This document discusses various pediatric respiratory emergencies. It describes how the pediatric respiratory system makes children more vulnerable to respiratory failure. The most common causes of respiratory distress and failure in children are croup, epiglottitis, asthma, bronchiolitis, foreign body aspiration, and bronchopulmonary dysplasia. Each condition is discussed in detail, including pathophysiology, signs and symptoms, risk assessment, and management strategies. Special attention is given to distinguishing between similar conditions like asthma and bronchiolitis. Intubation tube sizes for children of different ages are also provided.

1. Pediatrics
Respiratory Emergencies

3. Respiratory Emergencies
 #1 cause of
Pediatric hospital admissions
Death during first year of life except for
congenital abnormalities

4. Respiratory Emergencies
Most pediatric cardiac arrest
begins as respiratory failure or
respiratory arrest

5. Pediatric Respiratory System
 Large head, small
mandible, small neck
 Large, posteriorly-
placed tongue
 High glottic opening
 Small airways
 Presence of tonsils,
adenoids

6. Pediatric Respiratory System
 Poor accessory muscle development
 Less rigid thoracic cage
 Horizontal ribs, primarily diaphragm
breathers
 Increased metabolic rate, increased O2
consumption

7. Pediatric Respiratory System
Decrease respiratory reserve +
Increased O2 demand =
Increased respiratory failure risk

8. Respiratory Distress

9. Respiratory Distress
 Tachycardia (May be bradycardia in neonate)
 Head bobbing, stridor, prolonged expiration
 Abdominal breathing
 Grunting--creates CPAP

10. Severity of Respiratory
Compromise
 Distress
 Failure
 Arrest

11. General Treatments
 Establish Airway
 Oxygen
 BVM
 ET
 NG tube
 Decompression
 Needle Cric

12. Respiratory Emergencies
 Croup
 Epiglottitis
 Asthma
 Bronchiolitis
 Foreign body aspiration
 Bronchopulmonary dysplasia

13. Laryngotracheobronchitis
Croup

14. Croup: Pathophysiology
 Viral infection (parainfluenza)
 Affects larynx, trachea
 Subglottic edema; Air flow obstruction

15. Croup: Incidence
 6 months to 4 years
 Males > Females
 Fall, early winter

16. Croup: Signs/Symptoms
 “Cold” progressing to hoarseness, cough
 Low grade fever
 Night-time increase in edema with:
Stridor
“Seal bark” cough
Respiratory distress
Cyanosis
 Recurs on several nights

17. Croup X-Ray

18. Croup: Management
 Mild Croup
Reassurance
Moist, cool air

19. Croup: Management
 Severe Croup
Humidified high concentration oxygen
Monitor EKG
IV tko if tolerated
Nebulized racemic epinephrine
Anticipate need to intubate, assist
ventilations

21.  http://www.youtube.com/watch?v=Qbn1
Zw5CTbA&feature=related
 https://www.youtube.com/watch?v=1Enq
2BvX9aw

22.  http://www.
youtube.co
m/watch?v=
7xDM8vuV
EPo&featur
e=related

23. Epiglottitis

24. Epiglottitis: Pathophysiology
 Bacterial infection (Hemophilus influenza)
 Affects epiglottis, adjacent pharyngeal tissue
 Supraglottic edema
Complete Airway
Obstruction

25. Epiglottitis: Incidence
 Children > 4 years old
 Common in ages 4 - 7
 Pedi incidence falling due to HiB vaccination
 Can occur in adults, particularly elderly
 Incidence in adults is increasing

26. Epiglottitis: Signs/Symptoms
 Rapid onset, severe distress in hours
 High fever
 Intense sore throat, difficulty swallowing
 Drooling
 Stridor
 Sits up, leans forward, extends neck slightly
 One-third present unconscious, in shock

28. Epiglottitis
Respiratory distress+
Sore throat+Drooling =
Epiglottitis

30. Stridor
 http://www.youtube.com/watch?v=Zkau4
yHsLLM

31. Epiglottitis: Management
 High concentration oxygen
 IV tko, if possible
 Rapid transport
 Do not attempt to visualize airway

32. Epiglottitis
Immediate Life Threat
Possible Complete Airway
Obstruction

33. Venn Diagram
croup
epiglottitis

34. Asthma

35. Asthma: Pathophysiology
 Lower airway hypersensitivity to:
Allergies
Infection
Irritants
Emotional stress
Cold
Exercise

36. Asthma: Pathophysiology
Bronchospasm
Bronchial Edema Increased Mucus
Production

37. Asthma: Pathophysiology

38. Asthma: Pathophysiology
Cast of airway
produced by
asthmatic mucus
plugs

39. Asthma: Signs/Symptoms
 Dyspnea
 Signs of respiratory distress
Nasal flaring
Tracheal tugging
Accessory muscle use
Suprasternal, intercostal, epigastric
retractions

40. Asthma: Signs/Symptoms
 Coughing
 Expiratory wheezing
 Tachypnea
 Cyanosis

41. Asthma: Prolonged Attacks
 Increase in respiratory water loss
 Decreased fluid intake
 Dehydration

42. Asthma: History
 How long has patient been wheezing?
 How much fluid has patient had?
 Recent respiratory tract infection?
 Medications? When? How much?
 Allergies?
 Previous hospitalizations?

43. Asthma: Physical Exam
 Patient position?
 Drowsy or stuporous?
 Signs/symptoms of dehydration?
 Chest movement?
 Quality of breath sounds?

44. Asthma: Risk Assessment
 Prior ICU admissions
 Prior intubation
 >3 emergency department visits in past year
 >2 hospital admissions in past year
 >1 bronchodilator canister used in past month
 Use of bronchodilators > every 4 hours
 Chronic use of steroids
 Progressive symptoms in spite of aggressive Rx

45. Asthma
Silent Chest
equals
Danger

46. Wheezing
 http://www.youtube.com/watch?v=YG0-
ukhU1xE

47. RETRACTIONS
 https://www.youtube.com/watch?v=Hv68
EQ3tCBI
 https://www.youtube.com/watch?v=42jJ1
8fkZ0Y

48. Head Bobbing
 https://www.youtube.com/watch?v=q0bH
wMayCJY

49. Golden Rule
 Pulmonary edema
 Allergic reactions
 Pneumonia
 Foreign body aspiration
ALL THAT WHEEZES IS NOT ASTHMA

50. Asthma: Management
 Airway
 Breathing
Sitting position
Humidified O2 by NRB mask
Dry O2 dries mucus, worsens plugs
Encourage coughing
Consider intubation, assisted ventilation

51. Asthma: Management
 Circulation
IV TKO
Assess for dehydration
Titrate fluid administration to severity of
dehydration
Monitor ECG

52. Asthma: Management
 Obtain medication history
Overdose
Arrhythmias

53. Asthma: Management
 Nebulized Beta-2 agents
Albuterol
Terbutaline
Metaproterenol
Isoetharine

54. Asthma: Management
 Nebulized anticholinergics
Atropine
Ipatropium

55. POSSIBLE BENEFIT IN PATIENTS
WITH VENTILATORY FAILURE
Asthma: Management
 Subcutaneous beta agents
Epinephrine 1:1000--0.1 to 0.3 mg SQ
Terbutaline--0.25 mg SQ

56. Asthma: Management
 Use EXTREME caution in giving two
sympathomimetics to same patient
 Monitor ECG

57. Asthma: Management
 Avoid
Sedatives
Depress respiratory drive
Antihistamines
Decrease LOC, dry secretions
Aspirin
High incidence of allergy

58. Status Asthmaticus
Asthma attack unresponsive to -2
adrenergic agents

59. Status Asthmaticus
 Humidified oxygen
 Rehydration
 Continuous nebulized beta-2 agents
 Atrovent
 Corticosteroids
 Aminophylline (controversial)
 Magnesium sulfate (controversial)

60. Magnesium Sulfate
 25-50 mg/kg over 20 minutes

61. Solu-Medrol
 1-2 mg/kg IV

62. Status Asthmaticus
 Intubation
 Mechanical ventilation
Large tidal volumes (18-24 ml/kg)
Long expiratory times
 Intravenous Terbutaline
Continuous infusion
3 to 6 mcg/kg/min

63. Bronchiolitis

64. Bronchiolitis: Pathophysiology
 Viral infection (RSV)
 Respiratory Syncytial Virus
 Inflammatory bronchiolar edema
 Air trapping

65. Bronchiolitis: Incidence
 Children < 2 years old
 80% of patients < 1 year old
 Epidemics January through May

66. Bronchiolitis: Signs/Symptoms
 Infant < 1 year old
 Recent upper respiratory infection exposure
 Gradual onset of respiratory distress
 Expiratory wheezing
 Extreme tachypnea (60 - 100+/min)
 Cyanosis

67. Asthma vs Bronchiolitis
 Asthma
 Age - > 2 years
 Fever - usually normal
 Family Hx - positive
 Hx of allergies - positive
 Response to Epi - positive
 Bronchiolitis
 Age - < 2 years
 Fever - positive
 Family Hx - negative
 Hx of allergies - negative
 Response to Epi - negative

68. Asthma or Bronchiolitis?

69. Bronchiolitis: Management
 Humidified oxygen by NRB mask
 Monitor EKG
 IV tko
 Anticipate order for bronchodilators
 Anticipate need to intubate, assist
ventilations

70. Foreign Body Airway Obstruction
FBAO

72. FBAO: High Risk Groups
 > 90% of deaths: children < 5 years old
 65% of deaths: infants

73. FBAO: Signs/Symptoms
 Suspect in any previously well, afebrile
child with sudden onset of:
Respiratory distress
Choking
Coughing
Stridor
Wheezing

74. FBAO: Management
 Minimize intervention if child conscious,
maintaining own airway
 100% oxygen as tolerated
 No blind sweeps of oral cavity
 Wheezing
Object in small airway
Avoid trying to dislodge in field

75. FBAO: Management
 Inadequate ventilation
Infant: 5 back blows/5 chest thrusts
Child: Abdominal thrusts

76. Bronchopulmonary Dysplasia
BPD

77. BPD: Pathophysiology
 Complication of infant respiratory distress
syndrome
 Seen in premature infants
 Results from prolonged exposure to high
concentration O2 , mechanical ventilation

78. BPD: Signs/Symptoms
 Require supplemental O2 to prevent cyanosis
 Chronic respiratory distress
 Retractions
 Rales
 Wheezing
 Possible cor pulmonale with peripheral edema

79. BPD: Prognosis
 Medically fragile, decompensate quickly
 Prone to recurrent respiratory infections
 About 2/3 gradually recover

80. BPD: Treatment
 Supplemental O2
 Assisted ventilations, as needed
 Diuretic therapy, as needed

81. Intubation: Tube Size
 Infant or Child < 2 : 4.0, 4.5, or 5
 Newborn: 3 (or more for a big baby)
 Preemie: 2.5 or 3

82. Intubation: Tube Sizes
 Child older than 2
 (16 + age in yrs) / 4
 Or
 (age in yrs / 4) + 4

86. Miscellaneous

88. Whooping Cough
 http://www.youtube.com/watch?v=wuvn-
vp5InE&feature=related
 https://www.youtube.com/watch?v=TIV4
60AQUWk

89.  http://reference.medscape.com/features/sl
ideshow/pediatric-respiratory

90. KIDS EAT EVERYTHING