Respiratory Emergencies in Pediatrics

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  • 1. Tricia Falgiani, MD Assistant Professor University of Florida Pediatric Emergency Medicine
  • 2. Objectives  Identify unique characteristics of the pediatric airway  Identify upper and lower airway diseases  Distinguish between airway urgencies and emergencies
  • 3. The Pediatric Airway  Passive flexion due to a large occiput  Relatively large tongue  Mass of adenoidal tissue  U-shaped and floppy epiglottis  Larynx is more anterior
  • 4. The Pediatric Airway  Cricoid ring is the smallest diameter  Narrow tracheal diameter and short distance between the tracheal rings  Airway cartilage is softer and more flexible  Short tracheal length  Large airways are more narrow
  • 5. The Pediatric Airway
  • 6. Airway Assessment  History  Acute or gradual onset?  Fever?  Drooling?  Voice changes?  Difficulty swallowing?  URI symptoms?  Significant past medical history?
  • 7. Airway Assessment  Physical Exam  Appearance  Alertness  Muscle tone  Ability to cry or speak  Work of breathing  Circulation  Pallor  Cyanosis  Mottling  Skin temperature
  • 8. First Impressions….  http://youtu.be/Ksl7Z3iwyL8  http://youtu.be/-4OhWQ8Ppko
  • 9. Respiratory Status  Bradypnea is more concerning than tachypnea  Normal rate/min  Newborn 30-60  6 months 25-35  1-3 years 20-30  4-6 years 18-26  Adolescent 12-18
  • 10. Signs of Respiratory Distress  Increased work of breathing  Retractions  Nasal flaring  Grunting  Head bobbing
  • 11. Signs of Respiratory Distress  Altered mental status  Agitation  Irritability  Lethargy  Coma
  • 12. Signs of Respiratory Distress  Color  Cyanosis  Pallor  Position  Sniffing position  Tripod position
  • 13. Signs of Respiratory Distress  Auscultation  Snoring  Grunting  Stridor  Wheezing  Rales (crackles)  Rhonchi
  • 14. Practical Points  Children have unique airway anatomy  Airway assessment begins with a good history  First impressions give us a lot of information  Signs of respiratory distress  Increased work of breathing  Altered mental status  Color  Position  Auscultation findings
  • 15. Common Pediatric Airway Diseases Upper Airway Diseases Lower Airway Diseases  Croup  Foreign Body  Epiglottitis  Bacterial tracheitis  Asthma  Bronchiolitis  Pneumonia  Foreign Body
  • 16. Laryngotracheobronchitis  Croup!  Upper airway disease  Viral infection of larynx, trachea and bronchi  Parainfluenza (75%)  Influenza  RSV  Adenovirus  Age 6months-3 years  Male > female  Winter months
  • 17. Clinical Presentation  Fever  Rhinorrhea  Nasal congestion  Barking cough  Inspiratory stridor  Respiratory distress  Worse at night
  • 18. Clinical Presentation  Gradual onset of URI symptoms (days)  Mild fever, hoarseness, barking cough  Sudden stridor and retractions  Dyspnea and tachypnea
  • 19. Westley Scoring System 0 1 2 3 Stridor None Only with agitation Mild at rest Severe at rest Retraction None Mild Moderate Severe Air entry Normal Mild decrease Moderate decrease Marked decrease Color Normal N/A N/A Cyanotic Level of consciousness Normal Restless when disturbed Restless when undisturbed Lethargic
  • 20. Westley Scoring System Score Degree Management 0-2 Mild Mist therapy 3-7 Moderate Racemic epi, steroids >8 Severe Racemic epi, steroids, admit
  • 21. Treatment  Labs and x-ray unnecessary  Mist therapy  Racemic epinephrine  Dexamethasone  0.6mg/kg
  • 22.  https://www.youtube.com/watch?v=Z1_uKqmPyLA&f eature=player_detailpage  https://www.youtube.com/watch?v=Qbn1Zw5CTbA&f eature=player_detailpage
  • 23. Foreign Body  Basics:  Airway emergency?  The airway is a funnel  Typically under 3 years of age  Impaired mentation  Candy and food  High index of suspicion
  • 24. Clinical Presentation  Sudden coughing or choking  Dyspnea  Stridor (upper)  Wheezing, rhonchi or rales (lower)  Unequal breath sounds (lower)
  • 25. Treatment  Maintain suspicion  Keep child calm with parent  Blow by oxygen if tolerated  Don’t agitate patient  Advanced airway maneuvers as indicated
  • 26. Epiglottitis
  • 27. Epiglottitis  Upper airway disease  Airway emergency  Life threatening bacterial infection of epiglottis and surrounding structures  Rare  Age 3-7 years  Winter months  Pathophysiology  H. Influenzae  S. Pneumoniae  Group A streptococcus  Staph aureus
  • 28. Clinical Presentation  Abrupt onset (hours)  Toxic appearing  Fever  Stridor  Drooling  Inability to swallow  Sore throat  Respiratory distress  Tripod position  Sudden obstruction
  • 29. Treatment  Secure airway  Don’t agitate child  Antibiotics  Ceftriaxone  Cefotaxime  Meropenem  Clindamycin/vanc ?
  • 30. Bacterial Tracheitis
  • 31. Bacterial Tracheitis  Rare (0.1 cases per 100,000 children per year)  Invasive exudative bacterial infection of the trachea  Male > Female  Age 3 weeks- 16 years  Pathophysiology  Staph aureus (MRSA)  Strep pyogenes  Strep pneumoniae  Moraxella catarrhalis  H. influenza type B (unvaccinated)
  • 32. Clinical Presentation  Similar to croup  URI prodrome  Fever  Stridor  Barky cough  Hoarseness  Sore throat  No drooling  Respiratory distress
  • 33. Treatment  Secure airway  Antibiotics  Ceftriaxone  Meropenem  Clinda or vanc
  • 34. Epiglottitis vs. Croup vs. Bacterial tracheitis Epiglottitis Croup Bacterial Tracheitis Anatomy Supraglottic Subglottic Tracheal lumen Etiology Bacterial Viral Bacterial Age Range 3-7 years, adults 6months-3 years 3weeks-16 yrs Onset 6-24 hours 2-3 days 1-3 days Toxicity Marked Mild to moderate Mild- marked Drooling Frequent Absent Absent Cough Unusual Frequent Frequent Hoarseness Unusual Frequent Frequent WBC Leukocytosis Normal Leukocytosis
  • 35. Causes of Stridor  Spasmodic croup  Retropharyngeal abscess  Peritonsillar abscess  Subglottic stenosis  Allergic reaction  Foreign body  Tracheomalacia  Laryngeal web  Laryngeal papillomatosis  Laryngeal hemangioma  Trachea fracture  Vocal cord paralysis  Inhalation injury  Uvulitis  Vascular ring  Double aortic arch  Aberrant subclavian artery  Pulmonary artery sling  Epiglottitis  Bacterial tracheitis  Diphtheria  Croup
  • 36. Asthma  Lower airway disease  Airway urgency/emergency  Chronic and recurrent  Bronchospasm  Airway inflammation  Ventilation problem with air trapping
  • 37. Assessment  Respiratory rate  Work of breathing  Oxygen saturation  Expiratory time  Mental status
  • 38. Clinical Presentation  Dyspnea  Retractions  Tachypnea  Nasal flaring  Inability to speak  Wheezing  Prolonged expiratory phase  Beware of the quiet chest
  • 39. Treatment  ABCs  Give oxygen  Nebulized albuterol  Steroids  Upright position  Severe attacks  Epinephrine  Magnesium sulfate
  • 40. Treatment  Secure airway  Surgical drainage  Antibiotics  Unasyn  Clindamycin  Vancomycin  Augmentin
  • 41. Asthma Caveats  Many patients/parents do not take this disease seriously  Parents may not have an asthma action plan at home  Albuterol is a short acting drug  If patient is requiring multiple albuterol treatments at home, they should be evaluated immediately
  • 42. Bronchiolitis  Lower airway disease  Airway urgency  2 months- 2 years  Chronically ill are at higher risk  Premature  Congenital heart disease  Less than 1 month old  Inflammation, edema and mucous in the lower airways  Viral etiology
  • 43. Clinical Presentation  Dyspnea  Tachypnea  Retractions  Nasal flaring  Wheezing  Long expiratory phase  Rales  Rhonchi  Decreased air movement
  • 44. Treatment  SUPPORTIVE!!!  Oxygen  Suctioning  Upright position  ?nebulized albuterol  ?nebulized hypertonic saline
  • 45. Pneumonia  Lower airway disease  Airway urgency  All ages  Younger patients can be very ill  Chronically ill at higher risk  Bacterial or viral etiology
  • 46. Clinical Presentation  Rales (may be localized)  Rhonchi  Tachypnea  Variable fever  +/- Respiratory distress  Hypoxemia
  • 47. Treatment  Oxygen  Fluids  Upright position  Antibiotic therapy
  • 48. Practical Points  Upper vs. Lower airway diseases- listen for the diagnosis!  Airway urgencies can quickly progress to airway emergencies  Beware of the neonate!  Trust the parents  Look for visual cues  Try not to agitate the patient
  • 49. Questions?