common respiratory problems in children common respiratory problems in children

Common Respiratory Problems

In Children

Common Respiratory Problems

In Children

4 months old 4 months old

One day history of One day history of excessive cryingexcessive crying

Sent home with the Sent home with the diagnosis of windy diagnosis of windy colic with anti-colic with anti-spasmodicsspasmodics

Next day:Next day:– Grunting, respiratory Grunting, respiratory

distress, fever.distress, fever.– Admitted ,oxygen, IV Admitted ,oxygen, IV

ceftriaxone.ceftriaxone.

Case 1:

Case (contd)Case (contd)

Second day:Second day:– Mother felt better but Mother felt better but

continues to be continues to be tachypnoeic, chest tachypnoeic, chest indrawing, fever indrawing, fever persisting.persisting.

– Vancomycin added Vancomycin added with oxygenwith oxygen

Case (contd)Case (contd)

Third dayThird day– Severe respiratory Severe respiratory

distressdistress– Pus drained through water Pus drained through water

seal drainageseal drainage– Antibiotics contd.Antibiotics contd.– Discharged after 2 wk.Discharged after 2 wk.

Strepto.pneumoniae isolated

16 month old boy with wheeze

Initial Vitals: HR 160 RR 60

BP 88/50Temp 38O2sat on RA 89%

Case 2

You do your pediatric triage

Appearance Crying, distressed, lookingaround, moving all 4 limbs

Breathing (work of) Laboured, chest caving in, +++indrawing

Circulation Colour OK, N cap refill

What would you like to do now?

Oxygen by mask applied, IV attempt started and pt now on cardiac monitor

Airway No stridor audible, no obvious secretions

Breathing +++ wheeze with little air entry bilat(inspiratory AND expiratory)

Circulation Warm extrem, PPP, cap refill 2 secs


Oxygen Salbutamol nebulizerIV Access established – orders?

CXR done / pending

ABG report

Venous Gas pH 7.35pCO2 38pO2 125

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of

35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%

History:

Has had a “cold” for almost 2 days now(mild fever, decreased energy / appetite with cough

and runny nose) Started getting wheezy this morning No history of exposure to allergens, inhalants

or FB aspiration

Family History of Asthma / no smokers / no petsOtherwise healthy with no known allergies

Continuous Salbutamol nebulizer for 15 mins has little effect

Still indrawing RR 65 Still alert and looking around, crying

Additional treatment?

IV steroids Methylprednisolone 1 mg/kg IV / IMContinue SalbutamolConsider racemic Epinephrine (0.5 mls)

Repeat Venous Gas about 30 mins laterpH 7.15pCO2 55pO2 120

Eyes rolling back, little crying now …

What do you want to do?

Drugs? Tube Size?

Ketamine 1-2 mg/kg IV Atropine 0.01 mg/kg IV (min 0.1 mg)Succinyl 1 mg/kg IV

4 – 4.5 tube



Other Options

IV Magnesium 25 mg/kg (max 2 gm)

IV Epinephrine

IV Salbutamol

Inhalational Anesthetics

Methylxanthines

Heli - Ox

Differential Diagnosis of Wheezing

H + N Vocal cord dysfunction

Chest AsthmaBronchiolitis Foreign Body Aspiration

CVS Congestive Heart FailureVascular Rings

Pediatric Asthma Guidelines

MILD• Nocturnal cough• Exertional SOB• Increased Salbutamol use • Good response to Salbutamol

O2 sat > 95%PEF > 75% (predicted / personal best)

± O2SalbutamolConsider po Steroids

Symptoms

Pre - Treat

Treatment

MODERATE• Normal mental status• Abbreviated speech• SOB at rest• Partial relief with Salbutamol and required > than q 4h

O2 sat 92%-95%PEF 50-75% (predicted / personal best)

O2 100%SalbutamolSystemic corticosteroidsConsider anticholinergic

Symptoms

Pre - Treat

Treatment

Pediatric Asthma Guidelines

Asthma Guidelines SEVERE• Altered mental status• Difficulty speaking• Laboured respirations• Persistant tachycardia• No prehospital relief with usual dose Salbutamol

O2 saturation <92%PEF, FEV1 <50%

100% O2Continuous or frequent b-agonistsSystemic corticosteroids & magnesium sulfateConsider anticholinergic & / or methylxanthines

Symptoms

Pre - Treat

Treatment

Asthma Guidelines

Symptoms

Pre - Treat

Treatment

NEAR DEATH• Exhausted , Confused• Diaphoretic• Cyanotic, Decreased respiratory effort, APNEA• Falling heart rate

O2 saturation <80% (spirometry not indicated)

As above PLUS

IV SalbutamolInhalational anesthetic, aminophyllineEpinephrine

18 mo Girl with 24 hr Hx of coughing with drooling

Hx: Has had an URTI for about a week and was getting mildly better until yesterday. She developed a fever and the cough got harsher.

Still drinking but not interested in solids

Vomited once last night

Started drooling this morning

CASE 3

T39.1 degrees rectally, P170, R28, BP 100/66

Appearance alert, awake, not toxic, in no acute distressDid not appear to prefer upright or a forward leaning position

EENT Moist MM, slight erythema of oropharynx, nasal crusting, N TMs, no rash / petechiae, no droolingSupple neck

Chest Clear when restingMild inspiratory stridor with crying

Rest of the exam N

Physical Exam

DDx?

• Croup• Epiglottitis• Bacterial tracheitis• RetroPharygeal abcess• Foreign Body aspiration

Other things on DDx of Inspiratory Stridor

Laryngeal WebTEFDiptheriaAirway thermal injurySubglottic stenosisPeritonsillar abcessGERDEsophageal FBLaryngeal fractureLaryngeal cystLymphoma

Soft tissue lateral neck radiograph

Lymph nodes between the posterior pharyngeal wall and the prevertebral fascia

• gone by 3 – 4 yrs of life• drain portions of the nasopharynx and the posterior

nasal passages• may become infected and progress to breakdown of the nodes and to suppuration

Retropharyngeal Abscess

ETIOLOGY

Complication of bacterial pharyngitisLess frequently - extension of infection from vertebral osteomyelitis

Group A hemolytic streptococci, oral anaerobes, and S. aureus

Recent or current history of an acute URTI

Abrupt onset:

High fever with difficulty in swallowing

Refusal of feeding

Severe distress with throat pain

Hyperextension of the head

Noisy, often gurgling respirations

Drooling

Typically …

Soft Tissue Neck Film

Patient position – MILD EXTENSION

Positive Film - Retropharyngeal soft tissue > ½ the width of the adjacent vertebral body - may see air in the retropharynx

On Exam …

Nasopharynx Bulging forward of the soft palate and nasal obstruction

Oropharynx Bulging of posterior phyaryngeal wallor

Not visualized

Complications

Abscess rupture - aspiration of pus.

Lateral extension - present externally on the side of the neck

Dissection along fascial planes into the mediastinum

Death may occur with aspiration, airway obstruction, erosion into major blood vessels, or mediastinitis.

Treatment

Ceftriaxone 75mg/kg/day/divided Q 12 hrlyClindamycin 20-30 mg/kg/day divided Q8H (if pre-fluctuant phase)

Decadron 0.6 mg/kg

Airway management

Surgical decompression

17 month old male with a one-hour history of noisy and abnormal breathing

Normal now but at the time, parents thought he was quite distressed.

Now, he is able to speak and drink fluids without difficulty

CASE 4

VS T36.8, P200 (crying), R28 (crying), O2 sat 99%

Alert with no signs of respiratory distressAble to speak, had no cyanosis, no drooling,

no dyspnea

H+N No obvious swelling, bleeding, FB seen

Chest Mild wheezing with ? mild inspiratory stridor

What would you like to do now???

Soft TissueNeck View

CXR (PA)

Next?

ExpiratoryCXR

Inspiratory View Expiratory View

Right DecubView

Foreign Body Aspiration

More common with food than toys

Highest risk between 1 and 3 years old(immature dentition – no molars, poor food control)

Common foods = peanuts, grapes, hard candies

Some foods swell with prolonged aspiration(may even sprout)

Clinical Manifestations

Typically …Acute respiratory distress (now resolved or ongoing)

Witnessed choking period

Uncommonly …Cyanosis and resp arrest

Symptoms: cough, gag, stridor, wheeze, drool, muffled voice

Investigations

Xrays Lateral neck Chest – inspiratory, expiratory, decubitus views

Expiratory views

Overinflation (partial obstruction with inspiratory flow)

Volume loss with mediastinal shift towards obstructed side (partial obstruction with expiratory flow)

Atelectasis (complete obstruction)

Decubitus views

Normal Smaller volumes and elevated diaphragmon side down

Abnormal Hyperinflation or “normal” volumes indecub position

If suspected …Need a bronchoscope to rule out or

remove Foreign Body

CASE 5

2 yo Boy with Barky Cough for 2 days

Runny nose, decreased appetite Not himself

No PMHx / FHx of significanceShots UTD

Other sibs with similar URTIs

Temp 38.9HR 140O2 sat 98% (drops to 90% when he crys)RR 40 (mild indrawing)

On Exam …

Irritable, crying, good colour

H & N sl erythema of throat, no pusN TMs, small cervical nodes

Chest Barky cough, inspiratory stridorNo wheeze noted

Diagnosis?

Racemic Epinephrine 0.5 ml dose

? Dexamethasone now or later

Re – Assess in 30 minutesNo improvement with 1st dose of epinephrine


IV Ceftriaxone PLUS Cloxacillin Consult Pediatric ICU / Pulmonary

for Bronch / Intubation

Re – ExamineOngoing Inspiratory StridorCries when trachea is examined

Bacterial tracheitis

An acute bacterial infection of the upper airway capable of causing life-threatening airway obstruction

Staph aureus most commonly (parainfluenza, Moraxella catarrhalis, H. influenzae, anearobes)

Most pts less than 3 years old

Usually follows an URTI (esp laryngotracheitis)

Mucosal swelling at the level of the cricoid cartilage, complicated by copious thick, purulent secretions

Brassy cough

High fever

“Toxicity" with respiratory distress (may occur immediately or after a few days of

apparent improvement)

Failed response to CROUP TREATMENT(mist, intravenous fluid, racemic epinephrine)

CLINICAL MANIFESTATIONS

Antibiotics (good Staph coverage)

Intubation or tracheostomy is usually necessary

? Decadron

Treatment

Pediatric Pneumonia

Neonate Bacteria more frequentE. coli, Grp B strep, Listeria, Kleb

1 – 3 mo Chlamydia trachomatis (unique)Commonly viral (RSV, etc.)B. Pertussis

1 – 24 mo S. pneumonia, Chlamydia pneumMycoplasma pneumonia

2 – 5 yrs RSVStrep pneumonia, Mycoplasma, Chlam

Severe Pneumonia:

Staph aureusStrep pneumoniaGrp. A strepHIBMycoplasma pneumonia

Pseudomonas if recently hospitalized

History:

Infants < 3 months Tachypnea, cough, retractions, grunting, isolated fever or hypothermia, vomiting, poor feeding, irritability, or lethargy

As age increases, symptoms are more specific

Fever and chills, headacheCough or wheezingChest pain, abdominal distress,

neck pain and stiffness

Physical Exam

Tachypnea is the best single indicator of pneumonia

Age in months Upper limit of Normal RR

< 2 60

2-12 50

> 12 40

Treatment

Neonates Ampicillin + Gentamycin / Cefotaxime

1 – 3 mo Erythromycin 10 mg/kg IV Q6H

1 – 24 mo Cefuroxime 50 mg/kg IV Q8H (not ICU)Ceftriaxone 50-75 mg/kg IV Q24H and Cloxacillin 50 mg/kg IV Q6H (ICU)

3 mo – 5 yrs Ceftriaxone / Erythro Clarithro / Azithro (outpt Tx)

Respiratory Failure in Respiratory Failure in ChildrenChildren

Respiratory failure: where is the Respiratory failure: where is the defect?defect?

Ventilation

DiffusionPerfusion

Abnormal oxygen carrying capacity

failure of cellular oxygen uptake

Types of Respiratory FailureTypes of Respiratory Failure

Type I failure, also Type I failure, also known as known as normocapnic or normocapnic or non-ventilatory non-ventilatory failure, is indicated failure, is indicated by hypoxemia (low by hypoxemia (low pO2 ) with a normal pO2 ) with a normal or low pCO2. or low pCO2.

It is commonly due to It is commonly due to ventilation/perfusion ventilation/perfusion (V/Q) abnormalities. (V/Q) abnormalities. Other causes include: Other causes include: impaired diffusion impaired diffusion across the alveolar-across the alveolar-capillary membrane capillary membrane (as occurs with (as occurs with pulmonary fibrosis pulmonary fibrosis and shunting) and shunting)

Type II failure:Type II failure:

An elevated pCO2 An elevated pCO2 is the hallmark , is the hallmark , also known as also known as ventilatory or ventilatory or hypercapnic hypercapnic failure. failure.

It is generally the It is generally the result of alveolar result of alveolar hypoventilation, hypoventilation, increased dead space increased dead space ventilation, or ventilation, or increased CO2 increased CO2 production. Other production. Other causes are factors causes are factors that impair the central that impair the central ventilatory drive in the ventilatory drive in the brainstem, restrict brainstem, restrict ventilation, or ventilation, or increase CO2 increase CO2 production.production.

Causes of Type I FailureCauses of Type I Failure

V/Q abnormaltitiesV/Q abnormaltities– Pneumonia, meconium Pneumonia, meconium

aspiraton, Pulmonary aspiraton, Pulmonary oedema.oedema.

Cyanotic heart Cyanotic heart diseasediseaseDiffusion Diffusion abnormalitiesabnormalities– Interstitial fibrosisInterstitial fibrosis

Inadequate systemic Inadequate systemic blood flowblood flow– ShockShock

Inadequate oxygen Inadequate oxygen carrying capacitycarrying capacity– Severe anemia, Severe anemia,

methhemoglobinemiamethhemoglobinemia

Inadequate cellular Inadequate cellular uptake:uptake:– Cyanide poisioningCyanide poisioning

Type II Failure: alveolar Type II Failure: alveolar hypoventialtionhypoventialtion

Neuromuscular:Neuromuscular:– CNS disease, GB CNS disease, GB

Syndrome.Syndrome.

Respiratory muscle Respiratory muscle disordersdisorders– Muscular dystrophyMuscular dystrophy

Chest wall / pleura:Chest wall / pleura:– Pliable chest, Pliable chest,

pneumothorax, pleural pneumothorax, pleural effusioneffusion

Airway disorders:Airway disorders:– Croup.Croup.

Pulmonary diseasePulmonary disease– Bronchiolitis, Bronchiolitis,

pneumonia, asthmapneumonia, asthma

Increased CO2 Increased CO2 production:production:– Sepsis, fever, burnSepsis, fever, burn

In children, respiratory failure most often is In children, respiratory failure most often is due to diseases of the lungs.due to diseases of the lungs.

CNS disorders that lead to respiratory CNS disorders that lead to respiratory failure are:failure are:

Control abnormalities that cause Type II Control abnormalities that cause Type II (hypercapnic) respiratory failure and (hypercapnic) respiratory failure and usually present without signs and usually present without signs and symptoms of respiratory distress (such as symptoms of respiratory distress (such as dyspnea, retractions, or tachypnea dyspnea, retractions, or tachypnea

A 16-year-old female arrives in the ED after A 16-year-old female arrives in the ED after the SLC result. No other history is available the SLC result. No other history is available because the friends who brought him to the because the friends who brought him to the ED left.ED left.

The vital signs are:The vital signs are:

Temperature (T) = 96°F; Temperature (T) = 96°F;

Pulse (P) = 90 beats/min; Pulse (P) = 90 beats/min;

Respiratory rate (R)Respiratory rate (R) = 6 breaths/min; = 6 breaths/min;

Blood pressure (BP) =120/80 mmHg; and Blood pressure (BP) =120/80 mmHg; and

Pulse oxygen saturation is 76% on room air. Pulse oxygen saturation is 76% on room air.

Arterial blood gas Arterial blood gas (ABG) is: pH = 7.13; (ABG) is: pH = 7.13; pO2 = 52; pCO2 = 81; pO2 = 52; pCO2 = 81; HCO3 = 26; and HCO3 = 26; and oxygen saturation = oxygen saturation = 75% on room air.75% on room air.

Glasgow coma scale: 4.Glasgow coma scale: 4.

Shallow respiration.Shallow respiration.

Pinpoint pupil.Pinpoint pupil.

Lungs and heart are Lungs and heart are normalnormal



ProblemProblem

This patient has hypercapnia and hypoxia.This patient has hypercapnia and hypoxia.

Of the physiologic events in respiration, Of the physiologic events in respiration, diffusion, transport, and the tissue/cellular diffusion, transport, and the tissue/cellular uptake of oxygen are normal, but uptake of oxygen are normal, but ventilation is impaired. ventilation is impaired.

Pin point pupil points to the poisoning Pin point pupil points to the poisoning probably narcotic drug.probably narcotic drug.

An 8-year-old male muscular An 8-year-old male muscular dystrophydystrophy

Eamination reveals Eamination reveals rhinorrhea and excessive rhinorrhea and excessive secretions in the secretions in the oropharynx. oropharynx. There are scattered There are scattered rhonchi in the lungs rhonchi in the lungs bilaterally. There is no bilaterally. There is no cyanosis. cyanosis. The neurologic exam is The neurologic exam is consistent with his consistent with his diagnosis of muscular diagnosis of muscular dystrophy with muscle dystrophy with muscle weakness weakness

His vital signs are:His vital signs are:T = 100.2°F; T = 100.2°F; P = 120 beats/min; P = 120 beats/min; R = 12 breaths/min; and R = 12 breaths/min; and BP = 100/70 mmHg; and BP = 100/70 mmHg; and Weight = 20 kg. Weight = 20 kg.

The ABG is: pH = 7.17; The ABG is: pH = 7.17; pO2 = 46; pCO2 = 78; pO2 = 46; pCO2 = 78; HCO3 = 32; and O2 HCO3 = 32; and O2 saturation = 71% on saturation = 71% on room air. room air.

This patient has Type This patient has Type II hypercapnic II hypercapnic respiratory failure respiratory failure secondary to failure of secondary to failure of the respiratory the respiratory muscles from a muscles from a primary muscle primary muscle disorder. disorder.



A 4-month-old female with A 4-month-old female with breathing difficulties.breathing difficulties.

Her vital signs are:Her vital signs are:T = 103.5° F; T = 103.5° F; P = 190 beats/min; P = 190 beats/min; R = 64 breaths/min; R = 64 breaths/min; BP = 80/50 mmHg; and BP = 80/50 mmHg; and Pulse oxygen saturation = Pulse oxygen saturation = 82% in room air82% in room air

Prematurity (30 weeks), Prematurity (30 weeks), respiratory distress respiratory distress syndrome requiring a syndrome requiring a ventilator. She also had a ventilator. She also had a congenital congenital gastrointestinal problem gastrointestinal problem requiring surgery at 6 requiring surgery at 6 weeks of age and has weeks of age and has continued to have continued to have gastrointestinal problems. gastrointestinal problems. She has She has bronchopulmonary bronchopulmonary dysplasiadysplasia

Small for her age. Small for her age. Respiratory distress with Respiratory distress with retractions, grunting, retractions, grunting, flaring, head nodding. flaring, head nodding. Skin is pale, sweaty, and Skin is pale, sweaty, and cyanotic with delayed cyanotic with delayed capillary fill. There are capillary fill. There are rales in both lung fields. rales in both lung fields. The chest roentgenogram The chest roentgenogram shows diffuse bilateral shows diffuse bilateral infiltrates.infiltrates.

The ABG on room air The ABG on room air is: pH = 7.61; pO2 = is: pH = 7.61; pO2 = 56; pCO2 = 24; HCO3 56; pCO2 = 24; HCO3 = 27; and oxygen = 27; and oxygen saturation is 78%.saturation is 78%.



A 2-month-old is brought to the ED with A 2-month-old is brought to the ED with a chief complaint of not eating for a chief complaint of not eating for

several days. several days.

Vital signs are:Vital signs are:

T = 36.8°C (R); T = 36.8°C (R);

P = 180 beats/min; P = 180 beats/min;

R = 58 breaths/min R = 58 breaths/min

BP = 55/30 mmHg; BP = 55/30 mmHg; and and

Pulse oxygen Pulse oxygen saturation is 78% on saturation is 78% on room air. room air.

O/E tachypnea, O/E tachypnea, retractions, and retractions, and cyanosis. The lungs cyanosis. The lungs are clear. The heart is are clear. The heart is tachycardic with no tachycardic with no murmurs. The liver murmurs. The liver edge is down 2 cm. edge is down 2 cm. The abdomen is non-The abdomen is non-tender. There is no tender. There is no edema and no rash. edema and no rash.

ABG drawn on 100% ABG drawn on 100% FiO2 shows FiO2 shows essentially no change essentially no change from the room air from the room air blood gas: pH = 7.48; blood gas: pH = 7.48; pO2 = 64; pCO2 = 35; pO2 = 64; pCO2 = 35; HCO3 = 23; and O2 HCO3 = 23; and O2 saturation is 79%. saturation is 79%.

An initial ABG An initial ABG reveals: pH = 7.48; reveals: pH = 7.48; pO2 = 62; pCO2 = 34; pO2 = 62; pCO2 = 34; and HCO3 = 23.and HCO3 = 23.



A 5-year-old male is seen for a cough of A 5-year-old male is seen for a cough of

several days duration that is not improvingseveral days duration that is not improving

O/E: sitting up and O/E: sitting up and leaning forward. leaning forward. wheezing bilaterally. wheezing bilaterally. Tachypnic with Tachypnic with intercostal retractions. intercostal retractions. Three continuous Three continuous salbutamol aerosols salbutamol aerosols were given by were given by nebuliser. nebuliser.

Vital signs are:Vital signs are:

T = 96.8°F (O); T = 96.8°F (O);


R = 44 breaths/min; R = 44 breaths/min; and and

Pulse oximetry is 94% Pulse oximetry is 94% on room air. on room air.

His lungs are clear, His lungs are clear, no wheeze or rales, no wheeze or rales, and no retractions. He and no retractions. He has dry mucous has dry mucous membranes and pale membranes and pale skin with tenting. skin with tenting.

Vital signs are now:Vital signs are now:

T = 96.8°F (O); T = 96.8°F (O);


R = 16 breaths/min; R = 16 breaths/min;

BP = 65/40 mmHg; BP = 65/40 mmHg; and and

Pulse oxygen Pulse oxygen saturation = 86% on saturation = 86% on room air. room air.

First ABG ; pH = 7.52; First ABG ; pH = 7.52; pO2 = 58; pCO2 = 24; pO2 = 58; pCO2 = 24; HCO3 = 14; and HCO3 = 14; and oxygen saturation = oxygen saturation = 88% on room air. 88% on room air.

The second ABG The second ABG shows: pH = 7.12; shows: pH = 7.12; pO2 = 68; pCO2 = 70; pO2 = 68; pCO2 = 70; HCO3 = 14; and HCO3 = 14; and oxygen saturation is oxygen saturation is 90% on 100% FiO2.90% on 100% FiO2.

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%

Treatment: Acute Respiratory FailureTreatment: Acute Respiratory Failure

Hypoxemia is more dangerous than hypercarbia.Hypoxemia is more dangerous than hypercarbia.

Administration of supplemental oxygenAdministration of supplemental oxygen

Ventilatory supportVentilatory support

Extracorporial Membrane Oxygenation (ECMO)Extracorporial Membrane Oxygenation (ECMO)

Never use bicarbonates unless lung can exhale Never use bicarbonates unless lung can exhale

common respiratory problems in children common respiratory problems in children

Documents

oxygen slide

treatment slide

mls slide

salbutamol o2

pneumoniae isolated

n cap refill slide

oxygen salbutamol nebulizer

options iv magnesium