Respiratory Emergencies

Respiratory Emergencies in Children Mohamed Khashaba,MD Professor of Pediatrics/Neonatology Head of NICU, MUCH

Children’s Respiratory Emergencies More serious compared to  .adults

Neonates, who are obligate nasal breathers, often experience serious respiratory distress with nasal obstruction.

Proportionally larger heads, prominent occiputs, and relatively lax cervical support, which increases the likelihood of airway obstruction in the supine position

A relatively large tongue in comparison to a small oropharynx further contributes to this problem.

The subglottis is the narrowest segment of the pediatric airway, in contrast to the glottis in adults.

Resistance

Airway or tube Diameter Poiseuille’s Law

R = L / r4

Clinical applications • Reduction of radius by ½ results in 16 fold increase of resistance.

• Resistance during inspiration is less than expiration.

• Accumulated secretions add to resistance.

Considering that the change in airway flow is directly proportional to the airway radius elevated to the fourth power, An airway with a diameter of 7 mm that develops a 0.5 mm edema will have a flow of 54% of baseline,

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Managing a child in respiratory Distress

The patient can remain in the caregiver arms while the examiner assesses the respiratory rate and the degree of distress

Tachypnea

Neonate > 60  Infants >50  Young child >40  Older child >30 

Dyspnea Laboured breathing  ) ) increased WOB Nasal flaring .1  . Expiratory grunting .2  .Use of accessory muscles .3  Retraction of chest wall.4  .) )recession .Difficult speaking or feeding .5 

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Increasing rate of respiration, nasal flaring, use of accessory muscles or presence of respiratory fatigue can indicate serious respiratory distress.

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Cyanosis is usually a very late sign of respiratory compromise.

Drowziness in addition to  cyanosis indicates severe hypoxemia and the need for .urgent intervention Pulse oximetry is the most  reliable objective measure of hypoxemia

Chest Shape .Hyperexpansion or barrel shape  .)Pectus exavatum )hollow chest  Pectus carinatum )pigeon  .) chest Harrison’s sulcus  .Assymetry of chest movement 

Palpation Chest expansion )3-5 cm in  school age ), check for .assymetry .) Trachea )selectively  .Location of apex beat 

Percussion Seldom informative in infants  Localized dullness indicate  .collapse or consolidation or fluid

Auscultation Use your ears for  auscultation before the stethoscope

Hoarse voice indicate .1  .abnormality of vocal cords Stridor .2  3. Harsh transmitted sounds from the upper airways are readily transmitted to the upper chest in infants.

Auscultation Quality and symmetry of .1  .breath sounds Wheezes: indicate distal .2  .airway obstruction Crackles discontinuous moist  sounds from opening of .bronchioles

Other aspects in examination   

Pulse rate,rhythm and quality. Heart examination Hepatomegaly or palpable liver.

Effect of position Noisy breathing caused by laryngo -omalacia, micrognathia, macrolgossia, and innominate artery compression diminishes when the baby lies prone with the neck extended.

Effect of position 

Respiratory distress caused by unilateral vocal cord paralysis may improve with the baby lying on the affected side.

Upper Respiratory Obstruction

supraglottic laryngeal obstruction 

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often present with a muffled or throaty voice. These patients tend to snore while sleeping and produce coarse inspiratory sounds at rest. Feeding is difficult for these patients and mouth breathing is the norm. Cough is not usually present.

Upper Respiratory Obstruction Croup  Viral laryngotracheobronchitis  Laryngomalacia  ) Bacterial tracheitis )rare 

Rare causes of URO Epiglottitis  Smoke inhalation  Trauma  .Retropharyngeal abscess  .Angioedema  .Tetany  .Laryngeal FB  I. Mononucleosis, measles,  diphtheria

Basic management of URO ’.t examine the throatDon .1  Reduce anxiety of the staff .2  .and patient Observe for signs of hypoxia .3  .or deterioration Adminster nebulized .4  ! adrenaline Urgent intubation if RF .5  .develops

Croup of laryng tracheal % 95  .infections Parainfluenza virus is the  leading cause, other viruses .also Peak incidence in the 2nd year of  .life .Commonest in automn 

Croup .Barking severe cough  .Harsh Stridor  .Hoarseness  .Preceeded by coryza  .Worse at night  .No drooling saliva 

Croup ttt !! Inhalation of warm moist air  .Inhaled and oral steroids  .Nebulized adrenaline 

Acute Epiglottitis .Onset over hours not days  .No preceeding coryza  .Absent cough  .Drooling saliva, unable to drink  .Toxic, very ill  .High fever > 38.5  .Soft whispering stridor  .Muffled voice  . Sits immobile, upright, open mouth

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Epiglottitis ttt :In suspected cases  .Urgent hospitalization  .ICU or anesthesia room  Intubation by senior staff with  .general anesthesia Rarely, tracheostomy is  .required

Epiglottitis ttt after intubation .Blood drawn for culture  IV antibiotics given  .Recovery within 2-3 days 

Lower Respiratory problems .Bronchiolitis  .Asthma  .Pneumonia  .Inhaled foreign body  . Air leak 

tracheobronchial obstruction 

usually have a normal voice and their stridor is generally expiratory with a component of wheezing. cough is usually present

Bronchiolitis Age 1-9 months  .Poor feeding dry cough, apnea  Hyperinflated chest in addition  .to other signs of RD .Apnea, cyanosis may occur  CXR hyperinflation, focal  .atelectasis

Bronchiolitis ttt Humidified 02 via nasal cannula  .or head box .Pulse oxymetry  .Fluids NG or IV  .?? Nebulized bronchodilators  Antibiotics, steroids are not  .helpful .MV in 2% of admitted cases 

Downes’ score

)Dowenes et )al., 1970

GRADE

0

1

2

RR

60

60-80

Cyanosi s Retracti on Gruntin g

None

In air

>80 or apneic episodes in 2 In40% 40%OO

None

Mild

Air entery

None

Audible by Clear stethosco Delayed pe

2

Moderate to severe Audible by naked ear Audible

Silverman Anderson retraction score FEATURE Chest Movemen t Intercost al Retractio Xiphoid n Retractio n Nasal Flaring Expirator y Grunt

)AWHONN.,2006) SCORE 0 Equal None

SCORE 1

SCORE 2

Respiratory Seesaw Lag Respirati on Minimal Marked

None

Minimal

Marked

None

Minimal

Marked

None

Audible With

Audible

Arterial Blood Gases )ABG) Score )Mathai et al., 2007)

PaO2 mm Hg pH PaCo2 mm Hg

0

1

2

3

> 60

50 – 60

< 50

< 50

> 7.3

7.20 – 7.29

7.1 – 7.19

< 7.1

< 50

50 - 60

61 - 70

> 70

Effect of position 

Respiratory distress caused by unilateral vocal cord paralysis may improve with the baby lying on the affected side.

Respiratory distress syndrome (RDS)

 Small lung

volume

 Ground glass

appearance

 Air bronchogram

Hyaline Membrane Disease

Meconium Aspiration Syndrome

Meconium Aspiration Syndrome  Diffuse

patchy pulmonary opacities

 Pneumothora

x

Pneumothorax .Respiratory Distress  Decrease breath sounds on  .affected side .Decreased vocal fremitus  Hyperresonance on affected  .side .Tachycardia  .Shift of mediastinum  .Cyanosis 

Imaging in Pneumothorax     

Radiolucency of affected lung. Lack of lung markings . Collapsed lung. Possible pneumomediastinum CT in small pnumothorax or to differentiate from a cyst.

Congenital Lobar Emphysema

Pneumomediastinum

Pneumopericardium

Management of Pneumothorax  

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Stabilization of the patient Urgent evacuation in symptomatic cases. Treat the underlying cause. Oxygen.

Lung Collapse

DIAPHRAGMATIC HERNIA

Staph. Pneumonia