Pediatric Airway Emergencies LMHER – February 28, 2017 Preparred by Shane Barclay

Goals and Objectives Recognize the child with acute respiratory distress. Know the causes of pediatric acute respiratory distress. Be aware of the anatomic differences with pediatric airways. Know how to manage pediatric acute respiratory distress.

Goals and Objectives Recognize the child with acute respiratory distress. Know the causes of pediatric acute respiratory distress. Be aware of the anatomic differences with pediatric airways Know how to manage pediatric acute respiratory distress.

Recognizing an Acute airway problem in pediatrics Two most common features of pediatric respiratory distress: Tachypnea Retractions With time Tachypnea will be replaced by bradypnea as fatigue sets in. Remember, the most common cause of Cardiac Arrest in children is Respiratory Arrest.

Recognizing an Acute airway problem in pediatrics The Initial Evaluation includes: Determining the severity. Trying to localize the cause. Determining the need for emergent intervention.

Determining Severity of pediatric emergencies There are 3 simple Observational assessment tools that can quickly evaluate a sick child: Appearance Breathing Circulatory status

Determining Severity of pediatric emergencies Appearance - “TICLS” mnemonic T – Tone. Seriously ill children tend to appear limp and have decreased muscle tone. I – Instructiveness. Sick children will often not interact or will be indifferent to distractions. C – Consolability. Sick children will often not be consolable however very sick children may be unresponsive. L – Look. Sick children will often stare or be unresponsive. S- Speech. Sick children will often have a weak cry.

Determining Severity of pediatric emergencies 2. Breathing Sounds – listen for abnormal sounds – Stridor, grunting, wheezing. Positioning – look for ‘sniffing position’ or ‘tripod’. Accessory muscles – supraclavicular, intercostal or substernal. Also head bobbing or nasal flaring.

Determining Severity of pediatric emergencies 3. Circulation Look for pallor or cyanosis. Capillary refill Cool skin

Recognizing an Acute airway problem in pediatrics The Initial Evaluation includes: Determining the severity. Trying to localize the cause. Determining the need for emergent intervention.

Localizing Respiratory distress 1. Upper airway 2. Lower airway 3. Cardiac 4. Central nervous system 5. Metabolic

Localizing Respiratory distress Upper airway Sniffing position Nasal flaring Prolonged inspiration Retractions – supraclavicular, suprasternal Stridor Hoarseness or ‘hot potato voice’ Barking cough

Localizing Respiratory distress 2. Lower Airway Retractions – intercostal, subcostal Nasal flaring Prolonged expiration Wheezing Grunting Rales

Localizing Respiratory distress 3. Cardiac disease cardiac murmurs, rales, JVD, edema 4. Central nervous system Cheyne-Stokes breathing 5. Metabolic Kussmal breathing (deep and labored)

Recognizing an Acute airway problem in pediatrics The Initial Evaluation includes: Determining the severity. Trying to localize the cause. Determining the need for emergent intervention.

Determining need for emergent airway intervention Upper airway foreign body or obstruction. Respiratory Failure. Tension pneumothorax. Cardiac tamponade. Epiglottitis. Croup. Tracheitis. Retropharyngeal abscess.

Management Overview of common acute pediatric airway These are short summaries, not complete reviews. Asthma Croup Bronchiolitis 4. Anaphylaxis

Pulmonary Index Score (PIS) Asthma Treatment/Management: 1. Assess Severity 2. Reverse Airflow obstruction 2. Correct hypoxia and/or hypercapnia 4. Reduce likelihood of recurrence

Asthma Pulmonary Index Score Pulmonary Index Score (PIS) Asthma Pulmonary Index Score Score Respiratory rate* Wheezing¶ Inspiratory/expiratory ratio Accessory muscle use Oxygen saturation ≤30 None 2:1 99 to 100 1 31 to 45 End expiration 1:1 + 96 to 98 2 46 to 60 Entire expiration 1:2 ++ 93 to 95 3 >60 Inspiration and expiration 1:3 +++ <93 < 7 = Mild, 7-11 = Moderate, > 12 Severe

Asthma Treatment of moderate to severe cases. Pulmonary Index Score (PIS) Asthma Treatment of moderate to severe cases. 1. Beta-agonists (salbutamol) – puffers as effective as nebulizers. 2. Prednisone 1 mg/kg PO, then 0.5 -1 mg/kg bid x 3-5 days or Dexamethasone 0.6 mg/Kg PO/IM/IV 3. Oxygen for hypoxia 4. Epinephrine 0/01 mg/KG IM q 20 min prn x 3 5? Consider MgSO4 25-75 mg/Kg IV over 20 minutes.

Croup = acute laryngotracheobronchitis = edema of laynx, trachea and bronchi. Usually 6 mos to 2 yrs Barking cough, hoarse, stridor, possible dysphagia

Croup Treatment: Keep the child calm. Oxygen – for mild croup this may be all this is necessary. Dexamethasone 0.6 mg/Kg PO or Budesonide 2 mg via nebulizer. Nebulized Epinephrine 0.5 mg/kg to max 5 mg. Should improve within 30 minutes. Observe for 3-4 hours. If no need for repeat treatment and appear stable, can be discharged. If they require repeat treatment, consider admission.

Bronchiolitis Usually < 2 yrs of age. URTI symptoms followed by LRT symptoms. Severity scores are inconsistent, but generally an SpO2 < 95% is considered severe.

Bronchiolitis Treatment: If mild: 1. Ensure hydration and relieve nasal congestion. (decongestants and OTC of NO value)

Bronchiolitis Treatment: Severe: A one time trial of salbutamol or epinephrine may be used, but clinical efficacy is questionable. Hypertonic saline neb and steroids, NOT recommended. IV fluids as needed. Nasal suctioning. Oxygen to maintain SpO2 > 90% Non invasive ventilation/CPAP ie transfer/ICU

Anaphylaxis A more complete review of anaphylaxis in general is available on the LMHER.com website. In children the most common (80-90%) signs and symptoms are cutaneous (urticaria, angioedema, pruritus etc) Warning signs: more than one organ system involved. Signs of respiratory distress Signs of impaired perfusion Abdominal pain, vomiting, dysrhythmias.

Anaphylaxis Treatment: Epinephrine 0.01 mg/kg IM in the thigh. Repeat q 5 min prn. Place patient recumbent with legs elevated. Normal saline bolus 20 ml/Kg Ranitidine 1 mg/Kg IV for itch. Methylprednisolone 1 mg/Kg IV ? Epinephrine infusion ? Vasopressor infusion 8. Call Pediatrics!

When you have to secure the airway Main Anatomical Differences in Pediatrics and Adults Small mandible and large head (towel under body and shoulders) Large tongue High larynx Epiglottis is long and stiff Narrowest area is the cricoid cartilage Trachea is short and directly in line with Right Bronchus

Equipment “Formulas” for blade, ETT size etc FORGET it, use a table or an app (ie palmPEDi etc)

Pediatric Airway management The next slide is a video by Reuben Strayer on Pediatric airway management.