Pediatric Airway Emergencies

1. Pediatric Airway Emergencies Prepared by Shane Barclay MD

2. Goals and Objectives • Recognize the child with acute respiratory distress. • Know the causes of pediatric acute respiratory distress. • Be aware of the anatomic differences with pediatric airways. • Know how to manage pediatric acute respiratory distress.

3. Goals and Objectives • Recognize the child with acute respiratory distress. • Know the causes of pediatric acute respiratory distress. • Be aware of the anatomic differences with pediatric airways • Know how to manage pediatric acute respiratory distress.

4. Recognizing an Acute airway problem in pediatrics Two most common features of pediatric respiratory distress: • Tachypnea • Retractions With time Tachypnea will be replaced by bradypnea as fatigue sets in. Remember, the most common cause of Cardiac Arrest in children is Respiratory Arrest.

5. Recognizing an Acute airway problem in pediatrics The Initial Evaluation includes: • Determining the severity. • Trying to localize the cause. • Determining the need for emergent intervention.

6. Determining Severity of pediatric emergencies There are 3 simple Observational assessment tools that can quickly evaluate a sick child: • Appearance • Breathing • Circulatory status

7. Determining Severity of pediatric emergencies • Appearance - “TICLS” mnemonic T – Tone. Seriously ill children tend to appear limp and have decreased muscle tone. I – Instructiveness. Sick children will often not interact or will be indifferent to distractions. C – Consolability. Sick children will often not be consolable however very sick children may be unresponsive. L – Look. Sick children will often stare or be unresponsive. S- Speech. Sick children will often have a weak cry.

8. Determining Severity of pediatric emergencies 2. Breathing Sounds – listen for abnormal sounds – Stridor, grunting, wheezing. Positioning – look for ‘sniffing position’ or ‘tripod’. Accessory muscles – supraclavicular, intercostal or substernal. Also head bobbing or nasal flaring.

9. Determining Severity of pediatric emergencies 3. Circulation Look for pallor or cyanosis. Capillary refill Cool skin

10. Recognizing an Acute airway problem in pediatrics The Initial Evaluation includes: • Determining the severity. • Trying to localize the cause. • Determining the need for emergent intervention.

11. Localizing Respiratory distress 1. Upper airway 2. Lower airway 3. Cardiac 4. Central nervous system 5. Metabolic

12. Localizing Respiratory distress • Upper airway Sniffing position Nasal flaring Prolonged inspiration Retractions – supraclavicular, suprasternal Stridor Hoarseness or ‘hot potato voice’ Barking cough

13. Localizing Respiratory distress 2. Lower Airway Retractions – intercostal, subcostal Nasal flaring Prolonged expiration Wheezing Grunting Rales

14. Localizing Respiratory distress 3. Cardiac disease cardiac murmurs, rales, JVD, edema 4. Central nervous system Cheyne-Stokes breathing 5. Metabolic Kussmal breathing (deep and labored)

15. Recognizing an Acute airway problem in pediatrics The Initial Evaluation includes: • Determining the severity. • Trying to localize the cause. • Determining the need for emergent intervention.

16. Some conditions that may require emergent airway intervention • Airway foreign body or obstruction. • Asthma • Croup • Bronchiolitis • Anaphylaxis • Epiglottitis • Respiratory Failure. • Tension pneumothorax. • Tracheitis. • Retropharyngeal abscess.

17. Some conditions that may require emergent airway intervention Only some of the prior conditions will be covered here.

18. Management Overview of some common acute pediatric airwayEmergencies The following are short summaries, not complete reviews. 1. Airway obstruction from foreign body 2. Asthma 3. Croup 4. Bronchiolitis 5. Anaphylaxis

19. Pulmonary Index Score (PIS) Airway foreign body Population: Most common in 1 - 4 year old. Locations: Larynx 3% Trachea/carina 13% Right lung 60% Left lung 23% Bilateral 2 %

20. Pulmonary Index Score (PIS) Airway foreign body Overall most FB are located within the lungs (90%). However, laryngeal placement is more common in younger children (infants) due to tracheal narrowing. Laryngeal foreign bodies are also associated with higher mortality.

21. Pulmonary Index Score (PIS) Airway foreign body Presentation: Most children will present with partial airway obstruction. Symptoms will be cough, stridor and tachypnea, but will be dependent on location of the foreign body. Initial coughing and even choking may then be followed by no symptoms for some time. Some 20% children will present with a FB after 1 month.

22. Pulmonary Index Score (PIS) Airway foreign body Management: If there is complete obstruction then back thrusts (up to 1 year) or Heimlich maneuver/abdominal thrust in older children should be done. If they can speak or cough, do not touch as this may dislodge the FB causing complete obstruction.

23. Pulmonary Index Score (PIS) Airway foreign body Management: If there is loss of spontaneous breathing the child should have CPR initiated and be intubated.

24. Pulmonary Index Score (PIS) Airway foreign body Management: Remember, if FB above the larynx you may need to do a cric. (needle cric if under 12, surgical cric if over 12) If below the larynx, intubate down to the right mainstem, (to push FB down) then pull back ETT and place patient right side down to ventilate the left lung.

25. Pulmonary Index Score (PIS) Airway foreign body Management: If stable, imaging studies should be done (CXR, CT) Definitive treatment is bronchoscopy with removal.

26. Pulmonary Index Score (PIS) Asthma Treatment/Management: 1. Assess Severity 2. Reverse Airflow obstruction 2. Correct hypoxia and/or hypercapnia 4. Reduce likelihood of recurrence

27. Pulmonary Index Score (PIS) Asthma Pulmonary Index Score < 7 = Mild, 7-11 = Moderate, > 12 Severe

28. Pulmonary Index Score (PIS) Asthma Treatment of moderate to severe cases. 1. Beta-agonists (salbutamol) – puffers as effective as nebulizers. 2. Prednisone 1 mg/kg PO, then 0.5 -1 mg/kg bid x 3-5 days or Dexamethasone 0.6 mg/Kg PO/IM/IV 3. Oxygen for hypoxia 4. Epinephrine 0/01 mg/KG IM q 20 min prn x 3 5? Consider MgSO4 25-75 mg/Kg IV over 20 minutes.

29. Pulmonary Index Score (PIS) Some notes on bronchodilators Salbutamol is a beta 2 agonist causing bronchodilation. Onset of action is rapid, within 5 – 10 minutes. Duration of action is around 4 – 6 hours. Ipratropium (Atrovent) is an anticholinergic drug which also causes bronchodilation. Ipratropium onset is up to 1 hour and duration of action is also from 4 – 6 hours.

30. Pulmonary Index Score (PIS) Some notes on bronchodilators So in acute asthma, first line treatment should be salbutamol. You can also give ‘Combivent’ (salbutamol and ipratropium), but after 1 or 2 Combivents, the anticholinergic receptors will be maximally blocked. Thus giving more than 2 ‘Combivent’ nebulizers is of limited value. Continue giving Salbutamol, but you can stop Combivent.

31. Croup = acute laryngotracheobronchitis = edema of larynx, trachea and bronchi. • Usually occurs in 6 mos to 2 year olds. • Barking cough, hoarse, stridor, possible dysphagia

32. Croup Treatment: Keep the child calm. Oxygen – for mild croup this may be all that is necessary. Dexamethasone 0.6 mg/Kg PO or Budesonide 2 mg via nebulizer. Nebulized Epinephrine 0.5 mg/kg to max 5 mg. Should improve within 30 minutes. Observe for 3-4 hours. If no need for repeat treatment and appear stable, can be discharged. If they require repeat treatment, consider admission.

33. Bronchiolitis Usually < 2 yrs of age. URTI symptoms followed by LRT symptoms. Severity scores are inconsistent, but generally an SpO2 < 95% is considered severe.

34. Bronchiolitis Treatment: If mild: 1. Ensure hydration and relieve nasal congestion. (decongestants and OTC of NO value)

35. Bronchiolitis Treatment: Severe: • A one time trial of salbutamol or epinephrine may be used, but clinical efficacy is questionable. • Hypertonic saline neb and steroids, NOT recommended. • IV fluids as needed. • Nasal suctioning. • Oxygen to maintain SpO2 > 90% • Non invasive ventilation/CPAP ie transfer/ICU

36. Anaphylaxis In children the most common (80-90%) signs and symptoms are cutaneous (urticaria, angioedema, pruritus etc) Warning signs: more than one organ system involved. - Signs of respiratory distress - Signs of impaired perfusion - Abdominal pain, vomiting, dysrhythmias.

37. Anaphylaxis Treatment: • Epinephrine 0.01 mg/kg IM in the thigh. Repeat q 5 min prn. • Place patient recumbent with legs elevated. • Normal saline bolus 20 ml/Kg • Ranitidine 1 mg/Kg IV for itch. • Methylprednisolone 1 mg/Kg IV • ? Epinephrine infusion • ? Vasopressor infusion 8. Call Pediatrics!

38. Epiglottitis Since the introduction of the Hib vaccine there has been a dramatic drop in epiglottitis, so that hopefully many young rural doctors can go through their career never having to deal with this horrific condition. However, there are other causes other than H flu, so beware!

39. Epiglottitis

40. Epiglottitis Infection of the epiglottitis is a cellulitis of the epiglottitis and surrounding tissues. With subsequent edema it can quickly cause complete airway obstruction.

41. Etiology of Epiglottitis • Bacteria • Viral • Fungal So Hib vaccine alone does not eliminate this disease and in fact in some series 25% of H. flu epiglottitis cases were in vaccinated children.

42. presentation of Epiglottitis • Respiratory distress – stridor, tachypnea, tripod position. • Drooling, dysphagia. • ‘Hot potato’ voice. • Marked retractions and labored breathing (can indicate impending respiratory failure)

43. Management • Do not attempt to look in the throat. • Do not attempt IV or other invasive painful procedures (this may lead to crying and occlusion of the airway) • Call ENT and anesthesia ? Remember this is rural medicine and no such luck! You need to have a plan as you are it!

44. Management Patient able to maintain their airway: • With the child in sitting position, provide humidified oxygen. • Do not to attempt to image patient if in severe distress. • Have airway cart and RSI drugs available. • Never leave the side of the child.

45. Management Patient appears to be unable to maintain their airway: • Attempt bag-valve mask ventilation. • If unable to oxygenate attempt intubation by RSI. • If unable to intubate, be ready to do needle cricothyrotomy if under 12 and surgical cricothyrotomy if over 12 . The next slide is a great video on needle cricothyrotomy.

47. Intubation of pediatric patients

48. When you have to secure the airway Main Anatomical Differences in Pediatrics and Adults • Small mandible and large head (towel under body and shoulders) • Large tongue • High larynx • Epiglottis is long and stiff • Narrowest area is the cricoid cartilage • Trachea is short and directly in line with Right Bronchus

49. Equipment “Formulas” for blade, ETT size etc FORGET it, use a table or an app (ie palmPEDi etc)

50. Pediatric Airway management The next slide is a video by Reuben Strayer on Pediatric airway management.