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GEMC: Pediatric Respiratory Distress: Resident Training
The document outlines key concepts related to pediatric respiratory distress, authored by Stuart A. Bradin. It emphasizes the importance of recognizing the differences in airway anatomy between children and adults, understanding various causes of airway obstruction, and managing acute cases effectively. Additionally, it provides guidelines for assessing respiratory distress in children, identifying critical signs, and focusing on timely interventions to prevent severe outcomes.
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GEMC: Pediatric Respiratory Distress: Resident Training
- 1. Project: Ghana EmergencyMedicine Collaborative Document Title: Pediatric Respiratory Distress Author(s): Stuart A Bradin (University of Michigan), DO, FAAP, FACEP, 2012 License: 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/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
- 2. Attribution Key for moreinformation see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 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
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- 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
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- 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)
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- 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
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- 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
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- 23. Respiratory Distress • Definedas 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
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- 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
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- 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
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- 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)
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- 37. Infec3ous Mononucleosis • Caused by Epstein-‐ Barr Virus (EBV) • Transmitted via contact w/ oropharyngeal secretions • Incubation period 4-‐6 weeks • Typical presentation: Adolescent or young adult Fever Pharyngitis Lymphadenopathy Splenomegaly • Other constitutional findings: h/a, anorexia, myalgias, chills, rash ( generalized maculopapular), malaise • Rare complications: myocarditis, myositis, transverse myelitis, encephalitis, pancreatitis/ cholecystitis, glomerulonephritis • Spontaneous splenic rupture 1-‐2 % • Labs supportive of EBV: elevated transaminases relative lymphocytosis w/ > 10% atypical lymphs mild leukocytosis (12-‐20,000) mild thrombocytopenia elevated ESR or CRP 37
- 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.
- 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
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- 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
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- 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)
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- 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
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- 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
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- 59. Diphtheria • Toxic appearance • “Bull neck”-‐ swelling nodes and neck • Gray adherent pharyngeal membrane • Croup like symptoms-‐ low grade fever hoarseness sore throat stridor • Rare US-‐ extensive immunization • Can result in laryngeal web • If suspected, treat: diphtheria antitoxin Penicillin Erythromycin • Early intubation/ trach 59 Dileepunnikri (Wikimedia Commons)
- 60. Non-‐infec3ous E3ologies for Upper Airway Obstruc3on • Caustic Ingestion • Burns • Anatomical • Foreign Bodies • Trauma/ bleeding • Anaphylaxis 60
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- 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
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- 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
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- 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
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- 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
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- 76. Pharyngeal lye ingestion 76 Alex Avriette (Flickr) 2006
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- 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
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- 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)
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- 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 savea 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 • 1yr 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 respiratorytract 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/inflammationof 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 agentscan 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
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- 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/ YoungChild • 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: ClassicPatterns 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
- 98. Staphyloccocal Pneumonia • Rapidlyprogressive • Fever, distress • Significant morbidity • 71% pleural effusion • Empyema • Abcess • Pneumothorax 98 Source Undetermined
- 99. Chlamydia trachomatis • 2-19weeks after birth • Conjuctivitis • Afebrile • Staccato cough • Tachypnea • Crackles • Eosinophilia • B/l diffuse infiltrates • Hyperinflation 99 Source Undetermined
- 100. Pneumococcal pneumonia • Unilobarinfiltrate • Round infiltrate • Tachypnea • Crackles • Fever/ chills acutely • GI symptoms • No resp symptoms 28% (Toikka, et al) • 40%- pleural effusion • Greatest incidence< 2yrs • Sickle cell disease • Asplenia 100 Source Undetermined
- 101. Mycoplasma • Bilateral diffuse interstitialinfiltrates • Film can be normal • Rarely effusion (<20%) • Gradual onset symptoms • Low grade fever • Non productive cough • Older child/ adolescent 101 Source Undetermined
- 102. Viral Pneumonia • Mostcommon < 5yrs age • Diffuse interstitial infiltrate • Atelectasis • Hyperinflation • Peribronchial thickening • Hilar adenopathy • RSV, Parainfluenza, Adenovirus, Influenza • Wheezing 102 Source Undetermined
- 103. Laboratory Diagnosis- BloodCultures • 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 • Pulmonarytoilet/ 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 • 3mth 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 • Littlechange 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 infectionmedium 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 • URIsymptoms • 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 forSevere 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 3or 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
- 114. Management • Supportive care • Fluids • Oxygen • Monitoring • Pulmonary toilet • Ventilatory support • Prevention- Respigam, Synagis 114
- 115. Management Controversies • Efficacyof bronchodilators • Benefits of steroids • Risk SBI in bronchiolitic with fever 115
- 116. Corticosteroids • Again, studiesinconclusive, 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 riskpts 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 • 12yr 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 • THEchronic 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 • 10million 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 • Boys50% > 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
- 125. Definition • Chronic inflammatory disease • Frequent exacerbations • Reversible airflow obstruction w/ meds • Multiple triggers- viral URI, mycoplasma, exercise, allergies, environmental (tobacco, dust, roaches) • Manifested as SOB, cough, wheeze, chest tightness 125 Source Undetermined
- 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
- 127. • Inhaled Betaagonists • Nebulized Anticholinergic Agents • Corticosteroids • Magnesium sulfate • Heliox • Intubation Treatment 127 Step 4: Severe Persistent Step 3: Moderate Persistent Step 2: Mild Persistent Step 1: Intermittent STEP- UP STEP- DOWN
- 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- MDIor 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 • NAEPPrecommendation 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 ofatropine • 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 formost 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 • Mainstayof 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 heliumand 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 • Shouldbe 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 • Peakflow, 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 asthmaticsrequire 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 forFatal 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 distressmultiple 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 maybe 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 asthmaaggressively • 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
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