pediatric respiratory emergency : upper
TRANSCRIPT
By Duangruethai Tunprom, MD. 3rd years emergency medical resident, PMK hospital
outline
Upper airway obstruction & infection Lower airway obstruction Disease of the lung
PALS in AHA 2010Management of Respiratory Emergencies
FlowchartManagement of Respiratory Emergencies Flowchart
Airway positioning, Oxygen, Pulse oximetry, ECG monitor(as indicated), BLS as indicated
Upper Airway ObstructionSpecific Management for Selected Conditions
Croup Anaphylaxis Aspiration Foreign Body
•Nebulized epinephrine•Corticosteroids
•IM epinephrine•Albuterol•Antihistamines•Corticosteroids
•Allow positio of comfort•Specialty consultation
Lower Airway ObstructionSpecific Management for Selected Conditions
Bronchiolitis Asthma
•Nasal suctioning•Bronchodilator trial
•Albuterol±ipratropium•Corticosteroids•Subcutaneous epinephrine
•Magnesium sulfate•Terbutaline
PALS in AHA 2010Management of Respiratory Emergencies
FlowchartManagement of Respiratory Emergencies Flowchart
Airway positioning, Oxygen, Pulse oximetry, ECG monitor(as indicated), BLS as indicated
Lung Tissue(Parenchymal)DiseaseSpecific Management for Selected Conditions
Pneumonia/pneumonitisInfection Chemical
Aspiration
Pulmonary EdemaCardiogenic or Noncardiogenic
(ARDS)
•Albuterol•Antibiotic(as indicated)
•Consider noninvasive or invasive ventilatory support with PEEP•Consider vasoactive support•Consider diureticDisordered Control of Breathing
Specific Management for Selected Conditions
Increased ICP Poisoning/Overdose Neuromuscular Disease
•Avoid hypoxemia•Avoid hypercarbia•Avoid hyperthermia
•Antidote(if avaiable)•Contact poison control
•Consider noninvasive or invasive ventilatory support
outline
Upper airway obstruction & infection Lower airway obstruction Disease of the lung
Upper airway obstruction & infection
Distingishing principles of disease Stridor Specific disorder
Supraglottic airway disease Subglottic tracheal diseases Disease of the trachea Aeroesophageal foreign bodies
Comparison of adult and pediatric airways
Comparison of adult and pediatric airways
Comparison of adult and pediatric airways
The airway is smaller The tongue is relatively larger The larynx is more cephalad in
position The epiglottis is short, narrow,
and angled away from the trachea
The vocal cords attach lower anteriorly
< 10 years of age, the narrowest portion of the airway is subglottic
Regions and associated pathology of pediatric upper airwaySupraglottic
•Craniofacial•Pierre Robin•Theacher Collins•Hallermann-streiff
•Macroglossia•Beckwith-Wiedemann•Down syndrome•Glycogen storage disease•Congenital hypothyroidism
•Choanal atresia•Encephalocele•Thyroglossal duct cyst•Lingual thyroid
Intrathoracic•Tracheomalacia•Tracheal stenosis•Vascular ring/sling•Mediastinal masses
Laryngeal•Laryngomalacia•Vocal cord paralysis•Congenital subglottic stenosis•Laryngeal web•Laryngeal cyst•Subglottic hemangioma•Laryngotracheoesophageal cleft
Cause of stridor
Feature Supraglottic Glottic Subglottic trachea
Sound Sonorous Biphasic stridor High pitched stridor
Gurgling Inspiratory stridor
Coarse
Expiratory stridor
Structures Nose Larynx Subglottic trachea
Pharynx Vocal cord
Epiglottis
Cause of stridorFeature Supraglottic Glottic Subglottic
trachea
Congenital
Micrognathia Laryngomalacia Subglottic stenosis
Pierre Robin syndrome
Vacal cord paralysis
Tracheomalacia
Treacher Collins syndrome
Laryngeal web Tracheal stenosis
Macroglossia Laryngocele Vascular ring
Down syndrome Hemangioma cyst
Storage disease
Choanal atresia
Lingual thyroid
Thyroglossal cyst
Acquired Adenopathy Papillomas Croup
Tonsillar hypertrophy Foreign body Bacterial tracheitis
Foreign body Subglottic stenosis
Pharyngeal abscess Foreign body
Epiglottitis
Infectious Non-infectious
Croup Epiglotitis Tracheitis Retropharyngeal
abscess
Symptoms at birth Laryngeal web Vocal cord paralysis Cystic hygroma Subglottic stenosis
Symptoms after neonatal period
Acquired
Infectious Non-infectious
Croup Epiglotitis Tracheitis Retropharyngeal
abscess
Symptoms at birth Symptoms after
neonatal period Subglottic hemangioma Laryngeal papilloma Laryngomalacia Tracheomalacia Vasular ring/sling
Acquired
Infectious Non-infectious
Croup Epiglotitis Tracheitis Retropharyngeal
abscess
Symptoms at birth Symptoms after neonatal
period Acquired
FB aspiration or ingestion Laryngospasm Psychogenic stridor Angioedema Paratracheal mass
(teratoma,lymphoma)
Vocal cord paralysis or subglottic stenosis (secondary to intubation)
Important item of history Onset & duration Asssociation symptom Progression with age Exacerbation Feeding pattern Airway procedure Choking episode Baseline noises, quality of cry and
voice
Comparison of infectious upper airway emergencies
Average age
Common etiology medication
Croup 6 mo-6 yrs Parainfluenzae Dexa ±racemic epinephrine
Bacterial tracheitis
4-6 yrs S.aueus Antibiotic IV
Retropharyngeal abscess
3 yrs GABHS, S.aueus,anaerobe
Antibiotic IV
Peritonsillar abscess
Adolescence GABHS Antibiotic PO & IV
Epiglottitis 2-8 yrs H.influenzae,Staphylococi,Streptococus
species
Antibiotic IV
Comparison of Croup,Epiglottitis & Bacterial
Tracheitis
Croup Epiglotitis Bacterial trachea
Peak age 6 mo-3 years 3-7 years 3-5 years
Pathogen Subglottic inflammation
Inflammation & edema epiglottis, aryepiglottic folds
Bacterial superinfection with inflammation of tracheal mucosa, copious mucopurulent secretion obstructing the trachea
Organism Parainflueazae, RSV,adenovirus
Haemophilus influenzae, Strep sp, Staphylococcus aureus
Staphyloccus aureus or mixed flora
Clinical Feature
Onset follow URI prodrome consisting of croupy cough, hoarse voice, low grade fever, inspiratory stridor
Rapid progression of high fever, toxicity, drooling, stridor
Several-day prodome of crouplike illness progressing to toxicity, inspiratory/expiratory stridor, marked distress
Lab & film Steeple sign on film neck PA veiw or normal
Thumbprint sign on lateral aspect of neck, thickened aryepiglottic folds,loss of air in varecula
Normal upper airway structures, shaggy tracheal air column
Management Steriod uncommonAerosolized epinephrine
Intubation, abtibiotics Intubation (70 %) antibiotics rare
Supraglottic airway disease Congenital
Choanal atresia Macroglossia Mic
Retropharyngeal abscess epiglottitis
Choanal atresia M/C congenotal anomaly of nose Bilateral choanal atresia life
threatening emergency Acute distress &cyanotic at birth Increase secretion &swellingasso with
URI exacerbation
Macroglossia
Beckwith-wiedemann syndrome
Micrognathia
Treacher Collins syndrome
Retropharyngeal abscess
Potential life threatening airway emergency
Retropharyngel space : Potential space between posterior
pharyngeal wall & prevertrebral fascia extend from base of skull to level of T2
Result from Direct trauma Suppuration of LN Hematogenous spread
Retropharyngeal abscess (cont.) Child < 3 years Polymicrobial with streptococcus &
anaerobe Variable manifestrations Fever, sorethroat, neck stiffness,
torticollis, trimus, stridor, muffled voice Complication
Meningitis, sepsis, aspiration pneumonia, mediastinitis, empyema
Need ± to intubation, ± surgical drainage
Film lateral neck : show retropharyngeal abscess
Retropharyngeal abscess (cont.)
Epiglottitis
Most fear ped emergency Previous Haemophilus influenzae Since HIB vaccine drop incidence epiglotitis 10.9
8/10000 m/c GABHS, S. aureus, Streptococcus pneumoniae Classic :acute onset, rapid progression, sniffing,
tripod position,drooling
Tripod position of epiglotitis
Normal epiglottis contrasted with thickness
epiglottis
Thumbprint sign
Disease of larynx
Laryngomalacia m/c chronic stridor in chronic stridor
in infants
Vocal cord paralysis
Laryngeal web
Laryngeal papiloma
Subglottic tracheal diseases Subglottic stenosis Subglottic hemangioma
Viral croup
m/c cause of upper airway distress 6 m0 – 6 years Peak 2 years Parainfluenza virus type 1 50 % Clinical diagnosis
Croup score
Viral croup Westley Croup Scoring System Mild ≤ 2
Moderate 3- 7
Severe≥ 8
Viral croup Downes croup score
Mild < 4 Moderate
4- 7 Severe > 7
CPG croup ชมรมโรคระบบหายใจและเวชบ�าบ�ดว�กฤตในเด�กแห�งประเทศไทย
ราชว�ทยาก!มารแพทย#แห�งประเทศไทย
Rebound phenomenon of epinephrine 1- 2 hours
Croup: Indication for admission Severe respiratory distress of failure Unusual symptoms
(hypoxia,hyperpyrexia) Dehydration Persistence of stridor at rest after
aerosolized epinephrine and steroids Persistence of tachycardia,tachypnea Complex past medical history
(prematurity, pulmonary, cardiac disease)
Viral croup (cont.)
Treatment
Dexa 0.6 mg/kg IM •ลด ETT 11 % 1%•ลด ICU days 129 21 days
Higher Dexa (> 0.3 mg/kg) more effective
Budesonide 2 mg via NB•Shorten ED stay•ลด rate of hospitalization
Prefer Racemic epinephrine : less cardiovascular S/E than L-epinephrine
Epinephrine (1:1000) MAX 2.5 ml in age < 4 yrs 5 ml in age ≥ 4 yrsStudies comparing L-epinephrine with racemic epinephrine
show no significant difference in response
CXR AP : showing Croup
Spasmodic croup feature
Overlap viral croup Sudden onset of severe stridor Barky cough without a viral prodrome
Associated with Allergy GERD Hypersensitivity reaction on later exposure to
the virus
Disease of Trachea
Tracheaomalacia Tracheal stenosis Vascular ring
Bacterial tracheitis
Overlap symptom both croup & epiglottitis WBC normal or slightly increase H/C usually normal Investigation
Plain x-ray Bronchoscope
Complication Toxic shock syndrome Septic shock Postintubation pulmonary edema ARDS
Subglottic narrowing
Hazy density within the tracheal lumen
Ragged edge of the usually smooth tracheal air column
Aeroesophageal obstruction Asphyxia : m/c cause of death of FB
aspiration Major of cases & death in toddlers <
3 years FB : round-shaped difficult to
manage
Airway FB obstruction management Visualize remove No finger sweep Infant
5 back blow follow 5 chest thrusts Child
Conscious Heimlich maneuver Unconscious Chest compression
If cyannose & cannot ventilate & cannot intubation Consider needle cricothyrotomy
Croup Epiglotitis Bacterial trachea
Peak age 6 mo-3 years 3-7 years 3-5 years
Pathogen Subglottic inflammation
Inflammation & edema epiglottis, aryepiglottic folds
Bacterial superinfection with inflammation of tracheal mucosa, copious mucopurulent secretion obstructing the trachea
Organism Parainflueazae, RSV,adenovirus
Haemophilus influenzae, Strep sp, Staphylococcus aureus
Staphyloccus aureus or mixed flora
Clinical Feature
Onset follow URI prodrome consisting of croupy cough, hoarse voice, low grade fever, inspiratory stridor
Rapid progression of high fever, toxicity, drooling, stridor
Several-day prodome of crouplike illness progressing to toxicity, inspiratory/expiratory stridor, marked distress
Lab & film Steeple sign on film neck PA veiw or normal
Thumbprint sign on lateral aspect of neck, thickened aryepiglottic folds, loss of air in varecula
Normal upper airway structures, shaggy tracheal air column
Management Steriod uncommonAerosolized epinephrine
Intubation, abtibiotics Intubation (70 %) antibiotics rare
Pedriatric Dosing For Antibiotics In Upper Airway Infections
PO Dose
Amoxicillin/clavulanic acid
90 mg/kg/d divided BID (max 875 mg/dose)
Clindamycin 25 mg/kg/d divided BID(max450 mg/dose)
IV Dose
Amoxicillin/clavulanic acid
100 mg/kg/d divided Q 6 hrs (max 8 g/d)
Clindamycin 40 mg/kg/d divided Q 8 hrs (max 2.7 g/d)
Cefotaxime 120 mg/kg/d divided Q 8 hrs (max 2g Q 8 hrs)
Ceftriaxone 50 mg/kg/d Q 24 hrs (max 2 g/d)
Vancomycin 10 mg/kg Q 6 hrs (max 2 g/d)
Oxacillin 150 mg/kg/d divided Q 6 hrs (max 8 g/d)
Dose from children’ hospital of Philadelphia formulary (Pharmacy handbook formulary, Lexi-Comp)
Thank you
http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=128&seg_id=2677
Rosen 7th ed emergency medicine Tintinalli 7th ed emergency medicine