Common Paediatric Respiratory conditions

Corrine Balit

Outline

Respiratory Distress : Signs and Treatment

Respiratory SupportsHigh Flow Nasal prong CPAP/ BIPAPVentilation

Bronchiolitis

Pertussis

Asthma

Case 1: 6 week old E.L.

6 week old infant presents with severe respiratory distress

Taken to resuscitation bay on arrival

Call from ED doctor asking for help

RespRR 90Tracheal tug Intercostal and subcostal recessionGruntingHead bobbing, nasal flaring

CVSHR 200Cap refill 3 secondsMottled

NeuroAgitated, Unsettled,

Respiratory Distress/ Failure

One of most common reason ICU will need to review a patient

Hard to determine which patients will need to come to ICU

Clinical assessment and reassessment is most important

May need to start some basic measures and then reassess again.

Increased work of breathing

Malformations of chest wall

Evidence of hypoxemia/hypercarbia

Tachypnea Large A diameter (barrel chest)

Agitation

Nasal Flaring Narrow AP diameter

Confusion

Chest wall retractions

Somnolence

Paradoxical breathing

Cyanosis

Agitation

Grunting

Accessory muscle use

Investigations

Venous Blood GasCarbon dioxide and pHLactate

Oximetry

Chest x-ray

Other investigations to support underlying cause.

Who needs to come to ICU

Clear cut ones that do and don’t

In-between that is the hardest.

IndicationsMod- Severe respiratory distress despite basic

treatmentRecurrent apnoeasRespiratory acidosis (pH < 7.2) Increasing oxygen requirementsChange in mental stateNeeding airway protection

Treatment of Respiratory Failure

Administration of supplemental oxygen + consider humidification

Evaluation of airway patency

Clear secretions / Airway toileting to maintain airway patency

Appropriate adjunctsSalbutamol +/- ipratropium Steroids if indicated

Respiratory Distress

RR < 60Mild-Mod Work of breathingOxygen requirement < 2LNot irritable/agitated

RR >60Mod-severe work of breathingIncreasing oxygen requirementIrritable/agitated

Basic Measures Nil by mouthCannula + IVF Humidified oxygen total flow of 2-3LAdjuncts appropriate to condition e.g. salbutamol, steroids

Mod-Severe Respiratory Distress

IV Cannula

Oxygen + humidification

Salbutamol, ipratropium, steroids

Indications for ICU-Ongoing mod-severe respiratory distress despite above-Apnoeas-Respiratory Acidosis-Fatigue

Treatment of Respiratory Distress

Specific treatment for conditions

Non-invasive supportHigh Flow nasal prong oxygenCPAPBIPAP

Mechanical ventilation IPPVHFOV

ECMO

Treatment of Respiratory Distress

Fluid ManagementGenerally restricted if receiving ventilatory supportTwo- thirds maintenanceNormal saline or Hartmann's as fluid for severe resp

distressWatch EUC

FeedsFeed once stable and improving Can feed while receiving NIV support

High Flow Nasal Prong oxygen

Delivered via nasal prong and using Fisher and Paykel System

Rational is two fold:High flows provide positive distending pressure to

the airway improving functional residual capacityUse of humidification

Humidification improves mucocillary clearance

Advantages:Tolerated better by childrenAvoid some of CPAP complication like nasal mucosal

injury

High Flow Nasal Prong oxygenFlow rates currently recommended up to 8L/Min

Prospective study in Brisbane where the used flow rates between 1 and 8 L/min were used and they used electrical impedance tomography and oesophageal pressures measured.

Found that using 8L/min flow rate delivered on average a CPAP effect of 4 cm H20 in infants with viral bronchiolitis

Definition of High flow nasal prong cannula1L/kg/minCurrent cannula for paediatrics up to 8L flow.

High Flow- Indications

Respiratory distress with hypoxemiaBronchiolitisPneumonia

Post extubation respiratory support

Facilitation of weaning from CPAP

Post operative respiratory failure

High Flow- Contraindications

Nasal obstruction Choanal atresiaLarge polyps

Foreign body aspiration

Children requiring airway protection

Severe life threatening hypoxia (not a replacement for intubation

Non-Invasive Ventilation

CPAP versus bi-level NIV

Difficulties is with appropriate size mask

Bubble CPAP good for infants (<10kg)

PEEP 5-10cm

Contraindications If airway protection is neededDecreased level of consciousnessNasal obstruction

Invasive Ventilation

Conventional Ventilation

High Frequency Ventilation

If intubating patient for severe respiratory distress suggest always using cuffed tube. Cuff doesn’t need to go up but there if you need it

Bronchiolitis

Bronchiolitis- aeitology

Respiratory Syncytial Virus

Para influenza virus

Adenovirus

Influenza virus

Rhinoviruses

Human metapneumovirus

Bronchiolitis- Pathology

Loss of epithelial cells

Cellular infiltration

Oedema around airway

Plugging of airway with mucus

Can get complete and partial plugging of airways resulting in localised atelectasis and over distention in other areas.

Imbalance of ventilation and perfusion leads to hypoxemia.

Bronchiolitis – Clinical Features

Coryzal symptoms

Wheezing

Pneumonia

Aponea

Hyponatremia

Seizures

Encephalopathy

Myocarditis

Investigations

NPA

Blood Gas

CXR

Septic workup if severe or very young

FBC, EUC

Bronchiolitis- Indications for ICU admission

Recurrent Apnoea

Slow irregular breathing

Decreased level of consciousness

Shock

Exhaustion

Hypoxia

Respiratory acidosis

Bronchiolitis- Management

Supportive CareOxygenSuctionFluids / Feeding

Always Nil by mouth if moderate- severe IV fluids : 2/3 maintenance if moderate- Severe

NG Tube Decompression of stomach Feeds once more stable

Infection Control

Bronchiolitis – Specific Treatments

Bronchodilators

Surfactant

Corticosteroids

Ribavirin

RSV Immunoglobulin

Palivizumab

Antibiotics

Bronchiolitis – Specific Treatments

Bronchodilators

B- agonistsMeta analysis: modest short term improvement in

clinical scores, without changes in oxygen saturation, rate of hospitilisation or length of hospital stay

AdrenalineRCT comparing adrenaline nebulised with placeboNo difference in length of hospital stay and no short

term or long term clinical improvement

Bronchiolitis – Specific TreatmentsCorticosteroids

Controversial, conflicting studiesCochrane review: no benefits in either length of stay

or clinical course in infants

SurfactantPromising as RSV affects endogenous surfactant

productiongiven to mechanically ventilated infants with RSV –

shortened time on mechanical ventilation, Individual case reports and series. Limited evidence, very expensive

Bronchiolitis – Specific Treatments

Ribavirin

Antiviral

Inhibits RSV replication

Evidence supports aerolised use, IV can be given

Early trials showed it to be effective

No convincing benefit on clinical outcomes expect to patients post BMT with RSV

Bronchiolitis – Specific Treatments

RSV- IG IVNo improvement on clinical outcome

PalivizumabMonoclonal antibodyFor prophylaxis for high risk infantsExpensive50% decrease in need for hospitlisation in high risk

infants

Bronchiolitis – Specific Treatments

Ipratropium bromideNot been demonstrated to be efficacious

HelioxHelium-oxygen gasProspective study looking at 70% helium, 30%

oxygen mixture- improved tachypnoea and tachycardia and shorter stay in PICU

Nitric oxideCase reports only

Bronchiolitis: Antibiotics

Used for secondary bacterial infection

Traditionally risk of secondary infection with RSV thought to be low but theses studies based on children not admitted to PICU.

Recent studies: PCCM 2010Secondary pneumonia in patients in PICU with RSV

reported to be as high as 20-50%

If child is unwell enough to be admitted to PICU with bronchiolitis, cultures should be taken and antibiotics started

Levin et al PCCM 2010

Prospective study looking at patients admitted with RSV bronchiolitis with progressive respiratory failure

Excluded patients who had pre-existing conditions

Found 39% had probable pneumonia by tracheal aspirate

Concluded that due to high rate of possible secondary bacterial pneumonia, empirical antibiotics for 24-48 hrs pending cultures may be justified in those sick enough to come to PICU

Bronchiolitis- Ventilation

High Flow Nasal Prongs

CPAP

Mechanical Ventilation IPPVHFOVECMO

My Approach – to moderate-severe bronchiolitis

Suction and clear airway esp nasal passages

Application of oxygen with humidification if possible

Nil by mouth

IV cannula + 2/3 maintaince IVF

Obtain venous blood gas (BC + FBC/EUC at time of IVC)

Decide on level of respiratory supportHigh flow Nasal prong Cannula to 8L/min (not available

in ED)Bubble CPAP

OG or NG if on respiratory support

Constant reassessment, looking forDecreasing respiratory rateDecrease in work of breathingHeart rate improving

If not responding to above to be intubated and ventilated

If sick enough with bronchiolitis to need ventilatory support I do blood culture and sputum culture and cover with antibiotics.

Need to monitor Sodium

Pertussis

Pertussis - Pathology

Bordetella Pertussis

Toxin damages respiratory epithelium and can produce systemic toxicity

Severe, Prolonged Coughing

Aponea in young infants

Whoop- loud stridor on inspiration after a paroxysm

Pertussis- Severe Complications

Pneumonia

Pulmonary Hypertension

Encephalopathy

Seizures

Global Myocardial dysfunction

Pertussis

Mortality highest inVery young infantsWCC > 100 000Presenting with pneumoniaNeed for circulatory support

Indications for ICUApnoeasSeizure Severe respiratory failure

Pertussis - Investigations

PCR on NPA

CXR

WCC

ECHO if severe

Pertussis- Management

Suction

Oxygen

Respiratory supportHigh flow nasal o2CPAPVentilation

Antimicrobials Azithromycin

Pertussis- Other Management

If leukocytosis (esp neutrophilia)Exchange transfusions or aphaeresis to remove

white cellsWith high white cell count can get leukocyte

aggregates in pulmonary vessels

If Pulmonary Hypertension presentConsider inhaled nitric oxide or sildenafil

If Severe respiratory failureECMO

Treat contacts

PCCM 2007

Retrospective study from RCH Melbourne

Median age at admission was 6 weeks

94% of patients were unimmunised at time of admission

Infants presenting with pneumonia had raised white cell count

38% needing intubation died

All patients who needed ECMO died

Asthma

Asthma – Management

Oxygen

B-adrenergic agonists

Corticosteroids

Anticholinergic

Magnesium Sulphate

Theophylline/ Aminophylline

Inhalational anaesthetics

Asthma- Management

Helium-Oxygen

Non-invasive ventilation

Ventilation

Ketamine

Adrenaline

B-adrenergic agonists

Salbutamol first line bronchodilator of choice

MDI with spacer as effective as nebulisation

When giving nebulisation, continuous nebulization is superior to intermittent doses (Cochrane Review 2009)Provides sustained stimulation of B-receptorsPromotes progressive bronchodilatation Improves drug delivery in distal airway

IV salbutamol

Considered in patients unresponsive to treatment with continuous nebulisation.

RCT in children 2002: IV salbutamol as a bolus , atrovent or IV salbutamol

+atrovent In severe asthma, IV salbutamol as a bolus lead to

more rapid recovery

Ipratropium bromide

Leads to bronchodilatation by decreasing parasympathetic-mediated cholinergic bronchomotor tone

Cochrane review 2009:Adding multiple doses of anticholinergic to B2

agonists appears safe and improves lung function Would avoid hospital admission in 1 of 12 such

patients

No studies in critically ill children admitted to PICU

Because safe, considered reasonable to use

Magnesium Sulphate

Acts as calcium antagonist leading to smooth muscle relaxation

5 x RCT looking at IV magnesium in children 4 of these studies showed improvement in

respiratory function and decrease in hospital admissions

1 study showed no significant difference between magnesium and placebo group

2 x meta analysis that showed adding magnesium provided additional benefit to children

Methylxanthines

Theophylline and Aminophylline

Role is in severe asthma who have failed other treatment

Meta analysis of RCT in paeds found no benefit in mild or moderate asthma

RCT in 163 children with status asthmaticus Aminophylline improved oxygen sats and pulmonary

functionNo difference in length of stay