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Peds Respiratory Emergencies. Adam Davidson Adam Oster May 7, 2009. Thank You’s. Nicole Kirkpatrick Adam Oster. Outline. Anatomy ABC’s Upper Airway Emergencies Lower Airway Emergencies. Anatomy. Prominent Occiput-can cause head flexion Usually no need to place pillow/towel

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peds respiratory emergencies

Peds Respiratory Emergencies

Adam Davidson

Adam Oster

May 7, 2009

thank you s
Thank You’s

Nicole Kirkpatrick

Adam Oster

outline
Outline

Anatomy

ABC’s

Upper Airway Emergencies

Lower Airway Emergencies

anatomy
Anatomy

Prominent Occiput-can cause head flexion

Usually no need to place pillow/towel

Head extension should put in sniffing position

Tongue is disproportionally large compared to mouth

Larynx is higher in neck (C3-C4 vs C4-C5 in adults)

Anterior larynx

Large/Floppy epiglottis (choice of laryngoscope blade?)

Narrowest portion is at cricoid

resuscitation
Resuscitation

Airway

Look: alert?, protecting?, cyanotic? Foreign body?

Listen: stidor, gurgling, crying, talking

Manage: sit pt up, oxygen, OPA/NPA, finger sweep, jaw thrust, prepare to intubate

resuscitation6
Resuscitation

Breathing

Look: rate, indrawing, accessory muscles, nasal flare, cyanosis

Listen: stridor, wheeze, crackles, AE bilat, quiet, able to speak in sentences

Manage: O2, meds, bag mask, intubation

Meds: Ventolin, Atrovent, Mg, Epi, Steroids, Abx, Lasix

Nasal flaring and chest retractions more sensitive than tachypnea for resp distress

resuscitation7
Resuscitation

Circulation

Look: pale, lethargic, diaphoretic, mottled, LOC

Listen: heart sounds, murmurs

Feel: pulses, pulsus paradoxus, cap refill

Manage: fluid if no signs CHF, PALS

Adjuncts: CXR, ABG/Cap Gas, ECG, Bloodwork, Soft-tissue films

cap gas versus abg s
Cap Gas versus ABG’s

Excellent approximations of pH and CO2

Are accurate for detecting hypoxemia but correlation falls off as PaO2 values rise

Errors occur with false +ves, therefore good screen

More blood flow to area, more accurate the reading

Make sure to warm area to increase vasodilation

resuscitation9
Resuscitation

RSI

Pre-Oxygenation

Pre-treatment:

Atropine: 0.02mg/kg (Minimum Dose?, Why?)

Lidocaine: 1.5 mg/kg

Induction:

Ketamine: 1.5-2mg/kg

Paralysis:

Succinycholine: 2mg/kg

physical exam
Physical Exam

Stridor

Hallmark of URT obstruction

Inspiratory: usually supraglottic, associated with collapse due to negative pressure

Associated with: drooling, hot-potato voice

Eg: abscess, croup, epiglottitis

Biphasic: usually fixed obstruction at glottis

Eg: laryngeal webs, vocal cord paralysis

Expiratory: usually sub-glottic, associated with positive pressure of expiration

Eg: Tracheitis, foreign body

physical exam11
Physical Exam

Grunting

LRT pathology

Forced expiration creating auto-PEEP

Presence usually represents significant distress

Wheeze

LRT pathology

Asthma, Bronchiolitis, Cardiac, Pneumonia

location
Location

Upper Airway

Lower Airways

Cardiac

CHF: congenital, myocarditis, cardiomyopathy

PE

Tamponade

Neurologic

SAH, Shaken Baby, meningitis, opiates, anxiety

Metabolic

DKA

CO poisoning, Methemoglobinemia, Hydrogen Sulphide

partial differential
Partial Differential

Foreign body

Epiglottitis

Croup

Tonsillitis

Abscess (retro/parapharyngeal, peritonsillar)

Anaphylaxis

Angioedema

Burns

Caustic Ingestion

Congenital Abnormality

Bacterial Tracheitis

slide15

13 year old female with fever and sore throat

Recurrent “Strep throat”

Can barely talk, hasn’t been able to eat or drink for 24hrs

peritonsillar abscess quinsy
Peritonsillar Abscess (Quinsy)

Risk Factors: chronic tonsillitis, mono, CLL, dental infection, older age

Odynophagia, dysphagia, drooling, hot-potato voice, rancid breath, fever, malaise, dehydration

Uvular deviation and trismus most specific for abscess

Abscess vs Cellulitis: aspiration of pus

May need sedation but needle less painful than I+D

Cut plastic needle cover to form guard

No cases in literature of carotid puncture

peritonsillar abscess
Peritonsillar Abscess

Needle aspiration shown to be as efficacious as I+D

Can be performed in ED

Admit: septic, dehydrated and not able to drink, unreliable follow-up, unable to aspirate

If able to tolerate PO fluids, can give dose of IV Abx and f/u with HPTP

Abx: Clinda (usually 1st choice), Ancef/Flagyl

Steroids: very few studies exist with conflicting data

Practice seems to vary between ENT surgeons

No evidence of harm

steroids for phayngeal swelling
Steroids For Phayngeal Swelling

Some ENT surgeons swear by giving steroids to reduce edema/swelling in the pharynx

Common practice for mono and peritonsillar abscess

Cochrane Review 2009 for steroids with mono

Symptomatic Relief for 12 hours only

No difference in complete resolution or length of disease

No evidence for peritsonsillar abscess, retropharyngeal abscess

Consider for patients with acute airway obstruction or those who can’t tolerate PO fluids (Dex 10mg IV)

Dickens, KP, et al. Should you use steroids to treat infectious mononucleosis? The Journal of Family Practice, 2008

retropharyngeal abscess
Retropharyngeal Abscess

More common in young children (Age: 6m-3yr)

Post URTI or secondary to FB trauma (toothbrush, popsicle stick, etc)

Toxic, febrile, drooling, stridor, dysphagia, opisthotonos (can look like meningitis)

Px: bulgling posterior pharyngeal wall

Soft tissue films: large retropharyngeal space (>1/2 width of vertebral body), retropharyngeal air

False +ve: expiration film, neck flexion

Treatment: IV Clinda, IV Dex, generally admitted to PICU for monitoring with ENT consult

croup laryngotracheobronchitis
Croup (Laryngotracheobronchitis)

Most common cause of stridor for ages 6m-3yr

Causes: always viral

Parainfluenza (MCC), Influenza, Adenovirus, RSV

Usually benign and self-limited

severe disease more common in males

Peaks in fall/winter

URTI with 3-4d hx of worsening cough

Barky cough, stridor, sx usually worse at night

Stridor worse with anxiety (ie: in ED)

Usually non-toxic with low-grade fever

Hypoxia is a rare and late sign

clinical croup score
Clinical Croup Score

Insp Breath Sounds:

Normal (o), Harsh (1), Delayed (2)

Stridor:

None (0), Inspiratory (1), Expiratory (2)

Cough:

None (0), Hoarse Cry (1), Bark (2)

Retractions/Flaring:

None (0), Suprasternal (1), Sub/intercostal (2)

Cyanosis:

None (0), Room Air (1), 40% O2 (2)

Mild: <4 Mod: 4-6 Severe: >6

croup treatment
Croup Treatment

Intubation: usually can be avoided with aggressive Tx

(if necessary, use ETT 1 size smaller than expected)

Steroids: Dex 0.6mg/kg (max 10-20mg?) PO/IM/IV

Good evidence for moderate, severe croup

Decr admission, intubation, return to ED, croup scores

NEJM 2004 showed benefit in mild croup as well

No side-effects, One dose lasts 48 hrs

Nebulized Epi:

1:1000 Epi (L isomer only) just as good as racemic

Nebulize 5ml q2-3hr for maximum of 3 doses (back to back if impending intubation)

Good evidence for severe croup

Contraindications: mechanical cardiac outflow obstructin (AS, ToF)

Complications: MI, V-tach

steroids and croup
Steroids and Croup

Dex shown to be superior to Prednisolone

Single dose of 0.15mg/kg equivalent to 0.3 and 0.6

croup disposition
Croup Disposition

Mild

Dex PO and D/C home

Moderate

Dex PO and observe for 3-4hrs before D/C

Severe

Dex (IV/IM) and Epi, observe for 4-6hrs before D/C

Admission

Co-morbidities, social situation, complicated airway or previous difficult intubation, dehydration

Discharge Instructions

Cool air, popsicles, humidity?, F/U with GP in 24-48hrs

bacterial tracheitis
Bacterial Tracheitis

Sub-glottic bacterial infection

Can occur at any age, males = females, no seasonal preference

Polymicrobial bacterial superinfection following Croup (primary infection less common)

Staph (50%), Strep, H flu, Moraxella

Bacterial invasion with copious mucous secretions

Airway obstruction secondary to mucous

bacterial tracheitis30
Bacterial Tracheitis

Patient with barky cough and low-grade fever suddenly develops high fever and toxic appearance

More respiratory distress than Croup

Can appear like Epiglottitis with fever, drooling, resp distress

Consider if:

Toxic looking Croup

Croup lasting >4 days

Croup not responding to treatment

bacterial tracheitis diagnosis
Bacterial TracheitisDiagnosis

Soft Tissue Films: “shaggy” irregular tracheal wall with intraluminal membrane, steeple sign

Dx: laryngobronchoscopy shows normal epiglottis w/ +++ secretions

Complications

Airway obstruction, ETT plugging (common, consider Trach)

Sepsis, DIC, Toxic Shock from Staph

bacterial tracheitis management
Bacterial Tracheitis Management

Airway management best done in OR with Anesthesia consult

IV Abx: Cefotaxime/Clindamycin

ICU Admission post OR

Daily bronchoscopy to remove secretions

Consider Trach if persistant ETT plugging

No benefit to steroids or nebulized epi

case 1
Case 1

2M male

3 day history of URTI associated with fever (38.5)

Onset of difficulty feeding, increased WOB today

Vitals - HR 160 RR 65 SpO2 90% on R/A T 37.9

TT, indrawing, nasal flaring, diffuse crackles and wheezes

differential diagnosis of wheeze
Differential diagnosis of Wheeze
  • Infection (Bronchiolitis, pneumonia)
  • Asthma
  • Cystic Fibrosis
  • CHF
  • Foreign body
  • Anaphylaxis
  • Croup
  • Epiglottis
  • Vocal cord dysfunction
  • GERD
  • Bronchopulmonary dysplasia
you think he has bronchiolitis
You think he has bronchiolitis
  • What do you tell his parents about his illness and its natural history?
bronchiolitis
Bronchiolitis
  • Viral infection
    • RSV, influenza, parainfluenza, echovirus, rhinovirus, adenovirus
    • Mycoplasm, Chlamydia
  • Children < 2 years, peak at 2 M
  • October to May
  • Contact/Droplet
  • Peak at 3-5 d
  • Resolves 2 weeks
bronchiolitis38
Bronchiolitis
  • Inflammation of terminal and respiratory bronchioles
    • Mucus plug + edema
    • Airway narrowing
    • Decrease compliance, increase resistance
    • Atelectasis and overdistention
bronchiolitis39
Bronchiolitis
  • Clinical presentation
    • Wheeze, tachypnea, indrawing
    • URT symptoms
    • Fever
    • Hypoxemia
    • Apnea
what factors put children at increased risk of severe bronchiolitis
What factors put children at increased risk of severe bronchiolitis?
  • History of
    • Prematurity
    • BPD
    • CF
    • Congenital heart disease
    • Immunocompromised
management
Management
  • You start oxygen and encourage feeding
  • When patient not feeding well you give 20 mL/kg bolus
  • RT asks you if you want this child to be treated with bronchodilators or steroids…
  • What do you think?
controversial
Controversial
  • Many trials done to examine use of
    • Epinephrine
    • ß-adrenergics
    • Steroids
      • IV
      • PO
      • Inhaled
evidence for epinephrine
Evidence for Epinephrine
  • Epinephrine vs. placebo or salbutamol
  • 5/8 showed short term improvement in clinical scores
  • 1/8 showed fewer hospitalization
  • 1/8 showed shorter duration of hospitalization
evidence for epinephrine44
Evidence for Epinephrine
  • Hartling et al, 2003
    • Meta-analysis
    • Epinephrine vs. bronchodilators or placebo
    • RCT, infants<2 years, quantitative outcome
    • 14 studies, 7 inpatient, 6 outpatient, 1 unknown
    • Outpatient results
      • Epi better than placebo or other bronchodilators in short term (O2 saturation, RR, clinical score)
evidence for epinephrine45
Evidence for Epinephrine
  • Cochrane Systematic Review
  • 14 RCT (1966-2003)
  • Inpatient and outpatient treatment
  • Epinephrine vs. placebo - outpatient (3)
    • Improvement at 60 minutes (1/3studies)
    • No difference in admission or O2 saturation
  • Epinephrine vs. Salbutamol - outpatient (4)
    • O2 saturation, HR, RR improved at 60 minutes
    • No difference in admission
slide46

Evidence for Bronchodilators

  • 13 RCT
  • Bronchodilators vs. placebo or ipatropium
  • 1/13 showed decreased admission
  • 4/13 showed some clinical improvement
evidence for bronchodilators
Evidence for Bronchodilators
  • Cochrane Systematic Review
  • 22 RCT (1966-2005)
  • Bronchodilators vs. placebo
  • No difference in admission or duration of hospitalization
  • Minor improvement in oximetry and symptoms in outpatient treatment
slide48

Previous studies used larger doses of epinephrine

    • Effect may not be due to alpha affects, but higher delivery of ß-agonist
slide49

RCT comparing racemic epinephrine, racemic albuterol, normal saline in equivalent doses in mild/moderate bronchiolitis

  • N = 65 (23-albuterol, 17 epi, 25 NS)
  • 5mg of drug in 3 mL at 0 and 30 minutes
  • Clinical assessment pre and post
  • 3 rd dose at 60 minutes if RDAI >8 or O2 saturation < 90% R/A
  • Final assessment at either 60 or 90 minutes
slide50

Required admission/home oxygen

    • 61% albuterol, 59% epinephrine, 64% NS
  • No difference in admission rates
  • No difference in O2 saturation, RR
  • ß-agonist not useful in Rx bronchiolitis
slide51

“ß-agonists should not be used routinely in management of bronchiolitis” Level B

  • “A carefully monitored trial of alpha adrenergic or ß-adrenergic medications is an option…and continued only if there is a documented positive clinical response using objective means of evaluation” Level B
  • “…it would be more appropriate that a bronchodilator trial…use salbutamol rather than racemic epinephrine”
slide53

Systematic review

  • Oral, IV and inhaled steroids
  • Oral
    • 6 RCT involving prednisone (1) prednisolone (2) Dexamethasone (2) Prednisolone and albuterol vs. Placebo and albuterol
    • Various outcomes (hospitalization, clinical score, length of stay, duration of ventilation)
    • 1 found decreased rate of admission, 1 found increased rate of admission,1 found shorter duration of ventilation, 1 found improved clinical status
    • Felt data was inconclusive
slide54

IV

    • 2 RCT
    • Dexamethasone to placebo
    • No benefit
      • Clinical score, admission, time to resolution, duration of oxygen therapy
slide55

Inhaled

    • 6 RCT
    • Mostly used budesonide
    • Worse wheeze/cough at 12 months in 1
    • Increase readmission
    • No benefit shown
slide56

Evidence for Steroids

  • Cochrance Systematic Review
  • 13 RCT
  • No difference
    • RR
    • O2 saturation
    • Admission
    • Length of stay
    • Subsequent visits
    • Readmission
slide57

RCT

    • Comparing admission to hospital and RACS 4 hours after dose of dexamethasone (1mg/kg) versus placebo
  • January 2004 - April 2006
  • N = 600 (305 dexamethasone, 295 placebo)
  • Admission
    • 39.7% in dex vs. 41% in placebo - no difference
  • RACS - sum of change in RDAI minus standardized score for change in RR (negative value = good response)
    • No difference
slide58

“Corticosteroid medications should not be used routinely in the management of bronchiolitis” Level B

palivizumab
Palivizumab
  • Humanized, mouse monoclonal anti-RSV antibody
  • Monthly X 5 months, 15 mg/kg IM
  • Prevention of serious RSV lower respiratory tract infection
    • Children < 2 years
    • Chronic lung disease of prematurity
    • Premature ≤ 32 weeks
    • Hemodynamically significant cyanotic or acyanotic congenital heart disease
hypertonic saline
Hypertonic saline
  • Mechanism incompletely understood
    • Osmotic hydration
    • Reduction of cross-linking
    • Edema reduction
slide62

RCT, multicentre comparing length of stay in admitted patients receiving treatment with 3% HS vs. NS

  • N=93 (47 - HS, 49 - NS)
  • Doses q 2h X3, q4h X5, q6h until D/C
  • Any other treatments mixed with appropriate solution
slide63

Length of stay

    • HS 2.6 days +/- 1.9 days
    • NS 3.5 days +/- 2.9 days
    • 26% reduction in LOS
    • P = 0.05
slide64

RCT comparing epinephrine 1.5 mg in 4 mL NS vs. epinephrine 1.5 mg in 4 mL of HS

  • N = 53 (25 NS, 27 HS)
  • Length of stay, change in clinical severity
  • NS 4 +/- 1.9, HS 3 +/- 1.2, p < 0.05
case 3
Case 3
  • 6 yo M with PMH of asthma
  • URTI X4 days, using blue puffer
  • Increase WOB today
  • HR 130, RR 35, 90% on R/A
  • Indrawing, Audible wheeze
  • Decreased breath sounds to R
  • Wheeze
evidence for anti cholinergics
Evidence for Anti-cholinergics
  • NEJM 1998
  • RDBCT
  • Albuterol vs. albuterol+ IB x 2 dose
  • N=434 (2-18 years)
  • IB
    • Decreased hospitalization (27 vs 36%, p = 0.05)
      • Similar hospitalization rates in moderate exacerbation
      • Markedly different rates in severe exacerbations
evidence for anti cholinergics68
Evidence for Anti-cholinergics
  • 32 studies, 16 pediatric
  • 10 studies - admission (1786 children)
    • Lower admission rate
    • NNT =13, 7 if only severe exacerbations included
  • 9 studies - spirometry
    • 1 or 2 doses had FEV1 difference of 12.4%
    • >2 doses had FEV1 difference of 16.3%
evidence for anti cholinergics69
Evidence for Anti-cholinergics
  • Cochrane Systematic Review 2000
  • 13 trials
  • Multiple doses decreased risk of admission by 25%
  • Single doses improved lung function at 60 and 120 minutes, but no admission
  • NNT= 12 to avoid 1 admission in kids with either moderate or severe exacerbation
  • NNT = 7 if severe exacerbations
nebulizer vs mdi spacer
Nebulizer vs. MDI/Spacer
  • RDBCT
  • N = 168 (2m to 24 months)
  • Nebulizer vs. Spacer
  • Primary outcome
    • Admission rates
  • Results
    • Controlled for difference in baseline
    • Spacer group admitted less
      • 5% vs. 20% p=0.05
nebulizer vs mdi spacer71
Nebulizer vs. MDI/Spacer
  • RDBCT
  • N=90 (5 -17 years) baseline FEV1 50-79%
  • Treatment groups
    • 6-10 puffs
    • 2 puffs
    • 0.15mg/kg nebulized
  • Primary outcome
    • Improvement in % predicted FEV1
  • Results
    • No significant difference in % predicted FEV1 between groups
nebulizer or mdi spacer
Nebulizer or MDI/Spacer
  • Cochrane Systematic Review 2006
  • Beta agonist via wet nebulizer vs. spacer
  • 25 outpatient trials
  • N = 2066 children, 614 adults
  • MDI+spacer was equivalent to wet nebulizer wrt hospital admission rates
  • MDI+spacer in kids
    • Decreased length of stay in ED
continuous vs intermittent
Continuous vs. Intermittent
  • Cochrane Systematic Review 2003
  • Continuous or near continuous (q 15 minutes or >4 treatments/h) vs. intermittent nebulization
  • Continuous beneficial
    • Decreased admission
    • Most pronounced if severe exacerbation
evidence for use of steroids
Evidence for use of steroids
  • Cochrane Systematic Review 2001
  • Benefit of treatment within 1 hour of ED presentation
  • 12 trials
  • N = 863
  • Reduced admission rates, NNT = 8
  • Most benefit
    • Not currently Rx with steroids
    • Severe exacerbation
  • Oral steroids worked well for kids
evidence for mgso4
Evidence for MgSO4
  • 5 trials
  • IV MgSO4 at any dose vs. placebo in patients < 18 y treated with beta-agonists and steroids
  • MgSO4 reduced hospitalization
  • NNT=4 for avoiding hospitalization
evidence for mgso476
Evidence for MgSO4
  • Cochrane Systematic Review
  • 7 trials (5 adult, 2 pediatric)
  • N= 665
  • In severe subgroup
    • Improved PEFR, FEV1, admission rates
    • Improvements not seen if all patients included
evidence for mgso477
Evidence for MgSO4
  • Cochrane Systematic Review 2005
  • Inhaled MgSO4
  • 6 trials
  • N=296 (2 pediatric)
  • Heterogenous studies therefore difficult to make definitive conclusion
  • MgSO4 with beta-agonists showed benefit
    • Pulmonary function
    • Admission rates
    • In severe exacerbations
evidence for iv salbutamol
Evidence for IV Salbutamol
  • Cochrane Systematic Review 2001
  • IV salbutamol in addition to other Rx vs. placebo
  • 15 trials
  • N=584
  • No benefit
    • Pulmonary function
    • Arterial gases
    • Vital signs
    • AE
    • Clinical success
other treatments
Other treatments
  • Heliox
  • NIPPV
case 380
Case 3
  • 5 M Male
  • Cough, fever, decreased energy and intake
  • Tachypnea, increased wob
  • SpO2 90% on R/A, RR 60
  • Crackles in RLL
  • CXR
    • Consolidation in RLL
epidemiology
Epidemiology
  • 4% of kids/y in U.S.
    • Decreases with increasing age
  • < 2 years – 80% viral
  • > 4 years – 40% viral
clinical features
Clinical features
  • Cough, fever, CP, tachypnea, grunting (infants), increased wob (indrawing, seesaw)
  • Typical presentation - bacterial
    • Rapid onset
    • Fever, chills, chest pain, cough
  • Atypical presentation – viral
    • Gradual onset
    • Malaise, h/a, cough, fever (low-grade)
  • Significant overlap
specific bugs
Specific bugs
  • B. pertussis
  • 3 stages
        • Catarrhal phase
          • Coryza, cough lasting 1-2 weeks
        • Paroxysmal phase
          • Coughing fits associated with gagging, cyanosis
          • Whoop is uncommon in infants
          • Lasts ~ 4 weeks
        • Recovery
          • Cough improves over months
        • Treatment
specific bugs85
Specific bugs
  • S. aureus
    • Rapid and severe
  • C. trachomatis
    • 50% of exposed will get conjunctivitis
    • 5-20% pneumonia
    • 2-19 weeks
    • Rarely febrile or systemically unwell
    • Staccatto cough
cxr in ambulatory setting
CXR in ambulatory setting
  • N = 522 (2M to 59M)
  • Randomized to CXR or no CXR
  • Primary outcome
  • Results
    • Median 7 days to recovery in both groups
    • CXR group
      • More diagnosed with pneumonia
      • 60% vs. 52% treated with antibiotics
      • More follow-up appts.
      • No difference in consultation, admission, repeat CXR at 28 days
slide87
CXR
  • Bacterial
    • Lobar or segmental consolidation
  • Viral and atypical bacterial
    • Interstitial infiltrates
    • Peribronchial thickening
    • Atelectasis
  • Significant overlap
    • Not useful in determining etiological agent
slide88
CXR
  • May want to avoid in mild acute LRTI
  • Use if <5 and if fever >39 or toxic
admission
Admission
  • SpO2<90-93%
  • Young age
  • Toxic
  • Immunocompromised
  • RR>70 (infant), >50 (older children)
  • Respiratory distress
  • Apnea/grunting
  • Not feeding or dehydrated
  • Social concerns