Pediatric respiratory emergency : upper

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  • Onset & duration : acute/chronic Asssociation symptom : respiratory distress, fever , toxicity, drooling , cyanosis Progression with age : Exacerbation Feeding pattern Airway procedure Choking episode Baseline noises,quality of cry and voice
  • approximately 80% of patients demonstrate genotypic abnormalities of the distal region of chromosome arm 11p. The Beckwith-Wiedemann syndrome region of 11p was the first identified example of imprinting in mammals (ie, the process whereby the 2 alleles of a gene are expressed differentially). cardinal features of Beckwith-Wiedemann syndrome include prenatal and postnatal overgrowth, 3 macroglossia, and anterior abdominal wall defects (most commonly, exomphalos). Variable findings include posterior helical indentations (pits of the external ear) and organ overgrowth , particularly hepatomegaly and nephromegaly.
  • Treacher Collins syndrome TCOF1 gene mutation at chromosome 5q32-q33.1 autosomal-dominant visible signs like prominent nose as well as sunken appearance in the middle part of the face underdeveloped facial bones Hearing loss cleft palate
  • Epinephrine (1:1000) ขนาดสูงสุด 2.5 มล . ถ้าอายุน้อยกว่า 4 ปี และ 5 มล . ถ้าอายุมากกว่าหรือเท่ากับ 4 ปี
  • & jet ventilation
  • Pediatric respiratory emergency : upper

    1. 1. By Duangruethai Tunprom, MD. 3 rd years emergency medical resident, PMK hospital
    2. 2. outline <ul><li>Upper airway obstruction & infection </li></ul><ul><li>Lower airway obstruction </li></ul><ul><li>Disease of the lung </li></ul>
    3. 3. PALS in AHA 2010 Management of Respiratory Emergencies Flowchart Management of Respiratory Emergencies Flowchart Airway positioning, Oxygen, Pulse oximetry, ECG monitor(as indicated), BLS as indicated Upper Airway Obstruction Specific Management for Selected Conditions Croup Anaphylaxis Aspiration Foreign Body <ul><li>Nebulized epinephrine </li></ul><ul><li>Corticosteroids </li></ul><ul><li>IM epinephrine </li></ul><ul><li>Albuterol </li></ul><ul><li>Antihistamines </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Allow positio of comfort </li></ul><ul><li>Specialty consultation </li></ul>Lower Airway Obstruction Specific Management for Selected Conditions Bronchiolitis Asthma <ul><li>Nasal suctioning </li></ul><ul><li>Bronchodilator trial </li></ul><ul><li>Albuterol±ipratropium </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Subcutaneous epinephrine </li></ul><ul><li>Magnesium sulfate </li></ul><ul><li>Terbutaline </li></ul>
    4. 4. PALS in AHA 2010 Management of Respiratory Emergencies Flowchart Management of Respiratory Emergencies Flowchart Airway positioning, Oxygen, Pulse oximetry, ECG monitor(as indicated), BLS as indicated Lung Tissue(Parenchymal)Disease Specific Management for Selected Conditions Pneumonia/pneumonitis Infection Chemical Aspiration Pulmonary Edema Cardiogenic or Noncardiogenic (ARDS) <ul><li>Albuterol </li></ul><ul><li>Antibiotic(as indicated) </li></ul><ul><li>Consider noninvasive or invasive ventilatory support with PEEP </li></ul><ul><li>Consider vasoactive support </li></ul><ul><li>Consider diuretic </li></ul>Disordered Control of Breathing Specific Management for Selected Conditions Increased ICP Poisoning/Overdose Neuromuscular Disease <ul><li>Avoid hypoxemia </li></ul><ul><li>Avoid hypercarbia </li></ul><ul><li>Avoid hyperthermia </li></ul><ul><li>Antidote(if avaiable) </li></ul><ul><li>Contact poison control </li></ul><ul><li>Consider noninvasive or invasive ventilatory support </li></ul>
    5. 5. outline <ul><li>Upper airway obstruction & infection </li></ul><ul><li>Lower airway obstruction </li></ul><ul><li>Disease of the lung </li></ul>
    6. 6. Upper airway obstruction & infection <ul><ul><li>Distingishing principles of disease </li></ul></ul><ul><ul><li>Stridor </li></ul></ul><ul><ul><li>Specific disorder </li></ul></ul><ul><ul><ul><li>Supraglottic airway disease </li></ul></ul></ul><ul><ul><ul><li>Subglottic tracheal diseases </li></ul></ul></ul><ul><ul><ul><li>Disease of the trachea </li></ul></ul></ul><ul><ul><ul><li>Aeroesophageal foreign bodies </li></ul></ul></ul>
    7. 7. Comparison of adult and pediatric airways
    8. 8. Comparison of adult and pediatric airways
    9. 9. Comparison of adult and pediatric airways <ul><li>The airway is smaller </li></ul><ul><li>The tongue is relatively larger </li></ul><ul><li>The larynx is more cephalad in position </li></ul><ul><li>The epiglottis is short, narrow, and angled away from the trachea </li></ul><ul><li>The vocal cords attach lower anteriorly </li></ul><ul><li>< 10 years of age, the narrowest portion of the airway is subglottic </li></ul>
    10. 10. Regions and associated pathology of pediatric upper airway <ul><li>Supraglottic </li></ul><ul><li>Craniofacial </li></ul><ul><ul><li>Pierre Robin </li></ul></ul><ul><ul><li>Theacher Collins </li></ul></ul><ul><ul><li>Hallermann-streiff </li></ul></ul><ul><li>Macroglossia </li></ul><ul><ul><li>Beckwith-Wiedemann </li></ul></ul><ul><ul><li>Down syndrome </li></ul></ul><ul><ul><li>Glycogen storage disease </li></ul></ul><ul><ul><li>Congenital hypothyroidism </li></ul></ul><ul><li>Choanal atresia </li></ul><ul><li>Encephalocele </li></ul><ul><li>Thyroglossal duct cyst </li></ul><ul><li>Lingual thyroid </li></ul><ul><li>Intrathoracic </li></ul><ul><li>Tracheomalacia </li></ul><ul><li>Tracheal stenosis </li></ul><ul><li>Vascular ring/sling </li></ul><ul><li>Mediastinal masses </li></ul><ul><li>Laryngeal </li></ul><ul><li>Laryngomalacia </li></ul><ul><li>Vocal cord paralysis </li></ul><ul><li>Congenital subglottic stenosis </li></ul><ul><li>Laryngeal web </li></ul><ul><li>Laryngeal cyst </li></ul><ul><li>Subglottic hemangioma </li></ul><ul><li>Laryngotracheoesophageal cleft </li></ul>
    11. 11. Cause of stridor Feature Supraglottic Glottic Subglottic trachea Sound Sonorous Biphasic stridor High pitched stridor Gurgling Inspiratory stridor Coarse Expiratory stridor Structures Nose Larynx Subglottic trachea Pharynx Vocal cord Epiglottis
    12. 12. Cause of stridor Feature Supraglottic Glottic Subglottic trachea Congenital Micrognathia Laryngomalacia Subglottic stenosis Pierre Robin syndrome Vacal cord paralysis Tracheomalacia Treacher Collins syndrome Laryngeal web Tracheal stenosis Macroglossia Laryngocele Vascular ring Down syndrome Hemangioma cyst Storage disease Choanal atresia Lingual thyroid Thyroglossal cyst Acquired Adenopathy Papillomas Croup Tonsillar hypertrophy Foreign body Bacterial tracheitis Foreign body Subglottic stenosis Pharyngeal abscess Foreign body Epiglottitis
    13. 13. <ul><li>Infectious </li></ul><ul><li>Non-infectious </li></ul><ul><li>Croup </li></ul><ul><li>Epiglotitis </li></ul><ul><li>Tracheitis </li></ul><ul><li>Retropharyngeal abscess </li></ul><ul><li>Symptoms at birth </li></ul><ul><ul><li>Laryngeal web </li></ul></ul><ul><ul><li>Vocal cord paralysis </li></ul></ul><ul><ul><li>Cystic hygroma </li></ul></ul><ul><ul><li>Subglottic stenosis </li></ul></ul><ul><li>Symptoms after neonatal period </li></ul><ul><li>Acquired </li></ul>
    14. 14. <ul><li>Infectious </li></ul><ul><li>Non-infectious </li></ul><ul><li>Croup </li></ul><ul><li>Epiglotitis </li></ul><ul><li>Tracheitis </li></ul><ul><li>Retropharyngeal abscess </li></ul><ul><li>Symptoms at birth </li></ul><ul><li>Symptoms after neonatal period </li></ul><ul><ul><li>Subglottic hemangioma </li></ul></ul><ul><ul><li>Laryngeal papilloma </li></ul></ul><ul><ul><li>Laryngomalacia </li></ul></ul><ul><ul><li>Tracheomalacia </li></ul></ul><ul><ul><li>Vasular ring/sling </li></ul></ul><ul><li>Acquired </li></ul>
    15. 15. <ul><li>Infectious </li></ul><ul><li>Non-infectious </li></ul><ul><li>Croup </li></ul><ul><li>Epiglotitis </li></ul><ul><li>Tracheitis </li></ul><ul><li>Retropharyngeal abscess </li></ul><ul><li>Symptoms at birth </li></ul><ul><li>Symptoms after neonatal period </li></ul><ul><li>Acquired </li></ul><ul><ul><li>FB aspiration or ingestion </li></ul></ul><ul><ul><li>Laryngospasm </li></ul></ul><ul><ul><li>Psychogenic stridor </li></ul></ul><ul><ul><li>Angioedema </li></ul></ul><ul><ul><li>Paratracheal mass (teratoma,lymphoma) </li></ul></ul><ul><ul><li>Vocal cord paralysis or subglottic stenosis (secondary to intubation) </li></ul></ul>
    16. 16. Important item of history <ul><li>Onset & duration </li></ul><ul><li>Asssociation symptom </li></ul><ul><li>Progression with age </li></ul><ul><li>Exacerbation </li></ul><ul><li>Feeding pattern </li></ul><ul><li>Airway procedure </li></ul><ul><li>Choking episode </li></ul><ul><li>Baseline noises, quality of cry and voice </li></ul>
    17. 17. Comparison of infectious upper airway emergencies Average age Common etiology medication Croup 6 mo-6 yrs Parainfluenzae Dexa ±racemic epinephrine Bacterial tracheitis 4-6 yrs S.aueus Antibiotic IV Retropharyngeal abscess 3 yrs GABHS, S.aueus,anaerobe Antibiotic IV Peritonsillar abscess Adolescence GABHS Antibiotic PO & IV Epiglottitis 2-8 yrs H.influenzae, Staphylococi, Streptococus species Antibiotic IV
    18. 18. Comparison of Croup,Epiglottitis & Bacterial Tracheitis Croup Epiglotitis Bacterial trachea Peak age 6 mo-3 years 3-7 years 3-5 years Pathogen Subglottic inflammation Inflammation & edema epiglottis, aryepiglottic folds Bacterial superinfection with inflammation of tracheal mucosa, copious mucopurulent secretion obstructing the trachea Organism Parainflueazae, RSV,adenovirus Haemophilus influenzae, Strep sp, Staphylococcus aureus Staphyloccus aureus or mixed flora Clinical Feature Onset follow URI prodrome consisting of croupy cough, hoarse voice, low grade fever, inspiratory stridor Rapid progression of high fever, toxicity, drooling, stridor Several-day prodome of crouplike illness progressing to toxicity, inspiratory/expiratory stridor, marked distress Lab & film Steeple sign on film neck PA veiw or normal Thumbprint sign on lateral aspect of neck, thickened aryepiglottic folds,loss of air in varecula Normal upper airway structures, shaggy tracheal air column Management Steriod uncommon Aerosolized epinephrine Intubation, abtibiotics Intubation (70 %) antibiotics rare
    19. 19. Supraglottic airway disease <ul><li>Congenital </li></ul><ul><ul><li>Choanal atresia </li></ul></ul><ul><ul><li>Macroglossia </li></ul></ul><ul><ul><li>Mic </li></ul></ul><ul><li>Retropharyngeal abscess </li></ul><ul><li>epiglottitis </li></ul>
    20. 20. <ul><li>Choanal atresia </li></ul><ul><ul><li>M/C congenotal anomaly of nose </li></ul></ul><ul><ul><li>Bilateral choanal atresia  life threatening emergency </li></ul></ul><ul><ul><li>Acute distress &cyanotic at birth </li></ul></ul><ul><ul><li>Increase secretion &swellingasso with URI exacerbation </li></ul></ul>
    21. 21. <ul><li>Macroglossia </li></ul>Beckwith-wiedemann syndrome
    22. 22. <ul><li>Micrognathia </li></ul>Treacher Collins syndrome
    23. 23. Retropharyngeal abscess <ul><li>Potential life threatening airway emergency </li></ul><ul><li>Retropharyngel space : </li></ul><ul><ul><li>Potential space between posterior pharyngeal wall & prevertrebral fascia extend from base of skull to level of T2 </li></ul></ul><ul><li>Result from </li></ul><ul><ul><li>Direct trauma </li></ul></ul><ul><ul><li>Suppuration of LN </li></ul></ul><ul><ul><li>Hematogenous spread </li></ul></ul>
    24. 24. Retropharyngeal abscess ( cont. ) <ul><li>Child < 3 years </li></ul><ul><li>Polymicrobial with streptococcus & anaerobe </li></ul><ul><li>Variable manifestrations </li></ul><ul><li>Fever, sorethroat, neck stiffness, torticollis, trimus, stridor, muffled voice </li></ul><ul><li>Complication </li></ul><ul><ul><li>Meningitis, sepsis, aspiration pneumonia, mediastinitis, empyema </li></ul></ul><ul><li>Need ± to intubation, ± surgical drainage </li></ul>
    25. 25. Film lateral neck : show retropharyngeal abscess
    26. 26. Retropharyngeal abscess ( cont. )
    27. 27. Epiglottitis <ul><li>Most fear ped emergency </li></ul><ul><li>Previous Haemophilus influenzae </li></ul><ul><li>Since HIB vaccine  drop incidence epiglotitis 10.9  8/10000 </li></ul><ul><li>m/c GABHS, S. aureus, Streptococcus pneumoniae </li></ul><ul><li>Classic :acute onset, rapid progression, sniffing, tripod position,drooling </li></ul>
    28. 28. <ul><li>Tripod position of epiglotitis </li></ul>
    29. 29. Normal epiglottis contrasted with thickness epiglottis Thumbprint sign
    30. 30. Disease of larynx <ul><li>Laryngomalacia </li></ul><ul><li>m/c chronic stridor in chronic stridor in infants </li></ul>
    31. 31. <ul><li>Vocal cord paralysis </li></ul>
    32. 32. <ul><li>Laryngeal web </li></ul>
    33. 33. <ul><li>Laryngeal papiloma </li></ul>
    34. 34. Subglottic tracheal diseases <ul><li>Subglottic stenosis </li></ul><ul><li>Subglottic hemangioma </li></ul>
    35. 35. Viral croup <ul><li>m/c cause of upper airway distress </li></ul><ul><li>6 m0 – 6 years </li></ul><ul><li>Peak 2 years </li></ul><ul><li>Parainfluenza virus type 1  50 % </li></ul><ul><li>Clinical diagnosis </li></ul>
    36. 36. Croup score
    37. 37. Viral croup Westley Croup Scoring System <ul><li>Mild ≤ 2 </li></ul><ul><li>Moderate 3- 7 </li></ul><ul><li>Severe≥ 8 </li></ul>
    38. 38. Viral croup Downes croup score <ul><li>Mild < 4 </li></ul><ul><li>Moderate 4- 7 </li></ul><ul><li>Severe > 7 </li></ul>
    39. 39. CPG croup ชมรมโรคระบบหายใจและเวชบำบัดวิกฤตในเด็กแห่งประเทศไทย ราชวิทยากุมารแพทย์แห่งประเทศไทย
    40. 40. Rebound phenomenon of epinephrine 1- 2 hours
    41. 41. Croup: Indication for admission <ul><li>Severe respiratory distress of failure </li></ul><ul><li>Unusual symptoms (hypoxia,hyperpyrexia) </li></ul><ul><li>Dehydration </li></ul><ul><li>Persistence of stridor at rest after aerosolized epinephrine and steroids </li></ul><ul><li>Persistence of tachycardia,tachypnea </li></ul><ul><li>Complex past medical history (prematurity, pulmonary, cardiac disease) </li></ul>
    42. 42. Viral croup (cont.) <ul><li>Treatment </li></ul><ul><li>Dexa 0.6 mg/kg IM </li></ul><ul><ul><li>ลด ETT 11 %  1% </li></ul></ul><ul><ul><li>ลด ICU days 129  21 days </li></ul></ul><ul><li>Higher Dexa (> 0.3 mg/kg)  more effective </li></ul><ul><li>Budesonide 2 mg via NB </li></ul><ul><ul><li>Shorten ED stay </li></ul></ul><ul><ul><li>ลด rate of hospitalization </li></ul></ul>Prefer Racemic epinephrine : less cardiovascular S/E than L-epinephrine Epinephrine (1:1000) MAX 2.5 ml in age < 4 yrs 5 ml in age ≥ 4 yrs Studies comparing L-epinephrine with racemic epinephrine show no significant difference in response
    43. 43. CXR AP : showing Croup
    44. 44. <ul><li>Spasmodic croup </li></ul><ul><ul><li>feature </li></ul></ul><ul><ul><ul><li>Overlap viral croup </li></ul></ul></ul><ul><ul><ul><li>Sudden onset of severe stridor </li></ul></ul></ul><ul><ul><ul><li>Barky cough without a viral prodrome </li></ul></ul></ul><ul><ul><li>Associated with </li></ul></ul><ul><ul><ul><li>Allergy </li></ul></ul></ul><ul><ul><ul><li>GERD </li></ul></ul></ul><ul><ul><ul><li>Hypersensitivity reaction on later exposure to the virus </li></ul></ul></ul>
    45. 45. Disease of Trachea <ul><li>Tracheaomalacia </li></ul><ul><li>Tracheal stenosis </li></ul><ul><li>Vascular ring </li></ul>
    46. 46. Bacterial tracheitis <ul><li>Overlap symptom both croup & epiglottitis </li></ul><ul><li>WBC normal or slightly increase </li></ul><ul><li>H/C usually normal </li></ul><ul><li>Investigation </li></ul><ul><ul><li>Plain x-ray </li></ul></ul><ul><ul><li>Bronchoscope </li></ul></ul><ul><li>Complication </li></ul><ul><ul><li>Toxic shock syndrome </li></ul></ul><ul><ul><li>Septic shock </li></ul></ul><ul><ul><li>Postintubation pulmonary edema </li></ul></ul><ul><ul><li>ARDS </li></ul></ul>Subglottic narrowing Hazy density within the tracheal lumen Ragged edge of the usually smooth tracheal air column
    47. 47. Aeroesophageal obstruction <ul><li>Asphyxia : m/c cause of death of FB aspiration </li></ul><ul><li>Major of cases & death in toddlers < 3 years </li></ul><ul><li>FB : round-shaped  difficult to manage </li></ul>
    48. 49. Airway FB obstruction management <ul><li>Visualize  remove </li></ul><ul><li>No finger sweep </li></ul><ul><li>Infant </li></ul><ul><ul><li>5 back blow follow 5 chest thrusts </li></ul></ul><ul><li>Child </li></ul><ul><ul><li>Conscious  Heimlich maneuver </li></ul></ul><ul><ul><li>Unconscious  Chest compression </li></ul></ul><ul><li>If cyannose & cannot ventilate & cannot intubation  Consider needle cricothyrotomy </li></ul>
    49. 52. Croup Epiglotitis Bacterial trachea Peak age 6 mo-3 years 3-7 years 3-5 years Pathogen Subglottic inflammation Inflammation & edema epiglottis, aryepiglottic folds Bacterial superinfection with inflammation of tracheal mucosa, copious mucopurulent secretion obstructing the trachea Organism Parainflueazae , RSV,adenovirus Haemophilus influenzae, Strep sp , Staphylococcus aureus Staphyloccus aureus or mixed flora Clinical Feature Onset follow URI prodrome consisting of croupy cough, hoarse voice, low grade fever, inspiratory stridor Rapid progression of high fever, toxicity , drooling , stridor Several-day prodome of crouplike illness progressing to toxicity , inspiratory/expiratory stridor, marked distress Lab & film Steeple sign on film neck PA veiw or normal Thumbprint sign on lateral aspect of neck, thickened aryepiglottic folds , loss of air in varecula Normal upper airway structures , shaggy tracheal air column Management Steriod uncommon Aerosolized epinephrine Intubation, abtibiotics Intubation (70 %) antibiotics rare
    50. 53. Pedriatric Dosing For Antibiotics In Upper Airway Infections Dose from children’ hospital of Philadelphia formulary (Pharmacy handbook formulary, Lexi-Comp) PO Dose Amoxicillin/clavulanic acid 90 mg/kg/d divided BID (max 875 mg/dose) Clindamycin 25 mg/kg/d divided BID(max450 mg/dose) IV Dose Amoxicillin/clavulanic acid 100 mg/kg/d divided Q 6 hrs (max 8 g/d) Clindamycin 40 mg/kg/d divided Q 8 hrs (max 2.7 g/d) Cefotaxime 120 mg/kg/d divided Q 8 hrs (max 2g Q 8 hrs) Ceftriaxone 50 mg/kg/d Q 24 hrs (max 2 g/d) Vancomycin 10 mg/kg Q 6 hrs (max 2 g/d) Oxacillin 150 mg/kg/d divided Q 6 hrs (max 8 g/d)
    51. 54. <ul><li>Thank you </li></ul>
    52. 55. <ul><li>http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=128&seg_id=2677 </li></ul><ul><li>Rosen 7 th ed emergency medicine </li></ul><ul><li>Tintinalli 7 th ed emergency medicine </li></ul>

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