Upper Airway Pathology Stridor Foreign BodiesAngioneurotic oedemaEpiglotitisCroupRetro-pharyngeal or peritonsilar abscessTrachitis Hypocalcemia, tumours, vocal cord palsyLower Airway Pathology Rhonchi, crepitations, BB, Bronchial AsthmaBronchiolitisPneumoniaTension PneumothoraxFBRespiratory emergencies Dr Rasnayaka M MudiyanseScope of the lecture

Respiratory distressRespiratory failureEffortsRR, Recessions, Grunting, head noddingEffects On CNS and CVSEfficacy Air entry, chest expansionOxygen saturationCarbon dioxideTreatments

Below 85% . Below 90 % .Below 95%.Above 95%.

1.

2.

3.

4. Causes of NON respiratory tachypnea

List causes of acute stridor 1. 2. 3. 4. 5. 6. 7.

Causes Viral Allergic spasmodic croup Bacterial Foreign BodiesURTI 1-3 days Fever, rhinorhea & coughBarking cough , Stridor , mild increased respiratory rate, recessionsProgress to severe disease Respiratory distress, increasing respiratory rate, nasal flaring, retractions, respiratory failure

1. 2. 3. 4. 1.2.5. 6. 7.

Homophiles Influence BSudden onset, rapid progress, neck is hyper extendedToxic, Sick, Drooling, Febrile ,Reduced voiceDONT disturbX-ray lateral thumb sign

1.2.3.4.5.6.

Staphylococcus aureus, moraxella catarhalis, H influence Croup, Toxic but no drooling, can lie flat , no dysphagiaSwelling at cricoid cartilage levelMist and adrenaline not effectiveAntibiotics, tracheostomy sos

CausesDrugs Penicillin, radio contrast, ARV, AVSFoods Nuts, fish, meat, ApplicantsLook for Upper airwayLower air wayCirculatory

1.2.3.4.5.6.

Retropharyngeal LN - Satph, strep, Anaerobs, H Influenzae, KlebsiellaAge 3-4 years M>FHigh fever, drooling, neck stiffness, torticollisUpper airway obstruction , rupture and aspiration pneumonia, extension to mediastinum, thrombophlebitis of internal jugular vein embolism to lungs.X ray neck lateral Widening of retropharyngeal space more than 2/3 of a vertebral bodySurgical drainage Antibiotics Cefuroxime + Cloxacillin

Age group below 2 yrsSevere 1-3 moPremature babiesPre-existing lung diseaseCHDImpaired immunityCauses RSV > 50%, Adeno, Influencea, ParainflueceaClinical features Tachypnoea, HyperinflationAdmit - Sick baby, Feeding effected, Maternal concernRecognize mild moderate ad severe bronchiolitis

Mild bronchiolitis

1. Normal ability to feed2. Little or no respiratory distress3. No requirement for oxygen ( SaO2 > 95%)4. No risk factorsTreatment for Mild bronchiolitis1.2.

Treatment for Moderate Bronchiolitis1.2.3.4.5.

Recognition of Moderate BronchiolitisRespiratory distress + ; RR > 50/minNasal flaringFeeding difficulty +Episodes of apneaRequirement for oxygen ( SaO2 < 92%No risk factors

Recognize Severe Bronchiolitis Unable to feed Severe respiratory distress Increasingly tired Prolong apnea Hypoxemia PaO2 < 92% Treatment1.2.3.4.5.6.

Ventilation IndicationsRecurrent apnoeaExhaustionHypercapniaHypoxaemiaConsider C x R & Antibiotics

* Exclude Heart Failure and Pneumothorax

Causes Pneumococci, Streptococci, Haemophilus influencae, Mycoplasma,E Coli, Staph, Clamidia Clinical featuresFever, Tachypnoea, Pleuratic chest pain abdominal pain, Grunting, Flaring of alea nasi

Asses severityABC care Oxygen, Fluids (restricted amounts)Antibiotics ( Ampiciline/Cefolosphorine , Erythro 7-10 days)Antibiotics for fever and Tachypnoea -WHOI.C.U. and Ventilator care

ClinicallyWheezingCoughingSOBPathologicallyBronchospasmsMucosal oedemaSecretions

Acute asthma- Exacerbations Mild Moderate SevereLife threateningChronic Asthma-Grading Mild intermittentMild persistingModerate persistingSevere persistingChild with any grade of asthma can have mild moderate or severe exacerbations

Feeding/Activity normalNo audible wheezingNot using accessory musclesNo chest windrowingRR < 50HR < 150

Feeding activity disturbedAudible wheezing presentUse of accessory musclesChest in-drawing presentRR>50/minHR> 150/minSaO2 < 92%

Unable to talk / feed Recessions and use of accessory musclesRR > 50 /minHR > 150 minPEFR < 50 %PaO2

Depressed LOC/ Agitated, DrowsyExhaustion Cyanosis or Saturation in air < 85%Poor respiratory effortSilent ChestPEFR < 33% of expected/ best Poor response to repeated doses of bronchodilators

Beta 2 agonists - oral or inhalerOral theophylines

Check precipitating factorsDoes he need a preventor?Patient education

Beta 2 agonists Inhaler or NebulisedTheophylinePrednisolone 2mg/kg/day 3-5 daysReassess in 30-60 min Home/wardPrecipitating factorsPatient educationDoes he/she need a preventor

Oxygen face mask 6-8 liters/min, nasal prongs 2 liters/minNebulisation with Oxygen every 20-30 min or continuesSalbutamol 2.5 (1/2 cc)- 5mg (1cc) +Ipratropium 250-500 mcg + 2 ml normal salineWhat is the diagnosis ( exclude Heart failure, pneumonia, DKA, bronchiolitis, pneumothorax, FB)What is the severityNeed resuscitation Immediate ABC, bag and maskLife threatening Ward ICUModerate/severe ward Mild OPD Home

SalbutamolIpratropium bromideBelow 1 yearBelow 5 yearsAbove 5 year

IV Aminophylin 5mg/kg in 2ml/kg N.Saline bolus/30mt 1mg/kg hrly IV Hydrocortisone 4mg/kg 6 hrly or 1mg/kg/hr IV AntibioticsIV fluids add potassium I.C.U. care IV Salbutamol 15 mcg/kg over 10 min 1-5 mcg/kg/minIV Magnesium sulphate 20- 100 mg/kg over 20 min, 6 hrlyAdrenaline 10 mic/kg sc ( 0.01ml/kg of 1:1000)IPPVMaintain SaO2 above 92%

Bronchial asthma - NO response to initial treatment , Consider following possibilities 1. 2. 3.4.5.6.

Suspect when Unequal Physical Signs Sudden onset, Unexplainable No responds to treatment

Treat by Needle thoracocentasis Chest drain

Indications for ventilation

PCO 2 > 8kpaHypoxia Po2 < 8kpaIncreasing exhaustion

Precipitating factors ?Prevention step?Home management Policy- Salbutamol via spacer Patient educationInhaler techniquesCounseling and psychological issuesDiagnosis

DEFINITIVE CARE

Causes of recurrent wheezingIntra bronchial foreign bodiesRecurrent LRTIMediastinal massesHeart failureGastro oesophagial reflux

H type gastro oesophagial fistula Immune deficiencyLoeffler syndromeVascular rings, Cystic fibrosis, Cilliary dyskinesia

Step and treatmentDay time SymptomsNight symptomsMild intermittent Step oneSymptoms less than twice/wkNo interval symptoms, Brief exacerbations Varying intensityless than twice/moMild persistent Step twoMore than twice /wk but less than once/day Exacerbations affect the lifemore than twice a moModerate persistent Step threeDaily symptoms Exacerbation more than twice /wk last daysmore than once a weekSever persistentStep fourContinuous symptoms Limited physical activity Frequent exacerbations Frequent

Step and treatmentDay time SymptomsNight symptomsMild intermittent Step one Once a weekOnce /moMild persistent Step two2-7 /week 2-4/ moModerate persistent Step threeDaily symptomsmore than once a weekSever persistentStep fourContinuous symptoms Frequent

Mild intermittentLong term control No daily medicationQuick relief for exacerbationsSalbutamol or TurbutalineEducationFacts about asthmaInhaler techniqueAvoidance of precipitating factorsManagement of exacerbationsRecognition of acute severe asthma

Mild persistentLong term control Inhaled steroids low doseBeclamethasone 50-200 micg per dayBudesonide 100 200 micg per dayFluticasone 100- 150 micg per dayEducationFacts about asthmaInhaler techniqueAvoidance of precipitating factorsManagement of exacerbationsRecognition of acute severe asthma

Moderate persistentMedium dose steroids Beclamethasone 200- 400 micg/dayBudesonide 200 600 micg/dayFluticasone 200 400 micg/dayORLow dose steroids + Long acting beta 2 agonist

For night symptomsLong acting beta agonists - inhaled or oralSustained release theophylineEDUCATION and counseling

Severe persistentHigh dose steroids + long acting bronchodilatorsBeclamethasone > 400 micg/dayBudesonid > 600 micg/dayFluticasone > 400 micg/dayLong acting oral beta 2 agonistsSustained release theophylinesOral steroidsEducation and counseling

Other drugs for asthma control

KetotifenSodium cromoglycateLeukotrene receptor antagonistsMontelucastZafirlukast

For Successful Asthma ControlPatient educationAbout the diseasePrecipitating factorsRecognition of acute severe asthmaHome management of acute severe AsthmaInhaler techniqueEncouragements and appreciationsConfidence building - Control is possibleFrequent monitoring