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Respiratory Distress

Respiratory Distress. National Pediatric Nighttime Curriculum Written by Liane Campbell, MD Lucile Packard Children’s Hospital, Stanford University. Learning Objectives. Review the initial assessment of patient in respiratory distress

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Respiratory Distress

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  1. Respiratory Distress National Pediatric Nighttime Curriculum Written by Liane Campbell, MD Lucile Packard Children’s Hospital, Stanford University

  2. Learning Objectives • Review the initial assessment of patient in respiratory distress • Review management of specific causes of respiratory distress • Upper airway obstruction • Lower airway obstruction • Lung tissue disease • Disordered control of breathing

  3. During a busy night, you get the following page: FYI: Sally, a 2 year old with PNA had a desat to 88% while on 2L NC. What do you do next? What initial management steps would you take?

  4. How do you initially assess a patient in respiratory distress?

  5. Initial Assesment • Rapid assessment • Quickly determine severity of respiratory condition and stabilize child • Respiratory distress can quickly lead to cardiac compromise • Airway • Support or open airway with jaw thrust • Suction and position patient • Breathing • Provide high concentration oxygen • Bag mask ventilation • Prepare for intubation • Administer medication iealbuterol, epinephrine • Circulation • Establish vascular access: IV/IO

  6. History and Physical Exam History Physical Exam Mental status Position of comfort Nasal flaring Accessory muscle use Respiratory rate and pattern Auscultation for abnormal breath sounds • Trauma • Change in voice • Onset of symptoms • Associated symptoms • Exposures • Underlying medical conditions

  7. What initial studies would you get for a patient in respiratory distress?

  8. Initial studies • Pulse oximetry • May be difficult in agitated patient • May be falsely decreased in very anemic patients • Imaging • Chest X Ray • Consider in patients with focal lung findings or respiratory distress of a unknown etiology • Soft tissue radiograph of lateral neck • May identify a retropharyngeal abscess or radiopaque foreign body • Labs • ABG/VBG • Chemistry: calculate anion gap • Urine toxicology and glucose if patient has altered mental status

  9. What are some examples of life threatening conditions?

  10. Life threatening conditions • Complete upper airway obstruction • No effective air movement, speech or cough • Respiratory failure • Pallor or cyanosis, altered mental status, tachypnea, bradypnea, apnea • Tension pneumothorax • Absent breath sounds on affected side, tracheal deviation and compromised perfusion • Pulmonary embolism • Chest pain, tachycardia, tachypnea • Cardiac tamponade • Apnea, tachycardia, hypotension, respiratory distress

  11. Specific Causes of Respiratory Distress • Upper airway obstruction • Lower airway obstruction • Lung tissue disease • Disordered control of breathing

  12. Case 1 8 month old ex-FT girl with 2-3 days of nasal congestion, cough, and sneezing, was RSV+ on admission with mild work of breathing requiring 0.5L O2. As you’re watching the monitors on Short Stay with the nurse at 2am, she’s now 84-89%. What is your diagnosis? What are your next steps?

  13. Case 2 4 year old boy admitted to GI service for monitoring and serial AXRs because he ingested a sharp object. He’s tucked in for the night with an AM AXR ordered. But after his dinner, he suddenly becomes stridulous, and starts crying and drooling. Parents just left the room to get dinner. What is your initial evaluation/management?

  14. Case 3 3 year old girl with 2 days of fever, noisy breathing and loud barking cough tonight. In the ED 3 hrs ago, got one racemic epi neb and a dose of oral steroids. Admitted for observation. Nurse calls now because his breathing is getting noisy at rest and he’s coughing. No respiratory distress. How do you manage him overnight?

  15. Case 4 Jonathan is a 2 year old with Pompe’s disease who is BiPAP dependent overnight with settings of 18/5 and a backup rate of 18. Over the past few hours, he has had an increase in his oxygen requirement from an FiO2 of 21 to 40% and has spiked to 39.2. What steps do you take to evaluate and manage him overnight?

  16. Upper Airway Obstruction • Causes: foreign body, tissue edema, trauma, viral infection, intubation, tongue movement to posterior pharynx with decreased consciousness • Symptoms • Partial obstruction: noisy inspiration (stridor), choking, gagging or vocal changes • Complete obstruction: no audible speech, cry or cough • Management • Rapidly decide if advanced airway is needed • Avoid agitation • Suction only if blood or debris are present • Reduce airway swelling • Inhaled epinephrine • Corticosteroids • Croup and anaphylaxis require additional management

  17. Lower Airway Obstruction • Bronchiolitis • Symptoms: copious nasal secretions, wheezes and crackles in child less than 2 years • Management • Oral or nasal suctioning • Viral studies, CXR, ABG/VBG • Trial of nebulizedalbuterol • Asthma • Symptoms: wheezing, tachypnea, hypoxia • Management • Mild-moderate: oxygen, albuterol, oral corticosteroids • Moderate to severe: oxygen, albuterol-ipratropium (Duo-Neb), corticosteroids (IV), magnesium sulfate • Impending respiratory failure: oxygen, albuterol-ipratropium, corticosteroids, assisted ventilation (bag-mask ventilation, BiPAP, intubation), adjunctive agents (terbutaline, magnesium sulfate), heliox

  18. Lung Tissue Disease • Etiologies of lung tissue disease • Infectious pneumonia • Aspiration pneumonitis • Non-cardiogenic pulmonary edema (ARDS) • Cardiogenic pulmonary edema (ARDS) • Consider positive expiratory pressure (CPAP, BiPAP or mechanical ventilation with PEEP) if hypoxemia is refractory to high concentrations of oxygen

  19. Disordered Control of Breathing • Abnormal respiratory pattern produces inadequate minute ventilation • Altered level of consciousness • Elevated intracranial pressure • Cushing’s triad • Poisoning or drug overdose • Administer specific antidote if available • Hyperammonemia • Metabolic acidosis • Neuromuscular disease • Restrictive lung disease => atelectasis, chronic pulmonary insufficiency, respiratory failure • Support oxygenation and ventilation while treating the underlying problem

  20. Take Home Points • The initial assessment of a patient in respiratory distress should be rapid and focused on quickly determining the severity of respiratory distress and need for emergent interventions • Specific causes of respiratory distress can be categorized as upper and lower airway obstruction, lung tissue disease and disordered control of breathing and require specific interventions

  21. Questions 1. Which of the following are NOT symptoms of an upper airway obstruction? • Gagging • Changes in voice quality • Noisy inspiration (stridor) • No audible speech, crying or cough • Crackles on auscultation (answers are in speaker’s notes)

  22. 2. During a busy evening shift, you admit a 2 year old male who presents with a barking cough, stridor at rest, and moderate retractions. He is alert and oriented and calms with his mother. His vital signs on admission are temperature 38.5, heart rate 165, respiratory rate 65, blood pressure 90/45 and oxygen saturation of 92%. Which of the following should NOT be included in your initial management? • Oxygen • Keeping the patient NPO • Nebulized racemic epinephrine • Dexamethasone • Nebulized albuterol

  23. 3. What is the first medication that should be given to a patient with anaphylaxis and respiratory distress? • Diphenhydramine • Ranitidine • Solumedrol • Epinephrine • Albuterol

  24. 4. While on call in January, you admit a 10 month old prev. healthy female who presents with cough, nasal congestion and fevers of 2 days and 1 day of tachypnea. She is fully immunized. On exam, her temp is 39.2, HR 130, RR 55 and O2 sat 93% on RA. Her lung exam reveals diffuse crackles and wheezes at the bases as well as moderate subcostal retractions, but no flaring, grunting or head bobbing. Which diagnostic test is most likely to demonstrate the cause of her respiratory distress? • Chest X Ray • Nasopharyngeal swab for viral panel • Blood culture • Urinalysis • CBC with differential

  25. 5. When performing an initial assessment of a patient in respiratory distress, the history should include all of the following elements EXCEPT: • Change in the quality of voice • Underlying medical conditions • Recent episodes of trauma • Previous episodes of respiratory distress • Detailed family history

  26. References Albisett, M. Pathogenesis and clinical manifestations of venous thrombosis and thromboembolism in infants and children. June 2010. UpToDate. Bailey, P. Oxygen delivery systems for infants, children and adults. May 2010. UpToDate. Ralston, M.et. al. Pediatric Advanced Life Support Provider Manual. 2006. American Heart Association. Sherman, S.C. and Schindlbeck, M. When is venous blood gas analysis enough? Emerg Med38(12):44-48, 2006 Simons, F. Anaphylaxis: Rapid recognition and treatment. September 2010. UpToDate. Weiner, D. Emergent evaluation of acute respiratory distress in children. May 2010. UpToDate.

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