Pediatrics Respiratory Emergencies. #1 cause of –Pediatric hospital admissions –Death during first year of life except for congenital abnormalities

PediatricsPediatricsRespiratory EmergenciesRespiratory Emergencies

Respiratory EmergenciesRespiratory Emergencies

#1 cause of #1 cause of – Pediatric hospital admissionsPediatric hospital admissions– Death during first year of life except for Death during first year of life except for

congenital abnormalitiescongenital abnormalities


Most pediatric cardiac arrest Most pediatric cardiac arrest begins as respiratory failure begins as respiratory failure

or respiratory arrestor respiratory arrest

Pediatric Respiratory SystemPediatric Respiratory System

Large head, small Large head, small mandible, small neckmandible, small neck

Large, posteriorly-Large, posteriorly-placed tongueplaced tongue

High glottis openingHigh glottis opening

Small airwaysSmall airways

Presence of tonsils, Presence of tonsils, adenoidsadenoids

Pediatric Respiratory SystemPediatric Respiratory System

Poor accessory muscle developmentPoor accessory muscle development

Less rigid thoracic cageLess rigid thoracic cage

Horizontal ribs, primarily diaphragm breathersHorizontal ribs, primarily diaphragm breathers

Increased metabolic rate, increased O2 Increased metabolic rate, increased O2 consumptionconsumption

Pediatric Respiratory Pediatric Respiratory SystemSystem

Decrease respiratory reserve Decrease respiratory reserve + Increased O+ Increased O22 demand = demand =

Increased respiratory failure Increased respiratory failure riskrisk

Respiratory DistressRespiratory Distress

Respiratory DistressRespiratory Distress

Tachycardia (May be bradycardia in neonate)Tachycardia (May be bradycardia in neonate)

Head bobbing, stridor, prolonged expirationHead bobbing, stridor, prolonged expiration

Abdominal breathingAbdominal breathing

Grunting--creates CPAPGrunting--creates CPAP


CroupCroup

EpiglottitisEpiglottitis

AsthmaAsthma

BronchiolitisBronchiolitis

Foreign body aspirationForeign body aspiration

LaryngotracheobronchitisLaryngotracheobronchitis

CroupCroup

Croup: PathophysiologyCroup: Pathophysiology

Viral infection (parainfluenza)Viral infection (parainfluenza)

Affects larynx, tracheaAffects larynx, trachea

Subglottic edema; Air flow obstructionSubglottic edema; Air flow obstruction

Croup: IncidenceCroup: Incidence

6 months to 4 years6 months to 4 years

Males > FemalesMales > Females

Fall, early winterFall, early winter

Croup: Signs/SymptomsCroup: Signs/Symptoms

““Cold” progressing to hoarseness, coughCold” progressing to hoarseness, coughLow grade feverLow grade feverNight-time increase in edema with:Night-time increase in edema with:– StridorStridor– ““Seal bark” coughSeal bark” cough– Respiratory distressRespiratory distress– CyanosisCyanosis

Recurs on several nightsRecurs on several nights

Croup: ManagementCroup: Management

Mild CroupMild Croup– ReassuranceReassurance– Moist, cool airMoist, cool air

Croup: ManagementCroup: Management

Severe CroupSevere Croup– Humidified high concentration oxygenHumidified high concentration oxygen– Monitor EKGMonitor EKG– IV tko IV tko ifif toleratedtolerated– Nebulized racemic epinephrineNebulized racemic epinephrine– Anticipate need to intubate, assist ventilationsAnticipate need to intubate, assist ventilations

Epiglottitis: PathophysiologyEpiglottitis: Pathophysiology

Bacterial infection (Hemophilus influenza)Bacterial infection (Hemophilus influenza)

Affects epiglottis, adjacent pharyngeal Affects epiglottis, adjacent pharyngeal tissuetissue

Supraglottic edemaSupraglottic edema

Complete Airway Obstruction

Epiglottitis: IncidenceEpiglottitis: Incidence

Children > 4 years oldChildren > 4 years old

Common in ages 4 - 7Common in ages 4 - 7

Pedi incidence falling due to HiB vaccinationPedi incidence falling due to HiB vaccination

Can occur in adults, particularly elderlyCan occur in adults, particularly elderly

Incidence in adults is increasingIncidence in adults is increasing

Epiglottitis: Signs/SymptomsEpiglottitis: Signs/Symptoms

Rapid onset, severe distress in hoursRapid onset, severe distress in hours

High feverHigh fever

Intense sore throat, difficulty swallowingIntense sore throat, difficulty swallowing

DroolingDrooling

StridorStridor

Sits up, leans forward, extends neck Sits up, leans forward, extends neck slightlyslightly

One-third present unconscious, in shockOne-third present unconscious, in shock


Respiratory distress+ Respiratory distress+ Sore throat+Drooling = Sore throat+Drooling =



Immediate Life ThreatImmediate Life Threat

Possible Complete Airway Possible Complete Airway ObstructionObstruction

Epiglottitis: ManagementEpiglottitis: Management

High concentration oxygenHigh concentration oxygen

IV tko, IV tko, ifif possiblepossible

Rapid transportRapid transport

Do Do notnot attempt to visualize airway attempt to visualize airway

AsthmaAsthma

Asthma: PathophysiologyAsthma: Pathophysiology

Lower airway hypersensitivity to:Lower airway hypersensitivity to:– AllergiesAllergies– InfectionInfection– IrritantsIrritants– Emotional stressEmotional stress– ColdCold– ExerciseExercise


Bronchospasm

Bronchial Edema Increased MucusProduction



Cast of airway produced by

asthmatic mucus plugs

Asthma: Signs/SymptomsAsthma: Signs/Symptoms

DyspneaDyspnea

Signs of respiratory distressSigns of respiratory distress– Nasal flaringNasal flaring– Tracheal tuggingTracheal tugging– Accessory muscle useAccessory muscle use– Suprasternal, intercostal, epigastric Suprasternal, intercostal, epigastric

retractionsretractions

Asthma: Signs/SymptomsAsthma: Signs/Symptoms

CoughingCoughing

Expiratory wheezingExpiratory wheezing

TachypneaTachypnea

CyanosisCyanosis

Asthma: Prolonged AttacksAsthma: Prolonged Attacks

Increase in respiratory water lossIncrease in respiratory water loss

Decreased fluid intakeDecreased fluid intake

DehydrationDehydration

Asthma: HistoryAsthma: History

How long has patient been wheezing?How long has patient been wheezing?

How much fluid has patient had?How much fluid has patient had?

Recent respiratory tract infection?Recent respiratory tract infection?

Medications? When? How much?Medications? When? How much?

Allergies?Allergies?

Previous hospitalizations?Previous hospitalizations?

Asthma: Physical ExamAsthma: Physical Exam

Patient position?Patient position?

Drowsy or stuporous?Drowsy or stuporous?

Signs/symptoms of dehydration?Signs/symptoms of dehydration?

Chest movement? Chest movement?

Quality of breath sounds?Quality of breath sounds?

Asthma: Risk AssessmentAsthma: Risk Assessment

Prior ICU admissionsPrior ICU admissions

Prior intubationPrior intubation

>3 emergency department visits in past year>3 emergency department visits in past year

>2 hospital admissions in past year>2 hospital admissions in past year

>1 bronchodilator canister used in past month>1 bronchodilator canister used in past month

Use of bronchodilators > every 4 hoursUse of bronchodilators > every 4 hours

Chronic use of steroidsChronic use of steroids

Progressive symptoms in spite of aggressive RxProgressive symptoms in spite of aggressive Rx

AsthmaAsthma

SILENT CHEST= DANGER OF SILENT CHEST= DANGER OF RESPIRATORY FAILURERESPIRATORY FAILURE

Golden RuleGolden Rule

Pulmonary edemaPulmonary edema

Allergic reactionsAllergic reactions

PneumoniaPneumonia

Foreign body aspirationForeign body aspiration

ALL THAT WHEEZES IS NOT ASTHMA

Asthma: ManagementAsthma: Management

AirwayAirway

BreathingBreathing– Sitting positionSitting position– Humidified O2 by maskHumidified O2 by mask

Dry O2 dries mucus, worsens plugsDry O2 dries mucus, worsens plugs

– Encourage coughingEncourage coughing– Consider intubation, assisted ventilationConsider intubation, assisted ventilation


CirculationCirculation– IV TKOIV TKO– Assess for dehydrationAssess for dehydration– Titrate fluid administration to severity of Titrate fluid administration to severity of

dehydrationdehydration– Monitor ECGMonitor ECG


Obtain medication historyObtain medication history– OverdoseOverdose– ArrhythmiasArrhythmias


Nebulized Beta-2 agentsNebulized Beta-2 agents– AlbuterolAlbuterol

POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE


Subcutaneous beta agentsSubcutaneous beta agents– Epinephrine 1:1000--0.1 to 0.3 mg SQEpinephrine 1:1000--0.1 to 0.3 mg SQ


Use EXTREME caution in giving two Use EXTREME caution in giving two sympathomimetics to same patientsympathomimetics to same patient

Monitor ECGMonitor ECG


AvoidAvoid– SedativesSedatives

Depress respiratory driveDepress respiratory drive

– AntihistaminesAntihistaminesDecrease LOC, dry secretionsDecrease LOC, dry secretions

– AspirinAspirinHigh incidence of allergyHigh incidence of allergy

Status AsthmaticusStatus Asthmaticus

Asthma attack unresponsive Asthma attack unresponsive to to -2 adrenergic agents-2 adrenergic agents


Humidified oxygenHumidified oxygen

RehydrationRehydration

Continuous nebulized beta-2 agentsContinuous nebulized beta-2 agents

CorticosteroidsCorticosteroids

Aminophylline (controversial)Aminophylline (controversial)

Magnesium sulfate (controversial)Magnesium sulfate (controversial)


IntubationIntubation

Mechanical ventilationMechanical ventilation– Large tidal volumes (18-24 ml/kg)Large tidal volumes (18-24 ml/kg)– Long expiratory timesLong expiratory times

Intravenous TerbutalineIntravenous Terbutaline– Continuous infusionContinuous infusion– 3 to 6 mcg/kg/min3 to 6 mcg/kg/min

BronchiolitisBronchiolitis

Bronchiolitis: PathophysiologyBronchiolitis: Pathophysiology

Viral infection (RSV)Viral infection (RSV)

Inflammatory bronchiolar edemaInflammatory bronchiolar edema

Air trappingAir trapping

Bronchiolitis: IncidenceBronchiolitis: Incidence

Children < 2 years oldChildren < 2 years old

80% of patients < 1 year old80% of patients < 1 year old

Epidemics January through MayEpidemics January through May

Bronchiolitis: Signs/SymptomsBronchiolitis: Signs/Symptoms

Infant < 1 year oldInfant < 1 year old

Recent upper respiratory infection exposureRecent upper respiratory infection exposure

Gradual onset of respiratory distressGradual onset of respiratory distress

Expiratory wheezingExpiratory wheezing

Extreme tachypnea (60 - 100+/min)Extreme tachypnea (60 - 100+/min)

CyanosisCyanosis

Asthma vs BronchiolitisAsthma vs Bronchiolitis

AsthmaAsthma–Age - > 2 yearsAge - > 2 years–Fever - usually normalFever - usually normal–Family Hx - positiveFamily Hx - positive–Hx of allergies - positiveHx of allergies - positive–Response to Epi - Response to Epi -

positivepositive

BronchiolitisBronchiolitis–Age - < 2 yearsAge - < 2 years–Fever - positiveFever - positive–Family Hx - negativeFamily Hx - negative–Hx of allergies - negativeHx of allergies - negative–Response to Epi - Response to Epi -

negativenegative

Bronchiolitis: ManagementBronchiolitis: Management

Humidified oxygen by maskHumidified oxygen by mask

Monitor EKGMonitor EKG

IV intoIV into

Anticipate order for bronchodilatorsAnticipate order for bronchodilators

Anticipate need to intubate, assist Anticipate need to intubate, assist ventilationsventilations

Foreign Body Airway Foreign Body Airway ObstructionObstruction

FBAOFBAO

FBAO: High Risk GroupsFBAO: High Risk Groups

> 90% of deaths: children < 5 years old> 90% of deaths: children < 5 years old

65% of deaths: infants65% of deaths: infants

FBAO: Signs/SymptomsFBAO: Signs/Symptoms

Suspect in any previously well, afebrile Suspect in any previously well, afebrile child with sudden onset of:child with sudden onset of:– Respiratory distressRespiratory distress– ChokingChoking– CoughingCoughing– StridorStridor– WheezingWheezing

FBAO: ManagementFBAO: Management

Minimize intervention if child conscious, Minimize intervention if child conscious, maintaining own airwaymaintaining own airway

100% oxygen as tolerated100% oxygen as tolerated

No blind sweeps of oral cavityNo blind sweeps of oral cavity

WheezingWheezing– Object in small airwayObject in small airway– Avoid trying to dislodge in fieldAvoid trying to dislodge in field

FBAO: ManagementFBAO: Management

Inadequate ventilationInadequate ventilation– Infant: 5 back blows/5 chest thrustsInfant: 5 back blows/5 chest thrusts– Child: Abdominal thrustsChild: Abdominal thrusts

Otitis MediaOtitis Media

It is an infection of the middle ear It is an infection of the middle ear

Acute Otitis media

Chronic Otitis media

EtiologyEtiology::

Suppurative Otitis media:Suppurative Otitis media:Bacteriologic: Hemophilus influenza, Beta Bacteriologic: Hemophilus influenza, Beta hemolytic streptococci or pneumococci.hemolytic streptococci or pneumococci.Secondary: common cold, measles or scarlet Secondary: common cold, measles or scarlet fever.fever.Nonsuppurative Otitis media:Nonsuppurative Otitis media:Allergy.Allergy.Auditory canal dysfunction (obstruction or Auditory canal dysfunction (obstruction or abnormal patency).abnormal patency).

Predisposing factorsPredisposing factors::

Auditory canal in children is shorter. Auditory canal in children is shorter. more accessible to invasion of more accessible to invasion of microorganism.microorganism.

Anatomic immaturity of tubal muscles Anatomic immaturity of tubal muscles and cartilage in children under two years and cartilage in children under two years of age.of age.

Certain craniofacial congenital defects Certain craniofacial congenital defects e.g. cleft palate and down syndrome e.g. cleft palate and down syndrome

Clinical manifestationsClinical manifestations::

History of common cold for several History of common cold for several dates.dates.Fever.Fever.Older child: pain in the affected ear, Older child: pain in the affected ear, headache, vomiting and/or impaired headache, vomiting and/or impaired hearing.hearing.Infant: may rub ear, anorexia, turn head Infant: may rub ear, anorexia, turn head from side to side and/or diarrhea.from side to side and/or diarrhea.Decreased hearing.Decreased hearing.

ComplicationsComplications::

Chronic otitis media.Chronic otitis media.

Mastoditis.Mastoditis.

Septicemia.Septicemia.

Meningitis and brain damage.Meningitis and brain damage.

Deafness.Deafness.

Diagnostic evaluationDiagnostic evaluation::

Pneumatic otoscope: bulging, red Pneumatic otoscope: bulging, red eardrum, rupture drum may be obscured eardrum, rupture drum may be obscured by secretions.by secretions.Culture and sensitivity: for secretions of Culture and sensitivity: for secretions of ruptured eardrum or by myringotomyruptured eardrum or by myringotomyTampanometery-to measure change in Tampanometery-to measure change in airpressureairpressureAcoustic reflectometery: measure sound Acoustic reflectometery: measure sound trasmission trasmission

Nursing interventionNursing intervention

Administer medications and treatments as prescribed.Administer medications and treatments as prescribed.

Wash hands prior to any treatment or contact with ear.Wash hands prior to any treatment or contact with ear.

Provide physical comfort:Provide physical comfort:Local heat.Local heat.

Encourage fluid intake to maintain hydration.Encourage fluid intake to maintain hydration.Give soft diet,.Give soft diet,.Observe for signs of complications Observe for signs of complications Provide emotional and psychological support Provide emotional and psychological support

TreatmentTreatment::

Identify the etiologyIdentify the etiology

Antibiotic according to culture Antibiotic according to culture

Analgesic and antipyretic Analgesic and antipyretic

Antihistaminic and decongestant Antihistaminic and decongestant

Follow up hearing tests Follow up hearing tests

SurgicalSurgical

pneumoniapneumonia

Definition: is Definition: is inflammation of the inflammation of the pulmonary pulmonary parenchyma occur as parenchyma occur as primary disease or as primary disease or as a complication of a complication of some other illnesssome other illness

EtiologyEtiology

1-Labor pneumonia: all or 1-Labor pneumonia: all or large segment of one or large segment of one or more pulmonary lobe is more pulmonary lobe is involvedinvolved2-Brocho-pneumonia: 2-Brocho-pneumonia: called lobular pneumonia called lobular pneumonia start in the terminal start in the terminal brochiolesbrochioles3-Interstial pneumonia:-3-Interstial pneumonia:-combined with the combined with the alveolar walls (interstitial) alveolar walls (interstitial) and peribronchial tissueand peribronchial tissue

Causes of pneumoniaCauses of pneumonia

11--Viral:- affact all age groupsViral:- affact all age groups

good prognosisgood prognosis

22--Primary typical pneumonia: affect 10%-Primary typical pneumonia: affect 10%-20% of hospitalized children20% of hospitalized children

))myeoplasma pnumyeoplasma pnu(.(.

33--Bacterial pnuBacterial pnu..

ManagementManagement

Can be treared at homeCan be treared at homeHospitalization for pleural effusion’ Hospitalization for pleural effusion’ empyema, staphylococcal pneumoniaempyema, staphylococcal pneumoniaIV fluildIV fluildO2 therapyO2 therapyAntiboiticAntiboiticSupportiveSupportiverestrest

Clinical SignClinical Sign

FeverFever

MalaiseMalaise

Rapid shalow respRapid shalow resp..

Chest painChest pain

Abdomenal painAbdomenal pain

Pleural effusionPleural effusion

ComplicationComplication

1-empyema1-empyema

2-pyopneumothorax2-pyopneumothorax

3-tension nuemothorax3-tension nuemothorax

4-pleural effusion4-pleural effusion

PrognosisPrognosis

Prognosis generally good for pneumococal Prognosis generally good for pneumococal infection resolve spontaneouslyinfection resolve spontaneously..

The course of treatment is generally The course of treatment is generally prolongprolong..

Early detection and treatment is effectiveEarly detection and treatment is effective

Nursing considerationNursing consideration

11--Isolation according to hospital policyIsolation according to hospital policy22--Bedrest is encourageBedrest is encourage

33--Fluid to prevent dehydrationFluid to prevent dehydration44--oral fluid is givenoral fluid is given

55--oxygenoxygenSitting positionSitting position

77--monitor vital signmonitor vital sign88--observe complicationobserve complication

99 - -suctionsuction1010 - -reduce stressreduce stress

Aspiration pneumoniaAspiration pneumonia

More common in children who has More common in children who has difficulty with swallowing or is unable to difficulty with swallowing or is unable to swallow because of swallow because of paralysis,weakness,congenital paralysis,weakness,congenital abnormalitiesabnormalities

Nursing managementNursing management

11--same as pneumoniasame as pneumonia

22--preventionprevention

33--proper feeding techniquesproper feeding techniques

44 - -family and health educationfamily and health education

55--treat the causetreat the cause

Cystic FibrosisCystic Fibrosis

Is the most common serious pulmonary Is the most common serious pulmonary and gastricand gastric

It is multisystem disorder mainly affect the It is multisystem disorder mainly affect the exocrine glandexocrine gland

Cystic fibrosis is inherited as autosomal Cystic fibrosis is inherited as autosomal recessive trait defect in chromosome recessive trait defect in chromosome number (7)number (7)

PathophysiologyPathophysiology

The basic biochemical defect in CF is The basic biochemical defect in CF is unknownunknown

The basic biochemical defect in CF is The basic biochemical defect in CF is unknownunknown

Clinical FeatureClinical Feature

Increase viscosity of mucus gland secretionIncrease viscosity of mucus gland secretion

Increase sweat electrolytesIncrease sweat electrolytes

Increase enzymatic and salivaIncrease enzymatic and saliva

Mechanical obstruction of secretion Mechanical obstruction of secretion

Meconium ileus which is the first signMeconium ileus which is the first sign

Thick secretion block the duct of the pancreasThick secretion block the duct of the pancreas

Rectal prolapsedRectal prolapsed

Bronchial obstruction result in hypoxia & acidsisBronchial obstruction result in hypoxia & acidsis

The result of pancreas blockageThe result of pancreas blockage

Cystic dilation of small lobe and gland that Cystic dilation of small lobe and gland that prevent essential pancreatic enzymes prevent essential pancreatic enzymes from reaching the duodenum result in from reaching the duodenum result in impair digestionimpair digestion

Disturbed GI function result in bulky stool, Disturbed GI function result in bulky stool, foul smell from undigested fatfoul smell from undigested fat

Biliary obstrucion Biliary obstrucion

Diagnosis of CFDiagnosis of CF

History of the diseaseHistory of the disease

Absence of pancreatic enzymesAbsence of pancreatic enzymes

Increase electrolyte concentration of sweatIncrease electrolyte concentration of sweat

Chronic pulmonary involvementChronic pulmonary involvement

Salty taste skinSalty taste skin

Chloride concentration more than 60 meq/l Chloride concentration more than 60 meq/l which consider as confirm diagnosis of CF which consider as confirm diagnosis of CF

Management of CFManagement of CF

General goal of treatment:General goal of treatment:

1- promote normal life for the child1- promote normal life for the child

2- maintain good nutrient2- maintain good nutrient

3- prevent respiratory infection3- prevent respiratory infection

4-psychological adjustment4-psychological adjustment


Pulmonary treatment:Pulmonary treatment:

Postal drainagePostal drainage

Chest physiotherapyChest physiotherapy

Oxygen therapyOxygen therapy


GI therapy:GI therapy:

Replacement of pancreatic enzymes with Replacement of pancreatic enzymes with meals and snakes.meals and snakes.

Provide coated enzymes to prevent from Provide coated enzymes to prevent from neutralization by gastric acidneutralization by gastric acid

Provide high caloriesProvide high calories

No restriction of fat No restriction of fat

Prognosis of CFPrognosis of CF

Early diagnosis and treatment Early diagnosis and treatment prolong life expectancy (God prolong life expectancy (God Knows)Knows)

According to the severity of S&SAccording to the severity of S&S

Good progress with lung Good progress with lung transplantationtransplantation

Complication of CFComplication of CF

Meconium ileusMeconium ileus

Rectal prolapsedRectal prolapsed

Nursing considerationNursing consideration

Take brief historyTake brief history

Assessment for resp.&GIAssessment for resp.&GI

Observe S&SObserve S&S

Teach the family Teach the family

Support Support

Medication awarenessMedication awareness

Teach about complicationTeach about complication

Documents

Pediatrics Respiratory Emergencies. #1 cause of –Pediatric hospital admissions –Death during first year of life except for congenital abnormalities