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/.
GEMC: Pediatric Respiratory Distress: Resident Training
1. Project: Ghana Emergency Medicine Collaborative
Document Title: Pediatric Respiratory Distress
Author(s): Stuart A Bradin (University of Michigan), DO, FAAP, FACEP,
2012
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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
àprogress
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
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.
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)
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
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
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
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
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
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
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
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
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
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