Pediatric Respiratory Distress. Dr. Karen Forward Dr. Mike Peddle
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1 Pediatric Respiratory Distress Dr. Karen Forward Dr. Mike Peddle
2 Objectives Discuss epidemiology & causes of respiratory distress in pediatric patients Identify differences between the pediatric and adult airways Correctly apply the Advance Life Support Patient Care standards in this patient population Discuss benefits and risks of common prehospital treatments for pediatric respiratory distress (i.e. Epi, Salbutamol, Intubation).
3 Case 3 year old male. CC: Breathing Problems HPI: Unwell with URTI symptoms earlier today Woke up from sleep with increased W.O.B, noisy breathing PMHX: Healthy Meds: None Allergies: None
4 On scene You and your partner arrive on scene Cats x 6 + Cigarette smoke Kid looks slightly pale, exhibiting increased WOB (TT, SCM use, IC/SC indrawing) when distressed, hoarse voice. Distress minimal when with mom. HR 150, RR 28, O2 sat-93%, BP 78/40, T now what?
5 EPIDEMIOLOGY AND COMMON CAUSES OF PEDIATRIC RESPIRATORY DISTRESS
6 Pediatric Respiratory Distress A common chief complaint Accounts for ~10% of pediatric emergency department visits Important cause for hospitalization: ~20-30% of admissions to the PCCU Important cause of mortality: One of the top 5 causes of death in pediatric patients ~20% of infant deaths
7 Respiratory Distress - features Respiratory Distress - look for: Increased work of breathing Nasal flaring Tracheal Tub Intercostal Indrawing Subcostal indrawing Abnormal Rhythm i.e. Gasping Abnormal Rate Too fast Too slow
8 Causes of Shortness of Breath Airway Respiratory System/ Lungs Cardiovascular System Miscellaneous: Metabolic Anemia Hyperventilation Poisoning CNS problem (i.e. Guillian Barre)
9 Airway Obstruction Foreign body Angioedema Anaphalaxis Infectious Croup viral Epiglottitis Abscess Other i.e. Diptheria Trauma
10 Breathing Infectious: Pneumonia bacterial/viral Croup (laryngotracheobronchitis) Bronchiolitis Idiopathic: Asthma Reactive Airways Disease Pneumothorax Traumatic: Pneumothorax (tension or simple) Hemothorax +/- Rib Fractures/Flail Chest Pulmonary Contusion
11 Cardiac Arrhythmias: SVT HR >220 bpm, no P waves Congenital Cardiac Anomalies with heart failure: Present with Tachy, Tachy, Megaly, Megaly Tachycardia Tachypnea Cardiomegaly Hepatomegaly Usually < 1 year of age.
12 DIFFERENCES BETWEEN PEDIATRIC AND ADULT AIRWAYS
13 Why can children be scary? Fatigue easily & decompensate quickly Small airways High resistance! Lower residual capacity High metabolisms so need a lot of O2 Inadequate compensatory mechanisms Chest wall not very muscular Have trouble increasing Tidal Volume Uptodate, 2011
14 Why can children be scary? Decreased respiratory reserve Infants are nose breathers, block nose = resp. distress Also: Their anatomy = different than adults Uptodate, 2011
15 Airway Anatomy: Child Children s Airway Considerations Head large occiput Tongue relatively large Adenoids +tonsils = big Epiglottis floppy, omega shaped Narrowest portion cricoid ring
16 Nagler, J., Wang, V. J., Stack, A. M., Willey, J. F. Airway management in children: Unique pediatric considerations. UpToDate. Last Updated: April 7, Retrieved: October 18, From:
17 Respiratory Anatomy Larynx: High and anterior (C3-4) in children vs. C4-5 in adults Trachea: Compressible Narrow Sniff Position in infants is preferred
18 back to our case You sit the child in the back of the truck and note progressive increased work of breathing as well as a loud Barky cough
19 BASIC AND ADVANCE LIFE SUPPORT PATIENT CARE STANDARDS
20 Croup History of URTI AND Barking Cough & Stridor at rest with severe respiratory distress AND HR < 200 bpm And < 8 years Treat with 100% oxygen, NEB EPI 6-8Lpm according to weight Vital signs q5min
21 Croup & Croup Score What is Severe respiratory Distress? Two common severity scales: Alberta Clinical Practice Guideline Working Group Westley score
22 Alberta Croup Severity Scale Mild : occasional bark, no stridor at rest, minimal/no retractions Moderate: frequent bark, stridor at rest, increased WOB at rest, no/mild agitation Severe: above with agitation, may have insp and expiratory stridor Impending Failure: severe + lethargy Alberta Medical Association, 2003
23 Westley croup score Insp. Stridor None With Agitation At rest -- Retractions None Mild Moderate Severe Air Entry Normal Mild dec. Marked Dec -- LOC Normal Depressed LOC + 5 Cyanosis None With Agitation + 4, At rest +5 Total Score: < 3 points = Mild 3-6 points = Moderate >6 points = Severe Westley et al. 1978
24 SOB/ Respiratory Distress Respiratory Distress AND Wheezing Treatment: 100% O2 CR monitoring + O2 sat monitor Salbutamol MDI: 6puffs <25kg OR 8 puffs if >25kg NEB if afebrile, SRI, < 1yr, neurologic disease, severely ill. Transport to hospital
25 SOB/Respiratory Distress Vitals q5min If not significantly better can repeat x 2
26 BENEFITS AND RISKS OF COMMON PRE-HOSPITAL TREATMENTS
27 Epinephrine Indications: Cardiac Arrest Asystole/PEA Pulseless VT/VF (after failed defib). Bradycardia Bronchodilation Anaphalaxis Moderate-Severe Respiratory Distress Routes: S/C, IM, ETT, inhalation Neonatal Lexi-Drugs Online, 2011
28 Epinephrine Pathophysiology: Stimulates α and β1adrenergic receptors Increased HR and BP Stimulates β2 receptors Relaxation of bronchial smooth muscle Large doses: Stimulate skeletal and vascular smooth muscle contraction HTN Effects occur within: 1 minute for inhalational forms ~5-10 minutes for subcutaneous Neonatal Lexi-Drugs Online, 2011
29 Epinephrine Contraindications: Life-threatening situation: no contraindications Non-life threatening: Hypersensitivity Cardiac arrhythimas Acute angle-closure glaucoma Note: may raise Glucose levels in diabetics Neonatal Lexi-Drugs Online, 2011
30 Salbutamol Indications: Asthma Exercise-induced bronchospasm Routes: Inhalation, MDI, Oral (not recommended), IV (ICU) Pathophysiology: Acts on B2 receptors to induce bronchial smooth muscle relaxation Neonatal Lexi-Drugs Online, 2011
31 Salbutamol Side Effects: Tachycardia Tremors Insomnia Hyperactivity Others Contraindications: Allergy to Salbutamol Neonatal Lexi-Drugs Online, 2011
32 Mod to-severe Asthma Protocol Severe SOB from suspected asthma AND requiring BVM AND/OR severe agitation, confusion, cyanosis History of Asthma Treatment: O2 + BVM (if necessary) CV monitor + O2 sat monitoring EPI (1:1000) SC/IM (0.05mg to 0.5mg wt based).
33 back to our case You administered nebulized epinephrine as per Croup Protocol. The child now appears very pale, RR 8, poor respiratory effort, O2 saturation 88%
34 Intubation Indications: Inadequate oxygenation or ventilation Inability to maintain airway Inability to protect airway Potential for deterioration (i.e. burn victim, overdose). to name a few Uptodate, 2010
35 Considerations May be difficult to assess airway i.e. Mouth opening, Mallampati score Should look for signs of possible difficult airway: Retrognathia (i.e Pierre Robin Sequence large tongue, small chin) Cleft lip/palate Down syndrome Low tone, Atlantoaxial instability Uptodate, 2010
36 Intubation RSI medications Atropine as pre-medication <5 years Sedative + Paralytic Infants: Should roll Sniff Position Tube: Neonates : 3.5 Uncuffed Tube Size: (Age/4) + 4 Cuffed Tube Size: (Age/4) + 3 Insertion Depth: Tube size x 3 at teeth Uptodate, 2010
37 Complications: Failed Intubation Failed after 3 attempts Tube Problems displacement, obstruction, in esophagus Trauma local, barotrauma Pneumothorax Aspiration Pneumonia vomiting, gastric distension Hypoxia Bradycardia Uptodate, 2010
38 Summary Kids are not small adults Unique anatomy Unique pathophysiology Respiratory Distress has many causes Not just croup & asthma even though these are common Epinephrine, Ventolin - not without sideeffects, however, benefits generally outweigh risk.
39 References: Nagler, J., Wang, V. J., Stack, A. M., Willey, J. F. Airway management in children: Unique pediatric considerations. UpToDate. Last Updated: April 7, Retrieved: October 18, From: The Alberta Clinical Practice Guideline Steering Committee. Guideline for the diagnosis and management of croup.' Alberta Medical Association Practice Guideline Website. August, 2003.Accessed October 19, 2011 { e/croup.pdf} Westley C, Cotton E, Brooks J. Nebulized racemic epinephrine by IPPB for the treatment of croup. Am J Dis Child 1978; 132: 484 Pediatric and Neonatal Lexi-Drugs Online : EPINEPHrine (Systemic, Oral Inhalation). Retrieved October 18, 2011, from Pediatric and Neonatal Lexi-Drugs Online : Albuterol. Retrieved October 18, 2011, from
40 References Nagler, J,. Wang, V.J., Stack, A.M., Wiley, J.F. Emergent endotracheal intubation in children. UpToDate. Updated: December 7, Accessed: October 18,
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