United Airways Module

A Module For The Practicing PediatricianUnder The IAP Presidential Action Plan 2018

TeamDesignation Name

Chairperson Dr Santosh SoansCo-chairperson Dr Sachidanand Kamath IAP Coordinator Dr Bakul ParekhNational Coordinator Dr Jose OusephJoint National Coordianator Dr Salim A KhatibNational Scientific Convener Dr S Balasubramanian Jt. National Scientific Convener Dr S. Nagabhushana

Zonal ConvenersSouth Zone Dr Krishna Mohan RWest Zone Dr Rajendra C DevNorth Zone Dr Ashwani Kumar KamdarEast Zone Dr Santanu DebCentral Zone Dr Paka R Rajender

Contributors• Dr Barnali Bhattacharya• Dr Basavaraj• Dr Dhiren Gupta• Dr Ira Shah• Dr Indu Khosla• Dr Gautam Ghosh• Dr NC Gowrisankar• Dr Jagdish Chinnappa• Dr Jagdish Dhekne• Dr Jeeson Unni• Dr E Mahender• Dr Prabhakar murthy

• Dr Srinivas Gunda• Dr Subba Rao SD • Dr Sumanth Amperayani• Dr Sushil K Kabra• Dr Subramanya NK• Dr Salim A Khatib• Dr Tanu Singhal• Dr Thangavelu S• Dr Upendra K• Dr Vijay Yewale• Dr Vineet Sehgal

• Dr Pankaj Vaidya• Dr Pallab Chatterjee• Dr Pritish Nagar • Dr Palaniraman R• Dr P Ramachandran• Dr Sanjay Natu• Dr Sanjay Bafna• Dr Somu Sivabalan• Dr Sharath Balaji• Dr Shishir Modak• Dr Shivakumar• Dr Srikanta JT

Pediatric Respiratory Emergencies

Do’s and Don’ts

Objectives• Differentiate effortless tachypnea from respiratory distress• Recognize Respiratory Distress

• Respiratory Distress Vs Respiratory Failure

• Differentiate Upper Airway obstruction fromLower Airway obstruction

• Recognize life threatening signs

Rapid Assessment of Respiratory Distress

1. Respiratory rate - TachypneaAGE RESPIRATORY RATE (RR)• < 2 Mo ≥ 60 / minute• 2 Mo - 12 Mo ≥ 50 / minute• 12 Mo - 5 Yrs ≥ 40 / minute

2. RetractionsPresent or absent

• Absent to mild / moderate / severe & generalized with use of accessory muscles

Rapid Assessment of Respiratory Distress 3. Noisy breathing - Site of obstruction

• Upper airway obstruction• Snuffles Nasopharynx• Snoring Oropharynx• Inspiratory Stridor Larynx & Trachea (Extrathoracic

upper Airway obstruction)• Biphasic stridor (Intrathoracic upper Airway obstruction)Lower airway obstruction• Wheeze Bronchial treeLung: Grunt Parenchyma/ Pleura

Rapid Assessment of Respiratory Distress

4. Level of consciousness• Normal or Abnormal• Abnormal: restlessness, anxiety, irritability

lethargic, or depressed

5. Air Entry• Normal or decreased

6. Pulse Oximeter < 94% on room air (Hypoxia)

Triage (C – B – C) - Life Threatening Event (LTE) vs Others

Consciousness

Breathing

Initial Assessment

Colour

Assess & Classify Physiological Status

1. Respiratory Rate 2. Work of breathing (WOB) - Increased / decreased 3. Altered level of consciousness (ALC)4. SpO2 < 95 % is hypoxia

Normal Effortless Tachypnea

Respiratory distress

Respiratory failure

Rate N

WOB N N

ALC No Yes/No No Yes

SpO2 N N N /

What is Abnormal?

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Effortless Tachypnea vs Respiratory Distress

• Breathlessness & drowsiness

• No cough

• No response to nebulization

• SpO 2 - 97% in room air

• Breathlessness

• Cough

• Past wheezing episodes

• SpO2 – 90%

Effortless Tachypnea Respiratory Distress

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What is Abnormal?

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What is Abnormal?Respiratory Distress Respiratory Failure

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§ Depressed consciousness§ Head bobbing§ Retractions

Clinical LocalisationOther clinical

signs Upper airway disease

Lower airway disease

Parenchyma Pleura Disease

Cardiac

Tachypnea ++ ++ ++++ +++

Retractions ++++SSR, ICR

++ICR, SCR

++ICR, SCR

++ICR, SCR

Noisy breathing STRIDOR WHEEZE GRUNT GRUNT

Dullness on percussion

+ / -

Enlarged liver +

Cardiac signs: Gallop, tachycardia

What is Abnormal?

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What is Abnormal ?

Grunt - Expiratory Sound Stridor - Inspiratory

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Anatomic Diagnosis & Common Etiologies

Stridor (UAW)

Wheezing ( LAW)

Grunt (Parenchymal /

Pleural)Croup Asthma Pneumonia

FB airway Bronchiolitis Empyema

Pulmonary edema

ARDS

Serious Acute UAO

• ALTB / Croup, Epiglottitis, Tracheitis, Retropharyngeal abscess, Parapharyngeal abscess, Diphtheria

Infectious

• Glottic, subglottic Foreign Body

• Burns, Post intubation stridorTrauma

OthersAngioedema, Spasmodic croup, Tumors

Toxic Child with UAO

• High Fever

• Mild cough

• Pain

• Odynophagia

• Drooling

• Abnormal neck posture

• Neck swelling

• Mild stridor

THINK OF THE SCARY SIX

1. Diphtheria

2. Peri tonsillar abscess

3. Retro pharyngeal abscess

4. Para pharyngeal abscess

5. Epiglottitis

6. Tracheitis

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Case 1• 1 yr male child with Cough, Rhinnorhea since 2 days

• Difficulty breathing, change in voice for 1 day

• Examination• Irritable, Afebrile• RR 40 / min• Respiratory distress with retractions • Inspiratory stridor at rest• Air entry bilaterally equal• SpO2 - 93 % in room air

What is Abnormal ?

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Croup

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Mild croup Moderate croup

Severe croup Impending Respiratory

failure

Occasional barky cough Barky cough Frequent barky cough

Depressed level of

consciousnessNo stridor at rest Stridor at rest Stridor at rest Stridor at rest

No or Mild retractions Mild to moderate

retractions

Marked retractionsAgitation

Severe retractions Poor

air entryCyanosis or

pallor

Assessment of Severity - Croup

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Management of Croup • Do not separate child from care giver (minimize anxiety)

• If hypoxic administer O2 in non-threatening manner

• Nebulised Adrenaline (routinely available Adrenaline)

• Relieves airway obstruction with 10 mins

• First drug in moderate and severe croup

• Should be followed by IV/IM Dexamethasone

• Dose 0.5ml/kg 1 in 1000 dilution max. of 5ml

• Can be repeated if airway obstructive symptoms recur

Management of CroupSteroids - Definitive therapy in croup of any severity

• IM / IV Dexamethasone 0.6mg/kg/ single dose (most accepted option)

• Oral steroids are beneficial, even in mild croup

• Intramuscular dexamethasone and nebulized budesonide (2mg 12 hrly for 48 hrs) have an equivalent clinical effect

• A single dose of oral prednisolone is less effective

• Sedation is contraindicated

• No role for routine antibiotics

Case 2• 3 yr old brought after Bee Sting, presented with

• Difficulty in breathing, Noisy respiration

• O/E - Flushing of skin, Inspiratory Stridor

• What is your diagnosis?

Case 2• 3 yr old brought after Bee Sting, presented with

• Difficulty in breathing, Noisy respiration• O/E - Flushing of skin, Inspiratory Stridor

• What is your diagnosis?• Anaphylaxis

Management• Supine position with the lower extremities elevated• First line of treatment

• Inj-Epinephrine (1:1000 dilution) IV route also may be used in severe hypotension (0.01 mL/kg/dose of 1 : 10,000 slow IV push)

• IM: 0.01 ml/kg, max 0.5 ml - q 5-15 min• Adjuncts

• Salbutamol nebulisation • Cetrizine or Diphenhydramine• Ranitidine • Steroids – MPS or Hydrocortisone• Volume expanders (Crystalloid/colloids)

Inj-Epinephrine (1:1000 dilution) age based dose

Management• Carry Home Message

• Keep Adrenaline in clinic (Caution - short expiry )• Never administer Adrenaline Subcutaneous (SC) in Anaphylaxis

Case - 3 • 13 year old asthmatic girl presented with

• Severe cough for 3 days• Difficulty in breathing for 1 day

• Examination • Afebrile• Severe tachypnea• Nasal flaring with Intercostal & Subcostal retractions• Extensive Bilateral wheeze • SpO2 - 88 % in room air

• What is the Diagnosis ?

Acute Severe Asthma (ASA)

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Management• Oxygen to maintain SpO2 > 95%

• Bronchodilator

• Steroid

• Constant monitoring is essential

• Pulse Oximetry aids clinical assessment in monitoring

• Salbutamol• Nebulization or MDI (3-6 puff of SABA every 20 minutes in

the first hour) through space +/- mask• Nebulization with oxygen - flow rate of 6-8 liters/min

Dose is 2.5 mg (<20kg) & 5mg (>20kg) Every 20 min for three doses

• Ipratropium • Useful in moderate & severe attacks as an add on to

Salbutamol• Dose is 250 mcg < 20 kg and 500 mcg > 20 kg

Glucocorticoids• Oral is preferred to parenteral

• Give early ( within the 1st hour )

• Prednisolone 1-2 mg/kg (Max 40mg) OD or Hydrocortisone - 4mg/kg IV (Max 300mg) q6H or Oral/IM/IVDexamethasone 0.6mg/kg/dose (Max 16mg/dose) OD for 2 days

• Do not use inhaled Corticosteroids in acute exacerbations

Magnesium Sulphate Infusion• 50 mg / kg infusion in NS over 20 to 30 mins• Max dose 2 gms • Indications

• Persistent severe symptoms after SABA, ipratropium and steroids

• Caution - hypotension and muscular weakness

Do’s• Check SpO2 in all children with acute asthma

episode

• Use steroids early (Oral is effective )

• Mild & moderate exacerbations can be managed by

MDI Space +/- mask

Don'ts• Routine CXR not needed• Inhaled steroids• Oral Beta2 agonists/ LTRA• Nebulisation without oxygen• Antibiotics• Mucolytics / Cough medications / Sedation • Routine Chest physiotherapy

Initiate Treatment & then Refer• First give initial therapy then refer• Document examination findings and medications

• Refer with• With oxygen• Inhaled beta2 agonists• S/C adrenaline or terbutaline. 0.01 ML/KG sc MAX 0.5

mL• Rescue steroids

Case 4• 2 year 6 months old boy

• Sudden onset of Cough with Respiratory distress

• No fever or coryza , no past wheeze episodes

• O/E HR-118/min, R.R-68/min with chest retraction,

SpO2-95% on room air

• Air entry decreased on Left side

What is the Diagnosis?

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HyperareatedLeft Hemithorax

Mediastinum Shift to Right

Broncho – VascularMarkingsObstructive Emphysema, Left Side, Due to Foreign

Body

CXR - Mandatory in any Unexplained Respiratory Distress

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Foreign Body

Can cause complete or partial airway obstruction / Laryngeal spasm

• Respiratory distress • Respiratory failure• Cardio – respiratory arrest

Missed or delay in diagnosis• Pneumonia –

Acute/Recurrent• Lung abscess• Chronic lung disease

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When to Suspect Foreign Body?

• History of choking – highly suggestive (absence does not exclude)

• Acute or chronic respiratory symptom with unclear etiology • Absence of viral prodrome (fever, coryza, sneezing)• Respiratory illness not responding to standard therapy• Management

• Refer to Bronchoscopy at earliest• Rigid Bronchoscopy under GA • Procedure of choice for removal• Even if CXR is normal but history suggestive of foreign body

aspiration

Emergency Management• Complete Laryngotracheal (central) airway obstruction • “Cant talk / cough, Apneic , Cyanosed & ALC ”

< 1 Year > 1 Year

Case 5

• 6 months old child treated as bronchiolitis & referred in view of worsening distress

Cardiomegaly with pulmonary congestion

Message • Do not miss non – respiratory cause of respiratory

distress – CCF, especially in infants particularly in the

presence of disproportionate and persistent tachycardia

• Always assess cardiac size when viewing CXR

Case 6• 6 yrs old child being treated for GBS in a private hospital

was referred for altered mental status

• Referring note • Child maintaining saturation 96% in room air

Cause of Altered Mental Status

• Respiratory failure

• Though her Spo2 was normal, her PCO2 in ABG was

high

• Explaining the altered mental status

Case Progression

• Intubated & ventilated

• Ventilatory support for 2 weeks

• Discharged at 4 weeks

• Back to school in 3 months

ABGpH- 7.3pCO2- 62HCO3- 27BE- -1pO2- 76SaO2 95%

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Pearls• Respiratory emergency need not always present with primary

respiratory symptoms & sign

• Consider respiratory failure as a cause of altered mental status in sick children

• Both hypoxia & hypercapnia cause altered mental status

• In early respiratory failure SpO2 may be normal

• Ventilatory support changes morbidity and mortality in many neurological illnesses

Case 7• 6 yrs old with acute breathlessness, no fever

• RR- 50/m

• No distress

• No stridor, wheeze, crackles

• No hepatomegaly, no murmur / gallop

• Perfusion normal

• CXR – Hyper-areated lung fields

Different generations of airway

• Human airways have approximately 23 airway generations.

• The last 7 of these cover 95% of the total airway surface area. To treat asthmatic inflammation, we should probably target all airways

IAP 56

Infant with high grade fever with respiratory distress

Scenario

Diagnosis ?What next ?

IAP 57

Sites for Needle thoracocentesis

Pyopneumothorax drained

What is it?

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ACIDOTIC BREATHING – CHECK BICARB, ABG, SUGAR

Think of metabolic cause in SILENT TACHYPNEA

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What is it?

Summary• Respiratory Emergencies is the most common medical emergency in

children

• History and correct physical examination alone allows one to pinpoint

the cause to a particular part of the respiratory system and to make

the appropriate decisions for a proactive and life-saving management

of the critically ill child

• Look for and immediately manage life-threatening emergencies*, if any,

before proceeding for further assessment

Summary• Both hypoxia and hypercarbia can cause altered mental

status

• Administer O2 to any child with respiratory distress

• Administer in a non threatening manner

• Assessment can be done while O2 is provided

Devices

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PROBLEM SPECIFIC MANAGEMENT

Upper airway obstruction (stridor) Adrenaline nebulizationDexamethasone IM // oral

Lower airway obstruction (wheeze) Nebulization with O2Salbutamol, ipratropium , SC Adrenaline or SC Terbutaline

FB airway - Complete airway obstruction Cant talk, cough, cyanosed and ALC

Back blows and Abdominal thrusts Heimlich's maneuver No blind sweep to remove FB

Seizures causing respiratory failure IM midazolam along with BMV

Anaphylaxis Urticaria, angioedema, hypotension , Airway obstruction –UAW/LAW +/-GI symptoms

IM adrenaline

Specific Management Before or During Transport

Specific management should not delay ABC stabilization

Equipments

Clinic• Ambu Bag pediatric with reservoir • Three masks – Adult, pediatric,

infant • De lee suction • Inj Adrenaline, Midazolam• IV drip set, IV cannula• NS/RL • Oxygen Cylinder • Rs. 10,500 – 24,000

Clinic Optional/Hospital• O2 concentrator • Non rebreathing mask • Bain’s or Jackson Rees circuit• Laryngeal mask airway different

sizes• Intra-osseous or BMA needle

• Rs. 58,000 maximum

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We express our Gratitude for making this possible to

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