOS hospitalized pts

•  Schuh, et al 2002 – compared large dose Dex (1mg/kg) vs placebo in ED

•  4 hrs after med, improved clinical scores, decreased admit rates, no change sats/ rr

•  Multicenter PECARN –Corneli, et al, N Engl J Med 2007; 357:331-‐339July 26, 2007-‐

infants with acute moderate-‐to-‐severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes.

The new england journal of medicine established in 1812 july 26, 2007 vol. 357 no. 4 A Mul3center, Randomized, Controlled Trial of Dexamethasone for Bronchioli3s Howard M. Corneli, M.D., Joseph J. Zorc, M.D., Prashant Mahajan, M.D., M.P.H., Kathy N. Shaw, M.D., M.S.C.E., Richard Holubkov, Ph.D., Scoe D. Reeves, M.D., Richard M. Ruddy, M.D., Baqir Malik, M.D., Kyle A. Nelson, M.D., M.P.H., Joan S. Bregstein, M.D., Kathleen M. Brown, M.D., Maehew N. Denenberg, M.D., Kathleen A. Lillis, M.D., Lynn Babcock Cimpello, M.D., James W. Tsung, M.D., Dominic A. Borgialli, D.O., M.P.H., Marc N. Baskin, M.D., Getachew Teshome, M.D., M.P.H., Mitchell A. Goldstein, M.D., David Monroe, M.D., J. Michael Dean, M.D., and Nathan Kuppermann, M.D., M.P.H., for the Bronchioli3s Study Group of the Pediatric Emergency Care Applied Research Network (PECARN)* Abstr act From the University of Utah (H.M.C.) and Central Data Management and Coordina3ng Center (R.H., J.M.D.), Salt Lake City; the Children’s Hospital of Philadelphia, Philadelphia ( J.J.Z., K.N.S.); Children’s Hospital of Michigan, Detroit (P.M., B.M.); Cincinna3 Children’s Hospital Medical Center, Cincinna3 (S.D.R., R.M.R.); Washington University, St. Louis (K.A.N.); Columbia University, New York ( J.S.B.); Children’s Na3onal Medical Center, Washington, DC (K.M.B.); Devos Children’s Hospital, Grand Rapids, MI (M.N.D.); Women and Children’s Hospital of Buffalo, Buffalo, NY (K.A.L.); University of Rochester Medical Center, Rochester, NY (L.B.C.); Bellevue Hospital Center, New York (J.W.T.); Hurley Medical Center, Flint, MI (D.A.B.); Children’s Hospital, Boston (M.N.B.); University of Maryland, Bal3more (G.T.); Johns Hopkins Children’s Center, Bal3more (M.A.G.); Howard County General Hospital, Columbia, MD (D.M.); and the University of California, Davis, Medical Center, Sacramento (N.K.). Address reprint requests to Dr. Corneli at P.O. Box 581289, Salt Lake City, UT 84158-‐1289. *Other inves3gators in the PECARN Bronchioli3s Study Group are listed in the Appendix. N Engl J Med 2007;357:331-‐9. Copyright © 2007 Massachuse<s Medical Society. Background Bronchioli3s, the most common infec3on of the lower respiratory tract in infants, is a leading cause of hospitaliza3on in childhood. Cor3costeroids are commonly used to treat bronchioli3s, but evidence of their effec3veness is limited. Methods We conducted a double-‐blind, randomized trial comparing a single dose of oral department as moderate-‐to-‐severe bronchioli3s (defined by a Respiratory Distress Assessment Instrument score ≥6). We enrolled pa3ents at 20 emergency departments during the months of November through April over a 3-‐year period. The primary outcome was hospital admission aner 4 hours of emergency department observa3on. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events. Results Baseline characteris3cs were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, −1.3%; 95% confidence interval [CI], −9.2 to 6.5). Both groups had respiratory improvement during observa3on; the mean 4-‐hour RACS was −5.3 for dexamethasone, as compared with −4.8 for placebo (absolute difference, −0.5; 95% CI, −1.3 to 0.3). Mul3variate adjustment did not significantly alter the results, nor were differences detected in later outcomes. Conclusions In infants with acute moderate-‐to-‐severe bronchioli3s who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status aner 4 hours of observa3on, or later outcomes. (ClinicalTrials.gov number, NCT00119002.) The New England Journal of Medicine as published by New England Journal of Medicine. Downloaded from www.nejm.org at UNIVERSITY OF MICHIGAN on July 25, 2010. For personal use only. No other uses without permission. Copyright ©

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Serious Bacterial Infection

•  Defined as bacteremia, UTI, meningitis •  What is risk for concurrent SBI in infant < 2 mths, febrile,

with bronchiolitis? •  Kupperman, et al 1997 showed substantial risk for UTI in

febrile infant- rate unchanged whether concurrent bronchiolitis

•  Levin, et al 2004 PECARN study- risk SBI still high in neonate (<28 days) w/ bronchiolitis-

need FSWU 29-60 day- still high risk for UTI even with RSV

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Serious Bacterial Infection

•  Febrile infants with bronchiolitis may be at lower risk for SBI

•  However, reduced risk for bacteremia and meningitis is not zero- especially neonate

•  Rate for UTI, predominant SBI, remains significant despite having bronchiolitis

•  Still check for UTI in febrile infant with bronchiolitis

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Admission

•  High risk pts more disposed to severe disease •  Chronic lung disease •  Congenital heart disease •  Immunocompromised •  Infants < 3 mths age, especially if < 37 gestation •  Resp distress- rr > 70, Sats < 95% •  Any history of apnea •  Poor po/ decreased urine output/ concerns hydration

status •  Concerns re : follow up or compliance •  Parental anxiety/ fear

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Case 8 •  12 yr old male •  URI symptoms x 3 days, non

productive cough •  Increased distress past 6 hours •  Long hx asthma •  Multiple admissions, PICU x 2,

never intubated •  Ran out of Albuterol- used 1 MDI

past week •  Flovent “ as needed”, but ran out

1 mth ago •  Mom smokes, but “ not in house” •  Doesn’t know what peak flow

meter is

NRB placed, sats up to 95 % on 100% FIO2 Albuterol started at triage Pt still in distress What do you want to do? Where will this pt go? Does he need blood gas? Will chest film change your management?

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Pediatric Asthma

•  THE chronic disease of childhood •  Prevalence , morbidity and mortality all

dramatically increasing- U.S and other developed nations

•  17% US school aged children- 5.5 million kids

•  Increase occurred both sexes •  All ethnic groups •  Sharpest rise in kids < 5yrs and in

urban, minority population

121

Zach Copley (Flickr) 2007

Pediatric Asthma

•  10 million missed school days annually

•  Loss of parent productivity- $ 1 billion/year

•  Health care costs- > $6 billion/year •  13 million outpt vists/yr •  1.6 million annual ED visits •  > 5000 deaths/year

122

National Heart, Lung and Blood Institute (Wikimedia Commons)

Prevalence Rates

•  Boys 50% > girls •  African Americans 44% > white/ hispanics •  12% greater if below poverty line •  Highest at risk : poor, black, male

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Pediatric Asthma Mortality

•  Rates more than doubled since 1980 •  Black child 4x higher risk of dying •  Urban adolescent highest risk group •  Limited access to care •  Delay in seeking care •  Over use albuterol/ rescue meds •  Under use steroids •  Major risk factor for death = prior intubation

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Definition •  Chronic inflammatory

disease •  Frequent exacerbations •  Reversible airflow

obstruction w/ meds •  Multiple triggers- viral URI,

mycoplasma, exercise, allergies, environmental (tobacco, dust, roaches)

•  Manifested as SOB, cough, wheeze, chest tightness

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Source Undetermined

History

•  Current flare- onset/ severity symptoms

•  Prior flares- PICU, intubation, near fatal episodes

•  Baseline severity of disease- ED visits, last steroids, peak flow, hospitalization

•  Social issues: followup, compliance with meds, ability to pay for meds, distance to ED

•  Even those with mild RAD can present with sudden, severe, life threatening attack

Pressured speech Tachypnea Tachycardia Accessory muscle use Wheezing Aeration Prolongation expiratory phase Pulse oximetry Subtle changes in mentation

Physical exam

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•  Inhaled Beta agonists •  Nebulized

Anticholinergic Agents •  Corticosteroids •  Magnesium sulfate •  Heliox •  Intubation

Treatment

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Step 4: Severe Persistent

Step 3: Moderate Persistent

Step 2: Mild Persistent

Step 1: Intermittent

STEP-UP

STEP-DOWN

Inhaled Beta Agonists

•  Standard 1st line therapy •  Most effective way to relieve

airflow obstruction •  Rapid onset of action ( 5

minutes) •  Albuterol- relaxes smooth

muscle to relieve bronchospasm

•  Delivery- MDI vs Nebulizer •  Dosing- intermittent vs

continuous

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How to Use A Metered-Dose Inhaler 1. Shake the medicine. 2. A) Hold the inhaler so the mouthpiece is 1 ½ to 2 inches (about 2 to 3 finger widths) in front of your open mouth. Breathe out normally. Press the inhaler down once so it releases a spray of medicine into your mouth while you breathe in slowly. Continue to breathe in as slowly and deeply as possible. or B) If holding the inhaler in front of your mouth is too hard, breathe out all the way and then place the mouthpiece in your mouth and close your lips around it. Press the inhaler down once to release a spray of medicine into your mouth while you breathe in slowly. 3. Hold your breath for 10 seconds or as long as is comfortable. Breathe out slowly.

Albuterol Delivery- MDI or Nebulizer

•  Multiple studies demonstrate equivalent efficacy as long as MDI used with spacer/ mask ( Chou, 1995, Williams, 1996, Schuh, 1999, Leversha, 2000)

•  MDI/ spacer more efficient delivery of meds,portable, able to be incorporated for home plan

•  Optimal dose not well established most 4 puffs = 1 nebulized tx •  Nebulizer can deliver humidified

oxygen •  Nebulizer best for severely ill

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Miriamjoyce (Flickr) 2006

Albuterol Dosing

•  NAEPP recommendation is nebulized albuterol q 20 minutes x 3 treatments

•  < 50 kg- 2.5 mg (0.5cc) •  > 50 kg- 5.0 mg (1 cc) •  Essentially the same as continuous tx •  Continuous albuterol safe and effective •  Promptly initiate severe flare/ impending resp

failure, little response to initial therapy •  0.5 mg/kg/hr ( max-15-20 mg/ hr)

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Atrovent

•  Derivative of atropine •  Onset quick- 15 minutes, peak 40-60 minutes •  Weak bronchodilator itself •  Adjunctive med to be used with beta agonist (Schuh,

1995, Qureshi, 1998, Zorc, 1999) •  Use mod –severe attacks •  Administer concurrently with 1st 3 albuterol treatments •  Frequency/ efficacy further treatments after initial hour

not established

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Corticosteroids

•  Indicated for most pts in ED with asthma exacerbation •  Multiple studies have shown decreased hospitalization

rate when given steroids early in ED course (Scarfone, 1993, Rowe, 1992,, Tal , 1990)

•  Effective within 2-4 hrs of administration- 2mg/kg •  IV and po route equivalent •  PO route preferred- short course safe and effective •  Severe distress, emesis may force IV •  Qureshi, 2001 – 2 doses Dexamethasone = 5 days

prednisone (0.6 mg/kg, max 16 mg) •  Compliance improved, can give IM if pt fails po

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D4duong (Wikimedia Commons) 2012

Inhaled Steroids

•  Mainstay of chronic asthma management •  Potential use in acute setting ambivalent •  Initial studies-( Scarfone, 1995- nebulized dex,

Devidal, 1998, budesomide) encouraging •  However, Schuh, 2000 showed inhaled fluticasone

to be less efffective than oral prednisone in kids with severe attack in ED

•  If not on chronic control meds, consider starting maintenance inhaled steroid regimen from ED

133

Zpeckler (Flickr) 2009

Magnesium Sulfate

•  Bronchodilation- smooth muscle relaxant •  Effective IV route only •  Effects 20 minutes after infusion, can last up to 3 hrs •  Limited pediatric data but most suggest beneficial-

especially severe attack ( Ciarallo, 1996, 2000, Scarfone, 2000)

•  50-75 mg/ kg , Max dose 2 grams, IV over 20 minutes •  Severely ill asthmatics, potential PICU admission, not

responsive to aggressive conventional treatment have greatest benefit

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Heliox

•  Mixture helium and oxygen •  Reduces turbulent flow and airway resistance •  Use in upper airway obstruction well established •  Efficacy in lower airway disease controversial •  Need 60% helium to be effective •  Hypoxemia limits its usefulness

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Mechanical Ventilation •  Should be avoided if at all possible •  Should be “ last resort” •  Increases airway hyperresponsiveness •  Increased risk barotrauma •  Increased risk circulatory depression/arrest •  Early recognition poor response to therapy/ potential

PICU admission •  Indications include severe hypoxia, altered mentation,

fatigue, resp or cardiac arrest •  Rising CO2 in face of distress or fatigue •  Ketamine if intubation required

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Ancillary Studies

•  Peak flow, especially in comparison from baseline •  ABG– painful, invasive, not routine •  Decision to intubate never made based on ABG result alone-

look at pt! •  Baseline CBC, Basic not routinely needed •  Continuous albuterol- watch hypokalemia •  Mod- severe asthmatics may be dry- decreased po, emesis

from meds, insensible losses- may need IVF •  Chest film- reserve for 1st time wheezers, clinically suspected

pneumonia/ pneumomediastinum/pneumothorax, PICU player

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Disposition

•  Most asthmatics require at least 2 hrs assessment and treatment in ED

•  Must observe for at least 1 hr after initial 3 treatments/ steroids given

•  Consider likelihood follow up, compliance with meds, triggers

•  Admit if can’t tolerate po, distress, hypoxic, comorbidities, PICU admission or intubation in past, poor social situation

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Risk Factors for Fatal Flare

•  Hx of severe sudden exacerbation •  Prior PICU admission or intubation •  > 2 Hospitalizations past year •  > 3 ED visits past year •  > 2 MDI/ mth •  Current steroid or recent wean •  Medical comorbidiites •  Low socioeconomic status, urban setting •  Adolescent- poor perception of symptoms

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Conclusions •  Anatomic differences between pediatric and adult airway make kids

more susceptible to acute airway compromise •  Subglottic area is most narrow area in pediatric airway •  Any inflammation in child’s subglottic area greatly reduces airway

diameter •  Use pediatric assessment triangle to guide urgency of intervention •  Will quickly enable to recognize “ sick” child •  Goal: prevent progression of resp distress to resp failure and cardiac

arrest •  Multiple infectious and non infectious etiologies to upper airway

obstruction •  Choose appropriate antibiotics – Staph, strep , H. flu •  Age of patient may guide your diagnosis •  Meningismus may accompany deep neck infections •  Need high index of suspicion! •  Tracheitis may have supplanted epiglottitis and croup as etiology for

acute life threatening upper airway infection

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Conclusions

•  Identification aspirated FB can be difficult •  As w/ other FB, young kids most at risk •  Most aspirated FB radiolucent-‐ won’t be seen on film •  Peanuts consistently most common object aspirated •  High index of suspicion •  Think FB if acute onset symptoms-‐ wheeze/ cough in pt no prior RAD •  Recurrent pneumonias •  Kid not improving w/ appropriate therapy-‐ steroids, antibiotics •  Increased symptoms after eating-‐ especially if kid running/ jumping while

eating •  Bronchoscopy test of choice •  Caustic ingestions/ thermal injuries may have immediate and progressive

symptoms-‐ control airway early •  Treat anaphylaxis aggressively-‐ drug of choice is EPINEPHRINE

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Conclusions

•  Respiratory distress multiple etiologies •  Goal- prevent progression to resp failure and cardiac

arrest •  Age and season can guide diagnosis and tx •  Younger the pt, more likely to be viral- RSV •  Strep pneumo is most likely bacterial agent (outside

neonatal period) •  Mycoplasma increases with age •  Coexistence of viral and bacterial pathogens common •  Variety presentations for pediatric pneumonia

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Conclusions

•  Apnea may be 1st and only symptom bronchiolitis

•  More likely early in course, < 3 mths age •  Admit kids at risk for more severe disease •  Treatment is supportive •  May be small subset that benefit from steroids

and bronchodilators •  Neonate with bronchiolitis- still consider FSWU •  Febrile infant with bronchiolitis -risk UTI

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Conclusions

•  Treat asthma aggressively •  Start steroids early in ED course •  Dexamethasone improves compliance •  Early recognition of need for PICU •  MDI/spacer/ mask more efficient than nebulizer-

incorporate for home use •  Be wary of risk factors for fatal attack

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145 The McGraw-Hill Companies, Inc.

146 UpToDate

Ques3ons

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GEMC: Pediatric Respiratory Distress: Resident Training

Education

Transcript of GEMC: Pediatric Respiratory Distress: Resident Training