respiratory distress in children jana stockwell, md, faap children’s healthcare of atlanta at...
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Respiratory Respiratory distress in distress in
childrenchildren
Jana Stockwell, MD, FAAPJana Stockwell, MD, FAAPChildren’s Healthcare of AtlantaChildren’s Healthcare of Atlanta
at Eglestonat EglestonEmory UniversityEmory University
ACCT4Kids 2
Typical causes of distressTypical causes of distress
• Upper airwayUpper airway– CroupCroup– Retropharyngeal abscessRetropharyngeal abscess– EpiglottitisEpiglottitis– Foreign body aspirationForeign body aspiration
• Lower airwayLower airway– Reactive airway disease / asthmaReactive airway disease / asthma– BronchiolitisBronchiolitis– PneumoniaPneumonia– PneumothoraxPneumothorax
ACCT4Kids 3
Normal upper airway anatomyNormal upper airway anatomy
Esophagus
Trachea
Epiglottis
Tonsils
Tongue
Larynx
ACCT4Kids 4
Why are kids different?Why are kids different?
• Obligate nose-Obligate nose-breathersbreathers
• Tongue Tongue relatively largerrelatively larger
• Higher larynx Higher larynx (C(C33-C-C44 versus C versus C66) )
• Narrowing of Narrowing of airway causes airway causes exponential rise exponential rise of airway of airway resistanceresistance
• Less elasticity of Less elasticity of alveolialveoli
• Lower FRCLower FRC• DiaphragmDiaphragm
– FlatterFlatter– Muscle fibers more Muscle fibers more
vulnerable to fatiguevulnerable to fatigue
• Chest wallChest wall– More compliantMore compliant– Ribs more horizontalRibs more horizontal
ACCT4Kids 5
Signs & symptoms of distressSigns & symptoms of distress
• Nasal flaringNasal flaring• Hypoventilation, Hypoventilation,
apneaapnea• StridorStridor• GruntingGrunting• WheezingWheezing• Pallor, ashen colorPallor, ashen color WOBWOB• TachypneaTachypnea
• CyanosisCyanosis• Head bobbingHead bobbing• Tripod positioningTripod positioning• RetractionsRetractions Level of Level of
consciousnessconsciousness Air movementAir movement• AcidosisAcidosis• HypercapneaHypercapnea
ACCT4Kids 6
Croup Croup ((LLaryngoaryngoTTracheoracheoBBronchitis)ronchitis)
• Most severe in kids 6 mo - 3 years oldMost severe in kids 6 mo - 3 years old• MalesMales• Winter monthsWinter months• Associated illnessesAssociated illnesses
– Ear infectionEar infection– PneumoniaPneumonia– Organisms: parainfluenza types 1, 2 & 3, Organisms: parainfluenza types 1, 2 & 3,
adenovirus, RSV, influenzaadenovirus, RSV, influenza
ACCT4Kids 7
Croup symptomsCroup symptoms
• URI symptoms X 1-3 URI symptoms X 1-3 daysdays
• Low grade feverLow grade fever• ““Barking” cough, Barking” cough,
hoarsenesshoarseness• Inspiratory stridorInspiratory stridor• Worse at nightWorse at night• Prefer to sit upPrefer to sit up• Aggravated by Aggravated by
agitation & cryingagitation & crying
ACCT4Kids 8
Croup diagnosisCroup diagnosis
• Clinical diagnosisClinical diagnosis• Does Does notnot require require
neck X-rayneck X-ray– Consider X-ray in Consider X-ray in
patients with patients with atypical atypical presentation or presentation or clinical courseclinical course
• ““Steeple sign”Steeple sign”
Steeple sign
ACCT4Kids 9
Croup treatment & transportCroup treatment & transport
• Position of comfort, with parentPosition of comfort, with parent• Dexamethasone 0.6 mg/kg IV/IMDexamethasone 0.6 mg/kg IV/IM• Epi neb Epi neb • HelioxHeliox• SQ EpiSQ Epi• Cool mistCool mist
Hypopharnyx
Narrow air column
Trachea
Steeple sign
ACCT4Kids 10
Retropharyngeal abscessRetropharyngeal abscess
• Deep, potential, space of the neckDeep, potential, space of the neck• Children age 6 months to 6 yearsChildren age 6 months to 6 years• Other deep neck abscesses more Other deep neck abscesses more
frequent in older children & adultsfrequent in older children & adults– ParapharyngealParapharyngeal– PeritonsillarPeritonsillar
• Potential for airway compromise Potential for airway compromise • Complications secondary to mass Complications secondary to mass
effect, rupture of the abscess, or effect, rupture of the abscess, or spread of infectionspread of infection
ACCT4Kids 11
Retropharyngeal abscess - sxsRetropharyngeal abscess - sxs
• Fever, chills, Fever, chills, malaisemalaise
• Decreased Decreased appetiteappetite
• IrritabilityIrritability• Sore throatSore throat• Difficulty or pain Difficulty or pain
swallowingswallowing• Jaw stiffnessJaw stiffness• Neck stiffnessNeck stiffness
• Muffled voiceMuffled voice• ““Lump” in the throatLump” in the throat• Pain in the back & Pain in the back &
shoulders upon shoulders upon swallowingswallowing
• Difficulty breathing Difficulty breathing is an is an ominousominous complaint that complaint that signifies impending signifies impending airway obstructionairway obstruction
ACCT4Kids 12
Retropharyngeal abscessRetropharyngeal abscess
ACCT4Kids 13
Retropharyngeal abscessRetropharyngeal abscess
• Polymicrobial infection typicalPolymicrobial infection typical– Gram-positive organisms and Gram-positive organisms and
anaerobes predominatinganaerobes predominating– Gram-negative bacteria possibleGram-negative bacteria possible– Oropharyngeal flora Oropharyngeal flora
• Most common cause is group A Most common cause is group A beta-hemolytic streptococcibeta-hemolytic streptococci
ACCT4Kids 14
Retropharyngeal abscess - RxRetropharyngeal abscess - Rx
• Position airway - comfortPosition airway - comfort• Avoid unnecessary manipulationAvoid unnecessary manipulation• Monitor, CT of neck, possible OR Monitor, CT of neck, possible OR • Sedation & paralytics can relax airway Sedation & paralytics can relax airway
muscles, leading to complete muscles, leading to complete obstructionobstruction
• Endotracheal intubation is dangerousEndotracheal intubation is dangerous• Abx: clindamycin, cefoxitin, Timentin, Abx: clindamycin, cefoxitin, Timentin,
Zosyn, or UnasynZosyn, or Unasyn
ACCT4Kids 15
EpiglottitisEpiglottitis
• Acute, rapidly progressive cellulitis Acute, rapidly progressive cellulitis of the epiglottis and adjacent of the epiglottis and adjacent structuresstructures
• Before immunization - peak Before immunization - peak incidence at 3.5 years of ageincidence at 3.5 years of age
• Danger of airway obstruction - Danger of airway obstruction - medical emergencymedical emergency
• Prompt diagnosis and airway Prompt diagnosis and airway protection requiredprotection required
ACCT4Kids 16
Anatomy of oropharynxAnatomy of oropharynx
ACCT4Kids 17
Epiglottitis - signs & sxsEpiglottitis - signs & sxs
• More acute presentation in young More acute presentation in young children than in adolescents or adultschildren than in adolescents or adults
• Symptoms for <24 hrsSymptoms for <24 hrs– High fever, severe sore throat, High fever, severe sore throat,
tachycardia, systemic toxicity, drooling, tachycardia, systemic toxicity, drooling, tripod positiontripod position
• Moderate or severe respiratory Moderate or severe respiratory distress with inspiratory stridor & distress with inspiratory stridor & retractions retractions
ACCT4Kids 19
EpiglottitisEpiglottitis
ACCT4Kids 20
Epiglottitis - etiologyEpiglottitis - etiology
• Group A StreptococcusGroup A Streptococcus• Other pathogens seen less frequently Other pathogens seen less frequently
include:include:– Strep pneumoniaeStrep pneumoniae– Haemophilus parainfluenzaHaemophilus parainfluenza– Staph aureusStaph aureus
ACCT4Kids 21
Epiglottitis - Rx & transportEpiglottitis - Rx & transport
• Position of comfort, with parentPosition of comfort, with parent• Minimize manipulationMinimize manipulation• Intubation under controlled Intubation under controlled
circumstancescircumstances• OO22 prn, blow-by if not tolerating mask prn, blow-by if not tolerating mask• Avoid agitation (Do not try to start IV, Avoid agitation (Do not try to start IV,
obtain blood or examine airway!)obtain blood or examine airway!)• Consult anesthesia & ENTConsult anesthesia & ENT• IV for antibiotics, after airway secureIV for antibiotics, after airway secure
ACCT4Kids 22
Epiglottitis - TroubleEpiglottitis - Trouble
• If respiratory arrest If respiratory arrest BVM BVM ventilation ventilation if inadequate, if inadequate, attempt to intubate attempt to intubate if unable if unable to intubate, perform needle or to intubate, perform needle or surgical cricothyroidotomysurgical cricothyroidotomy
• IV antibioticsIV antibiotics– ceftriaxone / cefotaximeceftriaxone / cefotaxime
• Racemic epinephrine & steroids Racemic epinephrine & steroids are are ineffectiveineffective
ACCT4Kids 23
Foreign body (FB) aspirationForeign body (FB) aspiration
• Toddler through preschool age commonToddler through preschool age common– No molar teeth for thorough chewingNo molar teeth for thorough chewing– Talking, laughing, and running while Talking, laughing, and running while
eatingeating• In 2000, FB aspiration in kids <14 years oldIn 2000, FB aspiration in kids <14 years old
– >17,000 ED visits>17,000 ED visits– 160 deaths160 deaths
• Nuts, raisins, sunflower seeds, pieces of Nuts, raisins, sunflower seeds, pieces of meat and small smooth (grapes, hot dogs, meat and small smooth (grapes, hot dogs, & sausages)& sausages)
• Dried foods absorb waterDried foods absorb water
ACCT4Kids 24
FB aspirationFB aspiration
• Sudden episode of coughing / choking Sudden episode of coughing / choking while eating with subsequent wheezing while eating with subsequent wheezing (sometimes unilateral), coughing, or stridor(sometimes unilateral), coughing, or stridor
• Tragic cases occur with total or near-total Tragic cases occur with total or near-total occlusion of the airwayocclusion of the airway
• Frequent sites of FB lodgement:Frequent sites of FB lodgement:– Usually below vocal cordsUsually below vocal cords– Mainstem bronchiMainstem bronchi– TracheaTrachea– Lobar bronchi Lobar bronchi
ACCT4Kids 25
FB aspirationFB aspiration
• Extrathoracic FB:Extrathoracic FB:– Breath sounds are Breath sounds are inspiratoryinspiratory
• Intrathoracic FBIntrathoracic FB– Noises are Noises are symmetricsymmetric but more but more
prominent in central airwaysprominent in central airways– If FB is beyond the carina, the breath If FB is beyond the carina, the breath
sounds are usually sounds are usually asymmetricasymmetric• Kid chest transmits sounds wellKid chest transmits sounds well• Stethoscope head may be bigger than lung lobesStethoscope head may be bigger than lung lobes• Lack of asymmetry should Lack of asymmetry should notnot dissuade you from dissuade you from
considering the FB diagnosisconsidering the FB diagnosis
ACCT4Kids 26
FB aspirationFB aspiration
• Hyperinflation & air-trapping of the Hyperinflation & air-trapping of the affected lobe(s) is typicalaffected lobe(s) is typical– Best seen with X-ray taken at expirationBest seen with X-ray taken at expiration– Difficult in little kidsDifficult in little kids
• May see soft tissue opacity in May see soft tissue opacity in proximal airwayproximal airway
ACCT4Kids 28
Foreign bodiesForeign bodies
ACCT4Kids 29
FB aspiration - transport issuesFB aspiration - transport issues
• Position of comfortPosition of comfort• Heimlich maneuver, back blows Heimlich maneuver, back blows • BVM prnBVM prn• Magill forceps (if object above cords)Magill forceps (if object above cords)• Intubation prnIntubation prn• Needle cricothyrotomyNeedle cricothyrotomy• Surgical cricothyrotomySurgical cricothyrotomy• Rigid bronchoscopy for FB removalRigid bronchoscopy for FB removal
ACCT4Kids 31
RAD / Asthma - childrenRAD / Asthma - children
• <3 years - small intrapulmonary airways<3 years - small intrapulmonary airways• Poor collateral ventilationPoor collateral ventilation• Decreased elastic recoil pressureDecreased elastic recoil pressure• Partially developed diaphragmPartially developed diaphragm
ACCT4Kids 32
RAD / AsthmaRAD / Asthma
• Identify and remove asthma triggers Identify and remove asthma triggers • Albuterol, nebulizedAlbuterol, nebulized• Ipratopium bromide (Atrovent)Ipratopium bromide (Atrovent)• Methylprednisolone (Solumedrol)Methylprednisolone (Solumedrol)• Magnesium sulfateMagnesium sulfate• CPAP / BiPAP CPAP / BiPAP • HelioxHeliox• Epinephrine or terbutaline infusionEpinephrine or terbutaline infusion• Chest squeezeChest squeeze• Anesthetic gasesAnesthetic gases
ACCT4Kids 33
RAD / AsthmaRAD / Asthma
• If intubated for transport:If intubated for transport:– Low vent rate, even if pCOLow vent rate, even if pCO22 high high
• Very prolonged expiratory phaseVery prolonged expiratory phase• Listen to chest - does expiration end?Listen to chest - does expiration end?
– SedateSedate– ParalyzeParalyze– Continuous nebsContinuous nebs– Monitor for development Monitor for development
of pneumothoraxof pneumothorax
ACCT4Kids 34
BronchiolitisBronchiolitis
• Organisms: RSV most commonOrganisms: RSV most common– Others: parainfluenza, influenza, human Others: parainfluenza, influenza, human
metapneumovirus (hMPV), adenovirus, metapneumovirus (hMPV), adenovirus, mycoplasmamycoplasma
• Winter & springWinter & spring• MalesMales• Typically <2 years old, peak 2-8 mosTypically <2 years old, peak 2-8 mos• Disease more severe in babies 1-3 mo oldDisease more severe in babies 1-3 mo old• Risk factors: Heart disease, BPD, Risk factors: Heart disease, BPD,
prematurity, smoking in homeprematurity, smoking in home
ACCT4Kids 35
BronchiolitisBronchiolitis
ACCT4Kids 36
Bronchiolitis - sxsBronchiolitis - sxs
• Apnea, bradycardiaApnea, bradycardia• DesaturationsDesaturations• Cough, copious secretionsCough, copious secretions• Tachypnea, tachycardiaTachypnea, tachycardia• Crackles, wheezingCrackles, wheezing• Increased WOB, retractionsIncreased WOB, retractions• Flaring, gruntingFlaring, grunting• Pallor, cyanosisPallor, cyanosis
ACCT4Kids 37
Bronchiolitis - diagnosisBronchiolitis - diagnosis
• No diagnostic tests needed, but possibly:No diagnostic tests needed, but possibly:– Rapid viral panel (antigen or FA panel)Rapid viral panel (antigen or FA panel)– Viral culturesViral cultures– CXR - CXR - hyperinflation, peribronchial cuffing, patchy hyperinflation, peribronchial cuffing, patchy
atelectasisatelectasis• Tachypnea, Tachypnea, WOB, wheezing WOB, wheezing • Hx URIHx URI
– fever, cough, runny nose, fever, cough, runny nose, appetiteappetite• Apnea (may occur Apnea (may occur w/ow/o other symptoms) other symptoms)• May be complicated by secondary bacterial May be complicated by secondary bacterial
infectioninfection
ACCT4Kids 38
Bronchiolitis - transportBronchiolitis - transport
• Isolation - contact, dropletIsolation - contact, droplet• OO2, 2, keep sats ≥92%keep sats ≥92%• Pulmonary toilet, suctioning!Pulmonary toilet, suctioning!• CPAP / BiPAPCPAP / BiPAP• No steroidsNo steroids• Nebs largely unhelpful (<1/3)Nebs largely unhelpful (<1/3)• Chest PT Chest PT prolongsprolongs hospitalization hospitalization• Antibiotics depend on other sxsAntibiotics depend on other sxs
ACCT4Kids 39
PneumoniaPneumonia
• Types:Types:– Bronchopneumonia - lobar Bronchopneumonia - lobar
consolidationconsolidation– Interstitial - usually viralInterstitial - usually viral
• More common in infants & toddlers More common in infants & toddlers than in adolescentsthan in adolescents
• Commonly:Commonly:– Viral, pneumococcus, MycoplasmaViral, pneumococcus, Mycoplasma– In immunocompromised, anything is In immunocompromised, anything is
possible!possible!
ACCT4Kids 40
Pneumonia - sxsPneumonia - sxs
• CoughCough• TachypneaTachypnea• GruntingGrunting• RetractionsRetractions• Chest painChest pain• Vomiting, poor feeding, abdominal Vomiting, poor feeding, abdominal
painpain• Fever depends on typeFever depends on type
ACCT4Kids 41
PneumoniaPneumonia
ACCT4Kids 42
Pneumonia - transportPneumonia - transport
• OO2, 2, keep sats ≥92%keep sats ≥92%• CPAP, BiPAPCPAP, BiPAP• Antibiotics, if considered bacterialAntibiotics, if considered bacterial
– Cefotaxime + vancomycinCefotaxime + vancomycin– AzithromycinAzithromycin
• Monitor mental statusMonitor mental status• Intubate & ventilateIntubate & ventilate• Complications: effusion, abscessComplications: effusion, abscess
ACCT4Kids 44
Pneumothorax radiographsPneumothorax radiographs
ACCT4Kids 45
Tension PTXTension PTX
NormalNormal
Tension PTXTension PTXPTXPTX
R L
heartheart
LungLung
HeartHeart
AirleakAirleak