Respiratory Emergencies

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Respiratory Emergencies in the Pediatric
Population
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CASE 1
16 month old boy with wheeze
Initial Vitals HR 160 RR
60 BP 88/50 Temp 38 O2sat on
RA 89
3
You do your pediatric assessment triangle
Appearance Crying, distressed,
looking around, moving all 4
limbs Breathing (work of) Laboured, chest caving
in, indrawing Circulation Colour OK,
N cap refill
4
What would you like to do now?
Oxygen by mask applied, IV attempt started and
pt now on cardiac monitor Airway No stridor
audible, no obvious secretions Breathing
wheeze with little air entry bilat (inspiratory
AND expiratory) Circulation Warm extrem, PPP,
cap refill 2 secs
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What would you like to do now?
Oxygen Ventolin Atrovent IV Access established
orders?
CXR done / pending
Blood work Doctor?
Venous Gas pH 7.35 pCO2 38 pO2 125
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• History
• Has had a cold for almost 2 days now
• (mild fever, decreased energy / appetite with
  cough
• and runny nose)
• Started getting wheezy this morning
• No history of exposure to allergens, inhalants
• or FB aspiration

Family History of Asthma / no smokers / no
pets Otherwise healthy with no known allergies
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• Continuous Ventolin for 15 mins has little effect
• Still indrawing
• RR 65
• Still alert and looking around, crying

Additional treatment? IV steroids Solucortef 1
mg/kg IV / IM Continue Ventolin Consider
racemic Epinephrine (0.5 mls)
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Repeat Venous Gas about 30 mins later pH
7.15 pCO2 55 pO2 120
Eyes rolling back, little crying now What
do you want to do?
Drugs? Tube Size?
Ketamine 1-2 mg/kg IV Atropine 0.01 mg/kg IV
(min 0.1 mg) Succinyl 1 mg/kg IV
4 4.5 tube
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• Other Options
• IV Magnesium 25 mg/kg (max 2 gm)
• IV Epinephrine
• IV Ventolin
• Inhalational Anesthetics
• Methylxanthines
• Heli - Ox

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Differential Diagnosis of Wheezing
H N Vocal cord dysfunction Chest Asthma Br
onchiolitis Foreign Body Aspiration CVS Con
gestive Heart Failure Vascular Rings
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CAEP Pediatric Asthma Guidelines

• MILD
• Nocturnal cough
• Exertional SOB
• Increased Ventolin use
• Good response to Ventolin
• O2 sat gt 95
• PEF gt 75 (predicted / personal best)
• O2
• Ventolin
• Consider po Steroids

Symptoms Pre - Treat Treatment
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CAEP Pediatric Asthma Guidelines

• MODERATE
• Normal mental status
• Abbreviated speech
• SOB at rest
• Partial relief with Ventolin and required gt than
  q 4h
• O2 sat 92-95
• PEF 50-75 (predicted / personal best)
• O2 100
• Ventolin
• Systemic corticosteroids
• Consider anticholinergic

Symptoms Pre - Treat Treatment
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CAEP Pediatric Asthma Guidelines

• SEVERE
• Altered mental status
• Difficulty speaking
• Laboured respirations
• Persistant tachycardia
• No prehospital relief with usual dose Ventolin
• O2 saturation lt92
• PEF, FEV1 lt50
• 100 O2
• Continuous or frequent b-agonists
• Systemic corticosteroids magnesium sulfate
• Consider anticholinergic / or methylxanthines

Symptoms Pre - Treat Treatment (consider
RSI)
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CAEP Pediatric Asthma Guidelines

• NEAR DEATH
• Exhausted , Confused
• Diaphoretic
• Cyanotic, Decreased respiratory effort, APNEA
• Falling heart rate
• O2 saturation lt80
• (spirometry not indicated)
• As above PLUS
• RSI
• IV Ventolin
• Inhalational anesthetic, aminophylline
• Epinephrine

Symptoms Pre - Treat Treatment
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CASE 2
18 mo Girl with 24 hr Hx of coughing with drooling
Hx Has had an URTI for about a week and was
getting mildly better until yesterday. She
developed a fever and the cough got
harsher. Still drinking but not interested in
solids Vomited once last night Started
drooling this morning
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Physical Exam
T39.1 degrees rectally, P170, R28, BP 100/66
Appearance alert, awake, not toxic, in no acute
distress Did not appear to prefer upright or a
forward leaning position
EENT Moist MM, slight erythema of oropharynx,
nasal crusting, N TMs, no rash / petechiae,
no drooling Supple neck Chest Clear when
resting Mild inspiratory stridor with
crying Rest of the exam N
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• DDx?
• Croup
• Epiglottitis
• Bacterial
• tracheitis
• RetroPharygeal
• abcess
• Foreign Body
• aspiration

Other things on DDx of Inspiratory
Stridor Laryngeal Web TEF Diptheria Airway
thermal injury Subglottic stenosis Peritonsillar
abcess GERD Esophageal FB Laryngeal
fracture Laryngeal cyst Lymphoma
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Soft tissue lateral neck radiograph
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Retropharyngeal Abscess

• Lymph nodes between the posterior pharyngeal wall
  
• and the prevertebral fascia
• gone by 3 4 yrs of life
• drain portions of the nasopharynx and the
  posterior
• nasal passages
• may become infected and progress to breakdown
• of the nodes and to suppuration

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ETIOLOGY Complication of bacterial
pharyngitis Less frequently - extension of
infection from vertebral osteomyelitis Group A
hemolytic streptococci, oral anaerobes, and S.
aureus
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Typically

• Recent or current history of an acute URTI
• Abrupt onset
• High fever with difficulty in swallowing
• Refusal of feeding
• Severe distress with throat pain
• Hyperextension of the head
• Noisy, often gurgling respirations
• Drooling

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On Exam
Nasopharynx Bulging forward of the soft palate
and nasal obstruction Oropharynx Bulging of
posterior phyaryngeal wall or Not
visualized
Soft Tissue Neck Film Patient position MILD
EXTENSION Positive Film - Retropharyngeal soft
tissue gt ½ the width of the adjacent
vertebral body - may see air in the
retropharynx
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Complications Abscess rupture - aspiration of
pus. Lateral extension - present externally on
the side of the neck Dissection along fascial
planes into the mediastinum Death may occur with
aspiration, airway obstruction, erosion into
major blood vessels, or mediastinitis.
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• Treatment
• Clindamycin 20-30 mg/kg/day divided Q8H
• (if pre-fluctuant phase)
• Decadron 0.6 mg/kg
• Airway management
• Surgical decompression

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CASE 3
17 month old male with a one-hour history of
noisy and abnormal breathing
Normal now but at the time, parents thought he
was quite distressed. Now, he is able to speak
and drink fluids without difficulty
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VS T36.8, P200 (crying), R28 (crying), O2 sat 99
Alert with no signs of respiratory
distress Able to speak, had no cyanosis, no
drooling, no dyspnea HN No obvious
swelling, bleeding, FB seen Chest Mild wheezing
with ? mild inspiratory stridor
What would you like to do now???
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Soft Tissue Neck View
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CXR (PA)
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Next?
Expiratory CXR
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Inspiratory View
Expiratory View
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Right Decub View
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Foreign Body Aspiration

• More common with food than toys
• Highest risk between 1 and 3 years old
• (immature dentition no molars, poor food
  control)
• Common foods peanuts, grapes, hard candies
• Some foods swell with prolonged aspiration
• (may even sprout)

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Clinical Manifestations
Typically Acute respiratory distress (now
resolved or ongoing) Witnessed choking
period Uncommonly Cyanosis and resp arrest
Symptoms cough, gag, stridor, wheeze, drool,
muffled voice
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Investigations

• Xrays
• Lateral neck
• Chest inspiratory, expiratory, decubitus views
• Expiratory views
• Overinflation (partial obstruction with
  inspiratory flow)
• Volume loss with mediastinal shift towards
  obstructed
• side (partial obstruction with expiratory
  flow)
• Atelectasis (complete obstruction)

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Decubitus views Normal Smaller volumes and
elevated diaphragm on side down Abnormal Hyperi
nflation or normal volumes in decub position
If suspected Need a bronchoscope to rule out
or remove Foreign Body
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CASE 4
2 yo Boy with Barky Cough for 2 days

• Runny nose, decreased appetite
• Not himself
• No PMHx / FHx of significance
• Shots UTD
• Other sibs with similar URTIs

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On Exam
Temp 38.9 HR 140 O2 sat 98 (drops to 90 when
he crys) RR 40 (mild indrawing)
Irritable, crying, good colour H N sl erythema
of throat, no pus N TMs, small cervical
nodes Chest Barky cough, inspiratory
stridor No wheeze noted
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Diagnosis?
Racemic Epinephrine 0.5 ml dose ?
Dexamethasone now or later
Re Assess in 30 minutes No improvement with
1st dose of epinephrine
What would you like to do now?
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Re Examine Ongoing Inspiratory Stridor Cries
when trachea is examined
IV Cefuroxime PLUS Cloxacillin Consult
Pediatric ICU / Pulmonary for Bronch /
Intubation
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Bacterial tracheitis

• An acute bacterial infection of the upper airway
  capable
• of causing life-threatening airway obstruction
• Staph aureus most commonly
• (parainfluenza, Moraxella catarrhalis, H.
  influenzae, anearobes)
• Most pts less than 3 years old
• Usually follows an URTI (esp laryngotracheitis)
• Mucosal swelling at the level of the cricoid
  cartilage,
• complicated by copious thick, purulent
  secretions

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CLINICAL MANIFESTATIONS
Brassy cough High fever Toxicity" with
respiratory distress (may occur immediately or
after a few days of apparent improvement)
Failed response to CROUP TREATMENT (mist,
intravenous fluid, racemic epinephrine)
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Treatment
Antibiotics (good Staph coverage) Intubation or
tracheostomy is usually necessary ? Decadron

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Pediatric Pneumonia
Neonate Bacteria more frequent E. coli, Grp B
strep, Listeria, Kleb 1 3 mo Chlamydia
trachomatis (unique) Commonly viral (RSV,
etc.) B. Pertussis 1 24 mo S. pneumonia,
Chlamydia pneum Mycoplasma pneumonia 2 5
yrs RSV Strep pneumonia, Mycoplasma, Chlam
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Severe Pneumonia Staph aureus Strep
pneumonia Grp. A strep HIB Mycoplasma
pneumonia Pseudomonas if recently hospitalized
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History
Infants lt 3 months Tachypnea, cough,
retractions, grunting, isolated fever or
hypothermia, vomiting, poor feeding,
irritability, or lethargy
As age increases, symptoms are more
specific Fever and chills, headache Cough
or wheezing Chest pain, abdominal distress,
neck pain and stiffness
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Physical Exam
Tachypnea is the best single indicator of
pneumonia
Age in months Upper limit of Normal RR lt
2 55 2-12 45 gt 12 35
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Treatment
Neonates Ampicillin Gentamycin / Cefotaxime 1
3 mo Erythromycin 10 mg/kg IV Q6H 1 24
mo Cefuroxime 50 mg/kg IV Q8H (not
ICU) Ceftriaxone 50-75 mg/kg IV Q24H and
Cloxacillin 50 mg/kg IV Q6H (ICU) 3 mo 5
yrs Cefuroxime / Erythro IV (admitted) Clarithro
/ Azithro (outpt Tx)