Respiratory Emergencies in the Pediatric Population

CASE 1 16 month old boy with wheeze Initial Vitals: HR 160 RR 60 BP 88/50 Temp 38 O2sat on RA 89%

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

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

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

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

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)

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

Other Options IV Magnesium 25 mg/kg (max 2 gm) IV Epinephrine IV Ventolin Inhalational Anesthetics Methylxanthines Heli - Ox

Differential Diagnosis of Wheezing H + N Vocal cord dysfunction Chest Asthma Bronchiolitis Foreign Body Aspiration CVS Congestive Heart Failure Vascular Rings

CAEP Pediatric Asthma Guidelines MILD Nocturnal cough Exertional SOB Increased Ventolin use Good response to Ventolin O2 sat > 95% PEF > 75% (predicted / personal best) ± O2 Ventolin Consider po Steroids Symptoms Pre - Treat Treatment

CAEP Pediatric Asthma Guidelines MODERATE Normal mental status Abbreviated speech SOB at rest Partial relief with Ventolin and required > than q 4h O2 sat 92%-95% PEF 50-75% (predicted / personal best) O2 100% Ventolin Systemic corticosteroids Consider anticholinergic Symptoms Pre - Treat Treatment

CAEP Pediatric Asthma Guidelines SEVERE Altered mental status Difficulty speaking Laboured respirations Persistant tachycardia No prehospital relief with usual dose Ventolin O2 saturation <92% PEF, FEV1 <50% 100% O2 Continuous or frequent b-agonists Systemic corticosteroids & magnesium sulfate Consider anticholinergic & / or methylxanthines Symptoms Pre - Treat Treatment (consider RSI)

CAEP Pediatric Asthma Guidelines NEAR DEATH Exhausted , Confused Diaphoretic Cyanotic, Decreased respiratory effort, APNEA Falling heart rate O2 saturation <80% (spirometry not indicated) As above PLUS RSI IV Ventolin Inhalational anesthetic, aminophylline Epinephrine Symptoms Pre - Treat Treatment

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

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

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

Soft tissue lateral neck radiograph

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

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

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

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 > ½ the width of the adjacent vertebral body - may see air in the retropharynx

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.

Treatment Clindamycin 20-30 mg/kg/day divided Q8H (if pre-fluctuant phase) Decadron 0.6 mg/kg Airway management Surgical decompression

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

What would you like to do now??? 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 H+N No obvious swelling, bleeding, FB seen Chest Mild wheezing with ? mild inspiratory stridor What would you like to do now???

Soft Tissue Neck View

CXR (PA)

Next? Expiratory CXR

Inspiratory View Expiratory View

Right Decub View

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)

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

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)

If suspected … Decubitus views Normal Smaller volumes and elevated diaphragm on side down Abnormal Hyperinflation or “normal” volumes in decub position If suspected … Need a bronchoscope to rule out or remove Foreign Body

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

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

Diagnosis? Re – Assess in 30 minutes What would you like to do now? 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?

Re – Examine Ongoing Inspiratory Stridor Cries when trachea is examined IV Cefuroxime PLUS Cloxacillin Consult Pediatric ICU / Pulmonary for Bronch / Intubation

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

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)

Treatment Antibiotics (good Staph coverage) Intubation or tracheostomy is usually necessary ? Decadron

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

Severe Pneumonia: Staph aureus Strep pneumonia Grp. A strep HIB Mycoplasma pneumonia Pseudomonas if recently hospitalized

History: Infants < 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

Physical Exam Tachypnea is the best single indicator of pneumonia Age in months Upper limit of Normal RR < 2 55 2-12 45 > 12 35

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)