croup

1. COMMON PEDIATERIC
PULMONARY EMERGENCIES
By
Dr. Ashraf Hussein Ismail
ER Consultant

2. OBJECTIVES
• Diagnosis of the commonest
pulmonary emergencies
• ED management:
First aid
ED medications
When to dischrage the patient from ED?
When the patient will come back (F/U)?
When to admit the patient?

3. • Asthma
• Acute bronchiolitis
• Croup
• Pneumonia
• Foreign body inhalation

4. ASTHMA
• Asthma is a disease characterized by
reversible hyperresponsiveness, obstruction,
and inflammation of the lower airways.
• More than 10% of children are affected and,
despite recent therapeutic advances,
morbidity continues to be substantial

5. ASTHMA
• Following exposure to a triggering event, an
acute asthma exacerbation has an early
allergen response (EAR) phase,
accompanied by the release of leukotrienes,
and, in up to 50% of the cases, a late allergen
response (LAR) phase, induced by Th2
helper cells.

6. ASTHMA
• Common triggers include irritants (cigarette
smoke, gases), viral infections, weather
changes, allergens (dust, animals), exercise,
cold air, and emotional stress.

7. ASTHMA (Clinical presentation)
• Acute asthma presents with dyspnea, cough and
expiratory and, to a lesser extent, inspiratory
wheezing.
• Children with cough-variant asthma have
recurrent episodes of dry or productive cough
and little or no wheezing.

8. ASTHMA (Clinical presentation)
• Airway obstruction can lead to retractions
and decreased air entry, with little or no
audible wheezing.
• Tachycardia, tachypnea, and, in severe
attacks, cyanosis may be present; altered
mental status (agitation, lethargy) occurs
with impending ventilatory failure.
• Findings of an URTI are also often present.

9. ASTHMA (Complications)
• Atelectasis is common.
• Other respiratory complications:
**Pneumomediastinum, requires no specific tt.
**Pneumothorax (rare), which may be under
tension and require immediate evacuation.
• Respiratory failure may occur suddenly from
large-airway collapse or exhaustion

10. ASTHMA (Diagnosis)
• After the initial brief assessment, institute
treatment promptly.
• While the first bronchodilator treatment is
given, perform a focused history and physical
examination related to the acute exacerbation.

11. ASTHMA (Diagnosis)
• A more detailed history and physical examination
can be delayed until after the initial therapy is
given.
• Inquire about a history of prematurity,
mechanical ventilation, BPD, previous wheezing
episodes, or heart disease.
• Check for a family history of asthma, recurrent
bronchitis, eczema, allergic rhinitis, or other
allergies.

12. ASTHMA (Diagnosis)
• A trial of an inhaled β2 agonist may
simultaneously confirm the diagnosis and
provide clinical improvement.
• Relief of airway obstruction occurs in <15
minutes, and peak flow typically improves by
>20% from baseline.
• Less improvement may occur with severe or
prolonged episodes associated with more
inflammation.

13. ASTHMA (Diagnosis)
• Laboratory studies do not help in establishing the
diagnosis of asthma.
• A chest X-ray occasionally may be indicated in
the setting of significant tachypnea or persistent
tachycardia (rate >160/min) 20–30 minutes after
the completion of a β2 agonist treatment in an
afebrile child.

14. ASTHMA (Diagnosis)
Peak flowmeter
It measures the flow of air as
it's expelled from the lungs. To
do this, the child will blow into
the peak flow meter (as if
blowing up a balloon).
A marker will slide up a scale on the meter as the child
blows out to indicate how much air was exhaled. The
peak flow is the number where the marker stops on the
scale.

15. ASTHMA (Asess severity)
PEFR
Symptoms
Severity
≥70% predicted
or personal best
Dyspnea during
activity
Mild
40-69% predicted
or personal best
Dyspnea interferes
with usual activity
Moderate
<40% predicted
or personal best
Dyspnea at rest
Severe
<25% predicted
or personal best
Too dyspneic to
speak
Life
threatening

16. ASTHMA (ED Management)
•Establish IV line for moderate to
severe cases
•O2 therapy:
- Monitor an ill patient with pulse oximetry.
- Provide supplemental oxygen (40% by mask)
to a patient with moderate wheezing.
- Use 100% oxygen if the attack is severe.

17. ASTHMA (ED Management)
•Inhaled β2-Agonists (Ventolin)
- Give 0.15 mg/kg (2.5 mg minimum; 5 mg
maximum) of albuterol every 20 minutes for 3 doses
then, 0.15–0.3 mg/kg every 1–4 hours as needed for
mild to moderate exacerbations.
- Substitute 4–8 puffs of an albuterol MDI (90
mcg/puff ) with a spacer every 20 minutes for
nebulized albuterol if the patient is cooperative.

18. ASTHMA (ED Management)
•Inhaled β2-Agonists (Ventolin)
- Repeat doses are given every 20–30 minutes
until no further improvement is noted in peak
flow, oxygen saturation, or respiratory rate.
- For severe exacerbations, give 0.5 mg/kg/hr by
continuous administration.

19. ASTHMA (ED Management)
•Subcutaneous epinephrine & terbutaline
A dose of SC epinephrine or terbutaline may be
given for severe attacks (peak flow <15% predicted
or nearly absent breath sounds) when aerosolized
medication may not reach the target small airways.
For epinephrine the dose is 0.01 mL/kg to 0.3 mL
maximum of the 1:1,000 preparation; for terbutaline,
use 0.01 mL/kg up to 0.25 mL maximum.

20. ASTHMA (ED Management)
•Steroid therapy, Indicated if:-
Requires two or more β2 agonist aerosol treatments to
meet criteria for discharge
Oxygen saturation is <92% on any assessment
 >2 days of coughing or awakening from sleep due to
asthma in the past week
Chronically uses (every day or every other day) oral
corticosteroids

21. ASTHMA (ED Management)
•Steroid therapy, Indicated if:-
ED visit within the past 2 weeks, has had a past ICU
admission
Hospitalized (for asthma) within the past 2 weeks
Three or more hospitalizations during the past year.
-- Use oral prednisone or prednisolone, 1–2 mg/kg (40
mg maximum).
-- If the patient cannot tolerate oral medication, give IV
methylprednisolone 2 mg/kg (maximum 125 mg)
followed by 0.5 mg/kg q 6 hours.

22. ASTHMA (ED Management)
•Ipratropium bromide (Atrovent)
Some asthmatics with severe airway obstruction
may respond better to a combination of inhaled
albuterol and ipratropium than to albuterol alone.
Give three consecutive ipratropium(250
microgram <12 years of age and 500 microgram
>12 years of age )-albuterol inhalations to a patient
whose asthma score or PEFR fails to improve after
the initial albuterol treatment.

23. ASTHMA (ED Management)
•Hydration
Encourage oral fluids; provide IV hydration if the
patient is seriously ill.
Assess the hydration status, obtain blood for
electrolytes when placing the IV line, and monitor
for the syndrome of inappropriate ADH excess in
severe asthma.

24. ASTHMA (ED Management)
•IV Magnesium sulfate
It may be useful for a patient whose condition
worsens or fails to improve significantly after
administration of β2 agonists and systemic
corticosteroids.
The dose is 40 mg/kg (3 g maximum) in 50 mL of
normal saline administered IV over 30 minutes.
Monitor the blood pressure every 10 minutes
during the infusion and every 30 minutes thereafter
for 4 hours.

25. ASTHMA (ED Management)
•IV Terbutaline
It may not offer any significant advantage over
continuously administered aerosols, consider IV
terbutaline for a patient with impending respiratory
failure.
•Mechanical ventilation
If the above-described therapy fails to achieve
adequate oxygenation, endotracheal intubation and
mechanical ventilation are necessary.

26. ASTHMA (Discharge Management)
When to discharge from ED?
A patient with acute asthma can be discharged
home when the peak flow is >60–70% predicted for
height, the oxygen saturation is >92% in room air,
wheezing is minimal, and there are no signs of
significant obstruction (retractions, tachypnea,
decreased air entry).

27. ASTHMA (Discharge Management)
When to discharge from ED?
Be sure that the family has a written action plan
for worsening symptoms and a follow-up
appointment within a week or two of the ED visit.

28. ASTHMA (Discharge Medications)
β2 agonists:
An older child (>3 years) can use an MDI or an
inhaler with a spacer, use 2 puffs q 6–8 h of
albuterol.
For younger child , use albuterol 0.5% (0.5–1.0
mL) by nebulizer in 3 mL of normal saline given
over 5–10 minutes.

29. ASTHMA (Discharge Medications)
Oral Corticosteroids:
Given for a patient required two or more acute
albuterol treatments, and for a patient who has
required acute therapy twice (or more) within 24
hours or three times in the past week.
Give oral prednisone (1 mg/kg per day, 40 mg
maximum q day or div bid) for 4 days.

30. ASTHMA (Discharge Medications)
Oral Corticosteroids:
For children who cannot tolerate prednisone
because of vomiting, a single dose of oral
dexamethasone (0.6 mg/kg q day, 10 mg maximum)
is an alternative.

31. ASTHMA (Discharge Medications)
Inhaled Corticosteroids (persistent asthma):
Use fluticasone (44 mcg/puff 4–11 years; 110 mcg/puff
12 years) 1 puff bid.
Prescribe budesonide inhalation suspension for
nebulization (0.25–0.5 mg) for children 0–4 years of age
whose asthma medications are nebulized.

32. ASTHMA (When to admit the
patient?)
•Status asthmaticus: continued moderate or severe
wheezing or other evidence of significant airway
obstruction after full ED management
• Repeated emergency visits over several days
when therapy is maximal or compliance uncertain
•Persistent tachypnea, inability to tolerate fluids or
medications, altered mental status

33. ASTHMA (When to admit the
patient?)
•Hypercapnia: pCO2 >40 mmHg
• Hypoxemia: pO2 <60 mmHg or oxygen saturation
< 92% in room air despite aggressive therapy
• Pneumothorax, pneumomediastinum, or
significant atelectasis

37. A Bronchiolitis
Bronchiolitis is the most common wheezing-
associated respiratory illness in children <2 years of
age.
Epidemics in the winter (December through early
February) are most frequently caused by respiratory
syncitial virus (RSV).
Human metapneumovirus (hMPV) causes
bronchiolitis in somewhat older children (median age 11
months) typically in the spring (March through April).

38. A Bronchiolitis
Diagnosis
Acute wheezing, cough, and respiratory distress
in a young infant are most often secondary to
bronchiolitis.
DD
Asthma
FB aspirations
Cong malformations
Cardiac diseases
GERD

39. A Bronchiolitis ( ED Management)
Assessment
Inquire about a history of wheezing, prematurity,
or mechanical ventilation (BPD), and check for a
family history of asthma or allergies.
Perform the examination with the infant
undressed from the waist up and sitting on the
parent’s lap.

40. A Bronchiolitis ( ED Management)
Assessment
Obtain an accurate RR, note any signs of RD
(flaring, grunting, retractions, cyanosis) or heart
disease (murmur, HSM), and assess the activity
level and ability to drink.
Obtain a chest X-ray if the infant has known
underlying pulmonary or heart disease or does not
respond to ED management.

41. A Bronchiolitis ( ED Management)
Patients with RR>60/min or signs of RD
Check the oxygen saturation in room air by pulse
oximetry, and give supplemental oxygen.
Suction the nares if necessary.
Start an IV and give maintenance fluids with
D5½NS
Give a trial dose of nebulized epinephrine
(1:1,000, 0.5 mL/kg, 2.5 mL maximum, in 3 mL NS)
or albuterol (0.5%, 0.50 mL in 3 mL NS) over 5–10
minutes.

42. A Bronchiolitis ( ED Management)
Patients with RR>60/min or signs of RD
If there is no substantial improvement, admit the
patient.
If the respiratory rate slows to 40–60/min and
there is no RD, discharge the patient with a trial of a
β2 agonist, provided oral intake is adequate and
daily follow-up can be arranged.

43. A Bronchiolitis ( ED Management)
Patients with RR 40-60/min
Supportive therapy (fluids, acetaminophen PRN)
is all that is needed if the infant is alert, is tolerating
fluids well, and has no signs of distress.
Close follow-up is warranted.

44. A Bronchiolitis ( ED Management)
Patients with RR 40-60/min(cont’)
A trial of inhaled albuterol (not routine), via MDI
and a spacer with a face mask (2 puffs q 4–6 h),
may be useful if the patient required mechanical
ventilation as a newborn, has BPD, there is a FH of
asthma or allergies, or the child improved following
acute bronchodilator therapy in the ED.

45. A Bronchiolitis ( ED Management)
Follow up (when to come back?)
Persistent tachypnea (> 60/min), difficulty
feeding: return at once.
All infants in 24 hours for reevaluation of feeding,
respiratory effort, weight.

46. A Bronchiolitis ( ED Management)
When to admit the patient?
1. Respiratory rate >70/min after maximal ED
therapy, regardless of clinical appearance
2. Respiratory rate 60–70/min with lethargy or poor
oral intake

47. A Bronchiolitis ( ED Management)
When to admit the patient?
3. Infant <3 months of age with a respiratory rate
60–70/min after maximal ED therapy
4. Respiratory distress, oxygen saturation <92%
or pO2 <65 mmHg in room air, or normal-to-
elevated pCO2 (>40 mmHg)

48. A Bronchiolitis ( ED Management)
When to admit the patient?
5. Infant with CHD, BPD, or immunodeficiency (at
risk for complications of RSV infection) in the
progressive stage (first day or two) of the illness.
6. Parents uncomfortable with the severity of
illness or with limited resources at home
(especially if the infant is <3 months of age).

52. CROUP
Laryngotracheobronchitis, or croup, is an acute
subglottic inflammatory process generally caused
by parainfluenza virus, types 1 and 3, during the
late fall and early winter months.
Other causes are influenza viruses A and B,
measles, Mycoplasma pneumoniae, human
metapneumovirus and respiratory syncitial virus.

53. CROUP
Croup primarily occurs between 6 months and 3
years of age, but morbidity is greatest in the first
year of life, when the subglottic airway is relatively
narrow.
Although exhaustion may lead to obstruction of
the airway by mucus, death is infrequent.

54. CROUP (Clinical picture)
Clinically, this presents with inspiratory stridor,
suprasternal retractions, tachypnea, and
tachycardia.
Croup usually begins with low-grade fever and
rhinorrhea, followed by hoarseness and a barking,
“seal-like” cough.
With increasing obstruction there are
suprasternal and intercostal retractions, decreased
air entry, and increased work of breathing.

55. CROUP (Clinical picture)
High fever, dysphagia, and drooling are usually
absent.
Exhaustion and respiratory failure ensue in a
small number of cases (<2%), especially in patients
with pre-existing upper airway malformations like
tracheomalacia, micrognathia, laryngeal web, etc

56. CROUP (Clinical picture)
Spasmodic croup presents in the middle of the
night with the sudden onset of loud stridor and
croupy cough which resolves quickly and often
improves with cool mist.
There is little or no viral prodrome, and
dysphagia, drooling, high fever, and toxicity are
notably absent. The croup may recur on successive
nights, and recurrent episodes are common.

57. CROUP (Diagnosis)
Croup is a clinical diagnosis based on history and
physical findings.
On a PA view of the chest, the upper airway is
narrowed to appear like a “steeple,” and the infraglottic
region is hazy.

58. CROUP (Diagnosis)
Differential Diagnosis
Epiglottitis
Foreign body
Bacterial tracheitis
Laryngomalacia and subglottic stenosis
Retropharyngeal abscess

59. CROUP (ED Management)
Mild-to-moderate Croup
Make a rapid assessment of color, perfusion, work of
breathing, retractions, and air entry.
If the patient is in mild-to-moderate distress,
administer humidified oxygen, 4 L/min by face mask.
Some infectious croup episodes and almost all
spasmodic croup attacks will respond to mist with
diminished stridor and lessened respiratory distress.

60. CROUP (ED Management)
Mild-to-moderate Croup
Give a dose of oral or IM dexamethasone (0.3–0.6
mg/kg, 10 mg maximum) to a patient with a barking
cough or cough with hoarseness or rhonchi.
Most often, the condition of a patient with
spasmodic croup is markedly improved by the time
of ED arrival; however, caution the parents that the
illness may recur the following night.

61. CROUP (ED Management)
Severe Croup
Administer humidified oxygen, 4 L/min by face mask;
use 100% O2 delivered by a nonrebreather mask for a
patient with severe distress, and continuously monitor
with a pulse oximeter.
Treat with either nebulized racemic epinephrine
(Vaponephrine, 0.05 mL/kg [0.5 mL maximum] in 3 mL
NS) or L-epinephrine (1:1,000, 0.5 mL/kg in 3 mL NS; 4
years 2.5 mL maximum, >4 years 5 mL maximum) over
5–10 minutes.

62. CROUP (ED Management)
Severe Croup
Give dexamethasone to any patient who receives
nebulized epinephrine treatment( to prevent rebound
airway edema) and observe for at least 2 hours prior to
discharge from the ED.
 Maintain the humidified oxygen after the treatment.
Start an IV if the patient is not drinking adequately and
administer a 20 mL/kg bolus of isotonic crystalloid if the
patient appears dehydrated.

63. CROUP (ED Management)
Severe Croup
Obtain an ABG after epinephrine treatment if the child
is agitated or has increased work of breathing, as
carbon dioxide retention can occur in a young infant
with moderate-to-severe croup.
In addition, obtain radiographs of the chest and lateral
neck if the patient is in moderate-to-severe distress or
the diagnosis is unclear.

64. CROUP (ED Management)
When to discharge from ED?
Discharge the patient who clearly has croup if
there is no significant stridor at rest, for at least 2
hours, after treatment with epinephrine and
dexamethasone.

65. CROUP (ED Management)
Follow up (when to come back?)
Immediately if stridor at rest develops at
home, otherwise daily for the first 2–3 days

66. CROUP (ED Management)
When to admit the patient?
1. Stridor at rest that fails to resolve with
epinephrine and dexamethasone.
2. Rebound during a 2-hour observation period
following epinephrine and dexamethasone
treatment for stridor at rest.
3. Inadequate fluid intake.
4. Impending respiratory failure (pCO2 >40 mmHg;
O2 saturation <92% in room air).

69. Pneumonia
Pneumonia is a common disease with an
incidence of 1– 4.5 cases per 100 children per
year.
Pathogens can reach the lung parenchyma
via either microaspiration or hematogenous
spread.
While just 20–30% of pneumonias are
bacterial in origin, these are responsible for the
majority of severe complications.

70. Pneumonia (Etiologies)
Agents
Age
GBS, coliform bacteria, RSV,
staph aureus
Less then 2 wk
C trachomatis, RSV,
parainfluenza virus, Hib,
strept pneumoniae, S aureus
2wk – 3 months
Viral ( RSV, influenza), S
pneumoniae, rarely Hib
3 months – 5 years

71. Pneumonia (Etiologies)
Agents
Age
•Viral
•Mycoplasma pneumoniae
•S. pneumoniae
•Chlamydia pneumoniae
Over 5 years
•Mycobacterium tuberculosis
•Pertussis (<1 year old)
•Pneumocystis carinii (HIV
positive)
•Legionella sp
Other agents to
consider

72. Pneumonia (Clinical picture)
Cough, tachypnea, and fever are the common
symptoms of childhood pneumonia, while pallor,
fatigue, and other constitutional symptoms are
variable.
Posttussive vomiting can be a common
complaint in young children.
A neonate or young infant may present with
tachypnea, decreased activity, and poor feeding.

73. Pneumonia (Clinical picture)
With progression of the pneumonia, there may be
signs of respiratory distress, including nasal
flaring, intercostal or substernal retractions,
dyspnea, cyanosis, or apnea.
On auscultation, inspiratory rales may be heard
or the breath sounds may be locally decreased or
tubular, although adventitious sounds are harder to
appreciate in a young child.

74. Pneumonia (Clinical picture)
Dullness and diminished breath sounds may
indicate an effusion.
Abdominal pain can occur with lower-lobe
pneumonia and meningismus with upper-lobe
infection.

75. Pneumonia (Diagnosis)
Pneumonia can be diagnosed clinically when
fever, cough, and rales are present.
Obtain a chest X-ray (PA and lateral) when the
patient is in respiratory distress, the diagnosis is
uncertain, there is concern about a pleural effusion,
or an infant <2 months of age has respiratory signs
(including cough).

77. Pneumonia (Diagnosis)
Differential Diagnosis
Asthma
Congestive heart failure
Foreign body aspiration
Inhalation injury

78. Pneumonia (ED Management)
It is critical to immediately assess the adequacy
of breathing. If the patient is dyspneic or in
respiratory distress, assess the O2 sat with pulse
oximetry.
Administer supplemental oxygen if the patient is
in distress or has decreased oxygenation (oxygen
saturation <92%)
Consider an ABG if the patient has poor breath
sounds and is lethargic.

79. Pneumonia (ED Management)
Obtain a chest radiograph, if indicated (see
above).
Control fever by giving antipyretics to decrease
the temperature and its effects on work of breathing
(acetaminophen 15 mg/kg; ibuprofen 10 mg/kg).
Give IV fluids if the patient is dehydrated, looks
toxic or cannot tolerate oral feeding

80. Pneumonia (ED Management)
Obtain sepsis workup(CBC, CRP, ESR, blood
C/S) and serum electrolytes.
Perform lumbar puncture if the patient is toxic or
less than 2 months of age.

81. Pneumonia (ED Management)
Initial antibiotic therapy
Oral amoxicillin at home for 10 days for those
not indicated for admission.
For admitted patients:
** Cefuroxime IV 50 mg/kg q 8 hours
or Ceftriaxone IV 50mg/kg q 24 hours
** Add Vancomycin IV 10 mg/kg q 6 hours
if MRSA is suspected

82. Pneumonia (ED Management)
Initial antibiotic therapy
For children > 5 years old or if mycoplasma
infection is suspected, give one of the following:
 Erythromycin for 10 days
 Azithromycin for 5 days
 Clarithromycin for 7 days

83. Pneumonia (ED Management)
Follow up (when to come back?)
Respiratory distress at home: at once
Lobar pneumonia: 24 hours
Patient <2 years of age with suspected viral
pneumonia: 24–48 hours
All patients: at the end of treatment or about 2
weeks after presentation to assess for
improvement.

84. Pneumonia (ED Management)
When to admit the patient?
Patient <2 months of age with pneumonia
 Patient <6 months of age with lobar pneumonia
 Patient with pO2 <65 mmHg, oxygen saturation
<92%, pCO2 >40 mmHg
 Patient not taking fluids, exhausted, or with
parents unable to comply with instructions
 Presence of significant pleural effusion

87. FB Aspiration
Aspirated foreign bodies cause more deaths in
the United States than croup and epiglottitis
combined.
The peak incidence coincides with the period of
oral behavior, between 6 months and the early
school years.
Aspiration of a foreign body classically presents
with an immediate episode of coughing, gagging,
choking, or cyanosis.

88. FB Aspiration
Extrathoracic FB (laryngeal and tracheal)
The patient presents with stridor, a croupy
cough, varying degrees of dyspnea, or acute
hypoxemia and cyanosis.
The symptoms may vary with the degree of
obstruction of the airway.
The sound elicited by air moving over the object
varies with the size of the airway and degree of
inflammation induced.

89. FB Aspiration
Extrathoracic FB (laryngeal and tracheal)
Radiographs of the lateral neck and chest are
generally normal, as only a small number of
aspirated foreign bodies are radioopaque.
There may be signs of upper-airway obstruction,
such as ballooning of the hypopharynx, gastric
distention, or diminished lung volumes.

91. FB Aspiration
Extrathoracic FB
(laryngeal&tracheal)
Esophageal FB can
occasionally compress
the trachea from
behind; these tend to
be larger objects that
are more likely to be
radioopaque.

92. FB Aspiration
Intrathoracic FB (lower tracheal& bronchial)
A lower-airway foreign body presents with an
initial choking episode and varying periods of
quiescence, followed by persistent and often
progressive symptoms.
Commonly, there is cough, wheezing, and
dyspnea. With inflammation or secondary
atelectasis, fever and signs of pneumonia may
predominate, leading to a misdiagnosis of asthma
or recurrent pneumonia.

93. FB Aspiration
Intrathoracic FB (lower tracheal& bronchial)
A focal foreign body may produce unilateral
hyperinflation with widening of intercostal spaces.
On auscultation, localized or diffuse wheezing,
rales, or decreased air entry may be appreciated.

94. FB Aspiration
Intrathoracic FB (lower tracheal& bronchial)
Hyperinflation, atelectasis, and pneumonia are
the most common abnormalities.
Unilateral hyperinflation on the inspiratory film
may be seen, but it is less common.
In the older child, inspiratory and expiratory
chest films may reveal persistent hyperinflation of
the ipsilateral side during expiration.

96. FB Aspiration (ED
Management)
Assess the patency of the airway and breathing.
Complete obstruction demands immediate BLS
maneuvers:
-- five back blows followed by five chest
compressions
-- in a patient<12 months of age and 6–10
subdiaphragmatic abdominal thrusts (Heimlich
maneuver) for an older child.

97. FB Aspiration (ED
Management)
If there is an incomplete obstruction, place the
child in the sniffing position (maximal airway
opening), provide supplemental oxygen, and permit
the child’s own ventilation through a partly
occluded airway to be maintained.
Continuously monitor the patient with pulse
oximetry while awaiting an anesthesiologist and
bronchoscopist (pediatric surgeon or
otolaryngologist) to perform rigid bronchoscopy.

98. FB Aspiration (ED
Management)
Chest physiotherapy, may cause occlusion of a
major airway and hypoxemia, and is therefore
contraindicated.
Provide supplemental oxygen, and arrange for
semi-elective removal by rigid bronchoscopy under
general anesthesia.

99. FB Aspiration (ED
Management)
When to admit the patient?
Clinical suspicion of an airway foreign body
Respiratory symptoms after expulsion of an
airway foreign body

100. THANK YOU