Common Pediatric Respiratory Illness and Emergencies

Transcription

1 Common Pediatric Respiratory Illness and Emergencies Rob Cloutier, MD Assistant Professor Emergency Medicine & Pediatrics Oregon Health & Science University

2 Overview Review key differences between pediatric and adult patients Airway / Breathing Anatomy / physiology Assessment Intervention BLS / ALS Common Illness Croup Bronchiolitis Asthma

3 Children Not Just Small Adults!

4 Their Hearts Beat Faster Age Heart Rate 0-3 Months Months years years 60-95

5 Their Vital Signs Vary with Age Age HR(beats/min) BP(mm Hg) RR(breaths/min) Premature / mo / mo / mo / yr / yr / yr / yr /

6 Blood Pressure How do you estimate a normal or low BP? Normal SBP = (Age) Low SBP < (Age)

7 Size Matters How do you estimate a child s weight? Estimate 10 kg for a 1 year old, add 2 kg each year (up to years) What device is used in trauma situations to estimate weight, length, etc? Broselow tape How are all medications dosed in pediatrics? Units/kg

8 They re Growing. 0-3 months of age 3-9 months 9-14 months months g/day g/day g/day 7-9 g/day

9 They re Watery

10 The rule Maintenance fluid requirements are calculated on an hourly basis depending on the body weight: 4 ml/kg for the first 10 kg Adding 2 ml/kg for the second 10 kg And 1 ml/kg for each kg over 20 kg

11 They Have Different Proportions

12 From online.sfsu.edu

13 They have a limited repertoire

14 Common Signs of Sepsis in the Newborn Period Fever or hypothermia (even without other S/S) "Not looking well Tachycardia, bradycardia, shock, or poor perfusion Respiratory distress, apnea, grunting, cyanotic "spells Lethargy, irritability, seizures Full fontanelle Hypotonia Feeding difficulties, vomiting, abdominal distention Diarrhea Jaundice, hepatosplenomegaly Rash, localized infection. From: Martinot, A., LeClerc, F., Cremer, R., Lereurtre, C., & Hue, V. Sepsis in neonates and children: Definitions, epidemiology, and outcome. Pediatric Emergency Care, 13, (14),

15 They re Vulnerable Injury Abuse Exposure Fear

16 It s All About the ABc s Pediatric Cardio-Pulmonary Arrests Shock 10% Cardiac 10% Respiratory 80%

17 40 Age distribution of arrests # Arrests Age (years)

18 They Have Different Airways

19 Pediatric Airway Considerations Small airway Large tongue Cephalad larynx Low attachment of vocal cords Narrowest portion of airway cricoid Large occiput High metabolic rate

20 Airway Anatomy

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24 Anatomy Nose Nose is responsible for 50% of total airway resistance at all ages Infants are obligate nose-breathers blockage of nose = respiratory distress Consider choanal stenosis / atresia Adenoids get in the way NPA more difficult < 1 year of age

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26 Airway Anatomy Tongue Large Loss of tone with sleep, sedation, CNS dysfunction Frequent cause of upper airway obstruction

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28 Narrow Airway at Cricoid ETT size based on cricoid Cuffed tubes optional under age 8

29 Airway Anatomy Larynx High position Infant : C 1 6 months: C 3 Adult: C 5-6 Anterior position

30 Anatomy Epiglottis Relatively large size in children Omega shaped Floppy not much cartilage

31 Low Attachment of Vocal Cords Anteriorly NO blind intubations

32 How Adults Breath.

33 How Kids Breath. Soft rib cage No chest muscles Diaphragm dependent (what about the guts?) Compensate with increased RATE of breathing

34 High Metabolic Rate Oxygen consumption in infants is 6 to 8 ml/kg/min compared with 3 to 4 ml/kg/min in adults Hypoxemia develops more rapidly in the child

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36 Airway / Breathing Assessment Look Airway positioning Mental status Color Work of breathing Respiratory rate Respiratory depth Listen Upper Airway Stertor Stridor Hoarse / muffled voice Lower Airway Wheezes Rhonchi Rales Breath sounds

37 Signs of Respiratory Distress Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Inability to lie down Agitation Retractions Access muscles Wheezing Sweating Prolonged expiration Pulsus paradoxus Apnea Cyanosis

38 Impending Respiratory Failure Reduced air entry Severe work Cyanosis despite O 2 Irregular breathing / apnea Altered Consciousness Diaphoresis

39 Hypoxia in Children First Sign: Anxiety / Fussy / Irritable Second Sign: Lack of Engagement Third: Bradycardia Fourth: Obtundation

40 Anatomic Assessment Neck/cervical spine Face/HEENT Teeth

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46 Airway position for infants Roll under shoulders

47 Airway positioning for > 2 years of age Towel under head Sniffing position

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49 Facemask Oxygen Simple Facemask Non-rebreather

50 Airway adjuncts Nasal airway Oral airway Bag Valve Mask

51 Nasopharyngeal Airway Length: Nostril to Tragus Contraindications: Basilar skull fracture CSF leak Coagulopathy

52 A regular ETT can be cut and used as a nasal airway

53 Oral Airway Correct size

54 Oral Airway Wrong size: Too Long

55 Oral Airway Wrong size: Too Short

56 Bag-valve-mask

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58 Common Pediatric Respiratory Diseases Croup Bronchiolitis Asthma (Pneumonia)

59 The age group: Croup Toddlers 1-5 years of age Fall and Spring What's the problem: The vocal cords are infected with a virus Swollen Laryngitis Treatment Decrease the swelling Oxygenate

60 CROUP Epidemiology The most common cause of airway obstruction in children 6 months to 6 years Transmission by direct contact and exposure to nasopharyngeal secretions 2-6 day incubation period Duration of illness 3-7 days

61 CROUP Epidemiology Parainfluenza virus type I Parainfluenza virus type II Influenza type A Adenoviruses RSV Enteroviruses Mycoplasma pneumoniae

62 CROUP Pathophysiology Mucosal and submucosal edema involving the subglottic portion of the airway Edema, in combination with increased volume and viscosity of secretions, results in narrowing of tracheal lumen Bronchial constriction and atelectasis

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64 CROUP Evaluation Usually present with typical URI, followed by barky cough and hoarseness Cough most common symptom Stridor in 58% +/- fever May exhibit wheezing

65 CROUP Evaluation Clinical diagnosis Pulse oximetry; if hypoxic, consider lower respiratory tract component Radiography, rarely needed Steeple sign Ballooning of hypopharynx and dilation of the trachea proximal to subglottic narrowing

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67 TREATMENT Humidified Air and Oxygen Mechanism not fully understood, but a subset of patients respond to this treatment solely Moistens the throat and larynx Has not been shown to reduce subgottic edema Croup tents of little use

68 TREATMENT Racemic Epinephrine Alpha-adrenergic stimulation causes mucosal vasoconstriction 0.5 ml of 2.25% solution diluted in 2.5 ml of saline is safe for all ages Effects last 90 minutes to 2 hours Observe patient for at least 2 hours in the ED

69 TREATMENT Steroids Controversial in past, now widely accepted that steroids are beneficial for moderate to severe croup Its use for mild croup is now clear Oral, IM, or inhaled??

70 TREATMENT Steroids No statistical difference between oral dexamethasone and nebulized budesonide-- trend in favor of oral preparation (Geelhoed, 1995) A single PO dose of dexamethasone is as effective as an IM dose (Rittichier, 2000)

71 TREATMENT Recommendations MILD CROUP Hoarseness or mild stridor when agitated Consider steroids alone

72 TREATMENT Recommendations MODERATE TO SEVERE CROUP Stridor at rest, retractions, hypoxia Humidified air and oxygen Racemic epinephrine 0.5 ml in 2.5 ml saline 0.25 ml for patient <5 kg 0.75 ml for adolescent Dexamethasone 0.6 mg/kg PO

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76 BRONCHIOLITIS Epidemiology Respiratory syncytial virus (RSV) Parainfluenza virus type 3 Adenoviruses

77 BRONCHIOLITIS Epidemiology Children less than 2 years Highly contagious, spread by large droplets Outbreaks occur yearly between Oct and May, peaking in Jan and Feb Infants less than 1 year, those with cardiac, pulmonary and immune problems have most severe infections

78 BRONCHIOLITIS Pathophysiology Necrosis of respiratory epithelium and destruction of ciliated epithelial cells Peribronchiolar infiltration with lymphocytes Submucosa becomes edematous Cellular debris and fibrin form plugs within the bronchioles

79 BRONCHIOLITIS Pathophysiology RSV can cause severe pneumonia with necrosis of lung parenchyma and formation of hyaline membranes Complications include prolonged hospitalization, respiratory failure requiring mechanical ventilation, wheezing in the future, bronchiolitis obliterans

80 BRONCHIOLITIS Evaluation Several days of upper respiratory tract signs, usually associated with low-grade to moderate fever Worsening cough Tachypnea Irritability, malaise, anorexia

81 CXR BRONCHIOLITIS Evaluation Hyperaeration with areas of interstitial infiltration Consolidation, which may represent atelectasis, occurs in 25% Pulse oximetry Hypoxemia, often in face of benign radiograph

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83 TREATMENT Supportive O2 Suction Assisted Ventilation Controversial Albuterol Epinephrine Steroids

84 Asthma Age Group: All takers! Problem: Reactive Airways Mucous/Spasm

85 Assessment Work of breathing Expose the chest! Can they talk? Mental status Breath sounds Less is less! Tight vs PTX Pulse Oximetry Asthma

86 Asthma Treatment Oxygen Albuterol, albuterol, albuterol Additional considerations: Epinephrine (SC, IM, IV) Terbutaline (IM, IV) MgSO4 (IV) Ketamine (IM / IV)

87 Asthma DO NOT INTUBATE!

88 Review Kids have different airways Kids breath differently Look for Work of Breathing! Kids don t like hypoxia Be very generous with lot s of oxygen! Treatment Oxygen! Oxygen! Oxygen! Consider Albuterol driven by Oxygen! Consider Epinephrine Consider Steroids Transport..