1. Common Respiratory
Problems In
Children

2. Case 1: 4 months old One day history of excessive crying
Sent home with the diagnosis of windy colic with anti-spasmodics
Next day:
Grunting, respiratory distress, fever.
Admitted ,oxygen, IV ceftriaxone.

3. Case (contd) Second day:
Mother felt better but continues to be tachypnoeic, chest indrawing, fever persisting.
Vancomycin added with oxygen

4. Case (contd) Third day Severe respiratory distress
Pus drained through water seal drainage
Antibiotics contd.
Discharged after 2 wk.
Strepto.pneumoniae isolated

5. Case 2 16 month old boy with wheeze Initial Vitals: HR 160 RR 60
BP 88/50
Temp 38
O2sat on RA 89%

6. You do your pediatric triage
Appearance Crying, distressed, looking
around, moving all 4 limbs
Breathing (work of) Laboured, chest caving in,
+++indrawing
Circulation Colour OK, N cap refill

7. 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

8. What would you like to do now?
Oxygen
Salbutamol nebulizer
IV Access established – orders?
CXR done / pending
ABG report
Venous Gas pH
pCO2 38 pO
Normal ABG values are: pO2 of mmHg; pCO2 of mmHg; pH of ; and SaO2 of %

9. 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

10. Continuous Salbutamol nebulizer for 15 mins has little effect
Still indrawing
RR 65
Still alert and looking around, crying
Additional treatment?
IV steroids Methylprednisolone 1 mg/kg IV / IM
Continue Salbutamol
Consider racemic Epinephrine (0.5 mls)

11. Repeat Venous Gas about 30 mins later pH 7.15 pCO2 55 pO2 120
Normal ABG values are: pO2 of mmHg; pCO2 of mmHg; pH of ; and SaO2 of %
Eyes rolling back, little crying now …
What do you want to do?
Drugs? Tube Size?
Ketamine 1-2 mg/kg IV
Atropine mg/kg IV (min 0.1 mg)
Succinyl 1 mg/kg IV
4 – 4.5 tube

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

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

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

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

16. Asthma Guidelines Symptoms O2 saturation <92% PEF, FEV1 <50%
SEVERE
Altered mental status
Difficulty speaking
Laboured respirations
Persistant tachycardia
No prehospital relief with usual dose Salbutamol
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

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

18. CASE 3 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

19. 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

20. 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

21. Soft tissue lateral
neck radiograph

22. 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

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

24. 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

25. 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

26. 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.

27. Treatment Ceftriaxone 75mg/kg/day/divided Q 12 hrly
Clindamycin mg/kg/day divided Q8H
(if pre-fluctuant phase)
Decadron 0.6 mg/kg
Airway management
Surgical decompression

28. CASE 4 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

29. 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???

30. Soft Tissue
Neck View

31. CXR (PA)

32. Next?
Expiratory
CXR

33. Inspiratory View
Expiratory View

34. Right
Decub
View

35. 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)

36. 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

37. 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)

38. 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

39. CASE 5 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

40. 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

41. Diagnosis? Re – Assess in 30 minutes What would you like to do now?
Racemic Epinephrine 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?

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

43. 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

44. 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)

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

46. 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

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

48. 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

49. Physical Exam Tachypnea is the best single indicator of pneumonia
Age in months Upper limit of Normal RR
<
>

50. 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 mg/kg IV Q24H
and Cloxacillin 50 mg/kg IV Q6H (ICU)
3 mo – 5 yrs Ceftriaxone / Erythro
Clarithro / Azithro (outpt Tx)

51. Respiratory Failure in Children

52. Respiratory failure: where is the defect?
Ventilation
Diffusion
Perfusion
Abnormal oxygen carrying capacity
failure of cellular oxygen uptake

53. Types of Respiratory Failure
Type I failure, also known as normocapnic or non-ventilatory failure, is indicated by hypoxemia (low pO2 ) with a normal or low pCO2.
It is commonly due to ventilation/perfusion (V/Q) abnormalities. Other causes include: impaired diffusion across the alveolar-capillary membrane (as occurs with pulmonary fibrosis and shunting)

54. It is generally the result of alveolar hypoventilation, increased dead space ventilation, or increased CO2 production. Other causes are factors that impair the central ventilatory drive in the brainstem, restrict ventilation, or increase CO2 production.
Type II failure:
An elevated pCO2 is the hallmark , also known as ventilatory or hypercapnic failure.

55. Causes of Type I Failure
V/Q abnormaltities
Pneumonia, meconium aspiraton, Pulmonary oedema.
Cyanotic heart disease
Diffusion abnormalities
Interstitial fibrosis
Inadequate systemic blood flow
Shock
Inadequate oxygen carrying capacity
Severe anemia, methhemoglobinemia
Inadequate cellular uptake:
Cyanide poisioning

56. Type II Failure: alveolar hypoventialtion
Neuromuscular:
CNS disease, GB Syndrome.
Respiratory muscle disorders
Muscular dystrophy
Chest wall / pleura:
Pliable chest, pneumothorax, pleural effusion
Airway disorders:
Croup.
Pulmonary disease
Bronchiolitis, pneumonia, asthma
Increased CO2 production:
Sepsis, fever, burn

57. In children, respiratory failure most often is due to diseases of the lungs.
CNS disorders that lead to respiratory failure are:
Control abnormalities that cause Type II (hypercapnic) respiratory failure and usually present without signs and symptoms of respiratory distress (such as dyspnea, retractions, or tachypnea

58. A 16-year-old female arrives in the ED after the SLC result
A 16-year-old female arrives in the ED after the SLC result. No other history is available because the friends who brought him to the ED left.
The vital signs are:
Temperature (T) = 96°F;
Pulse (P) = 90 beats/min;
Respiratory rate (R) = 6 breaths/min;
Blood pressure (BP) =120/80 mmHg; and
Pulse oxygen saturation is 76% on room air.

59. Lungs and heart are normal
Arterial blood gas (ABG) is: pH = 7.13; pO2 = 52; pCO2 = 81; HCO3 = 26; and oxygen saturation = 75% on room air.
Glasgow coma scale: 4.
Shallow respiration.
Pinpoint pupil.
Lungs and heart are normal
Normal ABG values are: pO2 of mmHg; pCO2 of mmHg; pH of ; and SaO2 of %

60. Problem This patient has hypercapnia and hypoxia.
Of the physiologic events in respiration, diffusion, transport, and the tissue/cellular uptake of oxygen are normal, but ventilation is impaired.
Pin point pupil points to the poisoning probably narcotic drug.

61. An 8-year-old male muscular dystrophy
Eamination reveals rhinorrhea and excessive secretions in the oropharynx.
There are scattered rhonchi in the lungs bilaterally. There is no cyanosis.
The neurologic exam is consistent with his diagnosis of muscular dystrophy with muscle weakness
His vital signs are:
T = 100.2°F;
P = 120 beats/min;
R = 12 breaths/min; and
BP = 100/70 mmHg; and
Weight = 20 kg.

62. The ABG is: pH = 7.17; pO2 = 46; pCO2 = 78; HCO3 = 32; and O2 saturation = 71% on room air.
This patient has Type II hypercapnic respiratory failure secondary to failure of the respiratory muscles from a primary muscle disorder.
Normal ABG values are: pO2 of mmHg; pCO2 of mmHg; pH of ; and SaO2 of %

63. A 4-month-old female with breathing difficulties.
Prematurity (30 weeks), respiratory distress syndrome requiring a ventilator. She also had a congenital gastrointestinal problem requiring surgery at 6 weeks of age and has continued to have gastrointestinal problems. She has bronchopulmonary dysplasia
Her vital signs are:
T = 103.5° F;
P = 190 beats/min;
R = 64 breaths/min;
BP = 80/50 mmHg; and
Pulse oxygen saturation = 82% in room air

64. Small for her age. Respiratory distress with retractions, grunting, flaring, head nodding. Skin is pale, sweaty, and cyanotic with delayed capillary fill. There are rales in both lung fields. The chest roentgenogram shows diffuse bilateral infiltrates.
The ABG on room air is: pH = 7.61; pO2 = 56; pCO2 = 24; HCO3 = 27; and oxygen saturation is 78%.
Normal ABG values are: pO2 of mmHg; pCO2 of mmHg; pH of ; and SaO2 of %

65. A 2-month-old is brought to the ED with a chief complaint of not eating for several days.
Vital signs are:
T = 36.8°C (R);
P = 180 beats/min;
R = 58 breaths/min
BP = 55/30 mmHg; and
Pulse oxygen saturation is 78% on room air.
O/E tachypnea, retractions, and cyanosis. The lungs are clear. The heart is tachycardic with no murmurs. The liver edge is down 2 cm. The abdomen is non-tender. There is no edema and no rash.

66. An initial ABG reveals: pH = 7.48; pO2 = 62; pCO2 = 34; and HCO3 = 23.
ABG drawn on 100% FiO2 shows essentially no change from the room air blood gas: pH = 7.48; pO2 = 64; pCO2 = 35; HCO3 = 23; and O2 saturation is 79%.
An initial ABG reveals: pH = 7.48; pO2 = 62; pCO2 = 34; and HCO3 = 23.
Normal ABG values are: pO2 of mmHg; pCO2 of mmHg; pH of ; and SaO2 of %

67. A 5-year-old male is seen for a cough of several days duration that is not improving
O/E: sitting up and leaning forward. wheezing bilaterally. Tachypnic with intercostal retractions. Three continuous salbutamol aerosols were given by nebuliser.
Vital signs are:
T = 96.8°F (O);
P = 170 beats/min;
R = 44 breaths/min; and
Pulse oximetry is 94% on room air.

68. His lungs are clear, no wheeze or rales, and no retractions
His lungs are clear, no wheeze or rales, and no retractions. He has dry mucous membranes and pale skin with tenting.
Vital signs are now:
T = 96.8°F (O);
P = 102 beats/min;
R = 16 breaths/min;
BP = 65/40 mmHg; and
Pulse oxygen saturation = 86% on room air.

69. First ABG ; pH = 7.52; pO2 = 58; pCO2 = 24; HCO3 = 14; and oxygen saturation = 88% on room air.
The second ABG shows: pH = 7.12; pO2 = 68; pCO2 = 70; HCO3 = 14; and oxygen saturation is 90% on 100% FiO2.
Normal ABG values are: pO2 of mmHg; pCO2 of mmHg; pH of ; and SaO2 of %

70. Treatment: Acute Respiratory Failure
Hypoxemia is more dangerous than hypercarbia.
Administration of supplemental oxygen
Ventilatory support
Extracorporial Membrane Oxygenation (ECMO)
Never use bicarbonates unless lung can exhale