United Airways Module - Indian Academy of Pediatrics · 2020. 4. 11. · Assess & Classify...
Transcript of United Airways Module - Indian Academy of Pediatrics · 2020. 4. 11. · Assess & Classify...
United Airways Module
A Module For The Practicing PediatricianUnder The IAP Presidential Action Plan 2018
TeamDesignation Name
Chairperson Dr Santosh SoansCo-chairperson Dr Sachidanand Kamath IAP Coordinator Dr Bakul ParekhNational Coordinator Dr Jose OusephJoint National Coordianator Dr Salim A KhatibNational Scientific Convener Dr S Balasubramanian Jt. National Scientific Convener Dr S. Nagabhushana
Zonal ConvenersSouth Zone Dr Krishna Mohan RWest Zone Dr Rajendra C DevNorth Zone Dr Ashwani Kumar KamdarEast Zone Dr Santanu DebCentral Zone Dr Paka R Rajender
Contributors• Dr Barnali Bhattacharya• Dr Basavaraj• Dr Dhiren Gupta• Dr Ira Shah• Dr Indu Khosla• Dr Gautam Ghosh• Dr NC Gowrisankar• Dr Jagdish Chinnappa• Dr Jagdish Dhekne• Dr Jeeson Unni• Dr E Mahender• Dr Prabhakar murthy
• Dr Srinivas Gunda• Dr Subba Rao SD • Dr Sumanth Amperayani• Dr Sushil K Kabra• Dr Subramanya NK• Dr Salim A Khatib• Dr Tanu Singhal• Dr Thangavelu S• Dr Upendra K• Dr Vijay Yewale• Dr Vineet Sehgal
• Dr Pankaj Vaidya• Dr Pallab Chatterjee• Dr Pritish Nagar • Dr Palaniraman R• Dr P Ramachandran• Dr Sanjay Natu• Dr Sanjay Bafna• Dr Somu Sivabalan• Dr Sharath Balaji• Dr Shishir Modak• Dr Shivakumar• Dr Srikanta JT
Pediatric Respiratory Emergencies
Do’s and Don’ts
Objectives• Differentiate effortless tachypnea from respiratory distress• Recognize Respiratory Distress
• Respiratory Distress Vs Respiratory Failure
• Differentiate Upper Airway obstruction fromLower Airway obstruction
• Recognize life threatening signs
Rapid Assessment of Respiratory Distress
1. Respiratory rate - TachypneaAGE RESPIRATORY RATE (RR)• < 2 Mo ≥ 60 / minute• 2 Mo - 12 Mo ≥ 50 / minute• 12 Mo - 5 Yrs ≥ 40 / minute
2. RetractionsPresent or absent
• Absent to mild / moderate / severe & generalized with use of accessory muscles
Rapid Assessment of Respiratory Distress 3. Noisy breathing - Site of obstruction
• Upper airway obstruction• Snuffles Nasopharynx• Snoring Oropharynx• Inspiratory Stridor Larynx & Trachea (Extrathoracic
upper Airway obstruction)• Biphasic stridor (Intrathoracic upper Airway obstruction)Lower airway obstruction• Wheeze Bronchial treeLung: Grunt Parenchyma/ Pleura
Rapid Assessment of Respiratory Distress
4. Level of consciousness• Normal or Abnormal• Abnormal: restlessness, anxiety, irritability
lethargic, or depressed
5. Air Entry• Normal or decreased
6. Pulse Oximeter < 94% on room air (Hypoxia)
Triage (C – B – C) - Life Threatening Event (LTE) vs Others
Consciousness
Breathing
Initial Assessment
Colour
Assess & Classify Physiological Status
1. Respiratory Rate 2. Work of breathing (WOB) - Increased / decreased 3. Altered level of consciousness (ALC)4. SpO2 < 95 % is hypoxia
Normal Effortless Tachypnea
Respiratory distress
Respiratory failure
Rate N
WOB N N
ALC No Yes/No No Yes
SpO2 N N N /
What is Abnormal?
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Effortless Tachypnea vs Respiratory Distress
• Breathlessness & drowsiness
• No cough
• No response to nebulization
• SpO 2 - 97% in room air
• Breathlessness
• Cough
• Past wheezing episodes
• SpO2 – 90%
Effortless Tachypnea Respiratory Distress
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What is Abnormal?
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What is Abnormal?Respiratory Distress Respiratory Failure
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§ Depressed consciousness§ Head bobbing§ Retractions
Clinical LocalisationOther clinical
signs Upper airway disease
Lower airway disease
Parenchyma Pleura Disease
Cardiac
Tachypnea ++ ++ ++++ +++
Retractions ++++SSR, ICR
++ICR, SCR
++ICR, SCR
++ICR, SCR
Noisy breathing STRIDOR WHEEZE GRUNT GRUNT
Dullness on percussion
+ / -
Enlarged liver +
Cardiac signs: Gallop, tachycardia
What is Abnormal?
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What is Abnormal ?
Grunt - Expiratory Sound Stridor - Inspiratory
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Anatomic Diagnosis & Common Etiologies
Stridor (UAW)
Wheezing ( LAW)
Grunt (Parenchymal /
Pleural)Croup Asthma Pneumonia
FB airway Bronchiolitis Empyema
Pulmonary edema
ARDS
Serious Acute UAO
• ALTB / Croup, Epiglottitis, Tracheitis, Retropharyngeal abscess, Parapharyngeal abscess, Diphtheria
Infectious
• Glottic, subglottic Foreign Body
• Burns, Post intubation stridorTrauma
OthersAngioedema, Spasmodic croup, Tumors
Toxic Child with UAO
• High Fever
• Mild cough
• Pain
• Odynophagia
• Drooling
• Abnormal neck posture
• Neck swelling
• Mild stridor
THINK OF THE SCARY SIX
1. Diphtheria
2. Peri tonsillar abscess
3. Retro pharyngeal abscess
4. Para pharyngeal abscess
5. Epiglottitis
6. Tracheitis
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Case 1• 1 yr male child with Cough, Rhinnorhea since 2 days
• Difficulty breathing, change in voice for 1 day
• Examination• Irritable, Afebrile• RR 40 / min• Respiratory distress with retractions • Inspiratory stridor at rest• Air entry bilaterally equal• SpO2 - 93 % in room air
What is Abnormal ?
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Croup
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Mild croup Moderate croup
Severe croup Impending Respiratory
failure
Occasional barky cough Barky cough Frequent barky cough
Depressed level of
consciousnessNo stridor at rest Stridor at rest Stridor at rest Stridor at rest
No or Mild retractions Mild to moderate
retractions
Marked retractionsAgitation
Severe retractions Poor
air entryCyanosis or
pallor
Assessment of Severity - Croup
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Management of Croup • Do not separate child from care giver (minimize anxiety)
• If hypoxic administer O2 in non-threatening manner
• Nebulised Adrenaline (routinely available Adrenaline)
• Relieves airway obstruction with 10 mins
• First drug in moderate and severe croup
• Should be followed by IV/IM Dexamethasone
• Dose 0.5ml/kg 1 in 1000 dilution max. of 5ml
• Can be repeated if airway obstructive symptoms recur
Management of CroupSteroids - Definitive therapy in croup of any severity
• IM / IV Dexamethasone 0.6mg/kg/ single dose (most accepted option)
• Oral steroids are beneficial, even in mild croup
• Intramuscular dexamethasone and nebulized budesonide (2mg 12 hrly for 48 hrs) have an equivalent clinical effect
• A single dose of oral prednisolone is less effective
• Sedation is contraindicated
• No role for routine antibiotics
Case 2• 3 yr old brought after Bee Sting, presented with
• Difficulty in breathing, Noisy respiration
• O/E - Flushing of skin, Inspiratory Stridor
• What is your diagnosis?
Case 2• 3 yr old brought after Bee Sting, presented with
• Difficulty in breathing, Noisy respiration• O/E - Flushing of skin, Inspiratory Stridor
• What is your diagnosis?• Anaphylaxis
Management• Supine position with the lower extremities elevated• First line of treatment
• Inj-Epinephrine (1:1000 dilution) IV route also may be used in severe hypotension (0.01 mL/kg/dose of 1 : 10,000 slow IV push)
• IM: 0.01 ml/kg, max 0.5 ml - q 5-15 min• Adjuncts
• Salbutamol nebulisation • Cetrizine or Diphenhydramine• Ranitidine • Steroids – MPS or Hydrocortisone• Volume expanders (Crystalloid/colloids)
Inj-Epinephrine (1:1000 dilution) age based dose
Management• Carry Home Message
• Keep Adrenaline in clinic (Caution - short expiry )• Never administer Adrenaline Subcutaneous (SC) in Anaphylaxis
Case - 3 • 13 year old asthmatic girl presented with
• Severe cough for 3 days• Difficulty in breathing for 1 day
• Examination • Afebrile• Severe tachypnea• Nasal flaring with Intercostal & Subcostal retractions• Extensive Bilateral wheeze • SpO2 - 88 % in room air
• What is the Diagnosis ?
Acute Severe Asthma (ASA)
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Management• Oxygen to maintain SpO2 > 95%
• Bronchodilator
• Steroid
• Constant monitoring is essential
• Pulse Oximetry aids clinical assessment in monitoring
• Salbutamol• Nebulization or MDI (3-6 puff of SABA every 20 minutes in
the first hour) through space +/- mask• Nebulization with oxygen - flow rate of 6-8 liters/min
Dose is 2.5 mg (<20kg) & 5mg (>20kg) Every 20 min for three doses
• Ipratropium • Useful in moderate & severe attacks as an add on to
Salbutamol• Dose is 250 mcg < 20 kg and 500 mcg > 20 kg
Glucocorticoids• Oral is preferred to parenteral
• Give early ( within the 1st hour )
• Prednisolone 1-2 mg/kg (Max 40mg) OD or Hydrocortisone - 4mg/kg IV (Max 300mg) q6H or Oral/IM/IVDexamethasone 0.6mg/kg/dose (Max 16mg/dose) OD for 2 days
• Do not use inhaled Corticosteroids in acute exacerbations
Magnesium Sulphate Infusion• 50 mg / kg infusion in NS over 20 to 30 mins• Max dose 2 gms • Indications
• Persistent severe symptoms after SABA, ipratropium and steroids
• Caution - hypotension and muscular weakness
Do’s• Check SpO2 in all children with acute asthma
episode
• Use steroids early (Oral is effective )
• Mild & moderate exacerbations can be managed by
MDI Space +/- mask
Don'ts• Routine CXR not needed• Inhaled steroids• Oral Beta2 agonists/ LTRA• Nebulisation without oxygen• Antibiotics• Mucolytics / Cough medications / Sedation • Routine Chest physiotherapy
Initiate Treatment & then Refer• First give initial therapy then refer• Document examination findings and medications
• Refer with• With oxygen• Inhaled beta2 agonists• S/C adrenaline or terbutaline. 0.01 ML/KG sc MAX 0.5
mL• Rescue steroids
Case 4• 2 year 6 months old boy
• Sudden onset of Cough with Respiratory distress
• No fever or coryza , no past wheeze episodes
• O/E HR-118/min, R.R-68/min with chest retraction,
SpO2-95% on room air
• Air entry decreased on Left side
What is the Diagnosis?
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HyperareatedLeft Hemithorax
Mediastinum Shift to Right
Broncho – VascularMarkingsObstructive Emphysema, Left Side, Due to Foreign
Body
CXR - Mandatory in any Unexplained Respiratory Distress
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Foreign Body
Can cause complete or partial airway obstruction / Laryngeal spasm
• Respiratory distress • Respiratory failure• Cardio – respiratory arrest
Missed or delay in diagnosis• Pneumonia –
Acute/Recurrent• Lung abscess• Chronic lung disease
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When to Suspect Foreign Body?
• History of choking – highly suggestive (absence does not exclude)
• Acute or chronic respiratory symptom with unclear etiology • Absence of viral prodrome (fever, coryza, sneezing)• Respiratory illness not responding to standard therapy• Management
• Refer to Bronchoscopy at earliest• Rigid Bronchoscopy under GA • Procedure of choice for removal• Even if CXR is normal but history suggestive of foreign body
aspiration
Emergency Management• Complete Laryngotracheal (central) airway obstruction • “Cant talk / cough, Apneic , Cyanosed & ALC ”
< 1 Year > 1 Year
Case 5
• 6 months old child treated as bronchiolitis & referred in view of worsening distress
Cardiomegaly with pulmonary congestion
Message • Do not miss non – respiratory cause of respiratory
distress – CCF, especially in infants particularly in the
presence of disproportionate and persistent tachycardia
• Always assess cardiac size when viewing CXR
Case 6• 6 yrs old child being treated for GBS in a private hospital
was referred for altered mental status
• Referring note • Child maintaining saturation 96% in room air
Cause of Altered Mental Status
• Respiratory failure
• Though her Spo2 was normal, her PCO2 in ABG was
high
• Explaining the altered mental status
Case Progression
• Intubated & ventilated
• Ventilatory support for 2 weeks
• Discharged at 4 weeks
• Back to school in 3 months
ABGpH- 7.3pCO2- 62HCO3- 27BE- -1pO2- 76SaO2 95%
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Pearls• Respiratory emergency need not always present with primary
respiratory symptoms & sign
• Consider respiratory failure as a cause of altered mental status in sick children
• Both hypoxia & hypercapnia cause altered mental status
• In early respiratory failure SpO2 may be normal
• Ventilatory support changes morbidity and mortality in many neurological illnesses
Case 7• 6 yrs old with acute breathlessness, no fever
• RR- 50/m
• No distress
• No stridor, wheeze, crackles
• No hepatomegaly, no murmur / gallop
• Perfusion normal
• CXR – Hyper-areated lung fields
Different generations of airway
• Human airways have approximately 23 airway generations.
• The last 7 of these cover 95% of the total airway surface area. To treat asthmatic inflammation, we should probably target all airways
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Infant with high grade fever with respiratory distress
Scenario
Diagnosis ?What next ?
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Sites for Needle thoracocentesis
Pyopneumothorax drained
What is it?
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ACIDOTIC BREATHING – CHECK BICARB, ABG, SUGAR
Think of metabolic cause in SILENT TACHYPNEA
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What is it?
Summary• Respiratory Emergencies is the most common medical emergency in
children
• History and correct physical examination alone allows one to pinpoint
the cause to a particular part of the respiratory system and to make
the appropriate decisions for a proactive and life-saving management
of the critically ill child
• Look for and immediately manage life-threatening emergencies*, if any,
before proceeding for further assessment
Summary• Both hypoxia and hypercarbia can cause altered mental
status
• Administer O2 to any child with respiratory distress
• Administer in a non threatening manner
• Assessment can be done while O2 is provided
Devices
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PROBLEM SPECIFIC MANAGEMENT
Upper airway obstruction (stridor) Adrenaline nebulizationDexamethasone IM // oral
Lower airway obstruction (wheeze) Nebulization with O2Salbutamol, ipratropium , SC Adrenaline or SC Terbutaline
FB airway - Complete airway obstruction Cant talk, cough, cyanosed and ALC
Back blows and Abdominal thrusts Heimlich's maneuver No blind sweep to remove FB
Seizures causing respiratory failure IM midazolam along with BMV
Anaphylaxis Urticaria, angioedema, hypotension , Airway obstruction –UAW/LAW +/-GI symptoms
IM adrenaline
Specific Management Before or During Transport
Specific management should not delay ABC stabilization
Equipments
Clinic• Ambu Bag pediatric with reservoir • Three masks – Adult, pediatric,
infant • De lee suction • Inj Adrenaline, Midazolam• IV drip set, IV cannula• NS/RL • Oxygen Cylinder • Rs. 10,500 – 24,000
Clinic Optional/Hospital• O2 concentrator • Non rebreathing mask • Bain’s or Jackson Rees circuit• Laryngeal mask airway different
sizes• Intra-osseous or BMA needle
• Rs. 58,000 maximum
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We express our Gratitude for making this possible to
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