6/20/2017
Tami McDaniel, RRT, AE-C
#1 Cause of pediatric hospital admission
#1 Cause of death during the first year of life, except for congenital abnormalities
Almost all pediatric cardiac arrest begins as respiratory failure or respiratory arrest
1 6/20/2017
Pediatric Respiratory System
Pediatric Respiratory System
Large head, small mandible, small neck Large, posteriorly-placed tongue High glottic opening Small airways Presence of tonsils, adenoids
Pediatric Respiratory System
Poor accessory muscle development Less rigid thoracic cage Horizontal ribs, primarily diaphragm breathers Increased metabolic rate, increased O2 consumption
2 6/20/2017
Respiratory Assessment
Airway Look, listen and feel
Look for chest and abdomen movement Listen for breath sounds Feel for movement at nose or mouth
Breathing Assess : Rate Effort Tidal volume Airway and lung sounds
3 6/20/2017
Normal respiratory rates by age
<1year 30-60
1-3 years 24-40
4-5 years 22-34
6-12 years 18-30
13-18 years 12-16
Any respiratory rate > 60 is abnormal
Signs of increased respiratory effort Nasal flaring Retractions Head bobbing Seesaw respirations Prolonged inspiratory or expiratory times
4 6/20/2017
Mouth breathing Gasping Accessory muscle use Grunting
Grunting can be an ominous sign of impending respiratory failure
Pediatric Respiratory Diseases
Croup Epiglottitis Asthma Bronchiolitis Foreign body aspiration
5 6/20/2017
CROUP
Laryngotracheitis
Laryngotracheobronchitis
Croup
PATHOPHYSIOLOGY • Viral infection (parainfluenza) • Affects larynx, trachea • Subglottic edema; Air flow obstruction
Croup
Incidence Affects mostly 6 months – 4 year olds Affects males more than females- 1.4/1 Mostly in fall and early winter
6 6/20/2017
Croup Signs and Symptoms Low grade fever Hoarseness “Barking”cough Worsening Stridor at night Respiratory distress
Severe Croup
Signs and Symptoms Suprasternal, intercostal, and subcostal retractions. Biphasic stridor Lethargy Agitation
Croup MILD CROUP-MANAGEMENT Reassurance Cool mist humidifier
7 6/20/2017
Croup SEVERE CROUP – MANAGEMENT
High concentration humidified oxygen Monitor oxygen saturations and ecg Racemic epi nebulizer treatments
BE PREPARED TO INTUBATE
EPIGLOTTITIS
Epiglottitis Pathophysiology Bacterial infection – H-influlenza B, Streptococcus pneumonia Inflammation of the epiglottis and/or the supraglottictic tissue surrounding the epiglottis
8 6/20/2017
Epiglottitis Incidence 0.3 per 100,000 -Reduced incidence with HIB vaccine More males than females – 60%/40% No seasonal variation Most cases ages 2-7
Can occur at any age
Epiglottitis Signs & Symptoms Fever Sore throat Dysphagia Respiratory distress Drooling Anxiety
Epiglottitis Signs & Symptoms Stridor –early on suprasternal, subcostal, and intercostal retractions Differentiate from croup by absence of “barking” cough
9 6/20/2017
Epiglottitis Management – Do’s Keep child calm Make parents informed of seriousness of situation Take child to OR to secure airway as soon as possible Anyone with a diagnosis of epiglottitis is intubated
Epiglottitis Management – Don’ts Agitate the child No direct visualization of the airway – except in the OR No IV’s until airway is secure No lab work until airway is secure No suctioning until airway is secure
Epiglottitis Steroids are not indicated for the management of epiglottitis Racemic epinephrine has no role in the treatment of acute epiglottitis
10 6/20/2017
ASTHMA
Asthma Pathophysiology Mast cells, eosinophils, lymphocytes infiltrate airway after exposure to allergen or irritant Airway hyperresponsiveness results in Bronchial wall edema Smooth muscle contraction Excess mucous production
Asthma
11 6/20/2017
Asthma
Incidence 6.3 million children Prevalence highest in children <5 years 3rd ranked cause of pediatric hospitalizations 0.3 per 100,000 deaths in children
Asthma Signs & Symptoms Cough SOA Wheezing Chest tightness Retractions Air hunger Progressive fatigue
Asthma Management Quick history and physical exam Auscultation Use of accessory muscles Heart rate Respiratory rate O2 sats Peak Flow (PEFR)
12 6/20/2017
Asthma Management –mild to moderate exacerbation ( PEFR 50-80%) Nebulized beta agonist- up to 3 doses in 1 hour O2 for SpO2 <90% Oral steroids Reevaluate Continue neb tx’s 1-3 hours provided there is improvement
Asthma Management – Severe exacerbation (PEFR<50%) Nebulized high dose beta agonist every 20 minutes or continuous for 1 hour O2 for SpO2 <90% IV corticosteroids Reevaluate
Asthma Management – Severe exacerbation (PEFR<50%) Continue nebulized high dose beta agonist hourly or continuously
Be prepared to intubate
13 6/20/2017
Asthma Emergency interventions should NOT include
Antibiotics CPT Mucolytics Sedation
BRONCHIOLITIS
Bronchiolitis Pathophysiology Viral infection RSV most common cause (85%) Affects small airways Thick mucous – increased production Air trapping Tissue inflammation in airways
14 6/20/2017
Bronchiolitis Incidence Affects children less than 2 years of age Affects 4% of children <1year old Affects 6% of children 1-2 years old Mostly from November – April Peaks in January & February
Bronchiolitis Incidence More males than females (1.25 X) 90,000 hospitalization/year 4500 deaths /year
Bronchiolitis Signs & Symptoms Viral upper respiratory infection Cough Low grade fever SOA Expiratory wheezes Poor feeding
15 6/20/2017
Bronchiolitis Signs & Symptoms Cyanosis Retractions Grunting Apnea
Bronchiolitis Management Humidified oxygen Nasal & oral suctioning ( with saline drops) IV’s as needed for hydration
Bronchiolitis Management Trial of bronchodilator therapy to assess effectiveness Discontinue if not effective and agitation occurs Use bronchodilator therapy for children with history of asthma
16 6/20/2017
Bronchiolitis Despite the prominent role that inflammation plays in the pathogenesis of airway obstruction, corticosteroids have not clearly been shown to be of significant benefit in improving the clinical status of patients with bronchiolitis.
FOREIGN BODY AIRWAY OBSTRUCTION
FBAO Incidence High risk in children <7 years 90% of deaths are in children <5
17 6/20/2017
FBAO Signs & Symptoms Choking Coughing Stridor Respiratory distress Wheezing Inability to ventilate during CPR
FBAO Management Minimal intervention if child is conscious maintaining own airway O2
FBAO Management – totally obstructed Infant – 5 back blows followed by 5 chest thrusts
Child – 5 abdominal thrusts
18 6/20/2017
FBAO Management – Totally obstructed
Continue CPR until object dislodged
Pulse Oximetry Two light emitting diodes – one at the red spectrum and one at the infared spectrum Must be positioned so that the emitter and the detector are exactly opposite each other
Pulse Oximetry Sensor can be placed on finger, toe, top of ear and lobe of ear – for infants and newborns palm of hand or sole of foot Needs to be 5- 10 mm of tissue between the two diodes
19 6/20/2017
Pulse Oximetry- Limitations Motion artifact is the most common Recognized by a distorted wave form Poor Perfusion Inadequate arterial pulsation at the measurement site Ambient light interference causes “flooding” effect Can be avoided by covering sensor
CASE STUDIES
2 year old presents with cough, stridor, temp 99.5,child has a hoarse cry and a barking cough. In your assessment you note retractions and inspiratory and expiratory stridor. What do you think is wrong with this child? What would your treatment be?
3 year old with a history of fever, sore throat that has progressively worsened over the last 3 hours. You find the child sitting up leaning forward with hands on knees. The mother says the child has not had a cough. Your assessment notes drooling, retractions and anxiety. What do you think is wrong with this child? What would your treatment be?
20 6/20/2017
2 year old brought to the ER by EMS. Mom says she went in to wake the child up for day care and the child took one breath then stopped breathing. You notice that the chest is not rising with ventilations via bag/mask. What do you think is wrong with this child? What would your treatment be?
QUESTIONS?
21