RESPIRATORY EMERGENCIES

Moh supriatna TS

PICU RS Dr.Kariadi/FK UNDIPSEMARANG

INTRODUCTION

Respiratory disease is the most frequent medical emergency in out hospital pediatrics asthma bronchial is the most common

Several important physical sign and symptom can help distinguish respiratory distress from respiratory failure.

Using the PAT is an important first step in determining the severity of the disease & beginning treatment.

Good assessment and care are important for the pre hospital professional (by early intervention).

DEFINITIONSRespiratory distress abnormal physiologic condition increased WOB effectively compensating.Respiratory failure exhaust the energy reserves begin to decompensate.Respiratory arrest absence of effective breathing rapidly progress to full cardiopulmonary arrest low probability of survival.

EVALUATING THE PRESENTING COMPLAINTKey Question :Has your child ever had this kind of problem before ?Is your child taking any medications ?Has your child had a fever?

Did your child suddenly start coughing / chocking / gagging ?Has your child had an injury to this chest ?Possible Medical problem :Asthma, chronic lung disease. Asthma, chronic lung disease, congenital heart disease.Pneumonic, bronchiolitis, croup.Foreign body aspiration or ingestion.Pulmonary contusion, pneumothorax.

ASSESSMENT OF RESPIRATORY STATUS

THE PEDIATRIC ASSESSMENT TRIANGLE ( P.A.T)

appearance work of breathing

circulation to skin

These parts of the general impression will determine weather the child is in respiratory distress or in respiratory failure.

APPEARANCE

Characteristic of Appearance:The tickles(TICLS) Mnemonic

Characteristic Features to look for.Tone Is she moving or resisting examination vigorously ? Does she have good muscle tone.Interactiveness How alert is she? How readily does a person, object, or sound distract her or draw her attention? Will she reach for, grasp, and play with a toy or exam instrument, like a pen light or tongue blade? Or is she uninterested in playing or interacting with the caregiver or pre hospital professional?Consolability Can she be consoled or comforted by the caregiver or by the pre hospital professional?Look / Gaze Does she fix her gaze on a face ? Or is there a nobody home glassy-eyed state.Speech / Cry Is her speech or cry strong and spontaneous? Or is it weak, muffled, or hoarse.

WORK OF BREATHING (WOB)

Characteristic of Work of Breathing

CharacteristicFeatures to look forAbnormal airway Snoring, muffled or hoarse speech, stridor, sounds grunting, wheezing.Abnormal positioningSniffing position, tripoding, refusing to lie down.RetractionsSupraclavicular, intercostal, or substernal retractions of chest wall, head bobbing in infants.Flaring Nasal flaring

These indications of breathing effort will help identify :1. The anatomic locations of problem.2. The severity of the physiologic dysfunction.3. The urgency for treatment.

CIRCULATION TO SKIN

Characteristic of Circulation to skin

CharacteristicFeatures to look forPallorWhite or pale skin or mucous membrane coloration from inadequate blood flow. MottlingPatchy skin discoloration due to vasoconstriction.CyanosisBluish discoloration of skin and mucous membrane.

THE ABCDEs Hands-on ABCDE assessment :RESPIRATORY RATE

Normal RR varies in children of different ages

Normal Respiratory Rate for AgeAgeRespiratory Rate(breaths/min)Infant30 - 60Toddler24 - 40Preschooler22 - 34School-aged child18 - 30Adolescent12 - 16

AIR MOVEMENT & ABNORMAL LUNG SOUND

Interpretation of Abnormal Breath Sounds

Sound CauseExamplesStridor Upper airway obstruction Croup, foreign body aspiration, retro- pharyngeal abscess.Wheezing Lower airway obstructionAsthma, foreign body, bronchiolitis.Expiratory grunting Inadequate oxygenationPulmonary contusion, pneumonia, drowning.Inspiratory crackles Fluid, mucus, or blood inPneumonia, pulmonary the airway. contusion Absent breath sounds Complete airway Foreign body, severe despite increased obstruction (upper or asthma, pneumothorax, work of breathing lower airway) hemothorax. Physical barrier to Pleural fluid, pneumonia, transmission pneumothorax.

Causes of Poor Air Movement in ChildrenFunctional ProblemPossible CausesObstruction of airwaysAsthma, bronchiolitis, croup.Restriction of chest wall Chest wall injury, severe scoliosis or movement kyphosis.Chest wall muscle fatigueProlonged increased work of breathing, muscular dystrophy.Decreased control respiratoryHead injury, intoxication. drive.Chest injuryRib fractures, pulmonary contusion, pneumothorax.

PULSE OXYMETRI - is a useful tool for detecting & measuring hypoxia. - a reading of less than 90% (100% non rebreathing mask), usually indicates respiratory failure ( Normal : > 94 % ).

RESPIRATORY DISTRESS MANAGEMENTGENERAL NONINVASIVE TREATMENT Positioning Oxygen

Patient with Neurologic impairmentCaused by loss of oropharyngeal muscle tone due to the tongue and mandible falling back and partially blocking the pharynx.May relieve the obstruction with head tilt / chin lift or jaw thrust.Sometimes : secretions, blood, foreign bodies block the proximal airway.SUCTIONING !Maintenance of an adequate airway : Oropharyngeal / Nasopharyngeal Airway / ET Tube.UPPER AIRWAY OBSTRUCTIONSPECIFIC TREATMENT

C R O U P

A viral disease with inflammation, edema and narrowing of the larynx, trachea, bronchioles.

Treatment :Position of comfort, humidified O2 and avoiding agitation are the best treatments for suspected croup.The cool water vapor will help reduce the inflammation and obstruction of croup.

PHARMACOLOGIC TREATMENT :Nebulized epinephrine specific treatment 2 formulations :I. RACEMIC EPINEPHRINE, 2.25% solution 0,5 ml 4,5 ml N saline nebulizedII. EPINEPHRINE 1 : 1000 Solution 3 5 mg (3 5 ml) nebulized BEWARE OF SIDE EFFECTS ! NEED OBSERVATIONS IN THE ED FOR 4 6 HOURSINVASIVE AIRWAY MANAGEMENT VERY FEWCHILDREN

BACTERIAL UPPER AIRWAY INFECTIONSTend to progress rapidly with severe respiratory compromise developing over hours.Several possible causes, epiglotitis, tracheitis, diphteria, peritonsilar / retropharygeal abscess.Treatment :Give only general non invasive treatmentHigh flow O2.Position of comfort.Avoid agitating the child by trying to place an IV or another maneuver.Quickly transport ! Except : the child in respiratory failure initiate BVM ventilation, consider ET intubation.

FOREIGN BODY ASPIRATIONMay cause mechanical obstruction anywhere in the airwayA typical history is the sudden onset of coughing, chocking, gagging, shortness of breath in a previously well child without a feverTreatment :Never perform airway obstruction procedures if the child has only incomplete obstruction and can still cough, cry or speak !Use only general non invasive treatmentAvoid agitating the child

If the child has severe respiratory distress and at riskfor getting worse during transport perform foreignbody airway obstruction maneuvers.

Foreign Body Airways Obstruction ManeuversA g e TechniqueInfant ( < 12 months )Five back blows followed by five chest thrustsChild ( > 1 year )Five abdominal thrusts

If fail ? consider direct laryngoscopy using pediatric magill forcepsIf fail ? attempt BVM ventilation If fail ? Perform ET intubation

LOWER AIRWAY OBSTRUCTIONBronchiolitis and asthma are the most common condition causing lower lower airway obstruction in childrenWheezing is the clinical hallmark of lower airway obstruction of any cause.

ASTHMABeware of the following features of the initial assessment which suggest severe bronchospasm and respiratory failure :Altered appearanceExhaustionInability to reclineInterrupted speechSevere retractionsDecreased air movement

Several things suggest that a severe or potentially fatal attack is to come :

Prior intensive care unit admissions or intubation.More than three ED visits in a year.More than two hospital admissions in past year.Use of more than one metered dose inhaler ( MDI ) canister in the last month.Use of steroids for asthma in the past.Use of bronchodilators more frequently than every 4 hours.Progressive symptoms despite aggressive home therapy.

ALGORITHM FOR THE MANAGEMENT OF ASTHMAAssess SeverityEarly InterventionNebulizer -agonis 1-3 X, 3rd Nebulizer + anticholinergic.MildClinical observation improvement maintained dischargeSymptom (+) moderateModerateNebulizer 2-3 X : partial response Oxygen.Close observation in One Day Care + IV line.SevereNebulizer 3 X : no response Oxygen Close observation in One Day Care, IV line, Chest X-ray.DischargeAdd -agonist orally, reevaluation after 24-48 hours (Out patient Department / Asthma Clinic)One Day CareOxygen, steroid orally.Nebulizer every 2 hours.Clinical improvement (8-12 h) go to discharge.12 h : no clinical response admittedIn patientOxygen, fluid rescucitation (rehidration and acidosis), steroid parenterally every 6-8 h, nebulizer every 1-2 h, aminophyllin parenterally initial and maintenance doses24 h : clinical improvement (+) discharge.No clinical improvement and impending respiratory failure PICU Note :Severe asthma nebulizer 1 x + -agonist +anticholinergic(nebulizer (-) adrenalin SC 0,01 ml/BW/dose (max. 0,3 ml)Moderate and severe asthma oxygen 2-4 L/min from the beginning.

THE TRANSPORT DECISION : STAY OR GO ?Never transport a child who is in Respiratory failure without assisted ventilation.Never transport a child with an obstructed airway until after performing foreign body obstruction maneuver.If the PAT and ABCDEs are normal and the child has no history of serious breathing problems does not require urgent treatment or immediate transport.If the child has Respiratory distress without sign of upper airway obstruction transport indicated after general non invasive treatment.If the child has lower airway obstruction with wheezing begin specific treatment with a bronchodilator on scene, then transport.

ADDITIONAL ASSESSMENTFocused history and physical exam has the objectivities :To obtain a complete description of the main complaint.To determine the mechanism of injury or circumstances of illness.To perform additional physical exam of specific anatomic locations.

These parts of the additional assessment are optional in the physiologically distressed child.

To obtain the focused history use the SAMPLE mnemonic.

SAMPLE components in a child with respiratory distress.ComponentExplanationSigns/Symptoms Onset and nature of shortness of breathPresence of hoarseness, stridor, or wheezingPresence and quality of cough, chest painAllergiesKnown allergiesCigarette smoke exposureMedicationsExact names and doses of ongoing drugs, including metered dose inhalersRecent use of steroidsTiming and dose of last doseTiming and dose of analgesics / antipyretics Past medical problemsHistory of asthma, chronic lung disease, or heart problemsPrior hospitalizations for breathing problemsPrior intubations for breathing problemsImmunizationsLast food or liquidTiming of the childs last food or drink, including bottle or breast feedingEvents leading to the Evidence of increased work of breathinginjury or illnessFever history