Respiratory distress in children

1. Respiratory distress in children Prepared by: Dr. MOHAMMAD Mizyed Supervised by: Dr. Nadwa Al-zohlouf -2008-

2. Respiratory distress in children • Respiratory distress is one of the most common chief complaints for which children seek medical care. • It account about 10% of pediatric emergency visits to E.R . • The evaluation of acute respiratory distress should include determination of severity and the need of emergent intervention as well as underling cause.

3. Definition. • Respiratory distress defined as increased work of breathing. • distress develops as a result of: - an attempt to improve minute ventilation (tidal volume x RR) as in hypoxia. -as a result of respiratory stimulation or depression. -difficulty in mechanics of respiration ,typically from airway obstruction or muscle fatigue.

4. Nasal flaring Hypoventilation, apnea Stridor Grunting Wheezing Pallor  WOB Tachypnea Cyanosis Head bobbing Tripod positioning Retractions  Level of consciousness  Air movement Acidosis Hypercapnea Signs & symptoms of distress

5. Obligate nose-breathers Tongue relatively larger Higher larynx (C3-C4 versus C6) Narrow airway causes . Increased metabolic demands Less elasticity of alveoli. Lower FRC. Diaphragm Muscle fibers more vulnerable to fatigue Chest wall More compliant Ribs more horizontal Why are kids different?

6. SOrespiratory distress must be earyrecognised because they become fatigued and decompensated early than older patients

7. Tonsils Epiglottis Esophagus Tongue Trachea Larynx Normal upper airway anatomy

8. Typical causes of distress • LIFE THREATINING CONDITIONS:1-Complete or severe upper airway obstruction as foreign body aspiration, angioedema and epiglottitis. 2-Tension pneumothorax .3-Cardiac tamponade. 4- Pulmonary embolism5-Traumatic conditions as flail chest

9. Typical causes of distress • Respiratory Conditions: • Upper airway • Croup • Retropharyngeal abscess • Epiglottitis • Foreign body aspiration • Lower airway • Asthma • Bronchiolitis • Pneumonia • Pneumothorax

10. Typical causes of distress • Cardiovascular:-congestive heart failure. -cyanotic heart disease. -pericarditis. -myocarditis. • Nervous system -depressed ventilation. -hypotonia. -loss of protective reflexes.

11. Typical causes of distress • Gastrointestinal: -abdominal distension. -aspiration from GER. • Metabolic diseases: -acidosis. -hyperthyroidism. -hypothyroidism. • Hematological: -severe anemia. -methemoglobinemia. -acute chest syndrome. • Trauma.

12. EVALUATION. • initial rapid assessment should include: -identification of children with respiratory distress. -rapid assessment of respiratory status. -identification of children who require immediate intervention (life-threatining). -brief history while emergent treatment is initiated. -trial to keep the child calm and comfortable.

13. HISTORY • detailed history should obtained after stabilization of the child • Trauma as in pneumthorax, flail chest or head injury • Change in voiceusually occurs with upper airway pathology as hoarsness in croup • Onset & duration of symotoms. • History of foreign body aspiration/ingestion. • Associated symptoms as fever ,cough, vomiting or chocking • Exposure to specific toxins , infections or allergens. • Previous episodes as in asthma • Underlying medical conditions as Hx of asthma or sickle cell disease

14. PHYSICAL EXAMINATION • General observations: • mental status: anxiety, restlessness and lethargy. • position of comfort: as “sniffing position” (neck flexion with mild head extension) in upperairway obstruction and “tripod position” (child is sitting up and leaning forward on outstretched hands) in epiglottitis. • nasal flaring. • chest wall movement. • abnormal sounds as stridor, hoarsness & wheezes .

15. PHYSICAL EXAMINATION • Cyanosis • respiratory rate • respiratory pattern -rapid, shallow breathing as in asthma and bronciolitis (air trapping) -kussmal breathing as in matabolic acidosis (DKA) -ataxic respiration as in CNS infection or injury

16. PHYSICAL EXAMINATION • Palpation and percusion -subcutaneous emphysema which can be seen in pneumothorax -vibratory rhonchi. -increased tactile fremitus as in consolidation or decreased as in upper airway obstruction. - hyper-resonance or dullness

17. PHYSICAL EXAMINATION Auscultation -wheezes which is typically heard with asthma and bronchiolitis .unilateral wheezes indicates foreign body in lower airway. -cracklesas in pneumonia an pulmonary edema -pleural rub as in pneumonia and pleural abscess. -decreased breathing sounds as in atelectasis ,pneumonia and effusion.

18. Investigations -the clinical evaluation usually suggest the cause of respiratory distress. -diagnostic test should confirm the diagnosis and direct treatment, it may include; a-imaging -CXR -CT scan -Fluroscopy b-ABGs c-RBS d-cultures e-urine toxicology screen ……etc

19. TREATMENT • Depends upon the underlying cause of respiratory distress ,severity and response to initial therapy . • Initial therapy may include: -Oxygen -Bronchodialator -Antibiotics -Bronchoscopy -Intubation

20. Croup (LaryngoTracheoBronchitis) • Most severe in kids 6 mo - 3 years old • Males • Winter months • Associated illnesses • Ear infection • Pneumonia • Organisms: parainfluenza types 1, 2 & 3, adenovirus, RSV, influenza

21. Croup symptoms • URT symptoms X 1-3 days • Low grade fever • “Barking” cough, hoarseness • Inspiratorystridor • Worse at night • Prefer to sit up • Aggravated by agitation & crying

22. Croup diagnosis • Clinical diagnosis • Does not require neck X-ray • Consider X-ray in patients with atypical presentation or clinical course • “Steeple sign” Steeple sign

23. Hypopharnyx Narrow air column Trachea Steeple sign Croup treatment & transport • Position of comfort, with parent • Dexamethasone 0.6 mg/kg IV/IM • Epinephrine neb. • Heliox • SQ Epi. • Cool mist

24. Retropharyngeal abscess • Deep, potential, space of the neck • Children age 6 months to 6 years • Other deep neck abscesses more frequent in older children & adults • Parapharyngeal • Peritonsillar • Potential for airway compromise • Complications secondary to mass effect, rupture of the abscess, or spread of infection

25. Fever, chills, malaise Decreased appetite Irritability Sore throat Difficulty or pain swallowing Jaw stiffness Neck stiffness Muffled voice “Lump” in the throat Pain in the back & shoulders upon swallowing Difficulty breathing is an ominous complaint that signifies impending airway obstruction Retropharyngeal abscess - sxs ACCT4Kids

26. Retropharyngeal abscess

27. Retropharyngeal abscess • Polymicrobial infection typical • Gram-positive organisms and anaerobes predominating • Gram-negative bacteria possible • Oropharyngeal flora . • Most common cause is group A beta-hemolytic streptococci

28. Retropharyngeal abscess - Rx • Position airway – comfort. • Avoid unnecessary manipulation • Monitor, CT of neck, possible Op. • Sedation & paralytics can relax airway muscles, leading to complete obstruction. • Endotracheal intubation is dangerous. • Abx: clindamycin, ampicillin/sulbactam ACCT4Kids

29. Epiglottitis • Acute, rapidly progressive cellulitis of the epiglottis and adjacent structures. • Before immunization - peak incidence at 2-4 years of age. • Danger of airway obstruction - medical emergency. • Prompt diagnosis and airway protection is required

30. Epiglottitis - signs & sxs • More acute presentation in young children than in adolescents or adults. • Symptoms for <24 hrs • High fever, severe sore throat, tachycardia, systemic toxicity, drooling, tripod position. • Moderate or severe respiratory distress with inspiratorystridor & retractions (stridor suggest near complete airway obstruction)

31. Epiglottitis - lateral neck film Thumb sign (swollen epiglottis)

32. Epiglottitis

33. Epiglottitis - etiology • Group A Streptococcus • Other pathogens seen less frequently include: • Strep pneumoniae • Strep pyogenes • Staph aureus. • Haemophilus influenza type b was the most common cause before administration of HiB vaccine.

34. Epiglottitis - Rx & transport • Position of comfort, with parent • Minimize manipulatio • Intubation under controlled circumstances • O2prn, blow-by if not tolerating mask • Avoid agitation (Do not try to start IV, obtain blood or examine airway!) • Consult anesthesia & ENT • IV for antibiotics, after airway secure

35. Epiglottitis - Trouble • If respiratory arrest  Bag ventilation  if inadequate, attempt to intubate if unable to intubate, perform needle or surgical cricothyroidotomy • IV antibiotics • ceftriaxone / cefotaxime • Racemic epinephrine & steroids are ineffective

36. Foreign body (FB) aspiration • Toddler through preschool age common • No molar teeth for thorough chewing • Talking, laughing, and running while eating • Infants <3y account 73% of cases. • Nuts, raisins, sunflower seeds and pieces of meat .

37. FB aspiration • Sudden episode of coughing / choking while eating with subsequent wheezing (sometimes unilateral), coughing, or stridor • Tragic cases occur with total or near-total occlusion of the airway • Frequent sites of FB lodgement: • Usually below vocal cords • Mainstem bronchi • Trachea • Lobar bronchi

38. FB aspiration • Extrathoracic FB: • Breath sounds are inspiratory • Intrathoracic FB • Noises are symmetric but more prominent in central airways • If FB is beyond the carina, the breath sounds are usually asymmetric

39. FB aspiration • Hyperinflation & air-trapping of the affected lobe(s) is typical • Best seen with X-ray taken at expiration • Difficult in little kids. • May see soft tissue opacity in proximal airway

40. Clinical manifestation • Three stages: • Initial event: paroxysm of coughing, chocking & possibly airway obst. • Asymptomatic interval: F.B become lodged ,reflexes fatigue & immediate irritating symptoms subside. • Complications: .obstruction, erosion, or infection occurs which direct attention again to the presence of F.B .symptoms of this stage include fever.cough,hemoptysis,pneumonia and atelectasis

41. FB aspiration

42. Foreign bodies

43. FB aspiration - transport issues • Position of comfort • Heimlich maneuver, back blows • F.B removal by: -Magill forceps (if object above cords) -Rigid bronchoscopy. • Cricothyrotomymay be indicated to establish airway in upper airway obst.

44. THANK YOU