This document discusses several common pediatric respiratory emergencies. It begins by noting that respiratory issues are the leading cause of pediatric hospital admissions and deaths in the first year of life outside of congenital abnormalities. It then provides details on the pediatric respiratory system and risks for failure. Specific conditions covered include croup, epiglottitis, asthma, bronchiolitis, and foreign body airway obstruction. For each condition, it discusses pathophysiology, signs and symptoms, risk factors, and management strategies. Throughout it emphasizes the importance of maintaining the airway, providing oxygenation and ventilation support, and using caution with bronchodilators in critically ill pediatric patients.

1. Pediatrics
Respiratory Emergencies

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

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

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

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

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

7. Respiratory Distress

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

9. Respiratory Emergencies
 Croup
 Epiglottitis
 Asthma
 Bronchiolitis
 Foreign body aspiration

10. Laryngotracheobronchitis
Croup

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

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

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

14. Croup: Management
 Mild Croup
– Reassurance
– Moist, cool air

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

16. Epiglottitis

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

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

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

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

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

22. Epiglottitis
Immediate Life Threat
Possible Complete Airway
Obstruction

23. Asthma

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

25. Asthma: Pathophysiology
Bronchospasm
Bronchial Edema Increased Mucus
Production

26. Asthma: Pathophysiology

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

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

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

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

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

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

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

34. Asthma
 SILENT CHEST= DANGER OF
RESPIRATORY FAILURE

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

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

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

38. Asthma: Management
 Obtain medication history
– Overdose
– Arrhythmias

39. Asthma: Management
 Nebulized Beta-2 agents
– Albuterol

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

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

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

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

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

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

46. Bronchiolitis

47. Bronchiolitis: Pathophysiology
 Viral infection (RSV)
 Inflammatory bronchiolar edema
 Air trapping

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

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

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

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

52. Foreign Body Airway Obstruction
FBAO

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

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

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

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