Pedi respiratory

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Pediatrics Respiratory Emergencies

Transcript of Pedi respiratory

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PediatricsRespiratory 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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Severity of Respiratory Compromise

Distress Failure Arrest

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General Treatments

Establish Airway Oxygen BVM ET NG tube Decompression Needle Cric

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Respiratory Emergencies

Croup Epiglottitis Asthma Bronchiolitis Foreign body aspiration Bronchopulmonary dysplasia

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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 X-Ray

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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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Stridor

http://www.youtube.com/watch?v=Zkau4yHsLLM

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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 ThreatPossible Complete Airway

Obstruction

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Venn Diagram

croupepiglottitis

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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: PathophysiologyBronchospas

m

Bronchial Edema

Increased Mucus

Production

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Asthma: Pathophysiology

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Asthma: PathophysiologyCast 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 equals

Danger

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Wheezing

http://www.youtube.com/watch?v=YG0-ukhU1xE

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Head Bobbing

https://www.youtube.com/watch?v=q0bHwMayCJY

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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 Terbutaline Metaproterenol Isoetharine

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Asthma: Management

Nebulized anticholinergics Atropine Ipatropium

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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 Terbutaline--0.25 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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Magnesium Sulfate

25-50 mg/kg over 20 minutes

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Solu-Medrol

1-2 mg/kg IV

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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) Respiratory Syncytial Virus 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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Asthma or Bronchiolitis?

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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

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Bronchopulmonary Dysplasia

BPD

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BPD: Pathophysiology

Complication of infant respiratory distress syndrome

Seen in premature infants Results from prolonged exposure to high

concentration O2 , mechanical ventilation

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BPD: Signs/Symptoms

Require supplemental O2 to prevent cyanosis Chronic respiratory distress Retractions Rales Wheezing Possible cor pulmonale with peripheral edema

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BPD: Prognosis

Medically fragile, decompensate quickly Prone to recurrent respiratory infections About 2/3 gradually recover

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BPD: Treatment

Supplemental O2 Assisted ventilations, as needed Diuretic therapy, as needed

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Intubation: Tube Size

Infant or Child < 2 : 4.0, 4.5, or 5 Newborn: 3 (or more for a big baby) Preemie: 2.5 or 3

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Intubation: Tube Sizes

Child older than 2 (16 + age in yrs) / 4 Or (age in yrs / 4) + 4

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Miscellaneous

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KIDS EAT EVERYTHING

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