Pediatric Respiratory Emergencies - PowerPoint PPT Presentation

Loading...

PPT – Pediatric Respiratory Emergencies PowerPoint presentation | free to download - id: 476a88-YmVlN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Pediatric Respiratory Emergencies

Description:

Pediatric Respiratory Emergencies Emergency Medicine Rounds October 3, 2003 Dr. Edward Les Overview Croup Bronchiolitis Status asthmaticus others Case 1 3 year old ... – PowerPoint PPT presentation

Number of Views:605
Avg rating:3.0/5.0
Slides: 54
Provided by: Jaco87
Learn more at: http://calgaryem.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Pediatric Respiratory Emergencies


1
Pediatric Respiratory Emergencies
  • Emergency Medicine Rounds
  • October 3, 2003
  • Dr. Edward Les

2
Overview
  • Croup
  • Bronchiolitis
  • Status asthmaticus
  • others

3
Case 1
  • 3 year old girl brought to ED with a 2-day
    history of worsening cough and wheezing
  • Her mother has been giving her nebulized
    ventolin treatments every 4 hours for the past
    day without much improvement
  • In the ED her temp is 38.5, RR is 50, O2 sat 94
  • On exam moderate increased work of breathing,
    decreased aeration throughout and diffuse wheezes

4
Case 2
  • A 6-year-old girl comes to the ED with
    respiratory distress.
  • Known asthmatic, wheezing for 4 days
  • no response to ventolin MDI as often as q2h at
    home
  • She is diaphoretic, RR 60, O2 sat 88 on RA
  • Able to speak in short sentences b/w breaths
  • You immediately provide supplemental O2 and 3
    back-to-back Ventolin nebs, as well as oral
    roids 30 minutes later no improvement

5
Status asthmaticus
  • Definition
  • Any patient not responding to initial doses of
    nebulized bronchodilating agents
  • Helfaer et al Textbook of pediatric intensive
    care, 3rd ed. 1996.

6
Epidemiology of asthma
  • Clearly on the rise
  • Unclear why
  • 10 of kids in U.S. have asthma
  • Annual hospitalization rates doubled b/w
    1980-1993 for 1-4 year-olds
  • Asthma death rates double for 5-14 year age group

7
Risk Factors for Potentially Fatal Asthma
  • Medical factors
  • Previous attack with
  • Severe, unexpected, rapid deterioration
  • Respiratory failure
  • Seizure or loss of consciousness
  • Attacks precipitated by food
  • Ethnic factors
  • Nonwhite children (African American, Hispanic,
    other)
  • Psychosocial factors
  • Denial or failure to perceive severity of illness
  • Associated depression or other psychiatric
    disorder
  • Noncompliance
  • Dysfunctional family unit
  • Inner-city residents

8
But
  • As many as 1/3 of children who die from asthma
    have only had mild preceding asthma
  • Australian study of 51 pediatric deaths
  • Only 39 had potentially preventable elements
  • Robertson et al, Pediatric Pulmonol 19921395-100

9
Clinical presentation assessment
  • Signs and sx common knowledge
  • Measure pulse ox
  • Clinical asthma scores
  • Research tool
  • PFTs
  • Do in kids gt 5-6 years old
  • PEF ( of best) based on 3 attempts

10
PEF as predictor of asthma severity
  • PEF predicted ()
  • lt30
  • 30-50
  • 50-80
  • gt80
  • Exacerbation severity
  • Possibly life-threatening
  • Severe
  • Moderate
  • Mild

11
Treatment guidelines
  • O2 if needed
  • ?2 agonists salbutamol
  • Anticholinergics ipratropium
  • Steroids
  • Magnesium
  • Heli-ox
  • (Intubation)

12
Salbutamol
  • Method of delivery?
  • nebulization
  • lt10 kg 1.25 mg in NS
  • 10-20 kg 2.5 mg in NS
  • gt 20 kg 5 mg in NS
  • Single dose/re-evaluate vs q 20 min X3 vs
    continuous
  • O2 flow rate important
  • 10-12 LPM in order to deliver particles in 1-3
    mcm range

13
Salbutamol
  • Method of delivery?
  • MDI with spacer
  • Australian approach
  • lt 6 years 6 puffs
  • gt 6 years 12 puffs
  • Same frequency as for nebs
  • Equivalent (or better) efficacy

14
Salbutamol
  • Method of delivery?
  • IV patients unresponsive to treatment with
    continuous ventolin
  • 10 mcg/kg over 10 minutes,
  • then 0.2-5 mcg/kg/min
  • Need supplemental K

15
Anticholinergics ipratropium
  • When?
  • Immediately in moderate to severe asthma
  • Reduces duration and amount of treatment before
    discharge
  • Most severely ill kids benefit most
  • Schuh et al, J Pediatr 1995126639-645
  • 250-500 mcg with salbutamol q20min x 3

16
roids
  • For everybody in E.D.?
  • NAEPP to any patient that doesnt respond
    completely to one inhaled ? agonist treatment,
    even if the patient has a mild exacerbation

17
roids
  • Route of administration
  • PO and IV equal efficacy
  • Usually po
  • IV when cant tolerate po or very sick
  • Methylpredisone 0.5-1 mg/kg q6h, or
  • Hydrocortisone 2-4 mg/kg q6h
  • 1-2 mg/kg/day prednisone
  • 0.15-0.3 mg/kg/day dexamethasone

18
roids
  • Inhaled steroids for status asthmaticus?
  • Cochrane meta-analysis of six RCTs suggests
    benefit
  • Edmonds et al, in The Cochrane Library (Issue 2),
    2001
  • But
  • Compared inhaled to placebo, not to parenteral
    steroids
  • No children with severe asthma enrolled
  • PO or IV steroids remain avenue of choice

19
roids alert
  • Children with acute asthma and recent exposure to
    chickenpox should not receive steroids, unless
    they are considered immune
  • Even a single course of corticosteroids can
    increase the risk for fatal varicella
  • Kasper et al, Pediatr Infect Dis J,19909 729-32

20
Magnesium
  • Good evidence for efficacy in children
  • Ciarallo, et al, Arch Pediatr Adolesc Med,
    2000154979-983
  • 30 patients in RDBPC trial
  • Tx group 40mg/kg IV Mg over 20 minutes to
    children with moderate-severe asthma refractory
    to nebulization therapy
  • 50 of tx group discharged home
  • 100 of placebo group admitted (P 0.002)
  • Rowe, Ann Emerg Med, 200036(3)181-90
  • Systematic review of literature 7 trials (5
    adult, 2 pediatric)
  • Beneficial for patients who present with severe
    acute asthma

21
Magnesium
  • ? Causes relaxation of smooth muscle by
    inhibiting calcium uptake
  • Dose 30-75 mg/kg IV over 20 minutes
  • Max dose 2 g
  • Safe and well tolerated
  • Occasional nausea, flushing, weakness

22
Heli-ox
  • Not used much in ED
  • Theoretical advantage reduces turbulent flow
  • Prospective randomized double-blind crossover
    study in in 11 severe non-intubated pediatric
    asthmatics failed to show benefit
  • Carter et al, Chest 19961091256-61
  • Use limited by patients O2 requirement

23
Intubation/mechanical ventilation
  • Avoid if at all possible high
    morbidity/mortality
  • RSI which sedative?
  • Ketamine with atropine
  • Ventilation principles
  • Low rate, long exp times, controlled pressure,
    permissive hypercarbia

24
Case 1 (cont)
  • After appropriate treatment she is much improved
    with RR 30 and O2 sat 98 on RA, with minimal
    residual wheezing.
  • What are criteria for discharge home?
  • What therapy will you prescribe?

25
Asthma disposition from the ED
  • Asthma flow sheets very helpful
  • Patients should be observed for 30-60 minutes
    post-ventolin for symptom recurrence
  • Most require at least 2 hours ED care
  • Steroids kick in _at_ 4-6 hours

26
Asthma disposition
  • Consider hospitalization more strongly if
  • Prior hx of sudden, severe exacerbation
  • Prior intubation or ICU admission
  • ? 2 hospitalizations in last year
  • ? 3 ED visits in past year
  • ? 2 MDIs used in a month
  • Current steroid use or recent wean from steroids
  • Medical or psychiatric comorbidity
  • Poor perceiver of symptoms (adolescents)
  • Substance abuse
  • Low socioeconomic status
  • Baren JM in Emergency Asthma, 1999

27
Asthma disposition
  • NAEPP guidelines for discharge
  • PEF has returned to 70 of predicted
  • Exacerbation symptoms minimal or absent
  • Observed 30-60 minutes after last tx
  • Medications prescribed
  • PO steroids, ventolin, inhaled steroids
  • OP care can be established with a few days
  • Use asthma clinic!

28
Case 3
  • 4 month old girl brought to ED in February
    wheezing of 2 days duration
  • cough, rhinorrhea and fever to 37.8 C
  • poor feeding last 24 hours
  • wheezing is worsening
  • born at 31 weeks gestation required mechanical
    ventilation for 4 days after her birth
  • On exam
  • alert, RR 56 with mild retractions, O2 sat 94 RA
  • Diffuse wheezes bilaterally, scattered creps

29
CXR
30
Management options?
  • Supportive care
  • O2, fluids, suctioning, saline nose drops
  • Ventolin
  • Shuang huang lian
  • Racemic epinephrine
  • Ribavirin
  • Steroids
  • Vitamin A

31
Management options?
  • Supportive care
  • O2, fluids, suctioning, saline nose drops
  • Ventolin ?
  • Shuang huang lian
  • Racemic epinephrine ?
  • Ribavirin
  • Steroids ?
  • Vitamin A

32
Bronchiolitis
  • Primarily b/w 0 and 24 months
  • Peak 2-8 months
  • Infects almost all children
  • May be predictive of future asthma if
    hospitalized
  • 1 of all hospitalizations of children in 1st
    year of life
  • 300 million per year in U.S.
  • Mostly seasonal
  • 60-90 RSV
  • Extremely contagious
  • Affects terminal bronchioles in young children
  • Symptoms peak around day 5

33
Bronchiolitispredictors of severe disease
  • Ill or toxic appearing
  • SaO2 lt 95
  • Gestational age lt 34 weeks
  • RR gt 70 breaths per minute
  • Atelectasis on CXR
  • Age less than 3 months
  • Single best objective predictor infants SaO2
    while feeding
  • Shaw et al, Am J Dis Child, 1991145151-55

34
Salbutamol in bronchiolitis
  • Many studies
  • 1996 meta-analysis by Kellner et al in Arch
    Pediatr Adolesc Med 1501166-72 suggested benefit
  • Multiple conflicting reports since
  • Despite that used widely

35
Racemic epinephrine in bronchiolitis
  • Again, many studies
  • Generally more positive than salbutamol studies
  • Sanchez et al, J Pediatr 1993122145-51
  • Reijonen et al, Arch Pediatr Adolesc Med
    1995149686-92
  • Menon et al, J Pediatr 19951261004-1007
  • Certainly safe
  • Dose 0.25 0.5 mL neb in NS
  • L-isomer alone may be more effective

36
Steroids in bronchiolitis
  • Theoretically sound
  • Recent Sick Kids study
  • 1st study based in the ED
  • DBRPC trial involving 70 kids under 2 yrs
  • Dexamethasone group had hospitalization rate less
    than ½ of placebo group
  • Schuh et al, J Pediatr 2002140(1)
  • Recent meta-analysis also suggested statistical
    improvement with dexamethasone
  • Garrison, Pediatrics 2000105(4)E44
  • Overall, however, the bulk of individual studies
    have not shown benefit

37
Prevention of bronchiolitis
  • Palivizumab (Synergis)
  • Monoclonal antibody
  • effective
  • Given only to high risk infants
  • CLD
  • prems

38
Bronchiolitis indications for admission
  • Age generally if less than 1-2 months
  • Apnea
  • Oxygen requirement
  • Poor feeding
  • If received racemic epi in ED?
  • seems logical criteria given this is a med you
    cant prescribe for home management!
  • Underlying condition
  • e.g.
  • Prematurity
  • Congenital heart disease

39
Case 4
  • A 2 year old boy arrives at triage at 1 a.m with
    his Dad
  • Youre awakened by..
  • Hes brought back to obs
  • Sat is 90, moderate retractions, very hoarse
    voice, continued noisy breathing
  • Dad gives you xray taken one hour ago at walk-in
    clinic

40
(No Transcript)
41
Croup acute laryngotracheobronchitis
  • Stridor, barky cough, hoarseness
  • 6 months to 6 years of age
  • Often preceding URTI
  • Typically worse at night
  • Severe cases have biphasic stidor
  • Diagnosis is clinical

42
croup
43
Croup - treatment
  • Humidification
  • Often occurs on way to hospital
  • Corticosteroids
  • PO equivalent to IM
  • Dose 0.6 mg/kg (0.15 mg/kg may be adequate)
  • Nebulized budesonide also effective may be
    additive
  • Racemic epinephrine
  • Need to observe in ED 2-3 hours post admin
    potential rebound mucosal edema

44
Case 5

45
Epiglottitis
  • RARE now with Hib gone
  • Pneumococcus, Staph, Strep now more common as
    cause
  • 3 7 years of age
  • Rapid onset
  • Medical emergency
  • Dont bug the kid but dont let him out of your
    sight
  • Call anesthesia intubate in OR

46
Case 6
  • 3 year old with progressive stridor, fever,
    meningismus
  • Diagnosis?

47
Retropharyngeal abscess
  • 1-6 years
  • Retropharyngeal LNs gone after this
  • GAS, anaerobes, S. aureus
  • Need good film for diagnosis
  • Neck extended in inspiration
  • Width of prevertebral soft tissue gt ½ C3
    vertebral body
  • Loss of cervical lordosis
  • IV abx, ENT consult

48
Case 7
  • 4 year old fully immunized girl
  • Febrile, croupy cough, drooling, stridor
  • Looks unwell, but no acute distress
  • Coryza and sore throat for one day
  • No rashes no choking episodes
  • You give racemic epi no response
  • You order lateral neck XR no FB, no steeple
    sign, epiglottis normal, upper airway has
    irregular margins

49
Bacterial tracheitis
  • Uncommon
  • Can mimic croup quite closely may be a
    complication of croup
  • sicker, high fever, gradual onset of illness
  • S. aureus usual cause
  • Shaggy trachea on XR secondary to
    pseudomembrane formation
  • Admit to ICU for iv antibiotics and observation
  • not all croup is viral croup

50
Case 8
  • 15-month-old girl
  • Acute onset wheeze and cough 2 hours ago
  • Previously well
  • Has past hx bronchiolitis sib has asthma
  • On exam
  • afebrile, sat 95 RA, RR 44, AE sl decreased on
    left, wheeze LgtR

51
CXR

52
CXR- forced expiratory view
53
  • Miller time
About PowerShow.com