Transcript Document

Respiratory Distress
National Pediatric Nighttime Curriculum
Written by Liane Campbell, MD
Lucile Packard Children’s Hospital, Stanford
University
Learning Objectives
Review the initial assessment of patient in
respiratory distress
 Review management of specific causes of
respiratory distress

 Upper
airway obstruction
 Lower airway obstruction
 Lung tissue disease
 Disordered control of breathing
During a busy night, you get the following page:
FYI: Sally, a 2 year old
with PNA had a desat to
88% while on 2L NC.
What do you do next? What initial management steps
would you take?
How do you initially
assess a patient in
respiratory distress?
Initial Assesment

Rapid assessment



Airway



Support or open airway with jaw thrust
Suction and position patient
Breathing





Quickly determine severity of respiratory condition and stabilize
child
Respiratory distress can quickly lead to cardiac compromise
Provide high concentration oxygen
Bag mask ventilation
Prepare for intubation
Administer medication ie albuterol, epinephrine
Circulation

Establish vascular access: IV/IO
History and Physical Exam
History
 Trauma
 Change in voice
 Onset of symptoms
 Associated symptoms
 Exposures
 Underlying medical
conditions
Physical Exam
 Mental status
 Position of comfort
 Nasal flaring
 Accessory muscle use
 Respiratory rate and
pattern
 Auscultation for abnormal
breath sounds
What initial studies
would you get for a
patient in respiratory
distress?
Initial studies

Pulse oximetry
 May
 May

be difficult in agitated patient
be falsely decreased in very anemic patients
Imaging
 Chest X Ray
 Consider in patients with focal lung findings or respiratory
distress of a unknown etiology
 Soft tissue radiograph of lateral neck
 May identify a retropharyngeal abscess or radiopaque foreign
body

Labs
 ABG/VBG
 Chemistry: calculate anion gap
 Urine toxicology and glucose if patient
mental status
has altered
What are some
examples of life
threatening conditions?
Life threatening conditions

Complete upper airway obstruction
 No

effective air movement, speech or cough
Respiratory failure
 Pallor
or cyanosis, altered mental status, tachypnea,
bradypnea, apnea

Tension pneumothorax
 Absent
breath sounds on affected side, tracheal
deviation and compromised perfusion

Pulmonary embolism
 Chest

pain, tachycardia, tachypnea
Cardiac tamponade
 Apnea,
tachycardia, hypotension, respiratory distress
Specific Causes of Respiratory
Distress
Upper airway obstruction
 Lower airway obstruction
 Lung tissue disease
 Disordered control of breathing

Case 1
8 month old ex-FT girl with 2-3 days of nasal
congestion, cough, and sneezing, was
RSV+ on admission with mild work of
breathing requiring 0.5L O2. As you’re
watching the monitors on Short Stay with
the nurse at 2am, she’s now 84-89%.
What is your diagnosis?
What are your next steps?
Case 2
4 year old boy admitted to GI service for
monitoring and serial AXRs because he
ingested a sharp object. He’s tucked in for
the night with an AM AXR ordered. But
after his dinner, he suddenly becomes
stridulous, and starts crying and drooling.
Parents just left the room to get dinner.
What is your initial evaluation/management?
Case 3
3 year old girl with 2 days of fever, noisy
breathing and loud barking cough tonight.
In the ED 3 hrs ago, got one racemic epi
neb and a dose of oral steroids. Admitted
for observation.
Nurse calls now because his breathing is
getting noisy at rest and he’s coughing. No
respiratory distress. How do you manage
him overnight?
Case 4
Jonathan is a 2 year old with Pompe’s
disease who is BiPAP dependent
overnight with settings of 18/5 and a
backup rate of 18. Over the past few
hours, he has had an increase in his
oxygen requirement from an FiO2 of 21 to
40% and has spiked to 39.2.
What steps do you take to evaluate and
manage him overnight?
Upper Airway Obstruction


Causes: foreign body, tissue edema, trauma, viral infection,
intubation, tongue movement to posterior pharynx with
decreased consciousness
Symptoms



Partial obstruction: noisy inspiration (stridor), choking, gagging or
vocal changes
Complete obstruction: no audible speech, cry or cough
Management




Rapidly decide if advanced airway is needed
Avoid agitation
Suction only if blood or debris are present
Reduce airway swelling



Inhaled epinephrine
Corticosteroids
Croup and anaphylaxis require additional management
Lower Airway Obstruction

Bronchiolitis
 Symptoms:
copious nasal secretions, wheezes and
crackles in child less than 2 years
 Management




Oral or nasal suctioning
Viral studies, CXR, ABG/VBG
Trial of nebulized albuterol
Asthma
 Symptoms:
wheezing, tachypnea, hypoxia
 Management



Mild-moderate: oxygen, albuterol, oral corticosteroids
Moderate to severe: oxygen, albuterol-ipratropium (DuoNeb), corticosteroids (IV), magnesium sulfate
Impending respiratory failure: oxygen, albuterol-ipratropium,
corticosteroids, assisted ventilation (bag-mask ventilation,
BiPAP, intubation), adjunctive agents (terbutaline,
magnesium sulfate), heliox
Lung Tissue Disease

Etiologies of lung tissue disease
 Infectious
pneumonia
 Aspiration pneumonitis
 Non-cardiogenic pulmonary edema (ARDS)
 Cardiogenic pulmonary edema (ARDS)

Consider positive expiratory pressure (CPAP,
BiPAP or mechanical ventilation with PEEP)
if hypoxemia is refractory to high
concentrations of oxygen
Disordered Control of Breathing


Abnormal respiratory pattern produces inadequate
minute ventilation
Altered level of consciousness

Elevated intracranial pressure


Poisoning or drug overdose




Administer specific antidote if available
Hyperammonemia
Metabolic acidosis
Neuromuscular disease


Cushing’s triad
Restrictive lung disease => atelectasis, chronic pulmonary
insufficiency, respiratory failure
Support oxygenation and ventilation while treating the
underlying problem
Take Home Points
The initial assessment of a patient in
respiratory distress should be rapid and
focused on quickly determining the
severity of respiratory distress and need
for emergent interventions
 Specific causes of respiratory distress can
be categorized as upper and lower airway
obstruction, lung tissue disease and
disordered control of breathing and require
specific interventions

Questions
1. Which of the following are NOT symptoms
of an upper airway obstruction?
1.
2.
3.
4.
5.
Gagging
Changes in voice quality
Noisy inspiration (stridor)
No audible speech, crying or cough
Crackles on auscultation
(answers are in speaker’s notes)
2. During a busy evening shift, you admit a 2 year old
male who presents with a barking cough, stridor at
rest, and moderate retractions. He is alert and
oriented and calms with his mother. His vital signs
on admission are temperature 38.5, heart rate 165,
respiratory rate 65, blood pressure 90/45 and oxygen
saturation of 92%. Which of the following should
NOT be included in your initial management?
1. Oxygen
2. Keeping the patient NPO
3. Nebulized racemic epinephrine
4. Dexamethasone
5. Nebulized albuterol
3. What is the first medication that should be
given to a patient with anaphylaxis and
respiratory distress?
1.
2.
3.
4.
5.
Diphenhydramine
Ranitidine
Solumedrol
Epinephrine
Albuterol
4. While on call in January, you admit a 10 month old prev.
healthy female who presents with cough, nasal
congestion and fevers of 2 days and 1 day of
tachypnea. She is fully immunized. On exam, her temp
is 39.2, HR 130, RR 55 and O2 sat 93% on RA. Her
lung exam reveals diffuse crackles and wheezes at the
bases as well as moderate subcostal retractions, but no
flaring, grunting or head bobbing. Which diagnostic test
is most likely to demonstrate the cause of her
respiratory distress?
1.
2.
3.
4.
5.
Chest X Ray
Nasopharyngeal swab for viral panel
Blood culture
Urinalysis
CBC with differential
5. When performing an initial assessment of
a patient in respiratory distress, the
history should include all of the following
elements EXCEPT:
1.
2.
3.
4.
5.
Change in the quality of voice
Underlying medical conditions
Recent episodes of trauma
Previous episodes of respiratory distress
Detailed family history
References
Albisett, M. Pathogenesis and clinical manifestations
of venous thrombosis and thromboembolism in
infants and children. June 2010. UpToDate.
Bailey, P. Oxygen delivery systems for infants,
children and adults. May 2010. UpToDate.
Ralston, M.et. al. Pediatric Advanced Life Support
Provider Manual. 2006. American Heart
Association.
Sherman, S.C. and Schindlbeck, M. When is venous
blood gas analysis enough? Emerg Med 38(12):4448, 2006
Simons, F. Anaphylaxis: Rapid recognition and
treatment. September 2010. UpToDate.
Weiner, D. Emergent evaluation of acute respiratory
distress in children. May 2010. UpToDate.