Common Pediatric Respiratory Emergencies NAPNAP Chicago Session 314 Wednesday, March 21, 2018 Participant Objectives Discuss upper airway illness in the pediatric population Discuss lower airway illness in the pediatric population Discuss the acute obstructive process and intervention Discuss the management of respiratory distress Valarie Eichler, MSN, RN, CPNP-AC/PC Pediatric Nurse Practitioner Critical Care Services Children s Health Children s Medical Center Dallas Airway Anatomy Upper Airway Supraglottic Nose, nasopharynx, epiglottis Glottis Airway Anatomy Vocal cords, subglottic region, cervical trachea Lower Airway Intrathoracic Thoracic trachea, mainstem bronchi, lungs http://what-when-how.com/paramedic-care/airway-anatomy-and-physiology-clinical-essentials Airway Anatomy: Pediatric Considerations Large occiput Small mouth and large tongue Anterior Infants are obligatory nose breathers until around 5-6 months of age Narrow passages leads to increased airway resistance Airway Anatomy: Pediatric Considerations Right mainstem slightly larger than the left and angles in a more vertical position Distal airway is less developed and smaller Distal bronchioles continue to branch in the first year of life Alveoli continue to multiply in number and size through ~8 years of life Crichoid ring is the narrowest portion in infants and children 1
Pediatric vs Adult Airway Anatomy Airway Anatomy: Adult Considerations Longer mainstem bronchus Posterior Teeth Larger mouth General Assessment General appearance Color Work of breathing Respiratory rate Breath sounds Use of accessory muscles Pulse oximetry Infectious Etiologies of the Upper Airway Upper Airway Croup (Laryngotracheobronchitis) Retropharyngeal Abscess Peritonsilar Abscess Epiglottitis Viruses Upper Airway Viral Conditions RSV Rhinovirus/Enterovirus Parainfluenza Human Metapneumovirus Influenza A/B Adenovirus Pertussis 2
Croup: Presentation Barky or brassy cough Inspiratory stridor Stertor Retractions Persistent low grade fever Worsens at night and on day 2 3 Steeple Sign on PA/AP xray Croup Inflammation & Edema Croup: Pathophysiology Cellular infiltration of Lymphocytes, histocytes & neutrophils Endothelial damage Loss of ciliary function Mucus plugging Vocal Cord Edema Further contributes to the hoarseness VQ mismatch Hypoxemia Croup: Etiology & Epidemiology Generally viral in nature Parainfluenza Adenovirus RSV Peak season is usually late fall to early winter but can present year round Peak age 6 mo 36mo Rare after 5 6 yrs but can be seen in adolescents and adults Affects males slightly more than females 1.4:1 Dexamethasone Single dose (outpatient) 24hr dose (inpatient) Racemic Epinephrine Cool mist Croup: Management Retropharyngeal Abscess: Presentation Fever Sore throat Pain isolated to one side Dysphagia Tracheal deviation +/ Generalized edema Palpable fluctuant mass +/ Trismus Drooling Stridor Muffled voice 3
Retropharyngeal Abscess: Presentation History is important Retropharyngeal Abscess: Radiographically AP/PA film may see deviated trachea Recent prior intubation Trauma from foreign object in the oral cavity Dental procedures Recent infections Retropharyngeal Abscess: Radiographically Retropharyngeal Abscess: Radiographically Shifted mediastinal structures Retropharyngeal Abscess: Radiographically Retropharyngeal Abscess: Radiographically 4
Retropharyngeal Abscess: Radiographically Retropharyngeal Abscess: Radiographic Presentation Retropharyngeal Abscess: Radiographically Retropharyngeal Abscess: Epidemiology/Etiology Commonly bacterial H. Flu Strep Pneumoniae & Pyogenes Staph Aureus Often seen in toddlers & children ages 1 5 Retropharyngeal Abscess: Evaluation CBC w/diff Blood culture Inflammatory markers Plain films CT w/contrast Retropharyngeal Abscess: Management Do not upset or stimulate child Let them assume position of comfort Airway person should be your most experienced Empiric IV antibiotics May need surgical drainage Monitored in the PICU 5
Peri or in front of tonsils Peritonsillar Abscess Presents much like retropharyngeal abscess Local pain Sore throat, Trismus Difficulty swallowing Muffled voice Deviated uvula to unaffected side Peritonsillar Abscess Most common cause: GAS Can by associated with other bacteria and/or EBV More common in older children and adolescents Rarely causes UAW obstruction May have recent h/o pharyngitis Ominous signs: Drooling Tripod position CBC w/diff Peritonsillar Abscess: Evaluation Inflammatory markers Blood culture Throat culture Tissue/fluid culture if I&D performed CT neck with contrast Peritonsilar Abscess: Management Do not upset or stimulate child Let them assume position of comfort Airway person should be your most experienced Empiric IV antibiotics May need surgical drainage Monitored in the PICU Sudden onset Severe sore throat Toxic child Dysphagia Fever Agitation Epiglottitis: Presentation Thumb Sign on lateral xray Epiglottitis Can rapidly progress to total UAW obstruction Tripod position Drooling Muffled voice Stridor 6
Epiglottitis: Epidemiology/Etiology Epiglottitis: Management Toddler to child age group, 1 5 yrs Usually bacterial H. Flu Strep Pneumoniae Staph Aureus GAS Do not upset or stimulate child Let them assume position of comfort Immediate consult to ENT and/or anesthesia Airway person should be your most experienced Establish IV and obtain blood culture and labs Empiric IV antibiotics 7 10 days Steroids +/ Monitored in the PICU Viral Conditions: Presentation Infectious Etiologies of the Lower Airway Cough Inspiratory stridor +/ Stertor Retractions (depending on the degree of distress) Wheezing +/ Fever Tachycardia Tachypnea Toxic appearing Increased nasal secretions Hypoxia Viral Conditions: Presentation May exacerbate underlying pulmonary disease such as: Asthma Pulmonary Hypertension Laryngomalacia Tracheomalacia Tracheal Stenosis Vocal Cord Paralysis Rings/Slings TEF Chronic Lung Disease Viral Conditions: Presentation May exacerbate underlying cardiac or neuromuscular disease such as: Myocarditis Duchene's MD SMA Congenital heart disease Restrictive lung disease 7
Viral Conditions: Pathophysiology Respiratory Syncytial Virus (RSV) Leading cause of lower respiratory tract infections in the infant and young child populations. Actually begins in the UAW Virus attaches to the epithelial cells of the respiratory tract Cell to cell transfer via intracytoplasmic bridges called syncytia into the lower respiratory tract Often accompanied by secondary bacterial or super infection Viral Conditions: Etiology and Epidemiology Respiratory Syncytial Virus (RSV) Daycare Older siblings that attends school Cigarette smoke exposure Prematurity and multiple births Associated with bronchiolitis and viral pneumonia Peak incidence: 2 8 months 4 5 million cases in children <4 yrs of age in the US alone >125K admissions per year Viral Conditions: Evaluation Viral Conditions: General Management RSV Peribronchial Cuffing Usually supportative care Bronchodilators Steroids +/- Respiratory support (non-invasive) Heated high flow NC BIPAP CPAP Viral Conditions: RSV Management Ribavirin extreme conditions RSV IVIG no longer available Palivizumab for prophylaxis No vaccine available Status Asthmaticus: Presentation Wheezing No wheezes ominous sign Retractions Intercostal Suprasternal Subcostal Prolonged expiratory phase Nasal flaring Anxious Hypoxic 8
Status Asthmaticus: Status Asthmaticus: Stepwise Management Supplemental O2 Stacked inhaled bronchodilators Prednisone or Methylprednisolone Continuous inhaled bronchodilators MgSO4 as bolus Terbutaline (controversial) Heliox (controversial) Aminophylline drip Ketamine drip Pulmonary consult Status Asthmaticus: Stepwise Management Status Asthmaticus: Stepwise Management Noninvasive ventilation Heated High Flow Nasal Cannula BiPAP Intubation and mechanical ventilation as a last resort Inhaled anesthetic ECMO Status Asthmaticus: Stepwise Management Status Asthmaticus: Stepwise Management 9
Status Asthmaticus: Pathophysiology Status Asthmaticus: Pathophysiology Bronchospasm Bronchoconstriction Airway edema Increased mucus production/secretion Cellular infiltration of the airway walls, esp eosinophils Cytokine release inflammatory response Epithelial injury to the airway http://what-when-how.com/paramedic-care/airway-anatomy-and-physiology-clinical-essentials Status Asthmaticus: Etiology Status Asthmaticus: Epidemiology Genetics IgE mediated allergens Food/nuts Pet dander Environmental factors Tree/grass pollens Smoke Cockroach feces and saliva Peak age: 6 mo to 3 years Slightly higher predominance in males to females Status Asthmaticus: Discharge Planning Foreign Body Aspiration: Partial Obstruction Asthma Action Plan Required by Joint Commission for hospital discharge Environmental controls Algorithm for use of long term and rescue medications Medication regimens and rescue meds Plan of action when treatment is not effective When to seek emergent care Can be UAW or LAW positioning Esophageal positioning Not usually life threatening but causes respiratory distress 10
Foreign Body Aspiration Foreign Body Aspiration: Complete Obstruction Foreign Body Toddler age Infant with older sibling Acute cough Sudden onset of choking Difficulty breathing Cyanosis Severe wheezing Stridor Inspiratory films ENT consult DLB Caution with transport, as object could progress and obstruct airway. Surgical emergency for bronchoscopy in the OR. However children with UAW foreign bodies and esophageal foreign bodies that are compressing the airway are more likely to develop acute life threatening respiratory failure They tend to move and completely obstruct Or erode and perforate LAW FBA will have unilateral wheezing Roach aspiration Foreign Body Aspiration If there was significant UAW obstruction there is an increased risk of Post Obstructive Pulmonary Edema Negative Pressure Capillary leak Obstruction relieved Frothy pink secretions Facial edema Urticaria N/V Abdominal pain Altered LOC Syncope Wheezing Anxious SOB Hypotension Shock Anaphylaxis: Presentation Anaphylaxis Most common causes are food allergies and medications Dye or contrast also a common offender May be severe life threatening events Usually happens ~1 hour after exposure but can be within a few minutes 11
Anaphylaxis: Pathophysiology Edema involving the retropharynx and/or the larynx Bronchospasm Edema of LAW IgE mediated response or direct mast cell activation Leads to massive release of inflammatory factors Cytokine Histamine Prostaglandins Leukotrienes Anaphylaxis: Pathophysiology Target organs include the heart, vasculature, GI tract, lungs and the integumentary Vasodilatation Decreased CO and Coronary Artery perfusion Ischemia Hypotension Shock Anaphylaxis: Management Regardless of MOA treatment is the same ABCs Anaphylaxis: Management Epinephrine IM or SQ (Max single dose child: 0.3mg; adolescent: 0.5mg) May repeat every 5 15 min as needed IV access and fluid bolus(es) Diphenhydramine Albuterol Methylprednisolone Ranitidine Anaphylaxis: Management Benefits of Non-Invasive Ventilation If you are not sure always err on the side of caution. GIVE THE EPI!!!! CPAP & BiPAP Improved hypoxemia Improved gas exchange Augments fatigued respiratory muscles Provides + pressure support CPAP: inspiratory support BiPAP: bi level inspiratory and expiratory support 12
Indications for Intubation High 0 2 requirement Impending failure or s/s of exhaustion Failure to adequately ventilate Increasing CO 2 (>50 acutely) Inability to maintain airway Altered LOC &/or GCS <8 Therapeutic hyperventilation Hemodynamic Instability/Acidosis Respiratory depression Summary Many causes of acute respiratory distress and/or failure in the pediatric population Be suspicious Prompt recognition and action is key to successful outcomes Always form a list of differential diagnoses Remember that NIV has side effects as well and should not be taken lightly 13