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Pediatrics

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Asthma: Prolonged Attacks. Increase in respiratory water loss. Decreased fluid intake ... Asthma: Risk Assessment. Prior ICU admissions. Prior intubation ... – PowerPoint PPT presentation

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Title: Pediatrics


1
Pediatrics
  • Respiratory Emergencies

2
Respiratory Emergencies
  • 1 cause of
  • Pediatric hospital admissions
  • Death during first year of life except for
    congenital abnormalities

3
Respiratory Emergencies
  • Most pediatric cardiac arrest begins as
    respiratory failure or respiratory arrest

4
Pediatric Respiratory System
  • Large head, small mandible, small neck
  • Large, posteriorly-placed tongue
  • High glottic opening
  • Small airways
  • Presence of tonsils, adenoids

5
Pediatric Respiratory System
  • Poor accessory muscle development
  • Less rigid thoracic cage
  • Horizontal ribs, primarily diaphragm breathers
  • Increased metabolic rate, increased O2 consumption

6
Pediatric Respiratory System
  • Decrease respiratory reserve Increased O2
    demand Increased respiratory failure risk

7
Respiratory Distress
8
Respiratory Distress
  • Tachycardia (May be bradycardia in neonate)
  • Head bobbing, stridor, prolonged expiration
  • Abdominal breathing
  • Grunting--creates CPAP

9
Respiratory Emergencies
  • Croup
  • Epiglottitis
  • Asthma
  • Bronchiolitis
  • Foreign body aspiration
  • Bronchopulmonary dysplasia

10
Laryngotracheobronchitis
  • Croup

11
Croup Pathophysiology
  • Viral infection (parainfluenza)
  • Affects larynx, trachea
  • Subglottic edema Air flow obstruction

12
Croup Incidence
  • 6 months to 4 years
  • Males gt Females
  • Fall, early winter

13
Croup Signs/Symptoms
  • Cold progressing to hoarseness, cough
  • Low grade fever
  • Night-time increase in edema with
  • Stridor
  • Seal bark cough
  • Respiratory distress
  • Cyanosis
  • Recurs on several nights

14
Croup Management
  • Mild Croup
  • Reassurance
  • Moist, cool air

15
Croup Management
  • Severe Croup
  • Humidified high concentration oxygen
  • Monitor EKG
  • IV tko if tolerated
  • Nebulized racemic epinephrine
  • Anticipate need to intubate, assist ventilations

16
Epiglottitis
17
Epiglottitis Pathophysiology
  • Bacterial infection (Hemophilus influenza)
  • Affects epiglottis, adjacent pharyngeal tissue
  • Supraglottic edema

Complete Airway Obstruction
18
Epiglottitis Incidence
  • Children gt 4 years old
  • Common in ages 4 - 7
  • Pedi incidence falling due to HiB vaccination
  • Can occur in adults, particularly elderly
  • Incidence in adults is increasing

19
Epiglottitis Signs/Symptoms
  • Rapid onset, severe distress in hours
  • High fever
  • Intense sore throat, difficulty swallowing
  • Drooling
  • Stridor
  • Sits up, leans forward, extends neck slightly
  • One-third present unconscious, in shock

20
Epiglottitis
  • Respiratory distress Sore
    throatDrooling
  • Epiglottitis

21
Epiglottitis Management
  • High concentration oxygen
  • IV tko, if possible
  • Rapid transport
  • Do not attempt to visualize airway

22
Epiglottitis
  • Immediate Life Threat
  • Possible Complete Airway Obstruction

23
Asthma
24
Asthma Pathophysiology
  • Lower airway hypersensitivity to
  • Allergies
  • Infection
  • Irritants
  • Emotional stress
  • Cold
  • Exercise

25
Asthma Pathophysiology
Bronchospasm
Bronchial Edema
Increased Mucus Production
26
Asthma Pathophysiology
27
Asthma Pathophysiology
Cast of airway produced by asthmatic mucus plugs
28
Asthma Signs/Symptoms
  • Dyspnea
  • Signs of respiratory distress
  • Nasal flaring
  • Tracheal tugging
  • Accessory muscle use
  • Suprasternal, intercostal, epigastric retractions

29
Asthma Signs/Symptoms
  • Coughing
  • Expiratory wheezing
  • Tachypnea
  • Cyanosis

30
Asthma Prolonged Attacks
  • Increase in respiratory water loss
  • Decreased fluid intake
  • Dehydration

31
Asthma History
  • How long has patient been wheezing?
  • How much fluid has patient had?
  • Recent respiratory tract infection?
  • Medications? When? How much?
  • Allergies?
  • Previous hospitalizations?

32
Asthma Physical Exam
  • Patient position?
  • Drowsy or stuporous?
  • Signs/symptoms of dehydration?
  • Chest movement?
  • Quality of breath sounds?

33
Asthma Risk Assessment
  • Prior ICU admissions
  • Prior intubation
  • gt3 emergency department visits in past year
  • gt2 hospital admissions in past year
  • gt1 bronchodilator canister used in past month
  • Use of bronchodilators gt every 4 hours
  • Chronic use of steroids
  • Progressive symptoms in spite of aggressive Rx

34
Asthma
  • Silent Chest equals Danger

35
Golden Rule
ALL THAT WHEEZES IS NOT ASTHMA
  • Pulmonary edema
  • Allergic reactions
  • Pneumonia
  • Foreign body aspiration

36
Asthma Management
  • Airway
  • Breathing
  • Sitting position
  • Humidified O2 by NRB mask
  • Dry O2 dries mucus, worsens plugs
  • Encourage coughing
  • Consider intubation, assisted ventilation

37
Asthma Management
  • Circulation
  • IV TKO
  • Assess for dehydration
  • Titrate fluid administration to severity of
    dehydration
  • Monitor ECG

38
Asthma Management
  • Obtain medication history
  • Overdose
  • Arrhythmias

39
Asthma Management
  • Nebulized Beta-2 agents
  • Albuterol
  • Terbutaline
  • Metaproterenol
  • Isoetharine

40
Asthma Management
  • Nebulized anticholinergics
  • Atropine
  • Ipatropium

41
Asthma Management
  • Subcutaneous beta agents
  • Epinephrine 11000--0.1 to 0.3 mg SQ
  • Terbutaline--0.25 mg SQ

POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY
FAILURE
42
Asthma Management
  • Use EXTREME caution in giving two
    sympathomimetics to same patient
  • Monitor ECG

43
Asthma Management
  • Avoid
  • Sedatives
  • Depress respiratory drive
  • Antihistamines
  • Decrease LOC, dry secretions
  • Aspirin
  • High incidence of allergy

44
Status Asthmaticus
  • Asthma attack unresponsive to ?-2 adrenergic
    agents

45
Status Asthmaticus
  • Humidified oxygen
  • Rehydration
  • Continuous nebulized beta-2 agents
  • Atrovent
  • Corticosteroids
  • Aminophylline (controversial)
  • Magnesium sulfate (controversial)

46
Status Asthmaticus
  • Intubation
  • Mechanical ventilation
  • Large tidal volumes (18-24 ml/kg)
  • Long expiratory times
  • Intravenous Terbutaline
  • Continuous infusion
  • 3 to 6 mcg/kg/min

47
Bronchiolitis
48
Bronchiolitis Pathophysiology
  • Viral infection (RSV)
  • Inflammatory bronchiolar edema
  • Air trapping

49
Bronchiolitis Incidence
  • Children lt 2 years old
  • 80 of patients lt 1 year old
  • Epidemics January through May

50
Bronchiolitis Signs/Symptoms
  • Infant lt 1 year old
  • Recent upper respiratory infection exposure
  • Gradual onset of respiratory distress
  • Expiratory wheezing
  • Extreme tachypnea (60 - 100/min)
  • Cyanosis

51
Asthma vs Bronchiolitis
  • Asthma
  • Age - gt 2 years
  • Fever - usually normal
  • Family Hx - positive
  • Hx of allergies - positive
  • Response to Epi - positive
  • Bronchiolitis
  • Age - lt 2 years
  • Fever - positive
  • Family Hx - negative
  • Hx of allergies - negative
  • Response to Epi - negative

52
Bronchiolitis Management
  • Humidified oxygen by NRB mask
  • Monitor EKG
  • IV tko
  • Anticipate order for bronchodilators
  • Anticipate need to intubate, assist ventilations

53
Foreign Body Airway Obstruction
  • FBAO

54
FBAO High Risk Groups
  • gt 90 of deaths children lt 5 years old
  • 65 of deaths infants

55
FBAO Signs/Symptoms
  • Suspect in any previously well, afebrile child
    with sudden onset of
  • Respiratory distress
  • Choking
  • Coughing
  • Stridor
  • Wheezing

56
FBAO Management
  • Minimize intervention if child conscious,
    maintaining own airway
  • 100 oxygen as tolerated
  • No blind sweeps of oral cavity
  • Wheezing
  • Object in small airway
  • Avoid trying to dislodge in field

57
FBAO Management
  • Inadequate ventilation
  • Infant 5 back blows/5 chest thrusts
  • Child Abdominal thrusts

58
Bronchopulmonary Dysplasia
  • BPD

59
BPD Pathophysiology
  • Complication of infant respiratory distress
    syndrome
  • Seen in premature infants
  • Results from prolonged exposure to high
    concentration O2 , mechanical ventilation

60
BPD Signs/Symptoms
  • Require supplemental O2 to prevent cyanosis
  • Chronic respiratory distress
  • Retractions
  • Rales
  • Wheezing
  • Possible cor pulmonale with peripheral edema

61
BPD Prognosis
  • Medically fragile, decompensate quickly
  • Prone to recurrent respiratory infections
  • About 2/3 gradually recover

62
BPD Treatment
  • Supplemental O2
  • Assisted ventilations, as needed
  • Diuretic therapy, as needed
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