Respiratory Distress beyond the Neonate Tina M. Slusher, MD FAAP University of Minnesota [email protected] What is the biggest killer of under 5yo worldwide? 1. Diarrhea 2. Respiratory Illnesses 3. HIV/AIDS 4. Measles Figure 4 The Lancet 2010; 375:1969-1987 Most pediatric arrests are 1. 2. 3. Cardiac Respiratory Shock Acute Respiratory Emergencies • Frequent in • • infants/young children Must remember that pediatric airways are NOT simply little adult airways (higher and more anterior) Can progress rapidly if not recognized and treated appropriately Airway always FIRST! Correct airway position <2yo 1. 2. 3. A B C Which best shows SNIFFING Position? 1. Dog/Baby 2. Dog 3. Lady 4. ALL of the Above Correct position for child/adolescent ≥ 2yo Nasopharyngeal Airway Length: Length:Tragus Tragusto toNostril Nostril    Can make with cut ETT Can use in Awake patient Don’t use if worried about CSF leak , basilar skull fx or bleeding disorder Oral Airways Measure carefully Too short pushes back Too long occludes the airway First sign of respiratory distress in most children 1. 2. 3. Retractions Tachypnea Oxygen requirement 4. Tachycardia Tachypnea • Most common sign of respiratory distress in infant/child • Usually due to hypoxia & hypercarbia • Other causes include metabolic acidosis, pain, anxiety, or CNS insult – Generally quite tachypnea w/out “distress” Normal Resting Respiratory Rates (infants/children) AGE Newborn Infant (1-6mo) Infant (6-12mo) 1-4 yrs. 4-6 yrs. 6-12 yrs. >12 yrs. RATES (breathes/min) 30-60 30-50 24-46 20-30 20-25 16-20 12-16 Other Signs of Respiratory Distress • Seesawing or abdominal breathing • Head bobbing • respiratory effort-retractions, flaring – Retraction w/stridor or snoring ≈ upper airway obstruction – Retractions w/expiratory wheezing ≈ lower airway – Retractions w/grunting & RR ≈ lung tissue disease Signs of Respiratory Distress cont. • Retractions and flaring happen with recruitment of accessory muscles • Sometime close glottis to generate “PEEP” when in severe distress Allow position of comfort • Child’s way of attempting to solve/compensate for problem • Examples include: – Tripoding in lower airway diseases such as asthma – Jaw Thrust to help in acute upper airway obstruction Look for central cyanosis • If possible place child on pulse oximeter • If not available check child’s mucus membranes • Irritability, agitation, or lethargy can be signs of agitation What % oxygen does a premature neonate get from 1L per nasal canula 1. 2. 3. 4. 30% 25% 50% >60% Nasal(neonate) Cannula Conversion (GomellaGomella-Lange) Flow rate ¼L ½L ¾L 1L ≅ FI02 34% 44% 60% 66% Oxygen concentrators work best with nasal cannulas. Oxygen Therapy In an adult 1L flow ≅ 24% FIO2 ↑FIO2 by 4% for every 1L flow up to 6 L flow (2L ≅28%) Oxygen Delivery Techniques cont. Device Flow (L/min) % Oxygen Simple face mask 6-10 35-60 Face tent 10-15 35-40 Venturi mask 4-10 25-60 Partial 10-12 50-60 rebreathing mask Oxyhood 10-15 80-90 10-12 90-95 Nonrebreather mask Impending Respiratory Failure • Markedly increased WOB • Dropping saturations (especially below • • • • • 87% on oxygen) Decreased air entry esp. in asthma Sweating Irregular breathing / apnea Change in mental status Inability to talk in complete sentences Teach PPV well before considering teaching intubation IF considering intubation have a plan of what to do If no ventilator available If PPV and Patient not getting PINK and/or Chest not moving • Reposition, reposition, reposition airway • Change size of bag mask if needed • Make sure bag/mask not worn out or defective • Try suctioning • Make sure oxygen actually connected and oxygen cylinder not empty • Trial decompressing stomach w/nasogastric tube Acute Upper Airway Obstruction • Commonly presents as stridor • Causes include: – Croup (usually viral but can be bacterial or allergic) – Epiglottitis (rare with HIB vaccine but many countries still don’t have) – Retropharyngeal abscess – Foreign body (history sometimes helpful) • Treatment specific to cause • Trial of nebulized epinephrine w or w/out • steroids often warranted Short term intubation maybe needed and indicated EVEN in resource limited settings! *Croup Treatment • Racemic Epi: 4yo=0.05ml/kg up to max of 0.5ml Q1-2 hours>4yo 0.5ml q3-4 hours • Epinephrine: 0.5ml/kg of 1:1000 solution diluted in 3ml of NSS (max dose 4yo=2.5ml/dose; max dose >4yo=5ml/dose) Bacterial Pneumonia/Respiratory Infection Age Bacterial Pathogen <1mo Group B strep, E. Coli, Klebsiella, Pseudomonas, Listeria 1-3mo H. influ, S. pneumonia, Grp A or B strep, pertussis 3mo- 5 S. pneumonia, H. influ, yrs. Staph aureus, Grp A Strep, pertussis >5yo S. pneumonia, H. influ, Grp A Strep Empiric Therapy Amp + Aminoglycoside OR Amp + Cefotaxime Amp + Cefotax Cephalosporin + antistaph or pertussis coverage if indicated PCN OR Amp OR Cephalosporin + antistaph or pertussis coverage if indicated Musts to Diagnosis Pneumonia 1. 2. 3. 4. 5. 6. CXR Stethoscope Respiratory Rate Fever, cough 3&4 All of the above • Studies have shown doctors, labs, and X- ray’s are not required to drastically reduce mortality due to pneumonia. • Many lives have been saved by training village health workers to: Count respiratory rates. To administer oral antibiotics for children whose fevers and coughs or difficulty breathing w/ tachypnea. The Other Side • Adding simple markers like history of previous respiratory distress and response to BD therapy to the existing WHO guidelines it is possible to reliably differentiate pneumonia from acute exacerbation of asthma…. Bringing the overuse of antibiotics from 78.9% to 26.3% (p <0.001) Redefining the WHO algorithm for DX of PNA w/Simple Additional Markers Savitha MR. Khanagavi JB. Indian Journal of Pediatrics. 75(6):561-5, 2008 Jun. Vaccines do they make sense? • Intervention's TO PREVENT/ EVIDENCE OF • IMPACT Vaccination against measles, pertussis, pneumococcus and Hib – 22–34% reduction in incidence for Hib – 23–35% reduction in incidence for Spn – 4% reduction in all child deaths with Hib and 1% with measles • Prevention of HIV in children – 2% reduction in all child deaths http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_NCH_09.04_eng.pdf Countries that have introduced Hib vaccine and coverage in infants (2008) http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_NCH_09.04_eng.pdf Status of Global Pneumococcal conjugate vaccine introduction (2008) http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_NCH_09.04_eng.pdf Bronchiolitis • Cough, URI, often infant • Low grade fever • Apnea in neonate • Crackles • Air trapping • Appropriate to try bronchodilators but only continue if helps!!! • Antibiotics NOT indicated or helpful!! • New studies considering hypertonic saline Asthma • Primary Components – Smooth Muscle Spasm – Edema of the Airway – Mucus Plugging of Airway Needed to Treat Asthma 1. Steroids 2. Spacer for MDI 3. 2 agonist 4. 1 & 3 5. All of the above Common Finding in Asthma • Hyperinflation • – Air trapping and subsequent hyperinflation caused by obstruction of small airways w/premature closure Hypoxemia – Ventilation perfusion (V/Q) mismatching caused in part by mucus plugging Determine level of Distress • Look for: – Inability to speak in full sentences – Sweating – Change in consciousness – Decreased or absent breath sounds – Oxygen saturation <90% on oxygen – Tripoding and refusal to lie down Oxygen • Good in Asthma • Unlike Adults w/COPD will NOT depress respiratory drive • May need oxygen if as otherwise clearly improving Enough Fluid but NOT too MUCH • IF dehydrated rehydrate to euvolemia then stop • Extra fluid may wind up in LUNGS and worsen distress • As with pneumonia pts w/asthma at risk for fluid overload secondary to SIADH ß-Agonists • Mainstay of acute asthma treatment • Cause bronchial smooth muscles relaxation by • • their effect on ß2-receptors Epinephrine still useful but has more cardiac side effects than newer ones Albuterol, Salbutamol, and Terbutaline are more selective 2 drugs with fewer cardiac effects Metered Dose Inhalers (MDI’s) • Similar effect to nebs if pts using MDI with spacer – 4-8 puffs every 20 minutes for 3 doses compares favorably w/ nebs 2.5-5mg q 20 minutes in coordinated patients • If needed in severe asthma (in monitored situations) MDI dosing can be increased to 1 puff q 30-60 seconds DON”T Allow at HOME!!! (my suggestion) Boulet LP Canadian Asthma Consensus Group. CMAJ 1999;161(11suppl):S53-9. Ackerman AD. Continuous nebs…Crit Care Med 1993;21:1422-4 Home-made spacer for bronchodilator therapy in children with acute asthma: randomized trial” Zar et al Lancet 1999;354:979-82 • Interpretation – Conventional spacer and sealed 500 ml plastic bottle produced similar bronchodilation – Unsealed bottle gave intermediate improvement – Polystyrene cup was least effective as a spacer • Use of bottle spacers should be incorporated into guidelines for asthma management in developing countries. Sealed spacers Take 500 ml plastic cold drink bottles Cut hole in base to fit size and shape of MDI Seal bottle-MDI perimeter w/ glue Use opposite end as mouthpiece  agonist SQ (subcutaneous) • Epinephrine SQ may help avoid need for mechanical ventilation in pts w/status asthmaticus and is still useful in place where nebulizers and MDI’s not available – SQ dose is 0.01cc/kg 1/1000 up to a maximum of 0.5cc every 15-20 minutes x 3-4 doses or Q4hrs prn (max in adults is 0.3cc) • Terbutaline SQ can be given every 20 minutes • X 3 doses (0.01ml/kg of 1mg/cc drug) up to maximum of 0.4cc Statisticians Who WINS? Improvement in FEV1% Steroids in Red—Placebo in Yellow 1. Steroids 2. Placebo 140 120 FEV1% 100 80 Steroids Placebo 60 40 20 0 -20 -5 0 6 12 Hours 18 24 Fanta CH: Am J Med 1983;74:845 Steroids critical and first line • Asthma is an inflammatory illness!! • Don’t delay--Give early—can be given po or IV unless unable to take po Anticholinergics • Work best in severe asthma • Ipratropium – Nebulize 250 - 500 g every 6 hours Atropine •Alternative to Ipratropium bromide •Dose: 0.03-0.05mg/kg/dose •(max 2.5mg/dose q 6-8 hours) •Atropine comes in many different strengths so yours Theophylline • Formerly mainstay in all asthmatics but • Narrow therapeutic window with serious • • side effects led to ↓↓ use However still probably some patients who do NOT completely clear without its use AND it is often one of the few choices in the developing world. Theophylline another point of view…. (some people still like it  even in USA ) • Theophylline when added to continuous nebulized albuterol therapy and IV corticosteroids, is as effective as terbutaline in treating critically ill children…More cost effective…theophylline should be considered early in the management of critically ill asthmatic children” – Wheeler et al Pediatr Crit Care Med. 2005 Mar;6(2):142-7. Magnesium • Causes bronchodilation by smooth-muscle relaxation • • Dosage recommendation: 25 - 75 mg/kg i.v. over 20 minutes If responds may use drip of 25 mg/kg/hour and titrate up by about 5mg/kg/hour attempting to maintain magnesium levels of 4-6 mg/dL* or if in the developing world maintaining knee jerks—if knee jerk present should not have toxic magnesium levels) (*check units to determine therapeutic goal if measuring Mg levels) May be particularly beneficial in pts who are prone to Mg because of either prolonged heavy use of Beta 2 agonists or ? malnutrition Broaden your differential if not responding to therapy for asthma or IF something does not “SMELL” right! • Foreign body (esp. if unilateral) • Bronchiolitis (esp. if URI and young) • Heart or lung disease • Vocal cord dysfunction or mass (e.g. papiloma from HSV) • Tracheomalacia (esp. if from near birth)