Hamilton CME

1. Hamilton CME Paediatric Respiratory Emergencies Spring 2008

2. Paediatrics Stages of development: • Newborn / Neonate: Birth to 29 days • Infancy: 1 month to 1 year • Toddler: 1 – 3 years • Pre-school: 3 - 5 years • School child: 5 - 15 years • Adolescent: 15 - 19 years

3. Respiratory System: • The respiratory system matures as the child gets older. • Newborns are usually nose breathers. • This facilitates breathing while suckling. Age: Range of normal / min. Rapid / min. Newborn: 30-50 >60 Infancy: 20-30 >50 Toddler: 20-30 >40 Children: 15-20 >30

4. Given a Competent Primary Survey • Hands off approach. • When examining a child, perform the most critical assessment you need to do before the child starts to cry. • Take some history, visualize the child and decide which assessment you need to do first to confirm or rule out your suspicion. • Listen to MOM! ( ‘my baby doesn’t quite seem right’ ) • A good mother will often make a better diagnosis than a poor Doctor ( or Paramedic ).

5. Respiratory System • Infection: • Can cause a relative arterial hypoxemia. • Predisposed to disease because of size & structure. • Small airways, poor muscle development, can’t clear mucous well during infections.

6. Respiratory System • Respiratory Distress: Lower airway: • short trachea, bifurcation at 45o. • Airways close more easily. • Incomplete lung development until 8 years old. Chest wall: • Muscles tire more easily. • Highly compliant, makes rib cage inefficient in producing an increase in lung volume & allows for distortion under stress - retractions. • Large stomach & liver encroach on respiratory effort.

7. Pneumonia • Introduction • Pneumonia is defined pathologically as an inflammation of lower tract lung tissue. (1)

8. Pneumonia

9. Pneumonia • Pathophysiology • Defense mechanisms • Macrophages • Antibodies • Lymphatic drainage

10. Pneumonia • Pathophysiology •  anatomic defenses may be d/t preceding viral infection of upper respiratory tract.

11. Pneumonia • Pathophysiology • Acute inflammatory response • Exudative fluid • Fibrin deposition • Leukocytes • Macrophages

12. Pneumonia • Clinical Features • Fever can increase an infant's respiratory rate by 10 breaths/min for each degree centigrade of elevation. (1)

13. Pneumonia • Clinical Features • Adventitious breath sounds •  WOB • Grunting respirations • Abdominal distention

14. Signs of Respiratory Trouble: • Facial Signs • Colour ( lips and circumoral ) • Nasal flaring • Neck • Tracheal tugging • Supraclavicular Retractions • Chest • Lower Sternal Retraction • Intercostal and/or subcostal indrawing

15. Typical Acute onset High-grade fever Pleuritic chest pain Productive cough Bacterial pathogen Atypical Gradual onset Low-grade fever Non-productive cough Viral pathogen Pneumonia

16. Pneumonia • Clinical Features • Infants frequently lack the classic symptoms and present with a variety of nonspecific findings. (1)

17. Pneumonia • Clinical Features • More severe pneumonia is associated with deterioration of the patient's mental status, the use of accessory muscles, and the presence of retractions, nasal flaring, splinting, and cyanosis. (1)

18. Asthma

19. Asthma • Pathophysiology • Classifications • Extrinsic (IgE-mediated) • Intrinsic (infection-induced) • Mixed

20. Asthma • Pathophysiology • Two-stage process • Bronchoconstriction (early) • Mucosal edema & plugging (late)

21. Asthma • Pathophysiology • Bronchospasm, mucosal edema, and mucous plugging cause variable and reversible airflow obstruction with subsequent air trapping and impaired oxygen exchange.(2)

22. Asthma • Pathophysiology • Inadequate alveolar ventilation • Carbon dioxide retention • Respiratory acidosis • Respiratory failure

23. Asthma • Pathophysiology • The child with asthma is at higher risk of respiratory failure d/t: •  compliance of rib cage • Immature diaphragm • Lung tissue lacks elastic recoil • Airway walls are relatively thicker

24. Asthma • Evaluation • Treatment with inhaled β2-agonists should not be withheld while the initial evaluation is in progress. (2)

25. Asthma • Evaluation • “silent” or “quiet” wheezer • Prolonged expiratory phase • Extreme air trapping

26. Asthma • Evaluation • Tripod positioning • Nasal flaring • Polyphonic  wheezes • Cyanosis • Insensible fluid losses • Pulsus paradoxus & JVD

27. Asthma • Evaluation • History • Precipitating factors • Prescription medications • Hospitalizations • Intubations • Tracheostomies

28. Asthma • Evaluation • History • Neonatal - prematurity, BPD, NICU? • Adolescents - substance abuse? • All ages - aspiration / choking?

29. Asthma • Treatment • β2-Receptors are widely distributed on bronchial smooth muscle and airway epithelial cells. (2)

30. Asthma • Treatment • Salbutamol can be concurrently administered to an intubated patient via MDI and ETT spacer device or a patient assisted with BVM and spacer device.

31. Asthma

32. Asthma

33. Asthma • Treatment • Most children presenting in status asthmaticus will be dehydrated because of increased insensible losses. (2)

34. Asthma • Complications • Respiratory failure • Atelectasis • Pneumomediastinum • Pneumothorax

35. Bronchiolitis • Introduction • A clinical syndrome of wheezing, chest retractions, and tachypnea in children younger than age 2 years. (2)

36. Bronchiolitis • Epidemiology • October thru May • Peak age of incidence is 2 months

37. Bronchiolitis • Pathophysiology • Respiratory syncytial virus (RSV) causes 50 to 70 percent of clinically significant bronchiolitis. (2)

38. Bronchiolitis • Pathophysiology • Mucous plugging • Necrosis of respiratory epthelium • Destruction of ciliated epithelial cells • Submucosal edema

39. Bronchiolitis • Clinical Features • 911 may be called because of wheezing, increased respiratory symptoms, nasal congestion, and difficulty feeding. (2)

40. Bronchiolitis • Clinical Features • RSV-related apnea • Infants at highest risk are younger than 6 weeks old and have a history of prematurity, apnea of prematurity, and low O2 saturation. (2)

41. Bronchiolitis • Treatment • Keep patient & environment calm • Oxygen therapy PRN • Fluid therapy PRN

42. Bronchiolitis • Treatment • A trial of bronchodilator therapy, is an optional and reasonable treatment and can be aborted if the child fails to show a response. (2)

43. Bronchiolitis • Treatment • Epinephrine is an effective treatment for the wheezing of bronchiolitis. (2)

44. Stridor • Introduction • Stridor is due to Venturi effects created by somewhat linear airflow through a semi-collapsible tube, the airway. (3)

45. Stridor • Introduction • Supraglottic • Subglottic • Trachea • Primary bronchi

46. Stridor • Introduction • Expiratory stridor, or wheeze, is common in distal airways, since intrathoracic pressure may become much greater than atmospheric pressure during expiration. (3)

47. Stridor • Introduction • Patients with marked variation in the pattern of stridor should be considered to have a foreign body in the airway until proven otherwise. (3)

48. Epiglottitis • Clinical Features • Since the introduction of the Haemophilus influenzae vaccine, the incidence and demographics of this disease have changed remarkably. (3)

49. Epiglottitis • Clinical Features • Abrupt onset • High-grade fever • Sore throat • Stridor • Dysphagia +/- drooling

50. Epiglottitis • Treatment • DO NOT attempt to visualize the airway unless respiratory failure/arrest is imminent.