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Respiratory distress in children

Respiratory distress in children. Jana Stockwell, MD, FAAP Children’s Healthcare of Atlanta at Egleston Emory University. Typical causes of distress. Upper airway Croup Retropharyngeal abscess Epiglottitis Foreign body aspiration Lower airway Reactive airway disease / asthma

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Respiratory distress in children

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  1. Respiratory distress in children Jana Stockwell, MD, FAAP Children’s Healthcare of Atlanta at Egleston Emory University

  2. Typical causes of distress • Upper airway • Croup • Retropharyngeal abscess • Epiglottitis • Foreign body aspiration • Lower airway • Reactive airway disease / asthma • Bronchiolitis • Pneumonia • Pneumothorax ACCT4Kids

  3. Tonsils Epiglottis Esophagus Tongue Trachea Larynx Normal upper airway anatomy ACCT4Kids

  4. Obligate nose-breathers Tongue relatively larger Higher larynx (C3-C4 versus C6) Narrowing of airway causes exponential rise of airway resistance Less elasticity of alveoli Lower FRC Diaphragm Flatter Muscle fibers more vulnerable to fatigue Chest wall More compliant Ribs more horizontal Why are kids different? ACCT4Kids

  5. Nasal flaring Hypoventilation, apnea Stridor Grunting Wheezing Pallor, ashen color  WOB Tachypnea Cyanosis Head bobbing Tripod positioning Retractions  Level of consciousness  Air movement Acidosis Hypercapnea Signs & symptoms of distress ACCT4Kids

  6. 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 ACCT4Kids

  7. Croup symptoms • URI symptoms X 1-3 days • Low grade fever • “Barking” cough, hoarseness • Inspiratory stridor • Worse at night • Prefer to sit up • Aggravated by agitation & crying ACCT4Kids

  8. 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 ACCT4Kids

  9. Hypopharnyx Narrow air column Trachea Steeple sign Croup treatment & transport • Position of comfort, with parent • Dexamethasone 0.6 mg/kg IV/IM • Epi neb • Heliox • SQ Epi • Cool mist ACCT4Kids

  10. 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 ACCT4Kids

  11. 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

  12. Retropharyngeal abscess ACCT4Kids

  13. 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 ACCT4Kids

  14. Retropharyngeal abscess - Rx • Position airway - comfort • Avoid unnecessary manipulation • Monitor, CT of neck, possible OR • Sedation & paralytics can relax airway muscles, leading to complete obstruction • Endotracheal intubation is dangerous • Abx: clindamycin, cefoxitin, Timentin, Zosyn, or Unasyn ACCT4Kids

  15. Epiglottitis • Acute, rapidly progressive cellulitis of the epiglottis and adjacent structures • Before immunization - peak incidence at 3.5 years of age • Danger of airway obstruction - medical emergency • Prompt diagnosis and airway protection required ACCT4Kids

  16. Anatomy of oropharynx ACCT4Kids

  17. 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 inspiratory stridor & retractions ACCT4Kids

  18. Epiglottitis - lateral neck film ACCT4Kids

  19. Epiglottitis ACCT4Kids

  20. Epiglottitis - etiology • Group A Streptococcus • Other pathogens seen less frequently include: • Strep pneumoniae • Haemophilus parainfluenza • Staph aureus ACCT4Kids

  21. Epiglottitis - Rx & transport • Position of comfort, with parent • Minimize manipulation • Intubation under controlled circumstances • O2 prn, 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 ACCT4Kids

  22. Epiglottitis - Trouble • If respiratory arrest  BVM ventilation  if inadequate, attempt to intubate  if unable to intubate, perform needle or surgical cricothyroidotomy • IV antibiotics • ceftriaxone / cefotaxime • Racemic epinephrine & steroids are ineffective ACCT4Kids

  23. Foreign body (FB) aspiration • Toddler through preschool age common • No molar teeth for thorough chewing • Talking, laughing, and running while eating • In 2000, FB aspiration in kids <14 years old • >17,000 ED visits • 160 deaths • Nuts, raisins, sunflower seeds, pieces of meat and small smooth (grapes, hot dogs, & sausages) • Dried foods absorb water ACCT4Kids

  24. 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 ACCT4Kids

  25. 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 • Kid chest transmits sounds well • Stethoscope head may be bigger than lung lobes • Lack of asymmetry should not dissuade you from considering the FB diagnosis ACCT4Kids

  26. 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 ACCT4Kids

  27. FB aspiration ACCT4Kids

  28. Foreign bodies ACCT4Kids

  29. FB aspiration - transport issues • Position of comfort • Heimlich maneuver, back blows • BVM prn • Magill forceps (if object above cords) • Intubation prn • Needle cricothyrotomy • Surgical cricothyrotomy • Rigid bronchoscopy for FB removal ACCT4Kids

  30. Reactive airway disease / Asthma ACCT4Kids

  31. RAD / Asthma - children • <3 years - small intrapulmonary airways • Poor collateral ventilation • Decreased elastic recoil pressure • Partially developed diaphragm ACCT4Kids

  32. RAD / Asthma • Identify and remove asthma triggers • Albuterol, nebulized • Ipratopium bromide (Atrovent) • Methylprednisolone (Solumedrol) • Magnesium sulfate • CPAP / BiPAP • Heliox • Epinephrine or terbutaline infusion • Chest squeeze • Anesthetic gases ACCT4Kids

  33. RAD / Asthma • If intubated for transport: • Low vent rate, even if pCO2 high • Very prolonged expiratory phase • Listen to chest - does expiration end? • Sedate • Paralyze • Continuous nebs • Monitor for development of pneumothorax ACCT4Kids

  34. Bronchiolitis • Organisms: RSV most common • Others: parainfluenza, influenza, human metapneumovirus (hMPV), adenovirus, mycoplasma • Winter & spring • Males • Typically <2 years old, peak 2-8 mos • Disease more severe in babies 1-3 mo old • Risk factors: Heart disease, BPD, prematurity, smoking in home ACCT4Kids

  35. Bronchiolitis ACCT4Kids

  36. Bronchiolitis - sxs • Apnea, bradycardia • Desaturations • Cough, copious secretions • Tachypnea, tachycardia • Crackles, wheezing • Increased WOB, retractions • Flaring, grunting • Pallor, cyanosis ACCT4Kids

  37. Bronchiolitis - diagnosis • No diagnostic tests needed, but possibly: • Rapid viral panel (antigen or FA panel) • Viral cultures • CXR - hyperinflation, peribronchial cuffing, patchy atelectasis • Tachypnea, WOB, wheezing • Hx URI • fever, cough, runny nose, appetite • Apnea (may occur w/o other symptoms) • May be complicated by secondary bacterial infection ACCT4Kids

  38. Bronchiolitis - transport • Isolation - contact, droplet • O2, keep sats ≥92% • Pulmonary toilet, suctioning! • CPAP / BiPAP • No steroids • Nebs largely unhelpful (<1/3) • Chest PT prolongs hospitalization • Antibiotics depend on other sxs ACCT4Kids

  39. Pneumonia • Types: • Bronchopneumonia - lobar consolidation • Interstitial - usually viral • More common in infants & toddlers than in adolescents • Commonly: • Viral, pneumococcus, Mycoplasma • In immunocompromised, anything is possible! ACCT4Kids

  40. Pneumonia - sxs • Cough • Tachypnea • Grunting • Retractions • Chest pain • Vomiting, poor feeding, abdominal pain • Fever depends on type ACCT4Kids

  41. Pneumonia ACCT4Kids

  42. Pneumonia - transport • O2, keep sats ≥92% • CPAP, BiPAP • Antibiotics, if considered bacterial • Cefotaxime + vancomycin • Azithromycin • Monitor mental status • Intubate & ventilate • Complications: effusion, abscess ACCT4Kids

  43. Pneumothorax ACCT4Kids

  44. Pneumothorax radiographs ACCT4Kids

  45. Tension PTX Normal R L Lung Heart Airleak heart PTX Tension PTX ACCT4Kids

  46. Questions? ACCT4Kids

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