Simulation 01: Two Year-Old Child in Respiratory Distress (Croup) Flow Chart Opening Scenario 2 year-old child in respiratory distress - assess Section 1 Type: IG audible stridor with insp + exp wheezing; hypoxemia; cough and hoarse cry worsening over last eight hours Section 2 Type: DM Increase O2 flow to 2 L/min; recommend aerosol Rx with racemic epinephrine Section 3 Type: IG SpO2 improved but breath sounds decreased with continued audible stridor, barking cough and wheezing Section 4 Type: DM Repeat racemic epinephrine Rx and recommend steroid (IM or aerosol) Section 5 Type: DM SpO2= 92%, but stridor, wheezing and retractions continue; repeat racemic epinephrine Rx End
Opening Scenario (Links to Section 1) You are the respiratory therapist in a 300 bed community hospital working the evening shift. At 8:30 PM you are called to the Emergency Department to assist in the management of a child in respiratory distress. (Click the Start button below when ready to begin) 2
Information-Gathering Section Simulation Section #: 1 Links from: Opening Scenario Links to Section #(s): 2 Upon arrival at the bedside you observe an agitated 2 year old male child weighing about 12 kg on a nasal cannula at 1 L/min surrounded by anxious patients. The attending resident asks you to evaluate the child. (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed) Requested Information Data Score Complete blood count Pending +1 Arterial blood gas Pending +1 Laryngoscopy Physician disagrees -1 AP chest X-ray Pending +2 Lateral neck X-ray Pending +2 Breath sounds Audible stridor with inspiratory and +2 expiratory wheezing Vital signs HR 120 RR 28 BP 102/66 T 102 F +1 SpO2 87% +1 Recent history Parents report child has had runny nose, sore +2 throat, mild fever for past two days with cough and hoarse cry worsening over last eight hours Bedside spirometry (FVC) Physician disagrees -1 Perfect Score: 12 Minimum Pass Score: 10 3
Decision-Making Section Simulation Section #: 2 Links from Section #: 1 Links to Section #(s): 3 ABG results: ph = 7.35; PCO2 = 47 torr; HCO3 = 25 meq/l; PO2 = 55 torr; SaO2 = 88%. AP chest X-ray indicates some narrowing of the upper tracheal mucosa; lateral X-ray reveals haziness in the subglottic region with the hypopharynx overdistended. CBC indicates mild lymphocytosis. (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Increase O2 flow to 2 L/min and recommend 2 puffs albuterol (Proventil) via MDI+holding chamber Recommend cool mist tent therapy with 40% O2 Increase O2 flow to 2 L/min and recommend aerosol with one 5 ml ampule of tobramycin (300 mg) (TOBI) treatment via SVN Increase O2 flow to 2 L/min and recommend aerosol treatment with 0.25 ml 2.25% racemic epinephrine in 3 ml NS via SVN Increase O2 flow to 2 L/min, repeat blood gas and observe child for worsening symptoms Response to Selection Response Score -1 Physician agrees +2 3-2 -2-2 Link to Section Perfect Score: 2 Minimum Pass Score: 1 4
Information-Gathering Section Simulation Section #:3 Links from Section #: 2 Links to Section #(s): 4 20 minutes after increasing the O2 flow to 2 L/min and providing the racemic epinephrine aerosol treatment, you reassess the child. (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed) Requested Information Data Score SpO2 93% +1 Negative inspiratory force Physician disagrees -1 (NIF/MIP) Breath sounds Decreased breath sounds with continued +2 audible stridor, barking cough and wheezing Bedside spirometry (FVC) Physician disagrees -1 Vital signs HR 112 RR 26 BP 104/65 +1 Repeat chest X-ray Physician disagrees -1 General appearance No evidence of cyanosis, normal +1 consciousness, mild subcostal retractions Bronchial provocation test with Physician disagrees -2 methacholine Exhaled nitric oxide concentration Physician disagrees -2 Blood eosinophil count and IgE concentration Physician disagrees -1 Perfect Score: 5 Minimum Pass Score: 3 5
Decision-Making Section Simulation Section #:4 Links from Section #: 3 Links to Section #(s): Based on current assessment of the child, which of the following would you now recommend? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Increase the O2 flow to 4 L/min and repeat ABG Repeat aerosol treatment with racemic epinephrine via SVN and recommend IM dexamethasone Intubate the child and initiate SIMV with pressure support Repeat aerosol treatment with racemic epinephrine followed by 2 ml 0.5 mg nebulized budesonide (Pulmicort) via SVN Provide aerosol treatment with 0.25 ml 0.5% albuterol (Proventil) in 3 ml NS via SVN Response to Selection Response Link to Score Section -1 Physician agrees +2 5-2 Physician agrees +2 5-1 Perfect Score: 2 Minimum Pass Score: 1 6
Decision-Making Section Simulation Section #: 5 Links from Section #: 4 Link to Section(s): End 30 minutes after the second aerosol treatment, the child's condition remains essentially unchanged. The SpO2 is 92% with no evidence of cyanosis, but the stridor, wheezing and retractions continue, and mild tachycardia and tachypnea persist. Which of the following would you recommend at this time? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Administer 70/30 heliox therapy (70% helium + 30% O2) via nonrebreathing mask Initiate noninvasive positive pressure ventilation via oronasal mask Initiate positive expiratory pressure (PEP) therapy Repeat the racemic epinephrine aerosol treatment Intubate and initiate SIMV with pressure support Response to Selection Equipment not available - Make another selection in this section Response Score 0-2 Link to Section -2 Physician agrees. Treatment initiated +2 End -2 Perfect Score: 2 Minimum Pass Score: 2 7
RTBoardReview Simulation 01 2 Year-Old in Respiratory Distress Condition/Diagnosis: Croup (Laryngotracheobronchitis) Simulation Scoring Individual Response Scoring (Used for All RTBoardReview Simulations) Score Meaning +2 Essential/optimum to identifying or resolving problem +1 Likely helpful in identifying or resolving problem 0 Neither helpful nor harmful in identifying or resolving problem -1 Unnecessary or potentially harmful in identifying or resolving problem -2 Wastes critical time in identifying problem or causes direct harm to patient -3 Results in life-threatening harm to patient Summary Scoring of Simulation 01 Section IG Max IG Min DM Max DM Min 1 12 10 2 2 1 3 5 3 4 2 1 5 2 2 TOTALS 17 13 6 4 MPL% 76% 66% Cut Score = IG Min + DM Min = 13 + 4 = 17 MPL% = Minimum Pass Level as a percent = (Min/Max) x 100 IG and DM MPL% vary by problem; typically ranges are 77-81% for IG and 60-70% for DM If the IG or DM raw score is negative (e.g., -2) then the reported % score = 0 The Cut Score for a problem is the sum of IG Min + DM min To pass a problem, the sum of one s IG + DM raw scores must be the Cut Score 8
Take-Home Points RTBoardReview Simulation 01 2 Year-Old in Respiratory Distress Condition/Diagnosis: Croup (Laryngotracheobronchitis) Croup Croup is a viral infection of the upper airway occurring most commonly in children 6 months to 3 years of age. It is most often caused by the parainfluenza virus, adenovirus, respiratory syncytial virus (RSV), or influenza A and B. Infection causes inflammation and swelling of subglottic tissue, including the larynx, trachea and larger bronchi. Assessment/Information Gathering Diagnosis based mainly on typical age, history and physical exam findings (below) Determine age (peak incidence among infants and toddlers, i.e., 6 month to 3 years old) History of initial cold-like symptoms with possible low-grade fever that progresses to more severe symptoms (often at night), including include hoarseness, barking cough, and inspiratory stridor (with severe stridor, intercostal retractions may appear). Confirm physical findings as above plus assess for agitation; in more severe cases look for significant tachypnea and tachycardia; lethargy, hypotonia and cyanosis are late signs. Recommend lateral neck X-ray, looking for characteristic subglottic "steeple sign" Treatment/Decision-Making General Medical/Surgical Treatment o Recommend close respiratory and cardiac monitoring, including SpO2. o Recommend adequate hydration o Recommend antipyretic for fever o Recommend systemic steroids (oral or IM); aerosolized budesonide is an option. o Do not recommend, antibiotics or viral serology; lab tests of limited value o If admitted to hospital recommend droplet precautions Respiratory Management o Initiate supplemental O2 therapy as needed to keep SpO2 > 90% o Recommend or administer aerosolized racemic epinephrine (0.25 to 0.50 ml 2.25% solution with 3.0 ml saline), repeated up to three times as needed. o If repeat racemic epi treatments fail to relieve symptoms, recommend heliox via high-flow cannula or nonrebreathing mask. o If symptoms persist for > 4 hours after initial treatment, recommend hospital admission with close monitoring of respiratory status. o In the rare situation where obstruction worsens, consciousness decreases, and/or respiratory acidosis develops, recommend intubation and mechanical ventilation. 9
Follow-up Resources Standard Text Resources: Des Jardins, T., & Burton, G.G. (2011). Croup syndrome: laryngotracheobronchitis and acute epiglottitis (Chapter 39). In Clinical Manifestations and Assessment of Respiratory Disease, 6th Ed. Maryland Heights, MO: Mosby-Elsevier. Useful Web Links: Alberta Medical Association. Guideline for the diagnosis and management of croup. Alberta Clinical Practice Guidelines 2008 Update. www.topalbertadoctors.org/download/252/croup_guideline.pdf Muñiz, A. Croup. E-Medicine/Medscape. http://emedicine.medscape.com/article/962972-overview Bjornson, C.L. & Johnson, D.W. (2007). Croup in the paediatric emergency department. Paediatr Child Health. 12, 473 477. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2528757/pdf/pch12473.pdf 10