Download CQI - recert 2005 - Hamilton Health Sciences

Hamilton CME
Paediatric
Respiratory Emergencies
Spring 2008
Paediatrics
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Stages of development:
Newborn / Neonate:
Birth to 29 days
Infancy:
1 month to 1 year
Toddler:
1 – 3 years
Pre-school:
3 - 5 years
School child:
5 - 15 years
Adolescent:
15 - 19 years
Respiratory System:
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The respiratory system matures as the child
gets older.
Newborns are usually nose breathers.
This facilitates breathing while suckling.
Age:
Range of normal / min.
Rapid / min.
Newborn:
30-50
>60
Infancy:
20-30
>50
Toddler:
20-30
>40
Given a Competent Primary
Survey
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Hands off approach.
When examining a child, perform the most critical
assessment you need to do before the child starts to
cry.
Take some history, visualize the child and decide
which assessment you need to do first to confirm or
rule out your suspicion.
Listen to MOM! ( ‘my baby doesn’t quite seem
right’ )
– A good mother will often make a better diagnosis
than a poor Doctor ( or Paramedic ).
Respiratory System
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Infection:
– Can cause a relative arterial hypoxemia.
– Predisposed to disease because of size
& structure.
– Small airways, poor muscle
development, can’t clear mucous well
during infections.
Respiratory System
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Respiratory Distress:
Lower airway:
– short trachea, bifurcation at 45o.
– Airways close more easily.
– Incomplete lung development until 8 years old.
Chest wall:
– Muscles tire more easily.
– Highly compliant, makes rib cage inefficient in producing an
increase in lung volume & allows for distortion under stress retractions.
– Large stomach & liver encroach on respiratory effort.
Pneumonia
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Introduction
– Pneumonia is defined pathologically as an
inflammation of lower tract lung tissue. (1)
Pneumonia
Pneumonia
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Pathophysiology
– Defense mechanisms
• Macrophages
• Antibodies
• Lymphatic drainage
Pneumonia
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Pathophysiology
–  anatomic defenses may be d/t preceding
viral infection of upper respiratory tract.
Pneumonia
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Pathophysiology
– Acute inflammatory response
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•
•
•
Exudative fluid
Fibrin deposition
Leukocytes
Macrophages
Pneumonia
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Clinical Features
– Fever can increase an infant's respiratory
rate by 10 breaths/min for each degree
centigrade of elevation. (1)
Pneumonia
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Clinical Features
– Adventitious breath sounds
–  WOB
– Grunting respirations
– Abdominal distention
Signs of Respiratory
Trouble:
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Facial Signs
Colour ( lips and circumoral )
Nasal flaring
Neck
Tracheal tugging
Supraclavicular Retractions
Chest
Lower Sternal Retraction
Intercostal and/or subcostal indrawing
Pneumonia
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Typical
–
–
–
–
–
Acute onset
High-grade fever
Pleuritic chest pain
Productive cough
Bacterial pathogen
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Atypical
–
–
–
–
Gradual onset
Low-grade fever
Non-productive cough
Viral pathogen
Pneumonia
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Clinical Features
– Infants frequently lack the classic symptoms
and present with a variety of nonspecific
findings. (1)
Pneumonia
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Clinical Features
– More severe pneumonia is associated with
deterioration of the patient's mental status,
the use of accessory muscles, and the
presence of retractions, nasal flaring,
splinting, and cyanosis. (1)
Asthma
Asthma
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Pathophysiology
– Classifications
• Extrinsic (IgE-mediated)
• Intrinsic (infection-induced)
• Mixed
Asthma
 Pathophysiology
– Two-stage process
1.
2.
Bronchoconstriction (early)
Mucosal edema & plugging (late)
Asthma
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Pathophysiology
– Bronchospasm, mucosal edema, and
mucous plugging cause variable and
reversible airflow obstruction with
subsequent air trapping and impaired
oxygen exchange.(2)
Asthma
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Pathophysiology
– Inadequate alveolar ventilation
• Carbon dioxide retention
• Respiratory acidosis
• Respiratory failure
Asthma
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Pathophysiology
– The child with asthma is at higher risk of
respiratory failure d/t:
•
•
•
•
 compliance of rib cage
Immature diaphragm
Lung tissue lacks elastic recoil
Airway walls are relatively thicker
Asthma
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Evaluation
– Treatment with inhaled β2-agonists should
not be withheld while the initial evaluation is
in progress. (2)
Asthma
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Evaluation
– “silent” or “quiet” wheezer
• Prolonged expiratory phase
• Extreme air trapping
Asthma
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Evaluation
– Tripod positioning
– Nasal flaring
– Polyphonic  wheezes
– Cyanosis
– Insensible fluid losses
– Pulsus paradoxus & JVD
Asthma
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Evaluation
– History
•
•
•
•
•
Precipitating factors
Prescription medications
Hospitalizations
Intubations
Tracheostomies
Asthma
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Evaluation
– History
• Neonatal - prematurity, BPD, NICU?
• Adolescents - substance abuse?
• All ages - aspiration / choking?
Asthma
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Treatment
– β2-Receptors are widely distributed on
bronchial smooth muscle and airway
epithelial cells. (2)
Asthma
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Treatment
– Salbutamol can be concurrently
administered to an intubated patient
via MDI and ETT spacer device or a
patient assisted with BVM and spacer
device.
Asthma
Asthma
Asthma
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Treatment
– Most children presenting in status
asthmaticus will be dehydrated because of
increased insensible losses. (2)
Asthma
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Complications
– Respiratory failure
– Atelectasis
– Pneumomediastinum
– Pneumothorax
Bronchiolitis
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Introduction
– A clinical syndrome of wheezing, chest
retractions, and tachypnea in children
younger than age 2 years. (2)
Bronchiolitis
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Epidemiology
– October thru May
– Peak age of incidence is 2 months
Bronchiolitis
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Pathophysiology
– Respiratory syncytial virus (RSV) causes
50 to 70 percent of clinically significant
bronchiolitis. (2)
Bronchiolitis
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Pathophysiology
– Mucous plugging
• Necrosis of respiratory epthelium
• Destruction of ciliated epithelial cells
– Submucosal edema
Bronchiolitis
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Clinical Features
– 911 may be called because of wheezing,
increased respiratory symptoms, nasal
congestion, and difficulty feeding. (2)
Bronchiolitis
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Clinical Features
– RSV-related apnea
• Infants at highest risk are younger than 6 weeks old
and have a history of prematurity, apnea of
prematurity, and low O2 saturation. (2)
Bronchiolitis
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Treatment
– Keep patient & environment calm
– Oxygen therapy PRN
– Fluid therapy PRN
Bronchiolitis
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Treatment
– A trial of bronchodilator therapy, is an
optional and reasonable treatment and can
be aborted if the child fails to show a
response. (2)
Bronchiolitis
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Treatment
– Epinephrine is an effective treatment for the
wheezing of bronchiolitis. (2)
Stridor
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Introduction
– Stridor is due to Venturi effects created by
somewhat linear airflow through a semicollapsible tube, the airway. (3)
Stridor
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Introduction
– Supraglottic
– Subglottic
– Trachea
– Primary bronchi
Stridor
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Introduction
– Expiratory stridor, or wheeze, is common in
distal airways, since intrathoracic pressure
may become much greater than atmospheric
pressure during expiration. (3)
Stridor
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Introduction
– Patients with marked variation in the
pattern of stridor should be considered to
have a foreign body in the airway until
proven otherwise. (3)
Epiglottitis
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Clinical Features
– Since the introduction of the
Haemophilus influenzae vaccine, the
incidence and demographics of this
disease have changed remarkably. (3)
Epiglottitis
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Clinical Features
– Abrupt onset
– High-grade fever
– Sore throat
– Stridor
– Dysphagia +/- drooling
Epiglottitis
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Treatment
– DO NOT attempt to visualize the airway
unless respiratory failure/arrest is imminent.
Epiglotittis
Swollen, horseshoe-shaped epiglottis
of a child with epiglottitis
Same child with ETT in place.
Epiglotittis
Normal Paediatric trachea
Epiglottitis
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Treatment
– Should the child develop respiratory
fatigue or if airway obstruction or apnea
occurs before the airway has been
secured, bag-valve-mask ventilation can
be effective. (3)
Croup
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Introduction
– aka laryngotracheobronchitis
– Peak 1-2 y.o.
– Late fall thru early winter
–  child age =  effect of airway edema
Croup
Radiograph of patient with Croup.
Croup
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Clinical Features
– Insidious onset
– Barking cough
– Stridor
–  S&S @ night
Croup
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Treatment
– Croup is an upper airway infection made
worse by agitating the child.
– Do not attempt to examine the throat.
Croup
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Treatment
– Do not attempt to initiate an IV unless it is
required for essential medications or fluid
resuscitation.
Croup
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Treatment
– Nebulized epinephrine decreases airway
edema by vasoconstriction of the boggy
mucosal vessels. (3)
References
1.
Emergency Medicine: A Comprehensive Study Guide - 6th Ed
• VIRAL & BACTERIAL PNEUMONIA IN CHILDREN - Kathleen Brown, Willie Gilford, Jr.
2.
Emergency Medicine: A Comprehensive Study Guide - 6th Ed
• PEDIATRIC ASTHMA AND BRONCHIOLITIS - Maybelle Kou, Thom Mayer
3.
Emergency Medicine: A Comprehensive Study Guide - 6th Ed
• UPPER RESPIRATORY EMERGENCIES - Randolph Cordle