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“ Pediatric respiratory emergencies”
(Nelson, O.P. Ghai,)
Presented By:
Dr. Wasim Akram
Moderator
Dr. R. S. Sethi (MD, DCH...
Approach to a child with breathing
difficulty
– Synonymous with dyspnea,
– Respiratory distress
Definition
– Clinical state characterized by increased rate & increased
respiratory efforts
OR
– It refers to any type of ...
Features of respiratory distress
– Tachypnea
– Dyspnoea
– Nasal flaring
– Chest wall retraction
– Added sounds
– Head bobb...
Grading of acute respiratory
distress
Mild
– Tachypnea
– Dyspnea or shortness of breath
Moderate
– Tachypnea
– Minimal che...
Features of Respiratory failure
– Defined as a paCO2 of >50 or paO2 of <60 while
breathing 40% oxygen
– Clinical definitio...
Pathophysiology
Increased resistance due to edema
Pathophysiologic approach to clinical conditions
causing respiratory distress
Etiology Pathophysiology Clinical conditions...
Approach
– Our primary / first approach should be directed to find out the extent of
respiratory and cardiovascular dysfun...
Initial general assessment
– The goal is to rapidly assess for
– a)airway patency
– B)adequacy of gas exchange
– C)circula...
Pediatric Assessment Triangle
– A)Appearance ; interaction ,muscle tone, consolability,
look speech, cry
– B)Work of breat...
Primary general assessment
– It is done by using the assessment pentagon which
includes
Airway
Breathing
Circulation
D...
Airway
Assessment is aimed to decide whether airway is:
CLEAR: open and unobstructed
MAINTAINABLE: maintained by simple ...
Noisy Breathing
– Snoring
– Grunting
– Stridor
– Wheeze
– Ronchi
Stridor
– Coarse high pitched sound typically heard on inspiration.
Stridor
– Inspiratory harsh sound continuously.
Can occur during expiration (intrathoracic) or both phase of respiration.
...
Wheeze
– It is a whistling sound heard most often during expiration
indicating lower airway obstruction.
WHEEZE Vs RHONCHI
WHEEZE
– Continuous ,high pitched musical
sound
Heard during expiration, however can
be heard on inspira...
Grunting
– Short, low pitched sound heard during expiration produced by
forced expiration against a partially closed epigl...
2)breathing
< 2 months > 60/min
2 months – 1 year > 50/min
1 year – 5 years > 40/min
5 years > 30/min
a) Tachypnea
Breathing contd…..
– 2)BRADYPNOEA: apparently normal respiratory rate
which is inappropriate for the clinical situation
– ...
Breathing contd…..
– 4)See saw respiration it is seen in neuromuscular
weakness, but can also occur in late stage of sever...
3)Circulation
– PR
– Pulse volume: feeble pulse is the first sign of
compromised perfusion
– CRT
– BP
4)Disability
– Reduced O2 supply to brain affects consciousness muscle
tone and pupillary response
– Early manifestations ...
5)Exposure
– If indicated it is done to look for evidence of trauma,
petechae and purpura and warming
Categorization of severity of the
clinical condition
– Life threatening conditions
– If at any point during the assessment...
Signs of life-threatening illness in a child
with respiratory distress
Airway
Breathing
Circulation
Disability
Exposure
Co...
Immediate care
– The goal is to relieve hypoxemia and support respiratory functions until specific
therapy becomes effecti...
Ensure breathing if spontaneus normal breathing is
absent/inadequate by:
(a) Assisted ventilation by bag and mask ventilat...
Ventilation
– Nasal prongs are the recommended way of providing oxygen to most of the
children
– Infant 5 to 1l/min
– Chil...
Common oxygen delivery devices and
delivered oxygen concentration (FiO2) at given
flow rates
FiO2 Device (Flow rate/min)
2...
Ensure circulation
– If the patient is in shock, or has signs of severe sepsis, initiate
septic shock protocol. Establish ...
Subsequent management
– If pneumothorax is suspected/detected, proceed with
needle thoracotomy in the second intercostal s...
Child with respiratory distress
Approach to a child with breathing difficulty
Pediatric assessment triangle
Pediatric asse...
Diagnostic evaluation of
respiratory distress
A- History
– Acute, recurrent or chronic and nature of progression
– Associa...
Contd...
B - Physical Examination
– Assess stability of the airways, and ventilatory status.
 Respitatory (counted for a ...
Contd...
C – Diagnostic work - up
– Direct laryngoscopy, if upper airway obstruction is detected/suspected
– X-ray: cheat,...
Neurological illnesses
– Though neurological illnesses can lead to ‘breacthlessness’, it is
unlikely to be the only or chi...
Cardiac causes
– Detection of cardiac failure, shock, or cyansosis may
suggest a cardiac cause of breathlesness and should...
Metabolic causes
– When children manifest with kussmaul breathing a metabolic
cause should be suspected
– In such child pa...
Indication for urgent X-ray
– Most of the reparatory distress conditions do not require
urgent x-ray
– Its only indicated ...
Status ofABG
 Arterial Blood Gas analysis: single most important lab
test for evaluation of respiratory failure.
Respiratory failure: Evaluation
The following parameters are important in
evaluation of respiratory failure:
 PaO2
 PaCO...
Laboratory investigations
 Arterial BG
─ Info on oxygenation and ventilation status
─ Difficult to get in some patients
...
Alveolar-Arterial O gradient
 Normal 5-10 mm of Hg
 A sensitive indicator gas exchange.
 Useful in differentiating
extr...
Hypoxemia
1. Low PiO2 ~ at high altitude
2. Hypoventilation ~ Normal A-a gradient
3. Low V/Q mismatch ~ A-a gradient
4. R/...
Hypercapnia
 Better to be defined by pH rather than pCO2 Metabolic
alkalosis can raise pCO2 without acidosis
 Hypoventil...
12 yr girl with ascending weakness
 Anxious
 PR-120, RR-34, SpO2-95, BP-130/90,
 Chest: Shallow Respiration, B/L air
en...
12 yr girl with ascending weakness
 Anxious
 PR-120, RR-34, SpO2-88, BP-130/90,
 Chest: Shallow Respiration, B/L air en...
12 yr girl with ascending weakness
 Anxious on 50% oxygen
 PR-120, RR-34, SpO2-99, BP-130/90,
 Chest: Shallow Respirati...
12 year boy
 High fever, cough and fast breathing for 5 day
 PR-120, RR-42, SpO2-85 %, BP-110/68
 Chest: B/L Extensive ...
12 year boy
 High fever, cough and fast breathing for 5 day
 PR-120, RR-42, SpO2-85 %, BP-110/68
 Chest: B/L Extensive ...
V/Q mismatch- Diagnosis
 PaO2
 A-a gradient is
 PaCO2 may or may not be elevated
 Hyperoxia Test : Response
2 year boy withTOF
 Fever for 2 days
 P-120, RR-30, SpO2 on RA-78%,
 Chest clear, CVS- Short systolic murmur at base
pH...
R-L shunt: diagnosis
 PaO2 is
 PaCO2 is usually normal
 A-a gradient is
Approach to respiratory distress in children
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Approach to respiratory distress in children

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a novel ppt to understand the basic approach towards respiratory distress in child

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Approach to respiratory distress in children

  1. 1. “ Pediatric respiratory emergencies” (Nelson, O.P. Ghai,) Presented By: Dr. Wasim Akram Moderator Dr. R. S. Sethi (MD, DCH) Professor & Ex. HOD Dr. Om Shankar Chaurasiya (MD) Assistant Professor & Head Dr. G. S. Chaudhary (MD) Lecturer Dr. Aradhana Kankane (MD) Lecturer DEPARTMENT OF PAEDIATRICS M. L. B. Medical College, Jhansi Dr. Anuj Shamsher Sethi (MD) Lecturer Dr. Sapna Gupta (MD) Lecturer & All Resident
  2. 2. Approach to a child with breathing difficulty – Synonymous with dyspnea, – Respiratory distress
  3. 3. Definition – Clinical state characterized by increased rate & increased respiratory efforts OR – It refers to any type of subjective difficulty in breathing.
  4. 4. Features of respiratory distress – Tachypnea – Dyspnoea – Nasal flaring – Chest wall retraction – Added sounds – Head bobbing – CVS &CNS manifestation
  5. 5. Grading of acute respiratory distress Mild – Tachypnea – Dyspnea or shortness of breath Moderate – Tachypnea – Minimal chest wall retaractions – Flaring of alae nasi Severe – Marked tachynea (> 70 breaths/min) – Apneic episodes/bradypnea/irregular breathing – Lower chest wall retractions – Head bobbing (use of sternocleidomastoid muscles) – Cyanosis
  6. 6. Features of Respiratory failure – Defined as a paCO2 of >50 or paO2 of <60 while breathing 40% oxygen – Clinical definition : Severe respiratory distress with cardiovascular manifestation and central nervous system changes – Cvs changes; marked tachycardia, or bradycardia, hypotension – Cns changes: lethargy, somnolence ,seizures and coma
  7. 7. Pathophysiology
  8. 8. Increased resistance due to edema
  9. 9. Pathophysiologic approach to clinical conditions causing respiratory distress Etiology Pathophysiology Clinical conditions Interference with air flow (entry or exit) Upper airway obstruction Lower airway obstruction Mechanical compression Thoracic wall injuries Aucte laryngitis, laryngotracheitis, foreign body Bronchiolitis, asthma Large pleural effusion, pneumothorax Flail chest Interference with alveolar gas exchange Failure of alveolar ventilation Failure of diffusion Pneumonia, pulmonary edema Pneumonia, pulmonary edema Cardiovascular problems Mechanical or inadequate function Congestive cardiac failure, arrhythmias, myocarditis, pericarditis, Right-to-left shunts CNS Depression of respiratory center Stimulation of respiratory center Neuromuscular impairment of respiration Raised ict Acidosis, salicylate intoxication Acute paralytic poliomyelitis, Guillain-Barre syndrome, organophosphate poisonin, snake bite, diaphragmatic paralysis Other Insufficient oxygen supply to tissues and/or increased oxygen demands Compensation for metabolic acidosis Sepsis, severe anemia, high altitude, carbon monoxide exposure, smoke inhalation, meth-hemoglobinemia Diabetic ketoacisosis, acute renal failure
  10. 10. Approach – Our primary / first approach should be directed to find out the extent of respiratory and cardiovascular dysfunction and quantify its severity. – The assessment determines the urgency with which interventions need to be instituted – Assessment is aimed to deciding weather airways – Clear – Maintable – Not maintable – Any audible sound during breathing is suggestive of respiratory airway obstruction
  11. 11. Initial general assessment – The goal is to rapidly assess for – a)airway patency – B)adequacy of gas exchange – C)circulatory status Assessment begins with using Pediatric Assessment Triangle
  12. 12. Pediatric Assessment Triangle – A)Appearance ; interaction ,muscle tone, consolability, look speech, cry – B)Work of breathing: use of accessory muscle, bradypnoea – C)Abnormal skin colour: pallor and cyanosis
  13. 13. Primary general assessment – It is done by using the assessment pentagon which includes Airway Breathing Circulation Disability Exposure
  14. 14. Airway Assessment is aimed to decide whether airway is: CLEAR: open and unobstructed MAINTAINABLE: maintained by simple measure like position, suction etc NOT MAINTAINABLE: needs advance measure like intubation ANY AUDIBLE SOUND
  15. 15. Noisy Breathing – Snoring – Grunting – Stridor – Wheeze – Ronchi
  16. 16. Stridor – Coarse high pitched sound typically heard on inspiration.
  17. 17. Stridor – Inspiratory harsh sound continuously. Can occur during expiration (intrathoracic) or both phase of respiration. – Asses the severity – Drooling of saliva, respiratory distress, unable to swallow, cyanosis – Common causes: – Infective: epiglottitis, laryngotracheobronchitis, tracheitis, retropharyngeal abscess (rare) – Malignancy: tumor compression, papilloma – Allergic: angioneurotic oedema. – Congenital: laryngomalacia, laryngeal web, vascular ring, – Aspiration: foreign body. – Neuronal: paralysis of vocal cord. – Investigation – Blood count; Lateral neck X-ray; flexible bronchoscopy.
  18. 18. Wheeze – It is a whistling sound heard most often during expiration indicating lower airway obstruction.
  19. 19. WHEEZE Vs RHONCHI WHEEZE – Continuous ,high pitched musical sound Heard during expiration, however can be heard on inspiration Produced when air flows through narrowed airways. RHONCHI – Subtype of wheeze – Low pitched, snoring quality, continuous musical sound – Implies obstruction of larger airways by secretions.
  20. 20. Grunting – Short, low pitched sound heard during expiration produced by forced expiration against a partially closed epiglottis it keeps small airway and alveoli open to maintain oxygen – typically a sign of severe respiratory distress – Sometimes grunting can be heard in fever and abdominal pain
  21. 21. 2)breathing < 2 months > 60/min 2 months – 1 year > 50/min 1 year – 5 years > 40/min 5 years > 30/min a) Tachypnea
  22. 22. Breathing contd….. – 2)BRADYPNOEA: apparently normal respiratory rate which is inappropriate for the clinical situation – 3)RETRACTIONS: – Suprasternal retraction-upper airway obstruction – Intercostal Retraction – Parenchymal – Subcostal Retraction-LOWER AIRWAY OBSTRUCTION
  23. 23. Breathing contd….. – 4)See saw respiration it is seen in neuromuscular weakness, but can also occur in late stage of severe respiratory pathology – 5)pulse oximetry measure % saturation of hb with oxygen –
  24. 24. 3)Circulation – PR – Pulse volume: feeble pulse is the first sign of compromised perfusion – CRT – BP
  25. 25. 4)Disability – Reduced O2 supply to brain affects consciousness muscle tone and pupillary response – Early manifestations are anxious look and irritability and agitation followed by lethargy
  26. 26. 5)Exposure – If indicated it is done to look for evidence of trauma, petechae and purpura and warming
  27. 27. Categorization of severity of the clinical condition – Life threatening conditions – If at any point during the assessment, a life threatening condition is identified, appropriate interventions are instituted, before proceeding with the rest of the assessment.
  28. 28. Signs of life-threatening illness in a child with respiratory distress Airway Breathing Circulation Disability Exposure Complete or severe airway obstruction Apnea/bradypnea, markedly Increased work of breathing Absence of detectable pulse, poor perfusion, hypotension, bradycardia Unresponsiveness Significant hypothermia or bleeding, petechae/purpura consistent with septic shock
  29. 29. Immediate care – The goal is to relieve hypoxemia and support respiratory functions until specific therapy becomes effective. – This is done by (a) Ensuring an open airway and breathing, (b) Delivering oxygen without causing agitation, and (c) Ensuring adequacy of circulation, normal temperature and hydration. – Airway patency can be achieved with a) Proper positioning (extend the neck, pull the mandible forward, to lift the tongue), b) Cleaning the oropharynx of any secretions (manually if necessary), and c) Insertion of an oropharyngeal airway.
  30. 30. Ensure breathing if spontaneus normal breathing is absent/inadequate by: (a) Assisted ventilation by bag and mask ventilation, (b) Endotracheal intubation as soon as adequate expertise and equipment are available, (c) Providing oxygen. Never delay resuscitation tor lack of equipment or trained personnel.
  31. 31. Ventilation – Nasal prongs are the recommended way of providing oxygen to most of the children – Infant 5 to 1l/min – Child 1 to 2 litre However there is no significant difference in oxygen administration by nasal prongs or nasopharyngeal catheters For older children oxygen is best given by face mask
  32. 32. Common oxygen delivery devices and delivered oxygen concentration (FiO2) at given flow rates FiO2 Device (Flow rate/min) 25 – 50 % Nasal cannula (1 – 6 L) Nasal prons 35 – 65 % Simple Face Mask (6 – 12 L) 24 – 60 % Graded ventury mask (graded 4 – 12 L) 60 – 80 % Oxyhood (10 – 15 L) > 90 % Non rebreathing masks ( 10 – 12 L)
  33. 33. Ensure circulation – If the patient is in shock, or has signs of severe sepsis, initiate septic shock protocol. Establish intravenous access and initiate infusion of a saline bolus (20mg/kg). – If venous access is not feasible, consider intrasseous infusion in young children. – The first dose of an appropriate antibiotic for severe infections, including severe respiratory infection, must be administered without delay.
  34. 34. Subsequent management – If pneumothorax is suspected/detected, proceed with needle thoracotomy in the second intercostal space under water seal (using a syringe with saline), followed by intercostal drainage.
  35. 35. Child with respiratory distress Approach to a child with breathing difficulty Pediatric assessment triangle Pediatric assessment pentagone Secure airway, start oxygen, ensure breathing, restore circulation Is there stridor or drooling!Intubation or Tracheostomy Yes Is pneumothorax suspected ?Needle thoracotomy intercostal drainage Yes Is there fever ?First dose of antibiotic Yes No No No Detailed clinical examination for specific cause Pneumonia WheezingUAO Specific investigations Specific management CNS MetabolicCardiac
  36. 36. Diagnostic evaluation of respiratory distress A- History – Acute, recurrent or chronic and nature of progression – Associated symptoms: cough, fever, rash, chest pain – Preceding events : choking, foreign body inhalation trauma/accident, and exposure of chemical or environmental irritants. – Family history exposure to infections, tuberculosis, atopy.
  37. 37. Contd... B - Physical Examination – Assess stability of the airways, and ventilatory status.  Respitatory (counted for a full minute), rhythm, depth and work of breathing  Color, level of activity and playfulness.  Chest movements, indrawing of chest wall  Stridor (suggests upper airway obstruction)  Wheezing (suggests lower airway obstruction)  Grunttng (suggests alveolar disease causing loss of functional residua) capacity) – Tracheal position – Segmental percussion – Auscultation: Air entry, type of breath sounds, wheeze, rhonchi, crepitations – Clubbing, lymphadenopathy – Assessment of CVS and CNS C Diagnostic Work-up
  38. 38. Contd... C – Diagnostic work - up – Direct laryngoscopy, if upper airway obstruction is detected/suspected – X-ray: cheat, lateral neck, and decubitus views – Arterial blood gas analysis for hypoxemia (pa02 <60 mm Hg), hypercarbia (paCO2 >40 mm Hg), (acidosis pH < 7.3), alkalosis (pH > 7.5, and Sa02 monitoring – Sepsis work-up; Blood counts and culture studies
  39. 39. Neurological illnesses – Though neurological illnesses can lead to ‘breacthlessness’, it is unlikely to be the only or chief complaint. – Whether the neurological illness is acute (head injury, encephalitis, meningitis), subacute or chronic (Guillian Barre syndrome, spinal muscular atrophy) there is usually a prominent history or the initiating/primary events which suggest the possible cause.
  40. 40. Cardiac causes – Detection of cardiac failure, shock, or cyansosis may suggest a cardiac cause of breathlesness and should be managed accordingly
  41. 41. Metabolic causes – When children manifest with kussmaul breathing a metabolic cause should be suspected – In such child patient would have marked tachypnoea with minimum retraction and chest would be clear – common causes: – DKA – ARF – Severe dehydration – Septic shock
  42. 42. Indication for urgent X-ray – Most of the reparatory distress conditions do not require urgent x-ray – Its only indicated if following conditions is suspected – Pneumothorax – pleural effusion – Pneumomediastinum – Flail chest
  43. 43. Status ofABG  Arterial Blood Gas analysis: single most important lab test for evaluation of respiratory failure.
  44. 44. Respiratory failure: Evaluation The following parameters are important in evaluation of respiratory failure:  PaO2  PaCO2  Alveolar-Arterial PO2 Gradient P(A-a)O2 Gradient = PIO2 – PaCO2 / R 713 X FiO2 - PaCO2X0.8 - PaO2
  45. 45. Laboratory investigations  Arterial BG ─ Info on oxygenation and ventilation status ─ Difficult to get in some patients  Venous BG ─ Ventilation info but not oxygenation ─ Venous – good only if obtained from free flowing site – no tourniquet ─ PaCO2 slightly higher in VBG  Capillary – Easiest to obtain  Remember metabolic side (base deficit, [HCO3-])
  46. 46. Alveolar-Arterial O gradient  Normal 5-10 mm of Hg  A sensitive indicator gas exchange.  Useful in differentiating extrapulmonary and pulmonary causes of resp. failure.
  47. 47. Hypoxemia 1. Low PiO2 ~ at high altitude 2. Hypoventilation ~ Normal A-a gradient 3. Low V/Q mismatch ~ A-a gradient 4. R/L shunt ~ A-a gradient
  48. 48. Hypercapnia  Better to be defined by pH rather than pCO2 Metabolic alkalosis can raise pCO2 without acidosis  Hypoventilation  Severe low V/Q mismatch: major mechanism of hypercapnia in intrinsic lung disease  Can occur with many respiratory diseases, usually as patients get tired
  49. 49. 12 yr girl with ascending weakness  Anxious  PR-120, RR-34, SpO2-95, BP-130/90,  Chest: Shallow Respiration, B/L air entry  Flaccid paralysis pH - 7.30 pCO2 - 60 pO2 - 70 A-a Gradient = 4.73
  50. 50. 12 yr girl with ascending weakness  Anxious  PR-120, RR-34, SpO2-88, BP-130/90,  Chest: Shallow Respiration, B/L air entry  Flaccid paralysis pH - 7.30 pCO2 - 60 pO2 - 54 A-a Gradient = 20.98
  51. 51. 12 yr girl with ascending weakness  Anxious on 50% oxygen  PR-120, RR-34, SpO2-99, BP-130/90,  Chest: Shallow Respiration, B/L air entry  Flaccid paralysis pH - 7.30 pCO2 - 60 pO2 - 261 A-a Gradient = 20.98
  52. 52. 12 year boy  High fever, cough and fast breathing for 5 day  PR-120, RR-42, SpO2-85 %, BP-110/68  Chest: B/L Extensive crept with bronchial breathing, air entry  O2 by NRM (FiO2-90%)- SpO2- 98% pH - 7.45 pCO2 - 45 pO2 - 90 A-a Gradient = 495.45
  53. 53. 12 year boy  High fever, cough and fast breathing for 5 day  PR-120, RR-42, SpO2-85 %, BP-110/68  Chest: B/L Extensive crept with bronchial breathing, air entry  O2 by NRM (FiO2-90%)- SpO2- 98% pH - 7.45 pCO2 - 32 pO2 - 90 A-a Gradient = 511
  54. 54. V/Q mismatch- Diagnosis  PaO2  A-a gradient is  PaCO2 may or may not be elevated  Hyperoxia Test : Response
  55. 55. 2 year boy withTOF  Fever for 2 days  P-120, RR-30, SpO2 on RA-78%,  Chest clear, CVS- Short systolic murmur at base pH - 7.41 pCO2 - 34 pO2 - 40A-a Gradient = 556.95
  56. 56. R-L shunt: diagnosis  PaO2 is  PaCO2 is usually normal  A-a gradient is

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