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Common Paediatric Respiratory conditions

Common Paediatric Respiratory conditions. Corrine Balit . Outline. Respiratory Distress : Signs and Treatment Respiratory Supports High Flow Nasal prong CPAP/ BIPAP Ventilation Bronchiolitis Pertussis Asthma. Case 1: 6 week old E.L.

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Common Paediatric Respiratory conditions

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  1. Common Paediatric Respiratory conditions Corrine Balit

  2. Outline • Respiratory Distress : Signs and Treatment • Respiratory Supports • High Flow Nasal prong • CPAP/ BIPAP • Ventilation • Bronchiolitis • Pertussis • Asthma

  3. Case 1: 6 week old E.L. • 6 week old infant presents with severe respiratory distress • Taken to resuscitation bay on arrival • Call from ED doctor asking for help

  4. Resp • RR 90 • Tracheal tug • Intercostal and subcostal recession • Grunting • Head bobbing, nasal flaring • CVS • HR 200 • Cap refill 3 seconds • Mottled • Neuro • Agitated, • Unsettled,

  5. Respiratory Distress/ Failure • One of most common reason ICU will need to review a patient • Hard to determine which patients will need to come to ICU • Clinical assessment and reassessment is most important • May need to start some basic measures and then reassess again.

  6. Investigations • Venous Blood Gas • Carbon dioxide and pH • Lactate • Oximetry • Chest x-ray • Other investigations to support underlying cause.

  7. Who needs to come to ICU • Clear cut ones that do and don’t • In-between that is the hardest. • Indications • Mod- Severe respiratory distress despite basic treatment • Recurrent apnoeas • Respiratory acidosis (pH < 7.2) • Increasing oxygen requirements • Change in mental state • Needing airway protection

  8. Treatment of Respiratory Failure • Administration of supplemental oxygen + consider humidification • Evaluation of airway patency • Clear secretions / Airway toileting to maintain airway patency • Appropriate adjuncts • Salbutamol +/- ipratropium • Steroids if indicated

  9. Respiratory Distress RR < 60 Mild-Mod Work of breathing Oxygen requirement < 2L Not irritable/agitated RR >60 Mod-severe work of breathing Increasing oxygen requirement Irritable/agitated Basic Measures Nil by mouth Cannula + IVF Humidified oxygen total flow of 2-3L Adjuncts appropriate to condition e.g. salbutamol, steroids

  10. Mod-Severe Respiratory Distress IV Cannula Oxygen + humidification Salbutamol, ipratropium, steroids • Indications for ICU • Ongoing mod-severe respiratory distress despite above • Apnoeas • Respiratory Acidosis • Fatigue

  11. Treatment of Respiratory Distress • Specific treatment for conditions • Non-invasive support • High Flow nasal prong oxygen • CPAP • BIPAP • Mechanical ventilation • IPPV • HFOV • ECMO

  12. Treatment of Respiratory Distress • Fluid Management • Generally restricted if receiving ventilatory support • Two- thirds maintenance • Normal saline or Hartmann's as fluid for severe resp distress • Watch EUC • Feeds • Feed once stable and improving • Can feed while receiving NIV support

  13. High Flow Nasal Prong oxygen • Delivered via nasal prong and using Fisher and Paykel System • Rational is two fold: • High flows provide positive distending pressure to the airway improving functional residual capacity • Use of humidification • Humidification improves mucocillary clearance • Advantages: • Tolerated better by children • Avoid some of CPAP complication like nasal mucosal injury

  14. High Flow Nasal Prong oxygen • Flow rates currently recommended up to 8L/Min • Prospective study in Brisbane where the used flow rates between 1 and 8 L/min were used and they used electrical impedance tomography and oesophageal pressures measured. • Found that using 8L/min flow rate delivered on average a CPAP effect of 4 cm H20 in infants with viral bronchiolitis • Definition of High flow nasal prong cannula • 1L/kg/min • Current cannula for paediatrics up to 8L flow.

  15. High Flow- Indications • Respiratory distress with hypoxemia • Bronchiolitis • Pneumonia • Post extubation respiratory support • Facilitation of weaning from CPAP • Post operative respiratory failure

  16. High Flow- Contraindications • Nasal obstruction • Choanal atresia • Large polyps • Foreign body aspiration • Children requiring airway protection • Severe life threatening hypoxia (not a replacement for intubation

  17. Non-Invasive Ventilation • CPAP versus bi-level NIV • Difficulties is with appropriate size mask • Bubble CPAP good for infants (<10kg) • PEEP 5-10cm • Contraindications • If airway protection is needed • Decreased level of consciousness • Nasal obstruction

  18. Invasive Ventilation • Conventional Ventilation • High Frequency Ventilation • If intubating patient for severe respiratory distress suggest always using cuffed tube. • Cuff doesn’t need to go up but there if you need it

  19. Bronchiolitis

  20. Bronchiolitis- aeitology • Respiratory Syncytial Virus • Para influenza virus • Adenovirus • Influenza virus • Rhinoviruses • Human metapneumovirus

  21. Bronchiolitis- Pathology • Loss of epithelial cells • Cellular infiltration • Oedema around airway • Plugging of airway with mucus • Can get complete and partial plugging of airways resulting in localised atelectasis and over distention in other areas. • Imbalance of ventilation and perfusion leads to hypoxemia.

  22. Bronchiolitis – Clinical Features • Coryzal symptoms • Wheezing • Pneumonia • Aponea • Hyponatremia • Seizures • Encephalopathy • Myocarditis

  23. Investigations • NPA • Blood Gas • CXR • Septic workup if severe or very young • FBC, EUC

  24. Bronchiolitis- Indications for ICU admission • Recurrent Apnoea • Slow irregular breathing • Decreased level of consciousness • Shock • Exhaustion • Hypoxia • Respiratory acidosis

  25. Bronchiolitis- Management • Supportive Care • Oxygen • Suction • Fluids / Feeding • Always Nil by mouth if moderate- severe • IV fluids : 2/3 maintenance if moderate- Severe • NG Tube • Decompression of stomach • Feeds once more stable • Infection Control

  26. Bronchiolitis – Specific Treatments • Bronchodilators • Surfactant • Corticosteroids • Ribavirin • RSV Immunoglobulin • Palivizumab • Antibiotics

  27. Bronchiolitis – Specific Treatments Bronchodilators • B- agonists • Meta analysis: modest short term improvement in clinical scores, without changes in oxygen saturation, rate of hospitilisation or length of hospital stay • Adrenaline • RCT comparing adrenaline nebulised with placebo • No difference in length of hospital stay and no short term or long term clinical improvement

  28. Bronchiolitis – Specific Treatments • Corticosteroids • Controversial, conflicting studies • Cochrane review: no benefits in either length of stay or clinical course in infants • Surfactant • Promising as RSV affects endogenous surfactant production • given to mechanically ventilated infants with RSV – shortened time on mechanical ventilation, • Individual case reports and series. • Limited evidence, very expensive

  29. Bronchiolitis – Specific Treatments Ribavirin • Antiviral • Inhibits RSV replication • Evidence supports aerolised use, IV can be given • Early trials showed it to be effective • No convincing benefit on clinical outcomes expect to patients post BMT with RSV

  30. Bronchiolitis – Specific Treatments • RSV- IG IV • No improvement on clinical outcome • Palivizumab • Monoclonal antibody • For prophylaxis for high risk infants • Expensive • 50% decrease in need for hospitlisation in high risk infants

  31. Bronchiolitis – Specific Treatments • Ipratropium bromide • Not been demonstrated to be efficacious • Heliox • Helium-oxygen gas • Prospective study looking at 70% helium, 30% oxygen mixture- improved tachypnoea and tachycardia and shorter stay in PICU • Nitric oxide • Case reports only

  32. Bronchiolitis: Antibiotics • Used for secondary bacterial infection • Traditionally risk of secondary infection with RSV thought to be low but theses studies based on children not admitted to PICU. • Recent studies: PCCM 2010 • Secondary pneumonia in patients in PICU with RSV reported to be as high as 20-50% • If child is unwell enough to be admitted to PICU with bronchiolitis, cultures should be taken and antibiotics started

  33. Levin et al PCCM 2010 • Prospective study looking at patients admitted with RSV bronchiolitis with progressive respiratory failure • Excluded patients who had pre-existing conditions • Found 39% had probable pneumonia by tracheal aspirate • Concluded that due to high rate of possible secondary bacterial pneumonia, empirical antibiotics for 24-48 hrs pending cultures may be justified in those sick enough to come to PICU

  34. Bronchiolitis- Ventilation • High Flow Nasal Prongs • CPAP • Mechanical Ventilation • IPPV • HFOV • ECMO

  35. My Approach – to moderate-severe bronchiolitis • Suction and clear airway esp nasal passages • Application of oxygen with humidification if possible • Nil by mouth • IV cannula + 2/3 maintaince IVF • Obtain venous blood gas (BC + FBC/EUC at time of IVC) • Decide on level of respiratory support • High flow Nasal prong Cannula to 8L/min (not available in ED) • Bubble CPAP

  36. OG or NG if on respiratory support • Constant reassessment, looking for • Decreasing respiratory rate • Decrease in work of breathing • Heart rate improving • If not responding to above to be intubated and ventilated • If sick enough with bronchiolitis to need ventilatory support I do blood culture and sputum culture and cover with antibiotics. • Need to monitor Sodium

  37. Pertussis

  38. Pertussis - Pathology • Bordetella Pertussis • Toxin damages respiratory epithelium and can produce systemic toxicity • Severe, Prolonged Coughing • Aponea in young infants • Whoop- loud stridor on inspiration after a paroxysm

  39. Pertussis- Severe Complications • Pneumonia • Pulmonary Hypertension • Encephalopathy • Seizures • Global Myocardial dysfunction

  40. Pertussis • Mortality highest in • Very young infants • WCC > 100 000 • Presenting with pneumonia • Need for circulatory support • Indications for ICU • Apnoeas • Seizure • Severe respiratory failure

  41. Pertussis - Investigations • PCR on NPA • CXR • WCC • ECHO if severe

  42. Pertussis- Management • Suction • Oxygen • Respiratory support • High flow nasal o2 • CPAP • Ventilation • Antimicrobials • Azithromycin

  43. Pertussis- Other Management • If leukocytosis (esp neutrophilia) • Exchange transfusions or aphaeresis to remove white cells • With high white cell count can get leukocyte aggregates in pulmonary vessels • If Pulmonary Hypertension present • Consider inhaled nitric oxide or sildenafil • If Severe respiratory failure • ECMO • Treat contacts

  44. PCCM 2007 • Retrospective study from RCH Melbourne • Median age at admission was 6 weeks • 94% of patients were unimmunised at time of admission • Infants presenting with pneumonia had raised white cell count • 38% needing intubation died • All patients who needed ECMO died

  45. Asthma

  46. Asthma – Management • Oxygen • B-adrenergic agonists • Corticosteroids • Anticholinergic • Magnesium Sulphate • Theophylline/ Aminophylline • Inhalational anaesthetics

  47. Asthma- Management • Helium-Oxygen • Non-invasive ventilation • Ventilation • Ketamine • Adrenaline

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