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GEMC: Pediatric Respiratory Distress: Resident Training

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This is a lecture by Dr. Stuart Bradin from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the …

This is a lecture by Dr. Stuart Bradin from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. 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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  • 1. 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/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  • 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  • 3.      Pediatric  Respiratory  Distress   Stuart A Bradin, DO, FAAP, FACEP Assistant Professor of Pediatrics and Emergency Medicine 3
  • 4.                                    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
  • 5.                                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  àprogress  to  cardiac  arrest  in  minutes   •  Prompt  recognition  and  management  of  airway   compromise  is  critical  to  good  outcome   5
  • 6.                                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
  • 7.                                          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
  • 8.          The  Pediatric  Assessment  Triangle   8 Circulation/ Skin Color
  • 9.      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
  • 10.                                        Appearance   •  Level  of  consciousness   –  Irritability   –  Consolability   –  Distractibility     –  Eye  contact   –  Agitation   –  Lethargy   –  Quality  of  Cry   –  Speech   •  Developmental  considerations     10
  • 11.                                          Appearance   11 Clappstar (Flickr) Randy Deuro (Flickr)
  • 12.                                      Breathing           •  Tachypnea   •  Work  of  breathing   •  Abnormal  sounds   •  Position  of  comfort   12
  • 13.                                      Retrac3ons   •  Suprasternal   •  Supraclavicular   •  Intercostal   •  Subcostal     •  Nasal  flaring   Bobjgalindo (Wikimedia Commons)
  • 14. 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)
  • 15.                      Abnormal  Sounds   •  Grunting   –  Noted  at  end  expiration   –  Voluntary  closure  of  glottis   –  Physiologically  generates  PEEP   –  Worrisome  sign   •  Stridor   •  Audible  wheezing   15
  • 16.                                    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
  • 17.                                              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
  • 18.                              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
  • 19.                                      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)
  • 20. •  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)
  • 21. Circulation   •  Capillary  refill   •  Distal  vs  central  pulses   •  Temperature  of  extremities   •  Color   —  Pink   —  Pale     —  Blue  (central  cyanosis  vs  acrocyanosis)   —  Mottled   21
  • 22.                                Capillary  Refill   22 Aladaze (Flickr)
  • 23. 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
  • 24. 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
  • 25.                                                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)
  • 26. 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
  • 27.                  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
  • 28.                          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
  • 29.                                            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
  • 30.                      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
  • 31.    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
  • 32.                              EpigloH3s   32 Source Undetermined Med Chaos (Wikimedia Commons) Description: Left column: Normal epiglottis. Right column: Epiglottitis.
  • 33.                                          EpigloH3s   33Source Undetermined Wikimedia Commons 2013
  • 34.                                  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)
  • 35. 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)
  • 36.                                  What’s  This  Disease?                     36 Grook Da Oger (Wikimedia Commons) Fateagued (Wikimedia Commons)
  • 37.                                    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
  • 38.                                  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
  • 39.                                                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)
  • 40.                        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)
  • 41.                                  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
  • 42.                      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
  • 43.                                                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
  • 44.                                          Croup  Score   •  Westley  croup   score  most   common   •  Tool  to  describe   severity  of   obstruction   •  Higher  the  score,   the  greater  the   risk  for  resp   failure     44Source Undetermined
  • 45.                                          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”   45 Source Undetermined
  • 46.                      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
  • 47.                        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
  • 48.                                      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)
  • 49.                          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
  • 50.                                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
  • 51.            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  
  • 52.                        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
  • 53.                                            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
  • 54.                                                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)
  • 55.                                          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
  • 56.                                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
  • 57.                      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
  • 58.                          Retropharyngeal  Abscess   Predisposing  Factors:   Recent  infection   Penetrating  trauma/   FB   Crack  cocaine  use   adults   Recent  intubation   58 Source Undetermined
  • 59.                                              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)
  • 60. Non-­‐infec3ous  E3ologies  for  Upper  Airway   Obstruc3on   •  Caustic  Ingestion   •  Burns   •  Anatomical   •  Foreign  Bodies   •  Trauma/  bleeding   •  Anaphylaxis   60
  • 61.                                                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)
  • 62.            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
  • 63.                          Pediatric  vs  Adult  Airway   63Source Undetermined
  • 64.                                                  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
  • 65.                                        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   65 Source Undetermined
  • 66.                      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
  • 67.                                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
  • 68.                      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
  • 69.                                            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
  • 70.                          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
  • 71.                            “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
  • 72.                  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   72 Source Undetermined
  • 73.                                            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
  • 74.                                            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
  • 75.                                              Caus3c  Inges3on   75 Waldo Jaquith (Flickr) 2010 Ben McLeod (Flickr) 2005
  • 76.  Pharyngeal  lye  ingestion   76 Alex Avriette (Flickr) 2006
  • 77.                                            Thermal  Injuries   77 •  Burns to the airway can cause swelling that blocks the flow of air into the lungs Joshua Bousel (Flickr) 2006
  • 78.                      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
  • 79.                                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)
  • 80.                                    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)
  • 81.                                  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
  • 82.                                                  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
  • 83.                              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
  • 84.                                            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. 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
  • 86. 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
  • 87. 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?   87
  • 88.      Uh  Oh-­‐  What  do  you  see?         88 Source Undetermined
  • 89. 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
  • 90. 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
  • 91. 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
  • 92. 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
  • 93. 93 Source Undetermined
  • 94. 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
  • 95. 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
  • 96. 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
  • 97. 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 97
  • 98. Staphyloccocal Pneumonia •  Rapidly progressive •  Fever, distress •  Significant morbidity •  71% pleural effusion •  Empyema •  Abcess •  Pneumothorax 98 Source Undetermined
  • 99. Chlamydia trachomatis •  2-19 weeks after birth •  Conjuctivitis •  Afebrile •  Staccato cough •  Tachypnea •  Crackles •  Eosinophilia •  B/l diffuse infiltrates •  Hyperinflation 99 Source Undetermined
  • 100. 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 100 Source Undetermined
  • 101. Mycoplasma •  Bilateral diffuse interstitial infiltrates •  Film can be normal •  Rarely effusion (<20%) •  Gradual onset symptoms •  Low grade fever •  Non productive cough •  Older child/ adolescent 101 Source Undetermined
  • 102. Viral Pneumonia •  Most common < 5yrs age •  Diffuse interstitial infiltrate •  Atelectasis •  Hyperinflation •  Peribronchial thickening •  Hilar adenopathy •  RSV, Parainfluenza, Adenovirus, Influenza •  Wheezing 102 Source Undetermined
  • 103. 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 103
  • 104. 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 104
  • 105. 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 105
  • 106. 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 106
  • 107. 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
  • 108. Interventions •  ABC’s •  Oxygen •  Suction •  IV access, IVFP, check blood sugar •  Initial trial albuterol •  Consider Racemic Epinephrine •  Call for chest film •  Prepare for intubation 108 Source Undetermined
  • 109. 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
  • 110. 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
  • 111. 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 111
  • 112. 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 112
  • 113. 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 appearanc e well ill toxic Resp rate < 60 60-69 > 70 atelectasis absent present Pulse ox > 97 95-96 < 95 113
  • 114. Management •  Supportive care •  Fluids •  Oxygen •  Monitoring •  Pulmonary toilet •  Ventilatory support •  Prevention- Respigam, Synagis 114
  • 115. Management Controversies •  Efficacy of bronchodilators •  Benefits of steroids •  Risk SBI in bronchiolitic with fever 115
  • 116. 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. 116
  • 117. 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 117
  • 118. 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 118
  • 119. 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 119
  • 120. 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? 120
  • 121. 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
  • 122. 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)
  • 123. Prevalence Rates •  Boys 50% > girls •  African Americans 44% > white/ hispanics •  12% greater if below poverty line •  Highest at risk : poor, black, male 123
  • 124. 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 124
  • 125. 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 125 Source Undetermined
  • 126. 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   126
  • 127. •  Inhaled Beta agonists •  Nebulized Anticholinergic Agents •  Corticosteroids •  Magnesium sulfate •  Heliox •  Intubation Treatment   127 Step 4: Severe Persistent Step 3: Moderate Persistent Step 2: Mild Persistent Step 1: Intermittent STEP- UP STEP- DOWN
  • 128. 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 128 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.
  • 129. 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 129 Miriamjoyce (Flickr) 2006
  • 130. 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) 130
  • 131. 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 131
  • 132. 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 132 D4duong (Wikimedia Commons) 2012
  • 133. 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
  • 134. 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 134
  • 135. 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 135
  • 136. 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 136
  • 137. 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 137
  • 138. 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 138
  • 139. 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 139
  • 140.                                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   140
  • 141.                                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   141
  • 142. 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 142
  • 143. 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 143
  • 144. 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 144
  • 145. 145 The McGraw-Hill Companies, Inc.
  • 146. 146 UpToDate
  • 147. 147 Source Undetermined
  • 148.                                      Ques3ons   148