Peds Respiratory Emergencies

Adam DavidsonAdam OsterMay 7, 2009

Thank You’s

Nicole KirkpatrickAdam Oster

Outline

AnatomyABC’sUpper Airway EmergenciesLower Airway Emergencies

Anatomy

Prominent Occiput-can cause head flexion Usually no need to place pillow/towel Head extension should put in sniffing position

Tongue is disproportionally large compared to mouth

Larynx is higher in neck (C3-C4 vs C4-C5 in adults)Anterior larynxLarge/Floppy epiglottis (choice of laryngoscope

blade?)Narrowest portion is at cricoid

Resuscitation

AirwayLook: alert?, protecting?, cyanotic?

Foreign body?Listen: stidor, gurgling, crying,

talkingManage: sit pt up, oxygen, OPA/NPA,

finger sweep, jaw thrust, prepare to intubate

Resuscitation

BreathingLook: rate, indrawing, accessory muscles,

nasal flare, cyanosisListen: stridor, wheeze, crackles, AE bilat,

quiet, able to speak in sentencesManage: O2, meds, bag mask, intubationMeds: Ventolin, Atrovent, Mg, Epi, Steroids,

Abx, Lasix

Nasal flaring and chest retractions more sensitive than tachypnea for resp distress

Resuscitation

CirculationLook: pale, lethargic, diaphoretic, mottled,

LOCListen: heart sounds, murmursFeel: pulses, pulsus paradoxus, cap refillManage: fluid if no signs CHF, PALS

Adjuncts: CXR, ABG/Cap Gas, ECG, Bloodwork, Soft-tissue films

Cap Gas versus ABG’s

Excellent approximations of pH and CO2Are accurate for detecting hypoxemia but

correlation falls off as PaO2 values riseErrors occur with false +ves, therefore good screenMore blood flow to area, more accurate the readingMake sure to warm area to increase vasodilation

Resuscitation

RSIPre-OxygenationPre-treatment:

Atropine: 0.02mg/kg (Minimum Dose?, Why?) Lidocaine: 1.5 mg/kg

Induction: Ketamine: 1.5-2mg/kg

Paralysis: Succinycholine: 2mg/kg

Physical Exam

StridorHallmark of URT obstructionInspiratory: usually supraglottic, associated

with collapse due to negative pressure Associated with: drooling, hot-potato voice Eg: abscess, croup, epiglottitis

Biphasic: usually fixed obstruction at glottis Eg: laryngeal webs, vocal cord paralysis

Expiratory: usually sub-glottic, associated with positive pressure of expiration Eg: Tracheitis, foreign body

Physical Exam

Grunting LRT pathology Forced expiration creating auto-PEEP Presence usually represents significant distress

Wheeze LRT pathology Asthma, Bronchiolitis, Cardiac, Pneumonia

Location

Upper AirwayLower AirwaysCardiac

CHF: congenital, myocarditis, cardiomyopathy PE Tamponade

Neurologic SAH, Shaken Baby, meningitis, opiates, anxiety

Metabolic DKA CO poisoning, Methemoglobinemia, Hydrogen Sulphide

THE UPPER AIRWAY

Pediatric Respiratory Emergencies

Partial DifferentialForeign bodyEpiglottitisCroupTonsillitisAbscess (retro/parapharyngeal, peritonsillar)AnaphylaxisAngioedemaBurnsCaustic IngestionCongenital AbnormalityBacterial Tracheitis

13 year old female with fever and sore throat

Recurrent “Strep throat”

Can barely talk, hasn’t been able to eat or drink for 24hrs

Peritonsillar Abscess (Quinsy)

Risk Factors: chronic tonsillitis, mono, CLL, dental infection, older age

Odynophagia, dysphagia, drooling, hot-potato voice, rancid breath, fever, malaise, dehydration

Uvular deviation and trismus most specific for abscess

Abscess vs Cellulitis: aspiration of pusMay need sedation but needle less painful than

I+DCut plastic needle cover to form guardNo cases in literature of carotid puncture

Peritonsillar Abscess

Needle aspiration shown to be as efficacious as I+DCan be performed in EDAdmit: septic, dehydrated and not able to drink,

unreliable follow-up, unable to aspirateIf able to tolerate PO fluids, can give dose of IV Abx

and f/u with HPTPAbx: Clinda (usually 1st choice), Ancef/FlagylSteroids: very few studies exist with conflicting

data Practice seems to vary between ENT surgeons No evidence of harm

Steroids For Phayngeal Swelling

Some ENT surgeons swear by giving steroids to reduce edema/swelling in the pharynx

Common practice for mono and peritonsillar abscessCochrane Review 2009 for steroids with mono

Symptomatic Relief for 12 hours only No difference in complete resolution or length of disease

No evidence for peritsonsillar abscess, retropharyngeal abscess

Consider for patients with acute airway obstruction or those who can’t tolerate PO fluids (Dex 10mg IV)

Dickens, KP, et al. Should you use steroids to treat infectious mononucleosis? The Journal of Family Practice, 2008

Retropharyngeal Abscess

More common in young children (Age: 6m-3yr)Post URTI or secondary to FB trauma

(toothbrush, popsicle stick, etc)Toxic, febrile, drooling, stridor, dysphagia,

opisthotonos (can look like meningitis)Px: bulgling posterior pharyngeal wallSoft tissue films: large retropharyngeal space

(>1/2 width of vertebral body), retropharyngeal air False +ve: expiration film, neck flexion

Treatment: IV Clinda, IV Dex, generally admitted to PICU for monitoring with ENT consult

Croup (Laryngotracheobronchitis)Most common cause of stridor for ages 6m-

3yrCauses: always viral

Parainfluenza (MCC), Influenza, Adenovirus, RSVUsually benign and self-limited

severe disease more common in malesPeaks in fall/winterURTI with 3-4d hx of worsening cough

Barky cough, stridor, sx usually worse at nightStridor worse with anxiety (ie: in ED)Usually non-toxic with low-grade feverHypoxia is a rare and late sign

Clinical Croup Score

Insp Breath Sounds: Normal (o), Harsh (1), Delayed (2)

Stridor: None (0), Inspiratory (1), Expiratory (2)

Cough: None (0), Hoarse Cry (1), Bark (2)

Retractions/Flaring: None (0), Suprasternal (1), Sub/intercostal (2)

Cyanosis: None (0), Room Air (1), 40% O2 (2)

Mild: <4 Mod: 4-6 Severe: >6

Croup Treatment

Intubation: usually can be avoided with aggressive Tx (if necessary, use ETT 1 size smaller than expected)Steroids: Dex 0.6mg/kg (max 10-20mg?) PO/IM/IV

Good evidence for moderate, severe croup Decr admission, intubation, return to ED, croup scores NEJM 2004 showed benefit in mild croup as well No side-effects, One dose lasts 48 hrs

Nebulized Epi: 1:1000 Epi (L isomer only) just as good as racemic Nebulize 5ml q2-3hr for maximum of 3 doses (back to back if

impending intubation) Good evidence for severe croup Contraindications: mechanical cardiac outflow obstructin (AS,

ToF) Complications: MI, V-tach

Steroids and Croup

Dex shown to be superior to PrednisoloneSingle dose of 0.15mg/kg equivalent to 0.3 and 0.6

Croup Disposition

Mild Dex PO and D/C home

Moderate Dex PO and observe for 3-4hrs before D/C

Severe Dex (IV/IM) and Epi, observe for 4-6hrs before D/C

Admission Co-morbidities, social situation, complicated airway or

previous difficult intubation, dehydrationDischarge Instructions

Cool air, popsicles, humidity?, F/U with GP in 24-48hrs

Bacterial Tracheitis

Sub-glottic bacterial infectionCan occur at any age, males = females, no

seasonal preferencePolymicrobial bacterial superinfection

following Croup (primary infection less common)

Staph (50%), Strep, H flu, MoraxellaBacterial invasion with copious mucous

secretionsAirway obstruction secondary to mucous

Bacterial Tracheitis

Patient with barky cough and low-grade fever suddenly develops high fever and toxic appearance

More respiratory distress than CroupCan appear like Epiglottitis with fever,

drooling, resp distressConsider if:

Toxic looking Croup Croup lasting >4 days Croup not responding to treatment

Bacterial TracheitisDiagnosis

Soft Tissue Films: “shaggy” irregular tracheal wall with intraluminal membrane, steeple sign

Dx: laryngobronchoscopy shows normal epiglottis w/ +++ secretions

Complications Airway obstruction, ETT plugging (common, consider

Trach) Sepsis, DIC, Toxic Shock from Staph

Bacterial Tracheitis Management

Airway management best done in OR with Anesthesia consult

IV Abx: Cefotaxime/ClindamycinICU Admission post ORDaily bronchoscopy to remove secretionsConsider Trach if persistant ETT pluggingNo benefit to steroids or nebulized epi

THE LOWER AIRWAYSPediatric Respiratory Emergencies

Case 1

2M male3 day history of URTI associated with fever

(38.5)Onset of difficulty feeding, increased WOB

todayVitals - HR 160 RR 65 SpO2 90% on R/A T

37.9TT, indrawing, nasal flaring, diffuse crackles

and wheezes

Differential diagnosis of Wheeze

Infection (Bronchiolitis, pneumonia) Asthma Cystic Fibrosis CHF Foreign body Anaphylaxis Croup Epiglottis Vocal cord dysfunction GERD Bronchopulmonary dysplasia

You think he has bronchiolitis

What do you tell his parents about his illness and its natural history?

Bronchiolitis

Viral infection RSV, influenza, parainfluenza, echovirus,

rhinovirus, adenovirus Mycoplasm, Chlamydia

Children < 2 years, peak at 2 MOctober to MayContact/DropletPeak at 3-5 dResolves 2 weeks

Bronchiolitis

Inflammation of terminal and respiratory bronchioles Mucus plug + edema Airway narrowing Decrease compliance, increase resistance Atelectasis and overdistention

Bronchiolitis

Clinical presentation Wheeze, tachypnea, indrawing URT symptoms Fever Hypoxemia Apnea

What factors put children at increased risk of severe bronchiolitis?

History of Prematurity BPD CF Congenital heart disease Immunocompromised

Management

You start oxygen and encourage feedingWhen patient not feeding well you give 20

mL/kg bolusRT asks you if you want this child to be

treated with bronchodilators or steroids…What do you think?

Controversial

Many trials done to examine use of Epinephrine ß-adrenergics Steroids

IV PO Inhaled

Evidence for Epinephrine

Epinephrine vs. placebo or salbutamol5/8 showed short term improvement in

clinical scores1/8 showed fewer hospitalization1/8 showed shorter duration of

hospitalization

Evidence for Epinephrine

Hartling et al, 2003 Meta-analysis Epinephrine vs. bronchodilators or placebo RCT, infants<2 years, quantitative outcome 14 studies, 7 inpatient, 6 outpatient, 1 unknown Outpatient results

Epi better than placebo or other bronchodilators in short term (O2 saturation, RR, clinical score)

Evidence for Epinephrine

Cochrane Systematic Review14 RCT (1966-2003)Inpatient and outpatient treatmentEpinephrine vs. placebo - outpatient (3)

Improvement at 60 minutes (1/3studies) No difference in admission or O2 saturation

Epinephrine vs. Salbutamol - outpatient (4) O2 saturation, HR, RR improved at 60 minutes No difference in admission

13 RCT Bronchodilators vs. placebo or

ipatropium1/13 showed decreased admission4/13 showed some clinical improvement

Evidence for Bronchodilators

Evidence for Bronchodilators

Cochrane Systematic Review22 RCT (1966-2005)Bronchodilators vs. placeboNo difference in admission or duration of

hospitalizationMinor improvement in oximetry and

symptoms in outpatient treatment

Previous studies used larger doses of epinephrine Effect may not be due to alpha affects, but higher

delivery of ß-agonist

RCT comparing racemic epinephrine, racemic albuterol, normal saline in equivalent doses in mild/moderate bronchiolitis

N = 65 (23-albuterol, 17 epi, 25 NS)5mg of drug in 3 mL at 0 and 30 minutesClinical assessment pre and post3 rd dose at 60 minutes if RDAI >8 or O2

saturation < 90% R/AFinal assessment at either 60 or 90 minutes

Required admission/home oxygen 61% albuterol, 59% epinephrine, 64% NS

No difference in admission ratesNo difference in O2 saturation, RRß-agonist not useful in Rx bronchiolitis

“ß-agonists should not be used routinely in management of bronchiolitis” Level B

“A carefully monitored trial of alpha adrenergic or ß-adrenergic medications is an option…and continued only if there is a documented positive clinical response using objective means of evaluation” Level B

“…it would be more appropriate that a bronchodilator trial…use salbutamol rather than racemic epinephrine”

What about steroids?

Systematic reviewOral, IV and inhaled steroidsOral

6 RCT involving prednisone (1) prednisolone (2) Dexamethasone (2) Prednisolone and albuterol vs. Placebo and albuterol

Various outcomes (hospitalization, clinical score, length of stay, duration of ventilation)

1 found decreased rate of admission, 1 found increased rate of admission,1 found shorter duration of ventilation, 1 found improved clinical status

Felt data was inconclusive

IV 2 RCT Dexamethasone to placebo No benefit

Clinical score, admission, time to resolution, duration of oxygen therapy

Inhaled 6 RCT Mostly used budesonide Worse wheeze/cough at 12 months in 1 Increase readmission No benefit shown

Cochrance Systematic Review13 RCT No difference

RR O2 saturation Admission Length of stay Subsequent visits Readmission

Evidence for Steroids

RCT Comparing admission to hospital and RACS 4

hours after dose of dexamethasone (1mg/kg) versus placebo

January 2004 - April 2006N = 600 (305 dexamethasone, 295 placebo)Admission

39.7% in dex vs. 41% in placebo - no differenceRACS - sum of change in RDAI minus standardized

score for change in RR (negative value = good response) No difference

“Corticosteroid medications should not be used routinely in the management of bronchiolitis” Level B

Palivizumab

Humanized, mouse monoclonal anti-RSV antibody

Monthly X 5 months, 15 mg/kg IM Prevention of serious RSV lower

respiratory tract infection Children < 2 years Chronic lung disease of prematurity Premature ≤ 32 weeks Hemodynamically significant cyanotic or

acyanotic congenital heart disease

Any novel treatments?

Hypertonic saline

Mechanism incompletely understood Osmotic hydration Reduction of cross-linking Edema reduction

RCT, multicentre comparing length of stay in admitted patients receiving treatment with 3% HS vs. NS

N=93 (47 - HS, 49 - NS)Doses q 2h X3, q4h X5, q6h until D/CAny other treatments mixed with

appropriate solution

Length of stay HS 2.6 days +/- 1.9 days NS 3.5 days +/- 2.9 days 26% reduction in LOS P = 0.05

RCT comparing epinephrine 1.5 mg in 4 mL NS vs. epinephrine 1.5 mg in 4 mL of HS

N = 53 (25 NS, 27 HS)Length of stay, change in clinical severityNS 4 +/- 1.9, HS 3 +/- 1.2, p < 0.05

Case 3

6 yo M with PMH of asthmaURTI X4 days, using blue pufferIncrease WOB todayHR 130, RR 35, 90% on R/AIndrawing, Audible wheezeDecreased breath sounds to RWheeze

How do you want to treat this child?

Evidence for Anti-cholinergics

NEJM 1998RDBCTAlbuterol vs. albuterol+ IB x 2 doseN=434 (2-18 years)IB

Decreased hospitalization (27 vs 36%, p = 0.05) Similar hospitalization rates in moderate exacerbation Markedly different rates in severe exacerbations

Evidence for Anti-cholinergics

32 studies, 16 pediatric10 studies - admission (1786 children)

Lower admission rate NNT =13, 7 if only severe exacerbations included

9 studies - spirometry 1 or 2 doses had FEV1 difference of 12.4% >2 doses had FEV1 difference of 16.3%

Evidence for Anti-cholinergics

Cochrane Systematic Review 2000 13 trialsMultiple doses decreased risk of admission

by 25%Single doses improved lung function at 60

and 120 minutes, but no admissionNNT= 12 to avoid 1 admission in kids with

either moderate or severe exacerbationNNT = 7 if severe exacerbations

Nebulizer vs. MDI/Spacer

RDBCT N = 168 (2m to 24 months) Nebulizer vs. Spacer Primary outcome

Admission rates Results

Controlled for difference in baseline Spacer group admitted less

5% vs. 20% p=0.05

Nebulizer vs. MDI/Spacer

RDBCT N=90 (5 -17 years) baseline FEV1 50-79% Treatment groups

6-10 puffs 2 puffs 0.15mg/kg nebulized

Primary outcome Improvement in % predicted FEV1

Results No significant difference in % predicted FEV1 between groups

Nebulizer or MDI/Spacer

Cochrane Systematic Review 2006 Beta agonist via wet nebulizer vs. spacer 25 outpatient trials N = 2066 children, 614 adultsMDI+spacer was equivalent to wet nebulizer

wrt hospital admission ratesMDI+spacer in kids

Decreased length of stay in ED

Continuous vs. Intermittent

Cochrane Systematic Review 2003 Continuous or near continuous (q 15 minutes

or >4 treatments/h) vs. intermittent nebulization

Continuous beneficial Decreased admission Most pronounced if severe exacerbation

Evidence for use of steroids

Cochrane Systematic Review 2001 Benefit of treatment within 1 hour of ED

presentation12 trialsN = 863Reduced admission rates, NNT = 8Most benefit

Not currently Rx with steroids Severe exacerbation

Oral steroids worked well for kids

Evidence for MgSO4

5 trialsIV MgSO4 at any dose vs. placebo in

patients < 18 y treated with beta-agonists and steroids

MgSO4 reduced hospitalizationNNT=4 for avoiding hospitalization

Evidence for MgSO4

Cochrane Systematic Review7 trials (5 adult, 2 pediatric)N= 665In severe subgroup

Improved PEFR, FEV1, admission rates Improvements not seen if all patients included

Evidence for MgSO4

Cochrane Systematic Review 2005 Inhaled MgSO46 trialsN=296 (2 pediatric)Heterogenous studies therefore difficult to

make definitive conclusionMgSO4 with beta-agonists showed benefit

Pulmonary function Admission rates In severe exacerbations

Evidence for IV Salbutamol

Cochrane Systematic Review 2001 IV salbutamol in addition to other Rx vs.

placebo15 trialsN=584No benefit

Pulmonary function Arterial gases Vital signs AE Clinical success

Other treatments

HelioxNIPPV

Case 3

5 M MaleCough, fever, decreased energy and intakeTachypnea, increased wobSpO2 90% on R/A, RR 60Crackles in RLLCXR

Consolidation in RLL

Epidemiology

4% of kids/y in U.S. Decreases with increasing age

< 2 years – 80% viral> 4 years – 40% viral

Clinical features

Cough, fever, CP, tachypnea, grunting (infants), increased wob (indrawing, seesaw)

Typical presentation - bacterial Rapid onset Fever, chills, chest pain, cough

Atypical presentation – viral Gradual onset Malaise, h/a, cough, fever (low-grade)

Significant overlap

Pneumonia bugs

Specific bugs

B. pertussis3 stages

Catarrhal phase• Coryza, cough lasting 1-2 weeks

Paroxysmal phase• Coughing fits associated with gagging, cyanosis• Whoop is uncommon in infants• Lasts ~ 4 weeks

Recovery• Cough improves over months

Treatment

Specific bugs

S. aureus Rapid and severe

C. trachomatis 50% of exposed will get conjunctivitis 5-20% pneumonia 2-19 weeks Rarely febrile or systemically unwell Staccatto cough

CXR in ambulatory setting

N = 522 (2M to 59M) Randomized to CXR or no CXR Primary outcome Results

Median 7 days to recovery in both groups CXR group

More diagnosed with pneumonia 60% vs. 52% treated with antibiotics More follow-up appts. No difference in consultation, admission, repeat CXR at 28 days

CXR

Bacterial Lobar or segmental consolidation

Viral and atypical bacterial Interstitial infiltrates Peribronchial thickening Atelectasis

Significant overlap Not useful in determining etiological agent

CXR

May want to avoid in mild acute LRTIUse if <5 and if fever >39 or toxic

Admission

SpO2<90-93%Young ageToxicImmunocompromisedRR>70 (infant), >50 (older children)Respiratory distressApnea/gruntingNot feeding or dehydratedSocial concerns