Download Clinical Approach to Reactive Airways Disease Emergencies

Clinical Approach to Reactive Airways Disease Emergencies
Jim Andrus, MD
Pediatric and Pediatric Cardiovascular Critical Care
Sunrise Children’s Hospital
Medical Director, Pediatric Critical Care and Pediatrics
Chairman, Pediatrics
St. Rose Siena Hospital
Is It a Clean Air Problem?
Goal: To Be the Cavalry NOT the Four Horsemen of the Apocalypse
All That is Noisy is Not Wheezing
Differences of Clinical Sounds
• Quality of Sounds
– Stidor
• Inspiratory
• Expiratory
• Biphasic
– Wheezing
• Timing in Expiration‐Duration of Expiration
– Various Crackling Sounds
• Anatomic and Physiologic Locations
– Supraglottic
– Glottic
– Subglottic
Causes of Wheezing
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Reactive Airways Disease
Bronchiolitis
Bronchomalacia
FBA – Foreign Body Obstruction
Bronchomalacia – Don’t Look for Zebras
• Has Underlying Pathophysiology
– Congenital Heart Defect
• Atrial Enlargement
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Prematurity
Central Nervous Dysfunction
Muscle Dysfunction
Metabolic Defects
Bronchomalacia
Treatment of Bronchomalacia
• Frequently Seen as a Combination
– Laryngotracheobronchomalacia
– Tracheobronchomalacia
• Treatment
– Positioning
• Frequently Find the “Most Comfortable”
Position
– Calm
• Calm Environment
• Sedation
– Versed – IV/PO/Intranasal
– Oxygen
– Positive Pressure Ventilation
• HFNC
• CPAP
• BiPAP
Foreign Body Obstruction
• Clinical Presentation
– Depends on Position
• Esophagus
– Drooling
– Stridor
• Airway
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Tachypnea
Retractions
Absent Breath Sounds
Dyspnea
Grunting/Flairing
Wheezing
• DDx
– Pneumonia
– Congenital Anatomic Abnormalities
– RAD
• Laboratory Findings
– Hyperinflation +/‐ Atelectasis on CXR – +/‐ Fevers
– +/‐ Hypoxia and Hypoxemia
– Hyperinflation
Foreign Body Obstruction
Not Always Aspiration
FBA
Treatment of Foreign Body
• Aspiration
– Extraction
• BEST PERSON AVAILABLE
• ENT
• Pulmonology
• Ingestion
– Obstructive
• Extraction
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BEST PERSON AVAILABLE
ENT
GI
PedsSurgery
– Non‐obstructive
• Time
• GoLyteLy
Bronchiolitisvs Asthma
• Inflammation
• Inflammation
– Infectious
– Allergens
– Irritants
– Infectious
• Mucous Plugging/Secretions
– Nasal Secretions
– Airway Secretions
– Sloughing of the Airway
• Bronchospasm
• Mucous Plugging
• +/‐ Bronchospasm
Bronchiolitis
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Clinical Presentation
– SOB
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Tachypnea
Retractions
Dyspnea
Grunting
Flairing
Wheezing
– +/‐ Fevers
– +/‐ Hypoxia and Hypoxemia
– Hyperinflation
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DDx
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Pneumonia
Congenital Anatomic Abnormalities
RAD
Foreign Body Obstruction (FBA)
Laboratory Findings
– Hyperinflation +/‐ Infiltrate on CXR – Leukocytosis with Right Shift or Leukopenia
Bronchiolitis
• Etiology
– Infectious
• RSV
• Influenza
• Other Viruses
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Parainfluenza
Adenovirus
Metapneumovirus
Rhinovirus
The Undiscovered Thousands
• Mycoplasma
– M. pneumoniae
– M. hominis
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Ureaplasma
Chlamydia
Legionella
TB
PCP
Bronchiolitis
• Treatment
– Pulmonary Toilet
• Suctioning
• Mucolytics
– 3% Saline
– DNAse/PulmoZyme
– Nasal Toilet
• Suction
– Deep Nasopharyngeal
– Olive Tip
• Neosynephrine/Decadrongtt
– Bronchodilators
• Epinephrine vsAlbuterol
Basic Principles of Reactive Airways Disease
• Airway Inflammation
– Chronic
– Acute on Chronic
• Bronchospasm
– Acute Reaction to Airway Inflammation
• Mucous Plugging
– Acute Reaction to Airway Inflammation
The Inflammation of Asthma
Benefit of a Planned Step‐Wise Approach
• Systematic and Efficient
– Can Be Duplicated
• Always Prepared
• Can Be Studied
Bronchodilators
• Catecholamines
– Albuterol
• Beta‐Agonist – Pure Bronchodilator
– Epinephrine
• Alpha and Beta‐Agonist
– Bronchodilator
– Dries Secretions
• Anti‐Cholinergics
– Ipratroprium/AtroVent
Bronchodilators
• Albuterol
– Intermittent
• 2.5‐10 mg/dose q2‐8h
– Continuous
• 5‐20 mg/kg/hr
• Epinephrine
– Intermittent
• 2.5‐5 mg/dose
– Continuous
• Ipratropium
– 0.25‐1.0 mg/dose
Anti‐Inflammatories
• Steroids ‐ Methylprednisolone
– Physiology
• Anti‐Inflammatory
• Membrane Stabilizer
– Dose
• Load: 2 mg/kg
• Maintenance: 1 mg/kg q6‐12h
Role of Oral Anti‐Inflammatories
• Singular
• Zytec
• Caritin
Steps in the Emergency Room for
Mild to Moderate Status Asthmaticus
• Oxygen (As Needed)
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NC
SFM
NRFM
HFNC
• Steroids – No Advantage to IV over PO or IM
– Dexamethasone
– Prednisone
– MethylPrednisolone
• Bronchodilators
– Albuterol
– AtroVent
– Epinephrine
• More Helpful with Copious Secretions
Steps in the Emergency Room for
Moderate to Severe Status Asthmaticus
• Oxygen (As Needed)
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• Other Agents
NC
SFM
NRFM
HFNC
BiPAP
Intubation
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Magnesium
Aminophylline
Terbutylline
Helium
• Steroids – Advantage of IV
– Dexamethasone
– MethylPrednisolone
• Bronchodilators
– Albuterol
– AtroVent
– Epinephrine
• More Helpful with Copious Secretions
Magnesium
• Physiology
– Smooth Muscle Relaxant
– Membrane Stabilized
• Target Level – Unknown
– Mg=3‐5 mg/dL
• Dose
– Load: 25‐75 mg/kg
– Drip: 10‐30 mg/kg/hr
Aminophylline
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Uses
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Bronchospasm
Central Apnea
Diuretic
Increase Diaphragm Contraction
Physiology
– Bronchodilator
– Membrane Stabilizer
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Anti‐Inflammatory
Dose
– Varies with Age
– Load: 6 mg/kg over 20 min
– Drip: 0.9‐1.1 mg/kg/hr
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Levels
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Diaphragm=4‐8
Apnea=6‐12
Bronchodilator=12‐16
Toxic >20
Helium
• Uses
– Bronchospasm
– Upper and Lower Airway Obstruction
• Physiology
– Decreases Turbulent Flow
• Reynold’s Number
• ?Anti‐Inflammatory
• Cooling Effect
– Carrier Gas
• Dose
– 80/20
– 70/30
– 60/40
• Hints:
– Cannot be Hypoxic
Role of Sedation
• Decrease Endogenous Catecholamine Release
– Calms the Patient and the Parents
– Decrease Reynold’s Number
• Versed
– IV: 0.05‐0.1 mg/kg
– PO/Intranasal: 0.4‐0.5 mg/kg
Ketamine
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Activity/Physiology
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Dissociative Anesthetic
No Respiratory or Cardiac Suppression
Causes Endogenous Catecholamine Release
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Onset: 45‐90 seconds
Duration: 3‐15 minutes
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Duration of Activity Dependant on Multiple Factors
Dosing: –
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Bronchodilates; Supports BP and HR
IV Procedural Dosing – 1‐2mg/kg/dose
IV Intubation Dosing – 2‐4mg/kg/dose
IM Dosing ‐ Double
Side Effects: –
Endogenous Catecholamine Release
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Increased Pressures
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ICP
Occular
Abdominal
Analgesia?
Increase in Serum Potassium
Hallucinations
Hypersialygolic – Increases Saliva Production
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Increases All Bodily Secretions
Anxiolytics and Sedation
• Advantages
– Less Motion
– Decreased Catecholamine Release
• Decreased Vasoconstriction
• Decreased Sweating
– Decreased Parental Anxiety
• Disadvantages
– Delayed Waking from Sedation
• Best Anxiolytics for the Job
– Rapid Acting Benzodiazepines
• Versed 0.4‐0.5 mg/kg po/in
Anxiolysis Can Bring Calm to the Flock
The Beauty in Nature
Salar de Uyuni, Bolivia
Hands are NOT Restrained
Always Have Options
• Inadequate Air Entry
– svnAlbuterol and Epinephrine Ineffective
– iv Medications
• Terbutilline
• Epinephrine
• Isoproteranol
• Gases Anesthetics
– Bronchodilators
– ?Anti‐Inflammatories
• Chemotherapeutics
– Methotrexate
Positive Pressure
• “Non‐Invasive” Modalities
– HFNC
– CPAP
– BiPAP
• Intubation
– Versed/Ketamine/Rocuronium
• Mechanical Ventilation
– CMV
• Low‐PEEP
• High‐PEEP
– HFOV
The Great Magic Trick
Combinations of Agents
• Taylor toPatient Needs
• Use Your Imagination
Don’t Be Afraid to Ask for Help
Two Minds are Better than One
• Extra Hands for Procedures
• Anesthesia Department for Gas
• PICU Consult
– Even Welcome to Call Me
Lessons Learned
More Lessons Learned
Time is the Best Therapy to Let Anti‐Inflammatory Medications Work
Therapy – Maintaining Balance
Finding a Beautiful Ending