Common paediatric respiratory conditions
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Common Paediatric Respiratory conditions. Corrine Balit . Outline. Respiratory Distress : Signs and Treatment Respiratory Supports High Flow Nasal prong CPAP/ BIPAP Ventilation Bronchiolitis Pertussis Asthma. Case 1: 6 week old E.L.

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  • Respiratory Distress : Signs and Treatment

  • Respiratory Supports

    • High Flow Nasal prong


    • Ventilation

  • Bronchiolitis

  • Pertussis

  • Asthma

Case 1 6 week old e l
Case 1: 6 week old E.L.

  • 6 week old infant presents with severe respiratory distress

  • Taken to resuscitation bay on arrival

  • Call from ED doctor asking for help

Common paediatric respiratory conditions

  • Resp

    • RR 90

    • Tracheal tug

    • Intercostal and subcostal recession

    • Grunting

    • Head bobbing, nasal flaring

  • CVS

    • HR 200

    • Cap refill 3 seconds

    • Mottled

  • Neuro

    • Agitated,

    • Unsettled,

Respiratory distress failure
Respiratory Distress/ Failure

  • One of most common reason ICU will need to review a patient

  • Hard to determine which patients will need to come to ICU

  • Clinical assessment and reassessment is most important

  • May need to start some basic measures and then reassess again.


  • Venous Blood Gas

    • Carbon dioxide and pH

    • Lactate

  • Oximetry

  • Chest x-ray

  • Other investigations to support underlying cause.

Who needs to come to icu
Who needs to come to ICU

  • Clear cut ones that do and don’t

  • In-between that is the hardest.

  • Indications

    • Mod- Severe respiratory distress despite basic treatment

    • Recurrent apnoeas

    • Respiratory acidosis (pH < 7.2)

    • Increasing oxygen requirements

    • Change in mental state

    • Needing airway protection

Treatment of respiratory failure
Treatment of Respiratory Failure

  • Administration of supplemental oxygen + consider humidification

  • Evaluation of airway patency

  • Clear secretions / Airway toileting to maintain airway patency

  • Appropriate adjuncts

    • Salbutamol +/- ipratropium

    • Steroids if indicated

Common paediatric respiratory conditions

Respiratory Distress

RR < 60

Mild-Mod Work of breathing

Oxygen requirement < 2L

Not irritable/agitated

RR >60

Mod-severe work of breathing

Increasing oxygen requirement


Basic Measures

Nil by mouth

Cannula + IVF

Humidified oxygen total flow of 2-3L

Adjuncts appropriate to condition e.g. salbutamol, steroids

Common paediatric respiratory conditions

Mod-Severe Respiratory Distress

IV Cannula

Oxygen + humidification

Salbutamol, ipratropium, steroids

  • Indications for ICU

  • Ongoing mod-severe respiratory distress despite above

  • Apnoeas

  • Respiratory Acidosis

  • Fatigue

Treatment of respiratory distress
Treatment of Respiratory Distress

  • Specific treatment for conditions

  • Non-invasive support

    • High Flow nasal prong oxygen

    • CPAP

    • BIPAP

  • Mechanical ventilation

    • IPPV

    • HFOV

  • ECMO

Treatment of respiratory distress1
Treatment of Respiratory Distress

  • Fluid Management

    • Generally restricted if receiving ventilatory support

    • Two- thirds maintenance

    • Normal saline or Hartmann's as fluid for severe resp distress

    • Watch EUC

  • Feeds

    • Feed once stable and improving

    • Can feed while receiving NIV support

High flow nasal prong oxygen
High Flow Nasal Prong oxygen

  • Delivered via nasal prong and using Fisher and Paykel System

  • Rational is two fold:

    • High flows provide positive distending pressure to the airway improving functional residual capacity

    • Use of humidification

  • Humidification improves mucocillary clearance

  • Advantages:

    • Tolerated better by children

    • Avoid some of CPAP complication like nasal mucosal injury

High flow nasal prong oxygen1
High Flow Nasal Prong oxygen

  • Flow rates currently recommended up to 8L/Min

  • Prospective study in Brisbane where the used flow rates between 1 and 8 L/min were used and they used electrical impedance tomography and oesophageal pressures measured.

  • Found that using 8L/min flow rate delivered on average a CPAP effect of 4 cm H20 in infants with viral bronchiolitis

  • Definition of High flow nasal prong cannula

    • 1L/kg/min

    • Current cannula for paediatrics up to 8L flow.

High flow indications
High Flow- Indications

  • Respiratory distress with hypoxemia

    • Bronchiolitis

    • Pneumonia

  • Post extubation respiratory support

  • Facilitation of weaning from CPAP

  • Post operative respiratory failure

High flow contraindications
High Flow- Contraindications

  • Nasal obstruction

    • Choanal atresia

    • Large polyps

  • Foreign body aspiration

  • Children requiring airway protection

  • Severe life threatening hypoxia (not a replacement for intubation

Non invasive ventilation
Non-Invasive Ventilation

  • CPAP versus bi-level NIV

  • Difficulties is with appropriate size mask

  • Bubble CPAP good for infants (<10kg)

  • PEEP 5-10cm

  • Contraindications

    • If airway protection is needed

    • Decreased level of consciousness

    • Nasal obstruction

Invasive ventilation
Invasive Ventilation

  • Conventional Ventilation

  • High Frequency Ventilation

  • If intubating patient for severe respiratory distress suggest always using cuffed tube.

    • Cuff doesn’t need to go up but there if you need it

Bronchiolitis aeitology
Bronchiolitis- aeitology

  • Respiratory Syncytial Virus

  • Para influenza virus

  • Adenovirus

  • Influenza virus

  • Rhinoviruses

  • Human metapneumovirus

Bronchiolitis pathology
Bronchiolitis- Pathology

  • Loss of epithelial cells

  • Cellular infiltration

  • Oedema around airway

  • Plugging of airway with mucus

  • Can get complete and partial plugging of airways resulting in localised atelectasis and over distention in other areas.

  • Imbalance of ventilation and perfusion leads to hypoxemia.

Bronchiolitis clinical features
Bronchiolitis – Clinical Features

  • Coryzal symptoms

  • Wheezing

  • Pneumonia

  • Aponea

  • Hyponatremia

  • Seizures

  • Encephalopathy

  • Myocarditis


  • NPA

  • Blood Gas

  • CXR

  • Septic workup if severe or very young

  • FBC, EUC

Bronchiolitis indications for icu admission
Bronchiolitis- Indications for ICU admission

  • Recurrent Apnoea

  • Slow irregular breathing

  • Decreased level of consciousness

  • Shock

  • Exhaustion

  • Hypoxia

  • Respiratory acidosis

Bronchiolitis management
Bronchiolitis- Management

  • Supportive Care

    • Oxygen

    • Suction

    • Fluids / Feeding

      • Always Nil by mouth if moderate- severe

      • IV fluids : 2/3 maintenance if moderate- Severe

    • NG Tube

      • Decompression of stomach

      • Feeds once more stable

    • Infection Control

Bronchiolitis specific treatments
Bronchiolitis – Specific Treatments

  • Bronchodilators

  • Surfactant

  • Corticosteroids

  • Ribavirin

  • RSV Immunoglobulin

  • Palivizumab

  • Antibiotics

Bronchiolitis specific treatments1
Bronchiolitis – Specific Treatments


  • B- agonists

    • Meta analysis: modest short term improvement in clinical scores, without changes in oxygen saturation, rate of hospitilisation or length of hospital stay

  • Adrenaline

    • RCT comparing adrenaline nebulised with placebo

    • No difference in length of hospital stay and no short term or long term clinical improvement

Bronchiolitis specific treatments2
Bronchiolitis – Specific Treatments

  • Corticosteroids

    • Controversial, conflicting studies

    • Cochrane review: no benefits in either length of stay or clinical course in infants

  • Surfactant

    • Promising as RSV affects endogenous surfactant production

    • given to mechanically ventilated infants with RSV – shortened time on mechanical ventilation,

    • Individual case reports and series.

    • Limited evidence, very expensive

Bronchiolitis specific treatments3
Bronchiolitis – Specific Treatments


  • Antiviral

  • Inhibits RSV replication

  • Evidence supports aerolised use, IV can be given

  • Early trials showed it to be effective

  • No convincing benefit on clinical outcomes expect to patients post BMT with RSV

Bronchiolitis specific treatments4
Bronchiolitis – Specific Treatments

  • RSV- IG IV

    • No improvement on clinical outcome

  • Palivizumab

    • Monoclonal antibody

    • For prophylaxis for high risk infants

    • Expensive

    • 50% decrease in need for hospitlisation in high risk infants

Bronchiolitis specific treatments5
Bronchiolitis – Specific Treatments

  • Ipratropium bromide

    • Not been demonstrated to be efficacious

  • Heliox

    • Helium-oxygen gas

    • Prospective study looking at 70% helium, 30% oxygen mixture- improved tachypnoea and tachycardia and shorter stay in PICU

  • Nitric oxide

    • Case reports only

Bronchiolitis antibiotics
Bronchiolitis: Antibiotics

  • Used for secondary bacterial infection

  • Traditionally risk of secondary infection with RSV thought to be low but theses studies based on children not admitted to PICU.

  • Recent studies: PCCM 2010

    • Secondary pneumonia in patients in PICU with RSV reported to be as high as 20-50%

  • If child is unwell enough to be admitted to PICU with bronchiolitis, cultures should be taken and antibiotics started

Levin et al pccm 2010
Levin et al PCCM 2010

  • Prospective study looking at patients admitted with RSV bronchiolitis with progressive respiratory failure

  • Excluded patients who had pre-existing conditions

  • Found 39% had probable pneumonia by tracheal aspirate

  • Concluded that due to high rate of possible secondary bacterial pneumonia, empirical antibiotics for 24-48 hrs pending cultures may be justified in those sick enough to come to PICU

Bronchiolitis ventilation
Bronchiolitis- Ventilation

  • High Flow Nasal Prongs

  • CPAP

  • Mechanical Ventilation

    • IPPV

    • HFOV

    • ECMO

My approach to moderate severe bronchiolitis
My Approach – to moderate-severe bronchiolitis

  • Suction and clear airway esp nasal passages

  • Application of oxygen with humidification if possible

  • Nil by mouth

  • IV cannula + 2/3 maintaince IVF

  • Obtain venous blood gas (BC + FBC/EUC at time of IVC)

  • Decide on level of respiratory support

    • High flow Nasal prong Cannula to 8L/min (not available in ED)

    • Bubble CPAP

Common paediatric respiratory conditions

  • OG or NG if on respiratory support

  • Constant reassessment, looking for

    • Decreasing respiratory rate

    • Decrease in work of breathing

    • Heart rate improving

  • If not responding to above to be intubated and ventilated

  • If sick enough with bronchiolitis to need ventilatory support I do blood culture and sputum culture and cover with antibiotics.

  • Need to monitor Sodium

Pertussis pathology
Pertussis - Pathology

  • Bordetella Pertussis

  • Toxin damages respiratory epithelium and can produce systemic toxicity

  • Severe, Prolonged Coughing

  • Aponea in young infants

  • Whoop- loud stridor on inspiration after a paroxysm

Pertussis severe complications
Pertussis- Severe Complications

  • Pneumonia

  • Pulmonary Hypertension

  • Encephalopathy

  • Seizures

  • Global Myocardial dysfunction


  • Mortality highest in

    • Very young infants

    • WCC > 100 000

    • Presenting with pneumonia

    • Need for circulatory support

  • Indications for ICU

    • Apnoeas

    • Seizure

    • Severe respiratory failure

Pertussis investigations
Pertussis - Investigations

  • PCR on NPA

  • CXR

  • WCC

  • ECHO if severe

Pertussis management
Pertussis- Management

  • Suction

  • Oxygen

  • Respiratory support

    • High flow nasal o2

    • CPAP

    • Ventilation

  • Antimicrobials

    • Azithromycin

Pertussis other management
Pertussis- Other Management

  • If leukocytosis (esp neutrophilia)

    • Exchange transfusions or aphaeresis to remove white cells

    • With high white cell count can get leukocyte aggregates in pulmonary vessels

  • If Pulmonary Hypertension present

    • Consider inhaled nitric oxide or sildenafil

  • If Severe respiratory failure

    • ECMO

  • Treat contacts

Pccm 2007
PCCM 2007

  • Retrospective study from RCH Melbourne

  • Median age at admission was 6 weeks

  • 94% of patients were unimmunised at time of admission

  • Infants presenting with pneumonia had raised white cell count

  • 38% needing intubation died

  • All patients who needed ECMO died

Asthma management
Asthma – Management

  • Oxygen

  • B-adrenergic agonists

  • Corticosteroids

  • Anticholinergic

  • Magnesium Sulphate

  • Theophylline/ Aminophylline

  • Inhalational anaesthetics

Asthma management1
Asthma- Management

  • Helium-Oxygen

  • Non-invasive ventilation

  • Ventilation

  • Ketamine

  • Adrenaline

B adrenergic agonists
B-adrenergic agonists

  • Salbutamol first line bronchodilator of choice

  • MDI with spacer as effective as nebulisation

  • When giving nebulisation, continuous nebulization is superior to intermittent doses (Cochrane Review 2009)

    • Provides sustained stimulation of B-receptors

    • Promotes progressive bronchodilatation

    • Improves drug delivery in distal airway

Iv salbutamol
IV salbutamol

  • Considered in patients unresponsive to treatment with continuous nebulisation.

  • RCT in children 2002:

    • IV salbutamol as a bolus , atrovent or IV salbutamol +atrovent

    • In severe asthma, IV salbutamol as a bolus lead to more rapid recovery

Ipratropium bromide
Ipratropium bromide

  • Leads to bronchodilatation by decreasing parasympathetic-mediated cholinergic bronchomotor tone

  • Cochrane review 2009:

    • Adding multiple doses of anticholinergic to B2 agonists appears safe and improves lung function

    • Would avoid hospital admission in 1 of 12 such patients

  • No studies in critically ill children admitted to PICU

  • Because safe, considered reasonable to use

Magnesium sulphate
Magnesium Sulphate

  • Acts as calcium antagonist leading to smooth muscle relaxation

  • 5 x RCT looking at IV magnesium in children

    • 4 of these studies showed improvement in respiratory function and decrease in hospital admissions

    • 1 study showed no significant difference between magnesium and placebo group

  • 2 x meta analysis that showed adding magnesium provided additional benefit to children


  • Theophylline and Aminophylline

  • Role is in severe asthma who have failed other treatment

  • Meta analysis of RCT in paeds found no benefit in mild or moderate asthma

  • RCT in 163 children with status asthmaticus

    • Aminophylline improved oxygen sats and pulmonary function

    • No difference in length of stay