5/26/10. Upper Airway Emergencies Identify life threatening upper airway infections Recognize and treat anaphylaxis and airway burns in children

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1 Andi Marmor, MD Assistant Clinical Professor, Pediatrics University of California, San Francisco Upper Airway Emergencies Identify life threatening upper airway infections Recognize and treat anaphylaxis and airway burns in children Lower Airway Emergencies Know when to send a child for bronchoscopy to R/O aspirated FB Use the most effective treatments for status asthmaticus and acute asthma List indications for intubation for pediatric asthma Start appropriate controller therapy for children with persistent asthma Upper Airway Emergencies Identify life threatening upper airway infections Recognize and treat anaphylaxis and airway burns in children Lower Airway Emergencies Know when to send a child for bronchoscopy to R/O aspirated FB Use the most effective treatments for status asthmaticus and acute asthma List indications for intubation for pediatric asthma Start appropriate controller therapy for children with persistent asthma 1

2 Athena is a 16 mo girl who presents to the ED at 3am with fever, cough and difficulty breathing She has had a cold and cough for 2 days, then woke up unable to breath and making a funny noise at 2am Improved a bit on the way to the ED T = 38.9, O2 sat 99%, RR 40, HR 160 Frightened but alert, looking around, nontoxic with supple neck Rhinorrhea, no drooling, post OP exam deferred Clear lungs, moderate retractions and a slight squeak heard on each inspiration A. Lateral neck film B. Admit for IV antibiotics C. Direct visualization of the epiglottis D. Racemic epinephrine and systemic steroids E. Intubate to protect the airway 2

3 Affects 1 6% of children, usually during 2 nd year of life Clinical diagnosis: Viral prodrome, barky cough and stridor Legitimate source for fever! Standard treatments have included Racemic epinephrine Mist (humidified air) Systemic corticosteroids Affects 1 6% of children, usually during 2 nd year of life Clinical diagnosis: Viral prodrome, barky cough and stridor Legitimate source for fever! Standard treatments have included Racemic epinephrine Mist (humidified air) Systemic corticosteroids Affects 1 6% of children, usually during 2 nd year of life Clinical diagnosis: Viral prodrome, barky cough and stridor Legitimate source for fever! Standard treatments have included Racemic epinephrine Mist (humidified air) Systemic corticosteroids 3

4 Standard of therapy for mild croup RCT s have failed to show superiority over placebo No longer recommended in guidelines for croup management Proven efficacy in moderate/severe croup Reduced symptoms, hospitalizations, epi use Dexamethasone: 0.6mg/kg well studied, smaller doses may be equally effective IM and oral routes equal in efficacy Efficacy in mild croup 2004 RCT found decreased symptom duration, parental stress and lost sleep Trial of mist therapy for mild cases Racemic epinephrine: Stridor at rest Severe upper airway obstruction D/C after steroids AND 3 4 h of observation Oral corticosteroids: Moderate croup and any time epi is given May be beneficial in mild cases as well 4

5 A. Lateral neck film B. Admit for IV antibiotics C. Direct visualization of the epiglottis D. Racemic epinephrine and systemic steroids E. Intubate to protect the airway NORMAL AP NECK STEEPLE SIGN You give Athena nebulized epinephrine and a dose of PO dex, but her respiratory distress is worsening She is now fatigued, with cool extremities, audible stridor and an O2 sat of 94% She sits up with her chin forward, and refuses to lie down, but has a supple neck 5

6 A. Epiglottitis B. Tracheitis C. Retropharyngeal abscess D. Foreign body E. Anaphylaxis Infectious: Epiglottitis Tracheitis Retropharyngeal abscess/cellulitis Non infectious Anaphylaxis Airway burns Foreign body aspiration Infectious: Epiglottitis Tracheitis Retropharyngeal abscess/cellulitis Non infectious Anaphylaxis Airway burns Foreign body aspiration 6

7 Dramatic decline since Hib vaccination (1990) Causes? S. pneumonia, S. aureas > Hib Diagnosis: Clinical: Toxic, rapid progression, stridor, drooling Lateral neck film: thumbprint sign Direct visualization only in controlled setting Treatment: airway support and antibiotics Dramatic decline since Hib vaccination (1990) Causes? S. pneumonia, S. aureas > Hib Diagnosis: Clinical: Toxic, rapid progression, stridor, drooling Lateral neck film: thumbprint sign Direct visualization only in controlled setting Treatment: airway support and antibiotics 7

8 Has replaced epiglottitis as most common life threatening upper airway infection 3 X greater than croup and epiglottitis combined S. aureus most common cause Clinical Diagnosis Toxic, stridor, purulent secretions on oropharynx Direct visualization via bronchoscopy Treatment: Airway support and antibiotics A. Epiglottitis B. Tracheitis C. Retropharyngeal abscess D. Meningitis E. Anaphylaxis 8

9 Pathophysiology: Spread from nearby structures GAS, Staph, viridans strep, anaerobes Diagnosis: Clinical : Fever, neck swelling/pain, decreased ROM, drooling Radiologic: Lateral neck plain film, CT Treatment: Airway support and antibiotics +/ surgical drainage (25 50%) 9

10 Consider tracheitis and epiglottitis in the illappearing child with fever and stridor RPA more likely if neck pain/swelling present Defer lateral neck film until patient is stable Unlikely to change immediate management Avoid attempts to visualize posterior oropharynx or epiglottis in ED Airway support : Position, avoid distress Consider epi, steroids for relief of swelling May require manual ventilation, intubation or criocothyrotomy Broad spectrum antibiotics: Cefriaxone or ampicillin/sulbactam Clindamycin or vancomycin if MRSA suspected, or penicillin allergic 10

11 Upper Airway Emergencies Identify life threatening upper airway infections Recognize and treat anaphylaxis and airway burns in children Lower Airway Emergencies Know when to send a child for bronchoscopy to R/O aspirated FB Use the most effective treatments for status asthmaticus and acute asthma List indications for intubation for pediatric asthma Start appropriate controller therapy for children with persistent asthma Artemis is a 14 month old girl who vomits and becomes unresponsive while with her mother in the waiting room In triage she is noted to have diffuse urticaria, swelling of her lips and eyelids, audible stridor and wheeze on auscultation She has a HR of 180, RR of 50, blood pressure of 100/60, and O2 sat of 99% A. Give inhaled beta agonists (albuterol) via nebulizer B. Give IV methylprednisolone C. Give IV diphenhydramine D. Give SC/IM epinephrine E. Give IV epinephrine 11

12 Foods the most common cause in infants/ children History of allergy rare in infants Fatality more likely: History of atopy, asthma, peanut allergy, croup, or urticaria Clinical diagnosis, labs not helpful Symptoms occur 5 30 min after exposure Cutaneous: itching, urticaria, flushing Respiratory: upper/lower airway obstruction GI: vomiting, diarrhea, abd pain Cardiovascular: shock Biphasic course in 5 20% ABC s IM Epinephrine: 0.01 ml/kg of a 1:1,000 solution (max =0.5 mg) Lateral thigh/shoulder most rapid absorption Beta 2 agonists if bronchospasm is present Steroids: PO or IV May blunt the late phase response Antihistamines: most effective for cutaneous symptoms 12

13 A. Give inhaled beta agonists (albuterol) via nebulizer B. Give IV methylprednisolone C. Give IV diphenhydramine D. Give SC/IM epinephrine E. Give IV epinephrine Observe for at least 6 to 8 hours Discharge with Injectable epinephrine AND note for school Epi pen Jr: 0.15 mg, use for children <30 kg Consider allergist referral Med alert bracelet 10 seconds 13

14 Occur in up to 30% of children with burns Mechanisms: facial scald, smoke/steam inhalation, aspiration of hot liquids Increased mortality (isolated: 23%!!) Thermal epiglottitis Clinically and radiographically similar to infectious OP exam may be normal Rapid deterioration common Electively secure airway if signs of laryngeal edema Cuffed tube recommended Succinylcholine OK <24 hours from injury Bronchodilators: If bronchospasm is present Steroids: Trial warranted if severe airway swelling Upper Airway Emergencies Identify life threatening upper airway infections Recognize and treat anaphylaxis and airway burns in children Lower Airway Emergencies Know when to send a child for bronchoscopy to R/O aspirated FB Use the most effective treatments for status asthmaticus and acute asthma List indications for intubation for pediatric asthma Start appropriate controller therapy for children with persistent asthma 14

15 Apollo is an 18 month old toddler brought in because his asthma suddenly got worse Albuterol q4 hours for 2 days with a URI Earlier in the day had choked on a piece of popcorn. Exam: alert and well appearing, VS stable, but tachypneic, with paroxysms of cough, during which he turns red Diffuse wheezing bilaterally A. Blind finger sweep B. Heimlich maneuver C. Obtain inspiratory and expiratory chest films D. Obtain chest fluoroscopy E. Request rigid bronchoscopy Age: 1 3 More complications in young infants Foods most common objects >90% in bronchi vs trachea Classic history in ~50% Delay in diagnosis common, and associated with morbidity 15

16 25 50% of patients have normal PE and radiograph History is the most sensitive and specific diagnostic tool Inspiration/expiration films may show hyperinflation or atelectasis Bilateral decubitus films in younger children Normal AP chest Normal R lateral decub Abnormal L lateral decub Inspiration Expiration Inspiratory and expiratory films in FB aspiration: A hyperinflated right lung and a leftward mediastinal shift during expiration (B) suggest a foreign body in the right mainstem bronchus. From: Verghese et al,

17 Referral for rigid bronchoscopy if history, PE or Xray suggests FB aspiration Imaging only in children with unclear history, stable airway Bronchodilators and/or steroids may help relieve airway obstruction Acute complete airway obstruction: Infant: Back blows/abdominal thrusts Child: Heimlich maneuver A. Blind finger sweep B. Heimlich maneuver C. Obtain inspiratory and expiratory chest films D. Obtain chest fluoroscopy E. Request rigid bronchoscopy 17

18 Clinical diagnosis most appropriate in most cases Lateral neck films may help narrow the diagnosis, but stabilize airway first Management for all: airway support and broad spectrum antibiotics Anaphylaxis Consider in the child with upper airway obstruction without signs of infection IM epinephrine is the first line drug Send all home with injectable epinephrine Airway burns Diagnosis/management like infectious epiglottitis Secure airway if any evidence of laryngeal edema History is the best diagnostic tool Radiographs recommended only when history is unclear, and airway is stable Back blows/abdominal thrust or Heimlich only for acute complete airway obstruction 18

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