Acute respiratory distress in children

1. Acute Respiratory infections
in Children - Croup
“Respiratory emergencies are 1 of the most common reasons parents
seek evaluation for their children in the Emergency department”

2. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb157.pdf
Respiratory Disorders
Respiratory Disorders are the 2nd leading cause of
ER visits in children (#1 is Injury and poisoning)

3. • Discuss the differences between pediatric and adult anatomy
& physiology
•How to properly assess a pediatric patient with respiratory
distress and discuss emergency room presentation of common
pediatric respiratory diseases
• ABCDE tool for Assessment
•Discuss Most Common Pediatric Respiratory Emergencies
Objectives

4. Kids are
not little
Adults

5. NOSE: Generally smaller, increased resistance,
Smaller septum & nasal bridge is flat and flexible . . .
Obligatory nose breathers
VOCAL CORDS: located at C3-4 versus C5-6 in
adults . . . Larynx is more anterior
Contributes to aspiration if neck is hyperextended
CRICOID RING Is the narrowest part of the airway
instead of vocal cords
AIRWAY DIAMETER is 4 mm vs.. 20 mm in adult
TRACHEAL RINGS more elastic & cartilaginous,
can easily crimp off trachea
More SMOOTH MUSCLE, makes airway more
reactive or sensitive to foreign substances
Airway: Child vs Adult

6. Body Surface Area
Children do not have a
larger body surface area
than adults. They have a
larger PERCENTAGE of
surface area for their
weight than adults do.
This is because children
do not have highly
developed muscle.
Most of their mass is fat
and water which weighs
less. Bones are also less
dense at a younger age.

7. • Head to Body ratio and
relative size and location of
anatomic features make
children more susceptible to
head and abdominal injury
• Underdeveloped anatomy
leads to chest pliability and
less protection of thoracic
cage and less effective use
of accessory muscles
• Arrest – Cardiac arrest
typically results from
untreated respiratory arrest
Child vs Adult

8. Thorax - Child vs Adult
• Horizontal ribs – more diaphragmatic
breathing
• Flatter Diaphragm
• Ribs & Sternum is cartilage - less
stability of chest wall, requires more
use of diaphragm
• Less pulmonary reserve
• Heart takes up more thoracic space
• Poor accessory muscle development
• Larger abdominal organs - pushes up
diaphragm

9. Airway
Urgencies
can quickly
progress to
airway
Emergencies

10. ABCDE
Assessment Tool
Underlying Principle - -
• Use a systematic approach
• Complete initial exam and re-assess regularly
• Assess the effects of treatment/interventions
• Correct life-threatening abnormalities before
moving on to the next part of assessment

11. Look for signs of airway obstruction
• Paradoxical chest and abdominal
movements (See-Saw)
• Accessory Muscle Use
• Central cyanosis
• Absent to no Breath sounds
• Depressed consciousness
Treat airway obstruction as a medical emergency
• In the majority of cases, simple methods of airway
management are all that is necessary - - Positioning,
Chin Lift, Suctioning, Oral/Nasal Airway - - Tracheal
Intubation may be required where simple measures fail
Give Oxygen
• Keep SpO2 > 90% - - Diminish risk of hypoxic damage

12. Look for general signs of respiratory
distress, sweating, cyanosis,
accessory muscle use – It is vital to
diagnose and treat immediately life
threatening conditions (Severe
Asthma, Tension Pneumothorax,
Foreign Body)
•Respiratory Rate & rhythm
•Equal chest expansion
•Breath sounds
• Stridor, Rales, Rhonchi, Wheezing
•Air Exchange
•Chest deformity
•Abdominal distension

13. Respiratory pathology that may compromise circulatory state - - -
tension pneumothorax
• Look for signs of poor cardiac output
• Peripheral and central pulses
• Blood Pressure
• Reduced level of consciousness
• Low urine output (less wet diapers)
• Reduced PO intake
• Look for signs of bleeding
• IV Fluids for patients that present with tachycardia and/or
poor capillary refill
In almost all medical/surgical
emergencies, consider hypovolemia
to be the primary cause of shock
unless proven otherwise.

14. Signs of Disability - - coma/convulsion - -
Common causes of unconsciousness
include profound hypoxia, hypercapnea,
cerebral hypoperfusion or recent
sedative/analgesic drug ingestion
•Review ABC’s – exclude hypoxia and hypotension
• Assess tone, Pupil size
• R/O Accidental Ingestion – give appropriate
antagonist where available
• Monitor LOC
• Blood Glucose Level
D can also stand for signs of dehydration
• Signs of shock have already been looked for
while assessing circulation but specific
examination for skin turger, sunken eyes, dry
mucus membranes

15. Check Temperature - - Kids will
become hyper/hypo thermic faster
than an adult
Look all over the body - - - back, groin
Assess in well lit area

16. Other than Trauma - - -
5 Most Common Respiratory
Emergencies
• Asthma
• Croup
• Bronchiolitis
• Epiglotitis
• Foreign bodies

17. Upper
Airway
Disease
Croup
Foreign Body
Epiglottitis
Bacterial Tracheitis
Asthma
Bronchiolitis
Pneumonia
Foreign Body
Lower
Airway
Disease
Noise during Inspiration
Proximal to Thoracic Inlet
Nose – Pharynx – Larynx
• Awake/Crying
• It child Improves
• Nose/Pharynx
• If child Deteriorates
• Larynx
Noise during Exhalation
Distal to Thoracic Inlet
Trachea, Bronchi,
Peripheral Airways

18. Upper
Airway
Disease

19. Basics
Upper respiratory viral
infection
Occurs mostly among
ages 6 months to 3 years
More prevalent in fall and
spring
Edema develops,
narrowing the airway
lumen (Steeple Sign)
Severe cases may result
in complete obstruction
Croup

20. Croup
• Physical exam/Assessment
• Tachycardia, tachypnea
• Skin color - pale, cyanotic,
mottled
• Decrease in activity or
LOC
• Fever
• Breath sounds - wheezing,
diminished breath sounds
• Stridor, barking cough,
hoarse cry or voice
• Any difficulty swallowing?
• Drooling present

21. Management
Assess & monitor ABC’s
High flow humidified O2; blow
by if child won’t tolerate mask
Limit exam/handling to avoid
agitation
Be prepared for respiratory
arrest, assist ventilations and
perform CPR as needed
Do not place instruments in
mouth or throat
Rapid transport
Croup

22. Basics
Bacterial infection and
inflammation of the
epiglottis
Usually occurs in children 3-
6 years of age
Can occur in infants, older
children, & adults
Swelling may cause
complete airway obstruction
Thumb sign
True medical emergency
Epiglotitis

23. Assessment/History
When did child
become ill?
Has it suddenly
worsened after a
couple of days or
hours?
Sore throat?
Will child swallow
liquids or saliva?
Is drooling present?
High fever (102-103
degrees F)
Onset is usually
sudden
Epiglotitis
Signs & Symptoms
May be sitting in Tripod
position
May be holding mouth
open, with tongue
protruding
Muffled or hoarse cry
Inspiratory Stridor
Tachycardia/tachypnea
Pale, mottled, cyanotic
skin
Anxious, focused on
breathing lethargic
Very sore throat
Nasal Flaring
Look very sick with high
fever

24. Management
Assess & monitor ABC’s
Do not make child lie down
Do not manipulate airway
High flow humidified O2; blow
by if child won’t tolerate mask
Limit exam/handling to avoid
agitation
Be prepared for respiratory
arrest, assist ventilations and
perform CPR as needed
Transfer of Children’s Hospital
Epiglotitis

25. Aspirated Foreign Body
• Basics
• Common among the 1-3
age group who like to put
everything in their mouths
• Running or falling with
objects in mouth
• Inadequate chewing
capabilities
• Common items - gum, hot
dogs, grapes and peanuts

26. Assessment
Complete obstruction will
present as apnea
Partial obstruction may present
as labored breathing,
retractions, and cyanosis
Objects can lodge in the lower
or upper airways depending on
size
Object may act as one-way
valve allowing air in, but not
out
Aspirated Foreign Body

27. Aspirated Foreign Body
Complete Obstruction
Attempt to clear using BLS
techniques
Attempt removal with direct
laryngoscopy and Magill forceps
Cricothyrotomy may be indicated
Partial obstruction
Make child comfortable
Administer humidified oxygen
Encourage child to cough
Have intubation equipment
available
Transport to hospital for removal
with bronchoscope

28. Supraglottic Area (Insp. Stridor)
• Anaphylaxis
• Epiglottitis
• Retropharyngeal/Peritonsillar
Absess
• Laryngomalacia
• Congenital Malformation
• Tumor of oral cavity or pharynx
Glottic & Subglottic Area (Insp. Stridor)
• Laryngotracheitis (croup)
• Tracheomalacia
• Anaphylaxis
• Foreign Body in Airway
• Subglottic Stenosis
• Bacterial tracheitis
• Vocal Cord Paralysis
Intrathoracic Area (Exp Stridor and/or
Wheezing)
• Infection (bacterial tracheitis, bronchitis)
• Foreign Body in Airway or Esophagus)
• Anaphylaxis
• Congenital Malformation
• Tumor
https://www.uptodate.com/contents/assessment-of-stridor-in-
children?source=search_result&search=stridor&selectedTitle
=1~150
Stridor

29. Take-a-ways
• Kids can deteriorate quickly –
you constantly have to be on
your toes!
• Anatomy and Physiology is
different than adults - - Be
aware of the differences and
the impact disease can make
• Use the ABCDE Assessment
tool
• Do a thorough systematic
approach and reassess often

30. Take home note:
Remember that an adequate airway
and oxygen-rich approach may be the
difference between life and death
Sick pediatric patients can be terrifying,
but they usually only have one thing
wrong.
Support their airway,
breathing and
cardiovascular status and
their amazing bodies will
usually take care of the
rest