Review the initial assessment of patient in respiratory distressReview management of specific causes of respiratory distress- Upper airway obstruction
- Lower airway obstruction
- Lung tissue disease
- Disordered control of breathing
Rapid assessment Rapid assessment- Quickly determine severity of respiratory condition and stabilize child
- Respiratory distress can quickly lead to cardiac compromise
AirwayBreathing- Provide high concentration oxygen
- Bag mask ventilation
- Prepare for intubation
- Administer medication ie albuterol, epinephrine
Circulation- Establish vascular access: IV/IO
History
Pulse oximetry Pulse oximetry- May be difficult in agitated patient
- May be falsely decreased in very anemic patients
Imaging- Chest X Ray
- 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 has altered mental status
Complete upper airway obstruction 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
Upper airway obstruction Upper airway obstructionLower airway obstructionLung tissue diseaseDisordered control of breathing
Causes: foreign body, tissue edema, trauma, viral infection, intubation, tongue movement to posterior pharynx with decreased consciousness Causes: foreign body, tissue edema, trauma, viral infection, intubation, tongue movement to posterior pharynx with decreased consciousnessSymptoms- 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
Bronchiolitis 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 (Duo-Neb), corticosteroids (IV), magnesium sulfate
- Impending respiratory failure: oxygen, albuterol-ipratropium, corticosteroids, assisted ventilation (bag-mask ventilation, BiPAP, intubation), adjunctive agents (terbutaline, magnesium sulfate), heliox
Your intern calls you from the bedside of Jonathan, 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? Your intern calls you from the bedside of Jonathan, 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?
Etiologies of 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
Abnormal respiratory pattern produces inadequate minute ventilation Abnormal respiratory pattern produces inadequate minute ventilationAltered level of consciousness- Elevated intracranial pressure
- Poisoning or drug overdose
- Administer specific antidote if available
- Hyperammonemia
- Metabolic acidosis
Neuromuscular disease- Restrictive lung disease => atelectasis, chronic pulmonary insufficiency, respiratory failure
Support oxygenation and ventilation while treating the underlying problem
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 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
Albisett, M. Pathogenesis and clinical manifestations of venous thrombosis and thromboembolism in infants and children. June 2010. UpToDate. 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):44-48, 2006Simons, F. Anaphylaxis: Rapid recognition and treatment. September 2010. UpToDate.Weiner, D. Emergent evaluation of acute respiratory distress in children. May 2010. UpToDate.
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