Respiratory Respiratory distress in distress in

childrenchildren

Jana Stockwell, MD, FAAPJana Stockwell, MD, FAAPChildren’s Healthcare of AtlantaChildren’s Healthcare of Atlanta

at Eglestonat EglestonEmory UniversityEmory University

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Typical causes of distressTypical causes of distress

• Upper airwayUpper airway– CroupCroup– Retropharyngeal abscessRetropharyngeal abscess– EpiglottitisEpiglottitis– Foreign body aspirationForeign body aspiration

• Lower airwayLower airway– Reactive airway disease / asthmaReactive airway disease / asthma– BronchiolitisBronchiolitis– PneumoniaPneumonia– PneumothoraxPneumothorax

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Normal upper airway anatomyNormal upper airway anatomy

Esophagus

Trachea

Epiglottis

Tonsils

Tongue

Larynx

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Why are kids different?Why are kids different?

• Obligate nose-Obligate nose-breathersbreathers

• Tongue Tongue relatively largerrelatively larger

• Higher larynx Higher larynx (C(C33-C-C44 versus C versus C66) )

• Narrowing of Narrowing of airway causes airway causes exponential rise exponential rise of airway of airway resistanceresistance

• Less elasticity of Less elasticity of alveolialveoli

• Lower FRCLower FRC• DiaphragmDiaphragm

– FlatterFlatter– Muscle fibers more Muscle fibers more

vulnerable to fatiguevulnerable to fatigue

• Chest wallChest wall– More compliantMore compliant– Ribs more horizontalRibs more horizontal

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Signs & symptoms of distressSigns & symptoms of distress

• Nasal flaringNasal flaring• Hypoventilation, Hypoventilation,

apneaapnea• StridorStridor• GruntingGrunting• WheezingWheezing• Pallor, ashen colorPallor, ashen color WOBWOB• TachypneaTachypnea

• CyanosisCyanosis• Head bobbingHead bobbing• Tripod positioningTripod positioning• RetractionsRetractions Level of Level of

consciousnessconsciousness Air movementAir movement• AcidosisAcidosis• HypercapneaHypercapnea

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Croup Croup ((LLaryngoaryngoTTracheoracheoBBronchitis)ronchitis)

• Most severe in kids 6 mo - 3 years oldMost severe in kids 6 mo - 3 years old• MalesMales• Winter monthsWinter months• Associated illnessesAssociated illnesses

– Ear infectionEar infection– PneumoniaPneumonia– Organisms: parainfluenza types 1, 2 & 3, Organisms: parainfluenza types 1, 2 & 3,

adenovirus, RSV, influenzaadenovirus, RSV, influenza

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Croup symptomsCroup symptoms

• URI symptoms X 1-3 URI symptoms X 1-3 daysdays

• Low grade feverLow grade fever• ““Barking” cough, Barking” cough,

hoarsenesshoarseness• Inspiratory stridorInspiratory stridor• Worse at nightWorse at night• Prefer to sit upPrefer to sit up• Aggravated by Aggravated by

agitation & cryingagitation & crying

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Croup diagnosisCroup diagnosis

• Clinical diagnosisClinical diagnosis• Does Does notnot require require

neck X-rayneck X-ray– Consider X-ray in Consider X-ray in

patients with patients with atypical atypical presentation or presentation or clinical courseclinical course

• ““Steeple sign”Steeple sign”

Steeple sign

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Croup treatment & transportCroup treatment & transport

• Position of comfort, with parentPosition of comfort, with parent• Dexamethasone 0.6 mg/kg IV/IMDexamethasone 0.6 mg/kg IV/IM• Epi neb Epi neb • HelioxHeliox• SQ EpiSQ Epi• Cool mistCool mist

Hypopharnyx

Narrow air column

Trachea

Steeple sign

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Retropharyngeal abscessRetropharyngeal abscess

• Deep, potential, space of the neckDeep, potential, space of the neck• Children age 6 months to 6 yearsChildren age 6 months to 6 years• Other deep neck abscesses more Other deep neck abscesses more

frequent in older children & adultsfrequent in older children & adults– ParapharyngealParapharyngeal– PeritonsillarPeritonsillar

• Potential for airway compromise Potential for airway compromise • Complications secondary to mass Complications secondary to mass

effect, rupture of the abscess, or effect, rupture of the abscess, or spread of infectionspread of infection

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Retropharyngeal abscess - sxsRetropharyngeal abscess - sxs

• Fever, chills, Fever, chills, malaisemalaise

• Decreased Decreased appetiteappetite

• IrritabilityIrritability• Sore throatSore throat• Difficulty or pain Difficulty or pain

swallowingswallowing• Jaw stiffnessJaw stiffness• Neck stiffnessNeck stiffness

• Muffled voiceMuffled voice• ““Lump” in the throatLump” in the throat• Pain in the back & Pain in the back &

shoulders upon shoulders upon swallowingswallowing

• Difficulty breathing Difficulty breathing is an is an ominousominous complaint that complaint that signifies impending signifies impending airway obstructionairway obstruction

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Retropharyngeal abscessRetropharyngeal abscess

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Retropharyngeal abscessRetropharyngeal abscess

• Polymicrobial infection typicalPolymicrobial infection typical– Gram-positive organisms and Gram-positive organisms and

anaerobes predominatinganaerobes predominating– Gram-negative bacteria possibleGram-negative bacteria possible– Oropharyngeal flora Oropharyngeal flora

• Most common cause is group A Most common cause is group A beta-hemolytic streptococcibeta-hemolytic streptococci

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Retropharyngeal abscess - RxRetropharyngeal abscess - Rx

• Position airway - comfortPosition airway - comfort• Avoid unnecessary manipulationAvoid unnecessary manipulation• Monitor, CT of neck, possible OR Monitor, CT of neck, possible OR • Sedation & paralytics can relax airway Sedation & paralytics can relax airway

muscles, leading to complete muscles, leading to complete obstructionobstruction

• Endotracheal intubation is dangerousEndotracheal intubation is dangerous• Abx: clindamycin, cefoxitin, Timentin, Abx: clindamycin, cefoxitin, Timentin,

Zosyn, or UnasynZosyn, or Unasyn

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EpiglottitisEpiglottitis

• Acute, rapidly progressive cellulitis Acute, rapidly progressive cellulitis of the epiglottis and adjacent of the epiglottis and adjacent structuresstructures

• Before immunization - peak Before immunization - peak incidence at 3.5 years of ageincidence at 3.5 years of age

• Danger of airway obstruction - Danger of airway obstruction - medical emergencymedical emergency

• Prompt diagnosis and airway Prompt diagnosis and airway protection requiredprotection required

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Anatomy of oropharynxAnatomy of oropharynx

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Epiglottitis - signs & sxsEpiglottitis - signs & sxs

• More acute presentation in young More acute presentation in young children than in adolescents or adultschildren than in adolescents or adults

• Symptoms for <24 hrsSymptoms for <24 hrs– High fever, severe sore throat, High fever, severe sore throat,

tachycardia, systemic toxicity, drooling, tachycardia, systemic toxicity, drooling, tripod positiontripod position

• Moderate or severe respiratory Moderate or severe respiratory distress with inspiratory stridor & distress with inspiratory stridor & retractions retractions

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Epiglottitis - lateral neck filmEpiglottitis - lateral neck film

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EpiglottitisEpiglottitis

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Epiglottitis - etiologyEpiglottitis - etiology

• Group A StreptococcusGroup A Streptococcus• Other pathogens seen less frequently Other pathogens seen less frequently

include:include:– Strep pneumoniaeStrep pneumoniae– Haemophilus parainfluenzaHaemophilus parainfluenza– Staph aureusStaph aureus

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Epiglottitis - Rx & transportEpiglottitis - Rx & transport

• Position of comfort, with parentPosition of comfort, with parent• Minimize manipulationMinimize manipulation• Intubation under controlled Intubation under controlled

circumstancescircumstances• OO22 prn, blow-by if not tolerating mask prn, blow-by if not tolerating mask• Avoid agitation (Do not try to start IV, Avoid agitation (Do not try to start IV,

obtain blood or examine airway!)obtain blood or examine airway!)• Consult anesthesia & ENTConsult anesthesia & ENT• IV for antibiotics, after airway secureIV for antibiotics, after airway secure

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Epiglottitis - TroubleEpiglottitis - Trouble

• If respiratory arrest If respiratory arrest BVM BVM ventilation ventilation if inadequate, if inadequate, attempt to intubate attempt to intubate if unable if unable to intubate, perform needle or to intubate, perform needle or surgical cricothyroidotomysurgical cricothyroidotomy

• IV antibioticsIV antibiotics– ceftriaxone / cefotaximeceftriaxone / cefotaxime

• Racemic epinephrine & steroids Racemic epinephrine & steroids are are ineffectiveineffective

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Foreign body (FB) aspirationForeign body (FB) aspiration

• Toddler through preschool age commonToddler through preschool age common– No molar teeth for thorough chewingNo molar teeth for thorough chewing– Talking, laughing, and running while Talking, laughing, and running while

eatingeating• In 2000, FB aspiration in kids <14 years oldIn 2000, FB aspiration in kids <14 years old

– >17,000 ED visits>17,000 ED visits– 160 deaths160 deaths

• Nuts, raisins, sunflower seeds, pieces of Nuts, raisins, sunflower seeds, pieces of meat and small smooth (grapes, hot dogs, meat and small smooth (grapes, hot dogs, & sausages)& sausages)

• Dried foods absorb waterDried foods absorb water

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FB aspirationFB aspiration

• Sudden episode of coughing / choking Sudden episode of coughing / choking while eating with subsequent wheezing while eating with subsequent wheezing (sometimes unilateral), coughing, or stridor(sometimes unilateral), coughing, or stridor

• Tragic cases occur with total or near-total Tragic cases occur with total or near-total occlusion of the airwayocclusion of the airway

• Frequent sites of FB lodgement:Frequent sites of FB lodgement:– Usually below vocal cordsUsually below vocal cords– Mainstem bronchiMainstem bronchi– TracheaTrachea– Lobar bronchi Lobar bronchi

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FB aspirationFB aspiration

• Extrathoracic FB:Extrathoracic FB:– Breath sounds are Breath sounds are inspiratoryinspiratory

• Intrathoracic FBIntrathoracic FB– Noises are Noises are symmetricsymmetric but more but more

prominent in central airwaysprominent in central airways– If FB is beyond the carina, the breath If FB is beyond the carina, the breath

sounds are usually sounds are usually asymmetricasymmetric• Kid chest transmits sounds wellKid chest transmits sounds well• Stethoscope head may be bigger than lung lobesStethoscope head may be bigger than lung lobes• Lack of asymmetry should Lack of asymmetry should notnot dissuade you from dissuade you from

considering the FB diagnosisconsidering the FB diagnosis

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FB aspirationFB aspiration

• Hyperinflation & air-trapping of the Hyperinflation & air-trapping of the affected lobe(s) is typicalaffected lobe(s) is typical– Best seen with X-ray taken at expirationBest seen with X-ray taken at expiration– Difficult in little kidsDifficult in little kids

• May see soft tissue opacity in May see soft tissue opacity in proximal airwayproximal airway

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FB aspirationFB aspiration

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Foreign bodiesForeign bodies

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FB aspiration - transport issuesFB aspiration - transport issues

• Position of comfortPosition of comfort• Heimlich maneuver, back blows Heimlich maneuver, back blows • BVM prnBVM prn• Magill forceps (if object above cords)Magill forceps (if object above cords)• Intubation prnIntubation prn• Needle cricothyrotomyNeedle cricothyrotomy• Surgical cricothyrotomySurgical cricothyrotomy• Rigid bronchoscopy for FB removalRigid bronchoscopy for FB removal

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Reactive airway disease / AsthmaReactive airway disease / Asthma

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RAD / Asthma - childrenRAD / Asthma - children

• <3 years - small intrapulmonary airways<3 years - small intrapulmonary airways• Poor collateral ventilationPoor collateral ventilation• Decreased elastic recoil pressureDecreased elastic recoil pressure• Partially developed diaphragmPartially developed diaphragm

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RAD / AsthmaRAD / Asthma

• Identify and remove asthma triggers Identify and remove asthma triggers • Albuterol, nebulizedAlbuterol, nebulized• Ipratopium bromide (Atrovent)Ipratopium bromide (Atrovent)• Methylprednisolone (Solumedrol)Methylprednisolone (Solumedrol)• Magnesium sulfateMagnesium sulfate• CPAP / BiPAP CPAP / BiPAP • HelioxHeliox• Epinephrine or terbutaline infusionEpinephrine or terbutaline infusion• Chest squeezeChest squeeze• Anesthetic gasesAnesthetic gases

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RAD / AsthmaRAD / Asthma

• If intubated for transport:If intubated for transport:– Low vent rate, even if pCOLow vent rate, even if pCO22 high high

• Very prolonged expiratory phaseVery prolonged expiratory phase• Listen to chest - does expiration end?Listen to chest - does expiration end?

– SedateSedate– ParalyzeParalyze– Continuous nebsContinuous nebs– Monitor for development Monitor for development

of pneumothoraxof pneumothorax

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BronchiolitisBronchiolitis

• Organisms: RSV most commonOrganisms: RSV most common– Others: parainfluenza, influenza, human Others: parainfluenza, influenza, human

metapneumovirus (hMPV), adenovirus, metapneumovirus (hMPV), adenovirus, mycoplasmamycoplasma

• Winter & springWinter & spring• MalesMales• Typically <2 years old, peak 2-8 mosTypically <2 years old, peak 2-8 mos• Disease more severe in babies 1-3 mo oldDisease more severe in babies 1-3 mo old• Risk factors: Heart disease, BPD, Risk factors: Heart disease, BPD,

prematurity, smoking in homeprematurity, smoking in home

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BronchiolitisBronchiolitis

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Bronchiolitis - sxsBronchiolitis - sxs

• Apnea, bradycardiaApnea, bradycardia• DesaturationsDesaturations• Cough, copious secretionsCough, copious secretions• Tachypnea, tachycardiaTachypnea, tachycardia• Crackles, wheezingCrackles, wheezing• Increased WOB, retractionsIncreased WOB, retractions• Flaring, gruntingFlaring, grunting• Pallor, cyanosisPallor, cyanosis

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Bronchiolitis - diagnosisBronchiolitis - diagnosis

• No diagnostic tests needed, but possibly:No diagnostic tests needed, but possibly:– Rapid viral panel (antigen or FA panel)Rapid viral panel (antigen or FA panel)– Viral culturesViral cultures– CXR - CXR - hyperinflation, peribronchial cuffing, patchy hyperinflation, peribronchial cuffing, patchy

atelectasisatelectasis• Tachypnea, Tachypnea, WOB, wheezing WOB, wheezing • Hx URIHx URI

– fever, cough, runny nose, fever, cough, runny nose, appetiteappetite• Apnea (may occur Apnea (may occur w/ow/o other symptoms) other symptoms)• May be complicated by secondary bacterial May be complicated by secondary bacterial

infectioninfection

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Bronchiolitis - transportBronchiolitis - transport

• Isolation - contact, dropletIsolation - contact, droplet• OO2, 2, keep sats ≥92%keep sats ≥92%• Pulmonary toilet, suctioning!Pulmonary toilet, suctioning!• CPAP / BiPAPCPAP / BiPAP• No steroidsNo steroids• Nebs largely unhelpful (<1/3)Nebs largely unhelpful (<1/3)• Chest PT Chest PT prolongsprolongs hospitalization hospitalization• Antibiotics depend on other sxsAntibiotics depend on other sxs

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PneumoniaPneumonia

• Types:Types:– Bronchopneumonia - lobar Bronchopneumonia - lobar

consolidationconsolidation– Interstitial - usually viralInterstitial - usually viral

• More common in infants & toddlers More common in infants & toddlers than in adolescentsthan in adolescents

• Commonly:Commonly:– Viral, pneumococcus, MycoplasmaViral, pneumococcus, Mycoplasma– In immunocompromised, anything is In immunocompromised, anything is

possible!possible!

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Pneumonia - sxsPneumonia - sxs

• CoughCough• TachypneaTachypnea• GruntingGrunting• RetractionsRetractions• Chest painChest pain• Vomiting, poor feeding, abdominal Vomiting, poor feeding, abdominal

painpain• Fever depends on typeFever depends on type

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PneumoniaPneumonia

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Pneumonia - transportPneumonia - transport

• OO2, 2, keep sats ≥92%keep sats ≥92%• CPAP, BiPAPCPAP, BiPAP• Antibiotics, if considered bacterialAntibiotics, if considered bacterial

– Cefotaxime + vancomycinCefotaxime + vancomycin– AzithromycinAzithromycin

• Monitor mental statusMonitor mental status• Intubate & ventilateIntubate & ventilate• Complications: effusion, abscessComplications: effusion, abscess

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PneumothoraxPneumothorax

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Pneumothorax radiographsPneumothorax radiographs

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Tension PTXTension PTX

NormalNormal

Tension PTXTension PTXPTXPTX

R L

heartheart

LungLung

HeartHeart

AirleakAirleak

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Questions?Questions?