Transcript Respiratory Failure in Children

Common Respiratory
Problems
In
Children
Case 1:
4 months old
One day history of
excessive crying
Sent home with the
diagnosis of windy
colic with antispasmodics
Next day:
– Grunting, respiratory
distress, fever.
– Admitted ,oxygen, IV
ceftriaxone.
Case (contd)
Second day:
– Mother felt better but
continues to be
tachypnoeic, chest
indrawing, fever
persisting.
– Vancomycin added
with oxygen
Case (contd)
Third day
– Severe respiratory
distress
– Pus drained through water
seal drainage
– Antibiotics contd.
– Discharged after 2 wk.
Strepto.pneumoniae isolated
Case 2
16 month old boy with wheeze
Initial Vitals:
HR
RR
BP
Temp
O2sat on RA
160
60
88/50
38
89%
You do your pediatric triage
Appearance
Crying, distressed, looking
around, moving all 4 limbs
Breathing (work of)
Laboured, chest caving in,
+++indrawing
Circulation
Colour OK, N cap refill
What would you like to do now?
Oxygen by mask applied, IV attempt started and
pt now on cardiac monitor
Airway
No stridor audible, no obvious secretions
Breathing
+++ wheeze with little air entry bilat
(inspiratory AND expiratory)
Circulation Warm extrem, PPP, cap refill 2 secs
What would you like to do now?
Oxygen
CXR done / pending
Salbutamol nebulizer
IV Access established – orders?
ABG report
Venous Gas
pH
pCO2
pO2
7.35
38
125
Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of
35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
History:
 Has had a “cold” for almost 2 days now
(mild fever, decreased energy / appetite with cough
and runny nose)
 Started getting wheezy this morning
 No history of exposure to allergens, inhalants
or FB aspiration
Family History of Asthma / no smokers / no pets
Otherwise healthy with no known allergies
Continuous Salbutamol nebulizer
for 15 mins has little effect
 Still indrawing
 RR 65
 Still alert and looking around, crying
Additional treatment?
IV steroids Methylprednisolone 1 mg/kg IV / IM
Continue Salbutamol
Consider racemic Epinephrine (0.5 mls)
Repeat Venous Gas about 30 mins later
pH
7.15
pCO2
55
pO2
120
Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of
35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
Eyes rolling back, little crying now …
What do you want to do?
Drugs? Tube Size?
4 – 4.5 tube
Ketamine 1-2 mg/kg IV
Atropine 0.01 mg/kg IV (min 0.1 mg)
Succinyl 1 mg/kg IV
Other Options
 IV Magnesium 25 mg/kg (max 2 gm)
 IV Epinephrine
 IV Salbutamol
 Inhalational Anesthetics
 Methylxanthines
 Heli - Ox
Differential Diagnosis of Wheezing
H+N
Vocal cord dysfunction
Chest
Asthma
Bronchiolitis
Foreign Body Aspiration
CVS
Congestive Heart Failure
Vascular Rings
Pediatric Asthma Guidelines
MILD
Symptoms
• Nocturnal cough
• Exertional SOB
• Increased Salbutamol use
• Good response to Salbutamol
Pre - Treat
O2 sat > 95%
PEF > 75%
(predicted / personal best)
Treatment
± O2
Salbutamol
Consider po Steroids
Pediatric Asthma Guidelines
Symptoms
Pre - Treat
Treatment
MODERATE
• Normal mental status
• Abbreviated speech
• SOB at rest
• Partial relief with Salbutamol and required > than q 4h
O2 sat 92%-95%
PEF 50-75% (predicted / personal best)
O2 100%
Salbutamol
Systemic corticosteroids
Consider anticholinergic
Asthma Guidelines
SEVERE
Symptoms
• Altered mental status
• Difficulty speaking
• Laboured respirations
• Persistant tachycardia
• No prehospital relief with usual dose Salbutamol
Pre - Treat
O2 saturation <92%
PEF, FEV1 <50%
Treatment
100% O2
Continuous or frequent b-agonists
Systemic corticosteroids & magnesium sulfate
Consider anticholinergic & / or methylxanthines
Asthma Guidelines
Symptoms
NEAR DEATH
• Exhausted , Confused
• Diaphoretic
• Cyanotic, Decreased respiratory effort, APNEA
• Falling heart rate
O2 saturation <80%
Pre - Treat
(spirometry not indicated)
As above PLUS
Treatment
IV Salbutamol
Inhalational anesthetic, aminophylline
Epinephrine
CASE 3
18 mo Girl with 24 hr Hx of coughing with drooling
Hx:
Has had an URTI for about a week and was
getting mildly better until yesterday. She
developed a fever and the cough got harsher.
Still drinking but not interested in solids
Vomited once last night
Started drooling this morning
Physical Exam
T39.1 degrees rectally, P170, R28, BP 100/66
Appearance alert, awake, not toxic, in no acute distress
Did not appear to prefer upright or a forward leaning position
EENT
Chest
Moist MM, slight erythema of oropharynx,
nasal crusting, N TMs, no rash / petechiae,
no drooling
Supple neck
Clear when resting
Mild inspiratory stridor with crying
Rest of the exam N
DDx?
• Croup
• Epiglottitis
• Bacterial
tracheitis
• RetroPharygeal
abcess
• Foreign Body
aspiration
Other things on DDx of
Inspiratory Stridor
Laryngeal Web
TEF
Diptheria
Airway thermal injury
Subglottic stenosis
Peritonsillar abcess
GERD
Esophageal FB
Laryngeal fracture
Laryngeal cyst
Lymphoma
Soft tissue lateral
neck radiograph
Retropharyngeal Abscess
Lymph nodes between the posterior pharyngeal wall
and the prevertebral fascia
• gone by 3 – 4 yrs of life
• drain portions of the nasopharynx and the posterior
nasal passages
• may become infected and progress to breakdown
of the nodes and to suppuration
ETIOLOGY
Complication of bacterial pharyngitis
Less frequently
- extension of infection from vertebral osteomyelitis
Group A hemolytic streptococci, oral anaerobes,
and S. aureus
Typically …
Recent or current history of an acute URTI
Abrupt onset:
 High fever with difficulty in swallowing
 Refusal of feeding
 Severe distress with throat pain
 Hyperextension of the head
 Noisy, often gurgling respirations
 Drooling
On Exam …
Nasopharynx
Oropharynx
Bulging forward of the soft palate and
nasal obstruction
Bulging of posterior phyaryngeal wall
or
Not visualized
Soft Tissue Neck Film
Patient position – MILD EXTENSION
Positive Film - Retropharyngeal soft tissue > ½ the width
of the adjacent vertebral body
- may see air in the retropharynx
Complications
Abscess rupture - aspiration of pus.
Lateral extension - present externally on the side of the neck
Dissection along fascial planes into the mediastinum
Death may occur with aspiration, airway obstruction,
erosion into major blood vessels, or mediastinitis.
Treatment
 Ceftriaxone 75mg/kg/day/divided Q 12 hrly
Clindamycin 20-30 mg/kg/day divided Q8H
(if pre-fluctuant phase)
 Decadron 0.6 mg/kg
 Airway management
 Surgical decompression
CASE 4
17 month old male with a one-hour history
of noisy and abnormal breathing
Normal now but at the time, parents thought he was
quite distressed.
Now, he is able to speak and drink fluids without difficulty
VS T36.8, P200 (crying), R28 (crying), O2 sat 99%
Alert with no signs of respiratory distress
Able to speak, had no cyanosis, no drooling,
no dyspnea
H+N
No obvious swelling, bleeding, FB seen
Chest
Mild wheezing with ? mild inspiratory stridor
What would you like to do now???
Soft Tissue
Neck View
CXR (PA)
Next?
Expiratory
CXR
Inspiratory View
Expiratory View
Right
Decub
View
Foreign Body Aspiration
 More common with food than toys
 Highest risk between 1 and 3 years old
(immature dentition – no molars, poor food control)
 Common foods = peanuts, grapes, hard candies
 Some foods swell with prolonged aspiration
(may even sprout)
Clinical Manifestations
Typically …
Acute respiratory distress (now resolved or ongoing)
Witnessed choking period
Uncommonly …
Cyanosis and resp arrest
Symptoms: cough, gag, stridor, wheeze, drool,
muffled voice
Investigations
Xrays
 Lateral neck
 Chest – inspiratory, expiratory, decubitus views
Expiratory views
Overinflation (partial obstruction with inspiratory flow)
Volume loss with mediastinal shift towards obstructed
side (partial obstruction with expiratory flow)
Atelectasis (complete obstruction)
Decubitus views
Normal
Smaller volumes and elevated diaphragm
on side down
Abnormal
Hyperinflation or “normal” volumes in
decub position
If suspected …
Need a bronchoscope to rule out or
remove Foreign Body
CASE 5
2 yo Boy with Barky Cough for 2 days
 Runny nose, decreased appetite
 Not himself
No PMHx / FHx of significance
Shots UTD
Other sibs with similar URTIs
On Exam …
Temp 38.9
HR
140
O2 sat
98% (drops to 90% when he crys)
RR
40 (mild indrawing)
Irritable, crying, good colour
H&N
sl erythema of throat, no pus
N TMs, small cervical nodes
Chest
Barky cough, inspiratory stridor
No wheeze noted
Diagnosis?
Racemic Epinephrine
0.5 ml dose
? Dexamethasone now or later
Re – Assess in 30 minutes
No improvement with 1st dose of epinephrine
What would you like to do now?
Re – Examine
Ongoing Inspiratory Stridor
Cries when trachea is examined
IV Ceftriaxone PLUS Cloxacillin
Consult Pediatric ICU / Pulmonary
for Bronch / Intubation
Bacterial tracheitis
 An acute bacterial infection of the upper airway capable
of causing life-threatening airway obstruction
 Staph aureus most commonly
(parainfluenza, Moraxella catarrhalis, H. influenzae, anearobes)
 Most pts less than 3 years old
 Usually follows an URTI (esp laryngotracheitis)
 Mucosal swelling at the level of the cricoid cartilage,
complicated by copious thick, purulent secretions
CLINICAL MANIFESTATIONS
Brassy cough
High fever
“Toxicity" with respiratory distress
(may occur immediately or after a few days of
apparent improvement)
Failed response to CROUP TREATMENT
(mist, intravenous fluid, racemic epinephrine)
Treatment
Antibiotics (good Staph coverage)
Intubation or tracheostomy is usually necessary
? Decadron
Pediatric Pneumonia
Neonate
Bacteria more frequent
E. coli, Grp B strep, Listeria, Kleb
1 – 3 mo
Chlamydia trachomatis (unique)
Commonly viral (RSV, etc.)
B. Pertussis
1 – 24 mo
S. pneumonia, Chlamydia pneum
Mycoplasma pneumonia
2 – 5 yrs
RSV
Strep pneumonia, Mycoplasma, Chlam
Severe Pneumonia:
Staph aureus
Strep pneumonia
Grp. A strep
HIB
Mycoplasma pneumonia
Pseudomonas if recently hospitalized
History:
Infants < 3 months
Tachypnea, cough, retractions,
grunting, isolated fever or
hypothermia, vomiting, poor
feeding, irritability, or lethargy
As age increases, symptoms are more specific
Fever and chills, headache
Cough or wheezing
Chest pain, abdominal distress,
neck pain and stiffness
Physical Exam
Tachypnea is the best single indicator of pneumonia
Age in months
Upper limit of Normal RR
<2
60
2-12
50
> 12
40
Treatment
Neonates
Ampicillin + Gentamycin / Cefotaxime
1 – 3 mo
Erythromycin 10 mg/kg IV Q6H
1 – 24 mo
Cefuroxime 50 mg/kg IV Q8H (not ICU)
Ceftriaxone 50-75 mg/kg IV Q24H
and Cloxacillin 50 mg/kg IV Q6H (ICU)
3 mo – 5 yrs Ceftriaxone / Erythro
Clarithro / Azithro (outpt Tx)
Respiratory Failure in
Children
Respiratory failure: where is the
defect?
Ventilation
Diffusion
Abnormal oxygen
carrying capacity
Perfusion
failure of
cellular oxygen
uptake
Types of Respiratory Failure
Type I failure, also
known as
normocapnic or
non-ventilatory
failure, is indicated
by hypoxemia (low
pO2 ) with a normal
or low pCO2.
It is commonly due to
ventilation/perfusion
(V/Q) abnormalities.
Other causes include:
impaired diffusion
across the alveolarcapillary membrane
(as occurs with
pulmonary fibrosis
and shunting)
Type II failure:
An elevated pCO2
is the hallmark ,
also known as
ventilatory or
hypercapnic
failure.
It is generally the
result of alveolar
hypoventilation,
increased dead space
ventilation, or
increased CO2
production. Other
causes are factors
that impair the central
ventilatory drive in the
brainstem, restrict
ventilation, or
increase CO2
production.
Causes of Type I Failure
V/Q abnormaltities
– Pneumonia,
meconium aspiraton,
Pulmonary oedema.
Cyanotic heart
disease
Diffusion
abnormalities
– Interstitial fibrosis
Inadequate systemic
blood flow
– Shock
Inadequate oxygen
carrying capacity
– Severe anemia,
methhemoglobinemia
Inadequate cellular
uptake:
– Cyanide poisioning
Type II Failure: alveolar
hypoventialtion
Neuromuscular:
Airway disorders:
– CNS disease, GB
Syndrome.
Pulmonary disease
Respiratory muscle
disorders
– Bronchiolitis,
pneumonia, asthma
– Muscular dystrophy
Chest wall / pleura:
– Pliable chest,
pneumothorax, pleural
effusion
– Croup.
Increased CO2
production:
– Sepsis, fever, burn
In children, respiratory failure most often is
due to diseases of the lungs.
CNS disorders that lead to respiratory
failure are:
Control abnormalities that cause Type II
(hypercapnic) respiratory failure and
usually present without signs and
symptoms of respiratory distress (such as
dyspnea, retractions, or tachypnea
A 16-year-old female arrives in the ED after
the SLC result. No other history is available
because the friends who brought him to the
ED left.
The vital signs are:
Temperature (T) = 96°F;
Pulse (P) = 90 beats/min;
Respiratory rate (R) = 6 breaths/min;
Blood pressure (BP) =120/80 mmHg; and
Pulse oxygen saturation is 76% on room air.
Glasgow coma scale: 4.
Shallow respiration.
Pinpoint pupil.
Lungs and heart are
normal
Arterial blood gas
(ABG) is: pH = 7.13;
pO2 = 52; pCO2 = 81;
HCO3 = 26; and
oxygen saturation =
75% on room air.
Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of
35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
Problem
This patient has hypercapnia and hypoxia.
Of the physiologic events in respiration,
diffusion, transport, and the tissue/cellular
uptake of oxygen are normal, but
ventilation is impaired.
Pin point pupil points to the poisoning
probably narcotic drug.
An 8-year-old male muscular
dystrophy
His vital signs are:
T = 100.2°F;
P = 120 beats/min;
R = 12 breaths/min; and
BP = 100/70 mmHg; and
Weight = 20 kg.
Eamination reveals
rhinorrhea and excessive
secretions in the
oropharynx.
There are scattered
rhonchi in the lungs
bilaterally. There is no
cyanosis.
The neurologic exam is
consistent with his
diagnosis of muscular
dystrophy with muscle
weakness
The ABG is: pH = 7.17;
pO2 = 46; pCO2 = 78;
HCO3 = 32; and O2
saturation = 71% on
room air.
This patient has Type
II hypercapnic
respiratory failure
secondary to failure of
the respiratory
muscles from a
primary muscle
disorder.
Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of
35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
A 4-month-old female with
breathing difficulties.
Prematurity (30 weeks),
respiratory distress
syndrome requiring a
ventilator. She also had a
congenital
gastrointestinal problem
requiring surgery at 6
weeks of age and has
continued to have
gastrointestinal problems.
She has
bronchopulmonary
dysplasia
Her vital signs are:
T = 103.5° F;
P = 190 beats/min;
R = 64 breaths/min;
BP = 80/50 mmHg; and
Pulse oxygen saturation
= 82% in room air
Small for her age.
Respiratory distress with
retractions, grunting,
flaring, head nodding.
Skin is pale, sweaty, and
cyanotic with delayed
capillary fill. There are
rales in both lung fields.
The chest roentgenogram
shows diffuse bilateral
infiltrates.
The ABG on room air
is: pH = 7.61; pO2 =
56; pCO2 = 24; HCO3
= 27; and oxygen
saturation is 78%.
Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of
35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
A 2-month-old is brought to the ED with
a chief complaint of not eating for
several days.
Vital signs are:
T = 36.8°C (R);
P = 180 beats/min;
R = 58 breaths/min
BP = 55/30 mmHg;
and
Pulse oxygen
saturation is 78% on
room air.
O/E tachypnea,
retractions, and
cyanosis. The lungs
are clear. The heart is
tachycardic with no
murmurs. The liver
edge is down 2 cm.
The abdomen is nontender. There is no
edema and no rash.
An initial ABG
reveals: pH = 7.48;
pO2 = 62; pCO2 = 34;
and HCO3 = 23.
ABG drawn on 100%
FiO2 shows
essentially no change
from the room air
blood gas: pH = 7.48;
pO2 = 64; pCO2 = 35;
HCO3 = 23; and O2
saturation is 79%.
Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of
35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
A 5-year-old male is seen for a cough of
several days duration that is not improving
Vital signs are:
T = 96.8°F (O);
P = 170 beats/min;
R = 44 breaths/min;
and
Pulse oximetry is 94%
on room air.
O/E: sitting up and
leaning forward.
wheezing bilaterally.
Tachypnic with
intercostal retractions.
Three continuous
salbutamol aerosols
were given by
nebuliser.
His lungs are clear,
Vital signs are now:
no wheeze or rales,
T = 96.8°F (O);
and no retractions. He
P = 102 beats/min;
has dry mucous
R = 16 breaths/min;
membranes and pale
BP = 65/40 mmHg;
skin with tenting.
and
Pulse oxygen
saturation = 86% on
room air.
First ABG ; pH = 7.52;
pO2 = 58; pCO2 = 24;
HCO3 = 14; and
oxygen saturation =
88% on room air.
The second ABG
shows: pH = 7.12;
pO2 = 68; pCO2 = 70;
HCO3 = 14; and
oxygen saturation is
90% on 100% FiO2.
Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45
mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
Treatment: Acute Respiratory Failure
Hypoxemia is more dangerous than hypercarbia.
Administration of supplemental oxygen
Ventilatory support
Extracorporial Membrane Oxygenation (ECMO)
Never use bicarbonates unless lung can exhale