By Duangruethai Tunprom, MD. 3rd years emergency medical resident, PMK hospital

outline

Upper airway obstruction & infection Lower airway obstruction Disease of the lung

PALS in AHA 2010Management of Respiratory Emergencies

FlowchartManagement of Respiratory Emergencies Flowchart

Airway positioning, Oxygen, Pulse oximetry, ECG monitor(as indicated), BLS as indicated

Upper Airway ObstructionSpecific Management for Selected Conditions

Croup Anaphylaxis Aspiration Foreign Body

•Nebulized epinephrine•Corticosteroids

•IM epinephrine•Albuterol•Antihistamines•Corticosteroids

•Allow positio of comfort•Specialty consultation

Lower Airway ObstructionSpecific Management for Selected Conditions

Bronchiolitis Asthma

•Nasal suctioning•Bronchodilator trial

•Albuterol±ipratropium•Corticosteroids•Subcutaneous epinephrine

•Magnesium sulfate•Terbutaline

PALS in AHA 2010Management of Respiratory Emergencies

FlowchartManagement of Respiratory Emergencies Flowchart

Airway positioning, Oxygen, Pulse oximetry, ECG monitor(as indicated), BLS as indicated

Lung Tissue(Parenchymal)DiseaseSpecific Management for Selected Conditions

Pneumonia/pneumonitisInfection Chemical

Aspiration

Pulmonary EdemaCardiogenic or Noncardiogenic

(ARDS)

•Albuterol•Antibiotic(as indicated)

•Consider noninvasive or invasive ventilatory support with PEEP•Consider vasoactive support•Consider diureticDisordered Control of Breathing

Specific Management for Selected Conditions

Increased ICP Poisoning/Overdose Neuromuscular Disease

•Avoid hypoxemia•Avoid hypercarbia•Avoid hyperthermia

•Antidote(if avaiable)•Contact poison control

•Consider noninvasive or invasive ventilatory support

outline

Upper airway obstruction & infection Lower airway obstruction Disease of the lung

Upper airway obstruction & infection

Distingishing principles of disease Stridor Specific disorder

Supraglottic airway disease Subglottic tracheal diseases Disease of the trachea Aeroesophageal foreign bodies

Comparison of adult and pediatric airways

Comparison of adult and pediatric airways

Comparison of adult and pediatric airways

The airway is smaller The tongue is relatively larger The larynx is more cephalad in

position The epiglottis is short, narrow,

and angled away from the trachea

The vocal cords attach lower anteriorly

< 10 years of age, the narrowest portion of the airway is subglottic

Regions and associated pathology of pediatric upper airwaySupraglottic

•Craniofacial•Pierre Robin•Theacher Collins•Hallermann-streiff

•Macroglossia•Beckwith-Wiedemann•Down syndrome•Glycogen storage disease•Congenital hypothyroidism

•Choanal atresia•Encephalocele•Thyroglossal duct cyst•Lingual thyroid

Intrathoracic•Tracheomalacia•Tracheal stenosis•Vascular ring/sling•Mediastinal masses

Laryngeal•Laryngomalacia•Vocal cord paralysis•Congenital subglottic stenosis•Laryngeal web•Laryngeal cyst•Subglottic hemangioma•Laryngotracheoesophageal cleft

Cause of stridor

Feature Supraglottic Glottic Subglottic trachea

Sound Sonorous Biphasic stridor High pitched stridor

Gurgling Inspiratory stridor

Coarse

Expiratory stridor

Structures Nose Larynx Subglottic trachea

Pharynx Vocal cord

Epiglottis

Cause of stridorFeature Supraglottic Glottic Subglottic

trachea

Congenital

Micrognathia Laryngomalacia Subglottic stenosis

Pierre Robin syndrome

Vacal cord paralysis

Tracheomalacia

Treacher Collins syndrome

Laryngeal web Tracheal stenosis

Macroglossia Laryngocele Vascular ring

Down syndrome Hemangioma cyst

Storage disease

Choanal atresia

Lingual thyroid

Thyroglossal cyst

Acquired Adenopathy Papillomas Croup

Tonsillar hypertrophy Foreign body Bacterial tracheitis

Foreign body Subglottic stenosis

Pharyngeal abscess Foreign body

Epiglottitis

Infectious Non-infectious

Croup Epiglotitis Tracheitis Retropharyngeal

abscess

Symptoms at birth Laryngeal web Vocal cord paralysis Cystic hygroma Subglottic stenosis

Symptoms after neonatal period

Acquired

Infectious Non-infectious

Croup Epiglotitis Tracheitis Retropharyngeal

abscess

Symptoms at birth Symptoms after

neonatal period Subglottic hemangioma Laryngeal papilloma Laryngomalacia Tracheomalacia Vasular ring/sling

Acquired

Infectious Non-infectious

Croup Epiglotitis Tracheitis Retropharyngeal

abscess

Symptoms at birth Symptoms after neonatal

period Acquired

FB aspiration or ingestion Laryngospasm Psychogenic stridor Angioedema Paratracheal mass

(teratoma,lymphoma)

Vocal cord paralysis or subglottic stenosis (secondary to intubation)

Important item of history Onset & duration Asssociation symptom Progression with age Exacerbation Feeding pattern Airway procedure Choking episode Baseline noises, quality of cry and

voice

Comparison of infectious upper airway emergencies

Average age

Common etiology medication

Croup 6 mo-6 yrs Parainfluenzae Dexa ±racemic epinephrine

Bacterial tracheitis

4-6 yrs S.aueus Antibiotic IV

Retropharyngeal abscess

3 yrs GABHS, S.aueus,anaerobe

Antibiotic IV

Peritonsillar abscess

Adolescence GABHS Antibiotic PO & IV

Epiglottitis 2-8 yrs H.influenzae,Staphylococi,Streptococus

species

Antibiotic IV

Comparison of Croup,Epiglottitis & Bacterial

Tracheitis

Croup Epiglotitis Bacterial trachea

Peak age 6 mo-3 years 3-7 years 3-5 years

Pathogen Subglottic inflammation

Inflammation & edema epiglottis, aryepiglottic folds

Bacterial superinfection with inflammation of tracheal mucosa, copious mucopurulent secretion obstructing the trachea

Organism Parainflueazae, RSV,adenovirus

Haemophilus influenzae, Strep sp, Staphylococcus aureus

Staphyloccus aureus or mixed flora

Clinical Feature

Onset follow URI prodrome consisting of croupy cough, hoarse voice, low grade fever, inspiratory stridor

Rapid progression of high fever, toxicity, drooling, stridor

Several-day prodome of crouplike illness progressing to toxicity, inspiratory/expiratory stridor, marked distress

Lab & film Steeple sign on film neck PA veiw or normal

Thumbprint sign on lateral aspect of neck, thickened aryepiglottic folds,loss of air in varecula

Normal upper airway structures, shaggy tracheal air column

Management Steriod uncommonAerosolized epinephrine

Intubation, abtibiotics Intubation (70 %) antibiotics rare

Supraglottic airway disease Congenital

Choanal atresia Macroglossia Mic

Retropharyngeal abscess epiglottitis

Choanal atresia M/C congenotal anomaly of nose Bilateral choanal atresia life

threatening emergency Acute distress &cyanotic at birth Increase secretion &swellingasso with

URI exacerbation

Macroglossia

Beckwith-wiedemann syndrome

Micrognathia

Treacher Collins syndrome

Retropharyngeal abscess

Potential life threatening airway emergency

Retropharyngel space : Potential space between posterior

pharyngeal wall & prevertrebral fascia extend from base of skull to level of T2

Result from Direct trauma Suppuration of LN Hematogenous spread

Retropharyngeal abscess (cont.) Child < 3 years Polymicrobial with streptococcus &

anaerobe Variable manifestrations Fever, sorethroat, neck stiffness,

torticollis, trimus, stridor, muffled voice Complication

Meningitis, sepsis, aspiration pneumonia, mediastinitis, empyema

Need ± to intubation, ± surgical drainage

Film lateral neck : show retropharyngeal abscess

Retropharyngeal abscess (cont.)

Epiglottitis

Most fear ped emergency Previous Haemophilus influenzae Since HIB vaccine drop incidence epiglotitis 10.9

8/10000 m/c GABHS, S. aureus, Streptococcus pneumoniae Classic :acute onset, rapid progression, sniffing,

tripod position,drooling

Tripod position of epiglotitis

Normal epiglottis contrasted with thickness

epiglottis

Thumbprint sign

Disease of larynx

Laryngomalacia m/c chronic stridor in chronic stridor

in infants

Vocal cord paralysis

Laryngeal web

Laryngeal papiloma

Subglottic tracheal diseases Subglottic stenosis Subglottic hemangioma

Viral croup

m/c cause of upper airway distress 6 m0 – 6 years Peak 2 years Parainfluenza virus type 1 50 % Clinical diagnosis

Croup score

Viral croup Westley Croup Scoring System Mild ≤ 2

Moderate 3- 7

Severe≥ 8

Viral croup Downes croup score

Mild < 4 Moderate

4- 7 Severe > 7

CPG croup ชมรมโรคระบบหายใจและเวชบ�าบ�ดว�กฤตในเด�กแห�งประเทศไทย

ราชว�ทยาก!มารแพทย#แห�งประเทศไทย

Rebound phenomenon of epinephrine 1- 2 hours

Croup: Indication for admission Severe respiratory distress of failure Unusual symptoms

(hypoxia,hyperpyrexia) Dehydration Persistence of stridor at rest after

aerosolized epinephrine and steroids Persistence of tachycardia,tachypnea Complex past medical history

(prematurity, pulmonary, cardiac disease)

Viral croup (cont.)

Treatment

Dexa 0.6 mg/kg IM •ลด ETT 11 % 1%•ลด ICU days 129 21 days

Higher Dexa (> 0.3 mg/kg) more effective

Budesonide 2 mg via NB•Shorten ED stay•ลด rate of hospitalization

Prefer Racemic epinephrine : less cardiovascular S/E than L-epinephrine

Epinephrine (1:1000) MAX 2.5 ml in age < 4 yrs 5 ml in age ≥ 4 yrsStudies comparing L-epinephrine with racemic epinephrine

show no significant difference in response

CXR AP : showing Croup

Spasmodic croup feature

Overlap viral croup Sudden onset of severe stridor Barky cough without a viral prodrome

Associated with Allergy GERD Hypersensitivity reaction on later exposure to

the virus

Disease of Trachea

Tracheaomalacia Tracheal stenosis Vascular ring

Bacterial tracheitis

Overlap symptom both croup & epiglottitis WBC normal or slightly increase H/C usually normal Investigation

Plain x-ray Bronchoscope

Complication Toxic shock syndrome Septic shock Postintubation pulmonary edema ARDS

Subglottic narrowing

Hazy density within the tracheal lumen

Ragged edge of the usually smooth tracheal air column

Aeroesophageal obstruction Asphyxia : m/c cause of death of FB

aspiration Major of cases & death in toddlers <

3 years FB : round-shaped difficult to

manage

Airway FB obstruction management Visualize remove No finger sweep Infant

5 back blow follow 5 chest thrusts Child

Conscious Heimlich maneuver Unconscious Chest compression

If cyannose & cannot ventilate & cannot intubation Consider needle cricothyrotomy

Croup Epiglotitis Bacterial trachea

Peak age 6 mo-3 years 3-7 years 3-5 years

Pathogen Subglottic inflammation

Inflammation & edema epiglottis, aryepiglottic folds

Bacterial superinfection with inflammation of tracheal mucosa, copious mucopurulent secretion obstructing the trachea

Organism Parainflueazae, RSV,adenovirus

Haemophilus influenzae, Strep sp, Staphylococcus aureus

Staphyloccus aureus or mixed flora

Clinical Feature

Onset follow URI prodrome consisting of croupy cough, hoarse voice, low grade fever, inspiratory stridor

Rapid progression of high fever, toxicity, drooling, stridor

Several-day prodome of crouplike illness progressing to toxicity, inspiratory/expiratory stridor, marked distress

Lab & film Steeple sign on film neck PA veiw or normal

Thumbprint sign on lateral aspect of neck, thickened aryepiglottic folds, loss of air in varecula

Normal upper airway structures, shaggy tracheal air column

Management Steriod uncommonAerosolized epinephrine

Intubation, abtibiotics Intubation (70 %) antibiotics rare

Pedriatric Dosing For Antibiotics In Upper Airway Infections

PO Dose

Amoxicillin/clavulanic acid

90 mg/kg/d divided BID (max 875 mg/dose)

Clindamycin 25 mg/kg/d divided BID(max450 mg/dose)

IV Dose

Amoxicillin/clavulanic acid

100 mg/kg/d divided Q 6 hrs (max 8 g/d)

Clindamycin 40 mg/kg/d divided Q 8 hrs (max 2.7 g/d)

Cefotaxime 120 mg/kg/d divided Q 8 hrs (max 2g Q 8 hrs)

Ceftriaxone 50 mg/kg/d Q 24 hrs (max 2 g/d)

Vancomycin 10 mg/kg Q 6 hrs (max 2 g/d)

Oxacillin 150 mg/kg/d divided Q 6 hrs (max 8 g/d)

Dose from children’ hospital of Philadelphia formulary (Pharmacy handbook formulary, Lexi-Comp)

Thank you

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Rosen 7th ed emergency medicine Tintinalli 7th ed emergency medicine