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Peds Respiratory Emergencies

Peds Respiratory Emergencies. Adam Davidson Adam Oster May 7, 2009. Thank You’s. Nicole Kirkpatrick Adam Oster. Outline. Anatomy ABC’s Upper Airway Emergencies Lower Airway Emergencies. Anatomy. Prominent Occiput-can cause head flexion Usually no need to place pillow/towel

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Peds Respiratory Emergencies

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  1. Peds Respiratory Emergencies Adam Davidson Adam Oster May 7, 2009

  2. Thank You’s Nicole Kirkpatrick Adam Oster

  3. Outline Anatomy ABC’s Upper Airway Emergencies Lower Airway Emergencies

  4. Anatomy Prominent Occiput-can cause head flexion Usually no need to place pillow/towel Head extension should put in sniffing position Tongue is disproportionally large compared to mouth Larynx is higher in neck (C3-C4 vs C4-C5 in adults) Anterior larynx Large/Floppy epiglottis (choice of laryngoscope blade?) Narrowest portion is at cricoid

  5. Resuscitation Airway Look: alert?, protecting?, cyanotic? Foreign body? Listen: stidor, gurgling, crying, talking Manage: sit pt up, oxygen, OPA/NPA, finger sweep, jaw thrust, prepare to intubate

  6. Resuscitation Breathing Look: rate, indrawing, accessory muscles, nasal flare, cyanosis Listen: stridor, wheeze, crackles, AE bilat, quiet, able to speak in sentences Manage: O2, meds, bag mask, intubation Meds: Ventolin, Atrovent, Mg, Epi, Steroids, Abx, Lasix Nasal flaring and chest retractions more sensitive than tachypnea for resp distress

  7. Resuscitation Circulation Look: pale, lethargic, diaphoretic, mottled, LOC Listen: heart sounds, murmurs Feel: pulses, pulsus paradoxus, cap refill Manage: fluid if no signs CHF, PALS Adjuncts: CXR, ABG/Cap Gas, ECG, Bloodwork, Soft-tissue films

  8. Cap Gas versus ABG’s Excellent approximations of pH and CO2 Are accurate for detecting hypoxemia but correlation falls off as PaO2 values rise Errors occur with false +ves, therefore good screen More blood flow to area, more accurate the reading Make sure to warm area to increase vasodilation

  9. Resuscitation RSI Pre-Oxygenation Pre-treatment: Atropine: 0.02mg/kg (Minimum Dose?, Why?) Lidocaine: 1.5 mg/kg Induction: Ketamine: 1.5-2mg/kg Paralysis: Succinycholine: 2mg/kg

  10. Physical Exam Stridor Hallmark of URT obstruction Inspiratory: usually supraglottic, associated with collapse due to negative pressure Associated with: drooling, hot-potato voice Eg: abscess, croup, epiglottitis Biphasic: usually fixed obstruction at glottis Eg: laryngeal webs, vocal cord paralysis Expiratory: usually sub-glottic, associated with positive pressure of expiration Eg: Tracheitis, foreign body

  11. Physical Exam Grunting LRT pathology Forced expiration creating auto-PEEP Presence usually represents significant distress Wheeze LRT pathology Asthma, Bronchiolitis, Cardiac, Pneumonia

  12. Location Upper Airway Lower Airways Cardiac CHF: congenital, myocarditis, cardiomyopathy PE Tamponade Neurologic SAH, Shaken Baby, meningitis, opiates, anxiety Metabolic DKA CO poisoning, Methemoglobinemia, Hydrogen Sulphide

  13. THE UPPER AIRWAY Pediatric Respiratory Emergencies

  14. Partial Differential Foreign body Epiglottitis Croup Tonsillitis Abscess (retro/parapharyngeal, peritonsillar) Anaphylaxis Angioedema Burns Caustic Ingestion Congenital Abnormality Bacterial Tracheitis

  15. 13 year old female with fever and sore throat Recurrent “Strep throat” Can barely talk, hasn’t been able to eat or drink for 24hrs

  16. Peritonsillar Abscess (Quinsy) Risk Factors: chronic tonsillitis, mono, CLL, dental infection, older age Odynophagia, dysphagia, drooling, hot-potato voice, rancid breath, fever, malaise, dehydration Uvular deviation and trismus most specific for abscess Abscess vs Cellulitis: aspiration of pus May need sedation but needle less painful than I+D Cut plastic needle cover to form guard No cases in literature of carotid puncture

  17. Peritonsillar Abscess Needle aspiration shown to be as efficacious as I+D Can be performed in ED Admit: septic, dehydrated and not able to drink, unreliable follow-up, unable to aspirate If able to tolerate PO fluids, can give dose of IV Abx and f/u with HPTP Abx: Clinda (usually 1st choice), Ancef/Flagyl Steroids: very few studies exist with conflicting data Practice seems to vary between ENT surgeons No evidence of harm

  18. Steroids For Phayngeal Swelling Some ENT surgeons swear by giving steroids to reduce edema/swelling in the pharynx Common practice for mono and peritonsillar abscess Cochrane Review 2009 for steroids with mono Symptomatic Relief for 12 hours only No difference in complete resolution or length of disease No evidence for peritsonsillar abscess, retropharyngeal abscess Consider for patients with acute airway obstruction or those who can’t tolerate PO fluids (Dex 10mg IV) Dickens, KP, et al. Should you use steroids to treat infectious mononucleosis? The Journal of Family Practice, 2008

  19. Retropharyngeal Abscess More common in young children (Age: 6m-3yr) Post URTI or secondary to FB trauma (toothbrush, popsicle stick, etc) Toxic, febrile, drooling, stridor, dysphagia, opisthotonos (can look like meningitis) Px: bulgling posterior pharyngeal wall Soft tissue films: large retropharyngeal space (>1/2 width of vertebral body), retropharyngeal air False +ve: expiration film, neck flexion Treatment: IV Clinda, IV Dex, generally admitted to PICU for monitoring with ENT consult

  20. Croup (Laryngotracheobronchitis) Most common cause of stridor for ages 6m-3yr Causes: always viral Parainfluenza (MCC), Influenza, Adenovirus, RSV Usually benign and self-limited severe disease more common in males Peaks in fall/winter URTI with 3-4d hx of worsening cough Barky cough, stridor, sx usually worse at night Stridor worse with anxiety (ie: in ED) Usually non-toxic with low-grade fever Hypoxia is a rare and late sign

  21. Clinical Croup Score Insp Breath Sounds: Normal (o), Harsh (1), Delayed (2) Stridor: None (0), Inspiratory (1), Expiratory (2) Cough: None (0), Hoarse Cry (1), Bark (2) Retractions/Flaring: None (0), Suprasternal (1), Sub/intercostal (2) Cyanosis: None (0), Room Air (1), 40% O2 (2) Mild: <4 Mod: 4-6 Severe: >6

  22. Croup Treatment Intubation: usually can be avoided with aggressive Tx (if necessary, use ETT 1 size smaller than expected) Steroids: Dex 0.6mg/kg (max 10-20mg?) PO/IM/IV Good evidence for moderate, severe croup Decr admission, intubation, return to ED, croup scores NEJM 2004 showed benefit in mild croup as well No side-effects, One dose lasts 48 hrs Nebulized Epi: 1:1000 Epi (L isomer only) just as good as racemic Nebulize 5ml q2-3hr for maximum of 3 doses (back to back if impending intubation) Good evidence for severe croup Contraindications: mechanical cardiac outflow obstructin (AS, ToF) Complications: MI, V-tach

  23. Steroids and Croup Dex shown to be superior to Prednisolone Single dose of 0.15mg/kg equivalent to 0.3 and 0.6

  24. Croup Disposition Mild Dex PO and D/C home Moderate Dex PO and observe for 3-4hrs before D/C Severe Dex (IV/IM) and Epi, observe for 4-6hrs before D/C Admission Co-morbidities, social situation, complicated airway or previous difficult intubation, dehydration Discharge Instructions Cool air, popsicles, humidity?, F/U with GP in 24-48hrs

  25. Bacterial Tracheitis Sub-glottic bacterial infection Can occur at any age, males = females, no seasonal preference Polymicrobial bacterial superinfection following Croup (primary infection less common) Staph (50%), Strep, H flu, Moraxella Bacterial invasion with copious mucous secretions Airway obstruction secondary to mucous

  26. Bacterial Tracheitis Patient with barky cough and low-grade fever suddenly develops high fever and toxic appearance More respiratory distress than Croup Can appear like Epiglottitis with fever, drooling, resp distress Consider if: Toxic looking Croup Croup lasting >4 days Croup not responding to treatment

  27. Bacterial TracheitisDiagnosis Soft Tissue Films: “shaggy” irregular tracheal wall with intraluminal membrane, steeple sign Dx: laryngobronchoscopy shows normal epiglottis w/ +++ secretions Complications Airway obstruction, ETT plugging (common, consider Trach) Sepsis, DIC, Toxic Shock from Staph

  28. Bacterial Tracheitis Management Airway management best done in OR with Anesthesia consult IV Abx: Cefotaxime/Clindamycin ICU Admission post OR Daily bronchoscopy to remove secretions Consider Trach if persistant ETT plugging No benefit to steroids or nebulized epi

  29. Pediatric Respiratory Emergencies THE LOWER AIRWAYS

  30. Case 1 2M male 3 day history of URTI associated with fever (38.5) Onset of difficulty feeding, increased WOB today Vitals - HR 160 RR 65 SpO2 90% on R/A T 37.9 TT, indrawing, nasal flaring, diffuse crackles and wheezes

  31. Differential diagnosis of Wheeze • Infection (Bronchiolitis, pneumonia) • Asthma • Cystic Fibrosis • CHF • Foreign body • Anaphylaxis • Croup • Epiglottis • Vocal cord dysfunction • GERD • Bronchopulmonary dysplasia

  32. You think he has bronchiolitis • What do you tell his parents about his illness and its natural history?

  33. Bronchiolitis • Viral infection • RSV, influenza, parainfluenza, echovirus, rhinovirus, adenovirus • Mycoplasm, Chlamydia • Children < 2 years, peak at 2 M • October to May • Contact/Droplet • Peak at 3-5 d • Resolves 2 weeks

  34. Bronchiolitis • Inflammation of terminal and respiratory bronchioles • Mucus plug + edema • Airway narrowing • Decrease compliance, increase resistance • Atelectasis and overdistention

  35. Bronchiolitis • Clinical presentation • Wheeze, tachypnea, indrawing • URT symptoms • Fever • Hypoxemia • Apnea

  36. What factors put children at increased risk of severe bronchiolitis? • History of • Prematurity • BPD • CF • Congenital heart disease • Immunocompromised

  37. Management • You start oxygen and encourage feeding • When patient not feeding well you give 20 mL/kg bolus • RT asks you if you want this child to be treated with bronchodilators or steroids… • What do you think?

  38. Controversial • Many trials done to examine use of • Epinephrine • ß-adrenergics • Steroids • IV • PO • Inhaled

  39. Evidence for Epinephrine • Epinephrine vs. placebo or salbutamol • 5/8 showed short term improvement in clinical scores • 1/8 showed fewer hospitalization • 1/8 showed shorter duration of hospitalization

  40. Evidence for Epinephrine • Hartling et al, 2003 • Meta-analysis • Epinephrine vs. bronchodilators or placebo • RCT, infants<2 years, quantitative outcome • 14 studies, 7 inpatient, 6 outpatient, 1 unknown • Outpatient results • Epi better than placebo or other bronchodilators in short term (O2 saturation, RR, clinical score)

  41. Evidence for Epinephrine • Cochrane Systematic Review • 14 RCT (1966-2003) • Inpatient and outpatient treatment • Epinephrine vs. placebo - outpatient (3) • Improvement at 60 minutes (1/3studies) • No difference in admission or O2 saturation • Epinephrine vs. Salbutamol - outpatient (4) • O2 saturation, HR, RR improved at 60 minutes • No difference in admission

  42. Evidence for Bronchodilators • 13 RCT • Bronchodilators vs. placebo or ipatropium • 1/13 showed decreased admission • 4/13 showed some clinical improvement

  43. Evidence for Bronchodilators • Cochrane Systematic Review • 22 RCT (1966-2005) • Bronchodilators vs. placebo • No difference in admission or duration of hospitalization • Minor improvement in oximetry and symptoms in outpatient treatment

  44. Previous studies used larger doses of epinephrine • Effect may not be due to alpha affects, but higher delivery of ß-agonist

  45. RCT comparing racemic epinephrine, racemic albuterol, normal saline in equivalent doses in mild/moderate bronchiolitis • N = 65 (23-albuterol, 17 epi, 25 NS) • 5mg of drug in 3 mL at 0 and 30 minutes • Clinical assessment pre and post • 3 rd dose at 60 minutes if RDAI >8 or O2 saturation < 90% R/A • Final assessment at either 60 or 90 minutes

  46. Required admission/home oxygen • 61% albuterol, 59% epinephrine, 64% NS • No difference in admission rates • No difference in O2 saturation, RR • ß-agonist not useful in Rx bronchiolitis

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