1. Pediatrics Respiratory Emergencies

2. #1 cause of –Pediatric hospital admissions –Death during first year of life except for congenital abnormalities

3. Respiratory Emergencies Most pediatric cardiac arrest begins as respiratory failure or respiratory arrest

4. Pediatric Respiratory System Large head, small mandible, small neck Large, posteriorly- placed tongue High glottis opening Small airways Presence of tonsils, adenoids

5. Pediatric Respiratory System Poor accessory muscle development Less rigid thoracic cage Horizontal ribs, primarily diaphragm breathers Increased metabolic rate, increased O2 consumption

6. Pediatric Respiratory System Decrease respiratory reserve + Increased O 2 demand = Increased respiratory failure risk

7. Respiratory Distress

8. Tachycardia (May be bradycardia in neonate) Head bobbing, stridor, prolonged expiration Abdominal breathing Grunting--creates CPAP

9. Respiratory Emergencies CroupEpiglottitisAsthmaBronchiolitis Foreign body aspiration

10. Laryngotracheobronchitis Croup

11. Croup: Pathophysiology Viral infection (parainfluenza) Affects larynx, trachea Subglottic edema; Air flow obstruction

12. Croup: Incidence 6 months to 4 years Males > Females Fall, early winter

13. Croup: Signs/Symptoms “Cold” progressing to hoarseness, cough Low grade fever Night-time increase in edema with: –Stridor –“Seal bark” cough –Respiratory distress –Cyanosis Recurs on several nights

14. Croup: Management Mild Croup –Reassurance –Moist, cool air

15. Croup: Management Severe Croup –Humidified high concentration oxygen –Monitor EKG –IV tko if tolerated –Nebulized racemic epinephrine –Anticipate need to intubate, assist ventilations

16. Epiglottitis: Pathophysiology Bacterial infection (Hemophilus influenza) Affects epiglottis, adjacent pharyngeal tissue Supraglottic edema Complete Airway Obstruction

17. Epiglottitis: Incidence Children > 4 years old Common in ages 4 - 7 Pedi incidence falling due to HiB vaccination Can occur in adults, particularly elderly Incidence in adults is increasing

18. Epiglottitis: Signs/Symptoms Rapid onset, severe distress in hours High fever Intense sore throat, difficulty swallowing DroolingStridor Sits up, leans forward, extends neck slightly One-third present unconscious, in shock

19. Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis

20. Epiglottitis: Management High concentration oxygen IV tko, if possible Rapid transport Do not attempt to visualize airway

21. Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction

22. Asthma

23. Asthma: Pathophysiology Lower airway hypersensitivity to: –Allergies –Infection –Irritants –Emotional stress –Cold –Exercise

24. Asthma: Pathophysiology Bronchospasm Bronchial EdemaIncreased Mucus Production

25. Asthma: Pathophysiology

26. Cast of airway produced by asthmatic mucus plugs

27. Asthma: Signs/Symptoms Dyspnea Signs of respiratory distress –Nasal flaring –Tracheal tugging –Accessory muscle use –Suprasternal, intercostal, epigastric retractions

28. Asthma: Signs/Symptoms Coughing Expiratory wheezing TachypneaCyanosis

29. Asthma: Prolonged Attacks Increase in respiratory water loss Decreased fluid intake Dehydration

30. Asthma: History How long has patient been wheezing? How much fluid has patient had? Recent respiratory tract infection? Medications? When? How much? Allergies? Previous hospitalizations?

31. Asthma: Physical Exam Patient position? Drowsy or stuporous? Signs/symptoms of dehydration? Chest movement? Quality of breath sounds?

32. Asthma: Risk Assessment Prior ICU admissions Prior intubation >3 emergency department visits in past year >2 hospital admissions in past year >1 bronchodilator canister used in past month Use of bronchodilators > every 4 hours Chronic use of steroids Progressive symptoms in spite of aggressive Rx

33. Asthma SILENT CHEST= DANGER OF RESPIRATORY FAILURE

34. Golden Rule Pulmonary edema Allergic reactions Pneumonia Foreign body aspiration ALL THAT WHEEZES IS NOT ASTHMA

35. Asthma: Management AirwayBreathing –Sitting position –Humidified O2 by NRB mask Dry O2 dries mucus, worsens plugs –Encourage coughing –Consider intubation, assisted ventilation

36. Asthma: Management Circulation –IV TKO –Assess for dehydration –Titrate fluid administration to severity of dehydration –Monitor ECG

37. Asthma: Management Obtain medication history –Overdose –Arrhythmias

38. Asthma: Management Nebulized Beta-2 agents –Albuterol

39. POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE Asthma: Management Subcutaneous beta agents –Epinephrine 1:1000--0.1 to 0.3 mg SQ

40. Asthma: Management Use EXTREME caution in giving two sympathomimetics to same patient Monitor ECG

41. Asthma: Management Avoid –Sedatives Depress respiratory drive –Antihistamines Decrease LOC, dry secretions –Aspirin High incidence of allergy

42. Status Asthmaticus Asthma attack unresponsive to  -2 adrenergic agents

43. Status Asthmaticus Humidified oxygen Rehydration Continuous nebulized beta-2 agents AtroventCorticosteroids Aminophylline (controversial) Magnesium sulfate (controversial)

44. Status Asthmaticus Intubation Mechanical ventilation –Large tidal volumes (18-24 ml/kg) –Long expiratory times Intravenous Terbutaline –Continuous infusion –3 to 6 mcg/kg/min

45. Bronchiolitis

46. Bronchiolitis: Pathophysiology Viral infection (RSV) Inflammatory bronchiolar edema Air trapping

47. Bronchiolitis: Incidence Children < 2 years old 80% of patients < 1 year old Epidemics January through May

48. Bronchiolitis: Signs/Symptoms Infant < 1 year old Recent upper respiratory infection exposure Gradual onset of respiratory distress Expiratory wheezing Extreme tachypnea (60 - 100+/min) Cyanosis

49. Asthma vs Bronchiolitis Asthma –Age - > 2 years –Fever - usually normal –Family Hx - positive –Hx of allergies - positive –Response to Epi - positive Bronchiolitis –Age - < 2 years –Fever - positive –Family Hx - negative –Hx of allergies - negative –Response to Epi - negative

50. Bronchiolitis: Management Humidified oxygen by NRB mask Monitor EKG IV tko Anticipate order for bronchodilators Anticipate need to intubate, assist ventilations

51. Foreign Body Airway Obstruction FBAO

52. FBAO: High Risk Groups > 90% of deaths: children 90% of deaths: children < 5 years old 65% of deaths: infants

53. FBAO: Signs/Symptoms Suspect in any previously well, afebrile child with sudden onset of: –Respiratory distress –Choking –Coughing –Stridor –Wheezing

54. FBAO: Management Minimize intervention if child conscious, maintaining own airway 100% oxygen as tolerated No blind sweeps of oral cavity Wheezing –Object in small airway –Avoid trying to dislodge in field

55. FBAO: Management Inadequate ventilation –Infant: 5 back blows/5 chest thrusts –Child: Abdominal thrusts

56. Otitis Media It is an infection of the middle ear Acute Otitis media Chronic Otitis media

57. Etiology: Suppurative Otitis media: Bacteriologic: Hemophilus influenza, Beta hemolytic streptococci or pneumococci. Secondary: common cold, measles or scarlet fever. Nonsuppurative Otitis media: Allergy. Auditory canal dysfunction (obstruction or abnormal patency).

58. Predisposing factors: Auditory canal in children is shorter. more accessible to invasion of microorganism. Anatomic immaturity of tubal muscles and cartilage in children under two years of age. Certain craniofacial congenital defects e.g. cleft palate and down syndrome

59. Clinical manifestations: History of common cold for several dates. Fever. Older child: pain in the affected ear, headache, vomiting and/or impaired hearing. Infant: may rub ear, anorexia, turn head from side to side and/or diarrhea. Decreased hearing.

60. Complications: Chronic otitis media. Mastoditis.Septicemia. Meningitis and brain damage. Deafness.

61. Diagnostic evaluation: Pneumatic otoscope: bulging, red eardrum, rupture drum may be obscured by secretions. Culture and sensitivity: for secretions of ruptured eardrum or by myringotomy

62. Treatment: Identify the etiology Antibiotic according to culture Antibiotic according to culture Analgesic and antipyretic Antihistaminic and decongestant Follow up hearing tests Surgical

63. Nursing intervention Administer medications and treatments as prescribed. Wash hands prior to any treatment or contact with ear. Provide physical comfort: Local heat. Encourage fluid intake to maintain hydration. Give soft diet,. Observe for signs of complications Provide emotional and psychological support