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[Music]
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my name is jesse rankin i work at st
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david's children's hospital in the er
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there i'm a pediatric er physician
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i got the topic of pediatric respiratory
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distress which is somewhat broad
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but we're going to hit the highlights
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and i called my brother-in-law before i
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started this presentation because he's a
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paramedic in l.a county
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and i said so what would you want to
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know about pediatric respiratory
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distress
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and he said basically we want to know
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how not to f it up
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so i said that's so great we have
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similar motivations this is awesome
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so we're going to have some objectives
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today
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so try to recognize the different
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presentations of pediatric respiratory
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distress
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because they vary from an adult
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presentation of pediatric respiratory
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distress
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we're going to discuss just kind of like
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the heavy hitters the things i feel like
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we see all the time right so
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croup anaphylaxis bronchiolitis and
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asthma and we're going to try not to eff
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it up
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so all right so
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a couple things we need to think about
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in terms of what's different about
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the pediatric airway versus the adult
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airway in general
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everything is smaller but what that what
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is there is bigger in a smaller space
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right so your nasopharynx is smaller
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it's more easily occluded as are your
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nerves
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right so infants are obligate nose
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breathers so anytime their nose is
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congested they're going to be having
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some respiratory distress right
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their tongue their tonsils their
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adenoids those are all really big
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in relation to their oral cavity right
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they have
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a really long floppy epiglottis it's
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going to be more vulnerable to swelling
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like you'll see in croup
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and their larynx is more superior and
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anterior which sometimes can make an
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intubation a little bit more difficult
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we're not really going to get into
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intubation and
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that kind of thing today but just
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something in general to know
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and then their cartilage their tracheal
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cartilage is really floppy it's not well
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developed yet so
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it's easy to collapse when their neck is
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flexed which is why sometimes it's a lot
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better to kind of have them in the
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sniffing position
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so that airway is patent and not
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compromised in any way
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the other thing to think about is
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they're not just different anatomically
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they're also different physiologically
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right so
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increased metabolic rate increased
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oxygen consumption
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increasement of ventilation they have
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very small lung volumes this all equals
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the potential for really rapid
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decompensation right they're like fine
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until they're not and you're just like
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thanks for the warning that's awesome
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appreciate that
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so just kind of have to remember that um
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and unlike in adults where usually it's
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a primary cardiac event that's going to
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lead to a cardiopulmonary arrest and
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kids it's usually a primary respiratory
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event so we just kind of have to really
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mind our p's and cues when we're dealing
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with these kiddos
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okay so let's work on recognition i hope
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these videos play
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but we'll find out it'll be fun
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okay so in general it's really important
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to just recognize what you see right i
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always teach residents like you should
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walk into a room and
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decide in like five seconds if that
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patient is sick or not sick right so
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you guys can do the same thing it's not
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it's not rocket science
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so observe the child you know what do
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they look like are they alert are they
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playful
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or are they completely listless and
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parents always say the word lethargy
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right it's like the most
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top in the kids like running around the
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room and you're like okay great
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that's a that's a buzzword right but
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listless are they responding to painful
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stimuli are they
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are they mad at you when you're poking
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them and prodding them i like it when
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kids are crying and mad a crying child
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is a child that's breathing right so
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remember that this is what really scares
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me anytime you have a kid with
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respiratory issues and they are
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somnolent or they are starting to
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their mental status is starting to kind
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of wane you're in trouble that's
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probably a sign of impending respiratory
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failure
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okay okay so different signs of
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respiratory
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distress
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so your first sign you're going to see
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and you're going to see this early on is
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tachypnea right and it's just important
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to remember that
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kids in general will breathe at
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different rates and there's different
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normals
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depending on how old they are so good
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rule of thumb is
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um if they're a neonate it's probably
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usually around 50
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50 times a minute if they're less than
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six months it's usually around 40.
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if they're a year it's usually around
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30. right so try to keep that in mind
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we're dealing with these kiddos
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and um when you have these kiddos who
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are breathing really hard and fast and
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then they start to breathe slow
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and they get more lethargic that's when
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we're also heading into that danger zone
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okay so oh yeah it works
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um so retractions right so this is
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something you're going to see in kids
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so they can retract in all kinds of
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different places and sometimes
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where they're retracting can give you an
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idea of where they're having
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an obstruction right so babies are
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trying really hard to overcome this
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airway obstruction no matter where it is
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so they're generating really high
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negative intrathoracic pressures
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and that's causing their soft tissue in
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their chest wall to kind of sink in so
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that's what you see
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right um in general supraclavicular
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retractions or super sternal tractions
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are kind of more of an indication of an
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upper airway obstruction
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and then your intercostal and your
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subcostal retraction
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are in general more indicative of a
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lower airway obstruction
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okay so i know you guys have all seen
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this right
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and then you've seen the kids that are
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just like retracting to their spine and
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everything is it's just
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not good everybody's seen this right
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yeah so
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another thing that mostly just babies do
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is head bobbing
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right you guys seen this before so why
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do they do that so
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they're just trying to generate more
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negative interest rates pressure to get
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more air in their lungs right so they're
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obstructed so
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contraction of their neck muscles is
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going on in order to assist ventilation
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and since their neck extensor muscles
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aren't very developed yet
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their head that's kind of what's going
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on
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nasal flaring you've seen this a lot i'm
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sure too
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right so basically they're just trying
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to decrease the airway resistance by
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opening up other airways bigger
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right to get more air in so we'll see
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that a lot with infants as well
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and like we said the little ones they
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tend to breathe through their nose more
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so any level of obstruction in their
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in their nasopharynx is going to give
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them some difficulty
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tracheal tugging i know you guys have
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all seen this and this is what we're
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going to
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usually see in crew right or some kind
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of an upper airway obstruction
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uh this is your super sternum
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retractions just kind of see them
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sucking in right here above their
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sternum
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this is the one i really don't don't
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like
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especially since to the season we're in
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the middle of rsv
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right so basically these kids
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are trying to create their own peeps
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they're trying to
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create more uh positive end expiratory
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pressure when they're breathing out to
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open up those alveoli that are
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collapsing on expiration right
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so they're trying really hard to get air
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in and out and this is kind of an
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ominous sign
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you're going to see this more in lower
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respiratory tract disease like
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bronchiolitis that kind of thing
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you guys have seen and heard these
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things right yeah
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you can also see how this kid is sitting
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right so kids are going to kind of
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tripod a lot when they're having an
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airway obstruction
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they're just trying to align everything
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as much as they can to get the most air
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in so you're going to see them kind of
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neck neck extended out kind of leaning
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over a little bit right so that's
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pretty common as well
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and then i know we've all heard this
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before
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strider and you hear this a little
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better at the end of the video but
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this is a high-pitched noise right you
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usually hear it on inspiration
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you usually don't need a stethoscope to
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hear this right you can hear it from
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across
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the room and this usually indicates
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narrowing in your upper airway
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there's turbulent airflow going in
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because of that and you hear this noise
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okay it can be inspiratory strider
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you can have expiratory strider you can
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have biphasic strider
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and that kind of helps you kind of judge
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the level of obstruction of where the
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obstruction is occurring right
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inspiratory is usually going to be above
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your vocal cords
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expiratory it's going to be below okay
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and kids with you know really true
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strider and respiratory distress they
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give me a little
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anxiety i don't like upper airway
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obstructions
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but of course on the outside we pretend
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like everything's cool
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okay this is embarrassing i couldn't
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find a picture of a human with starter
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so this is a bulldog
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okay so sturter i just wanted to bring
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this up because strider and starter are
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sometimes
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very easily confused sturter is more
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of an obstruction of your nasal pharynx
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it's like snoring
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okay i know this dog is like really
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having a nice dream but um
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it's more lower pitched it's like a
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snore as opposed to the higher pitched
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strider that you'll hear
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and the obstruction here is above the
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larynx and usually in the nose right
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um a lot of times so it's kind of hard
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to tell like a kid who's really
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congested and
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stutterous sounds almost like strider
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sometimes so
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try to try to remember this video this
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bulldog
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when you're trying to differentiate
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between the two
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strider like we said it's going to be
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more high pitched
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it is usually a level kind of above the
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vocal cords that you're
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you're seeing that obstruction sturter
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is more lower pitched it's more snoring
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um and it's usually in the nasopharynx
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that the obstruction is kind of
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occurring
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okay so let's kind of put it all
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together
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so upper airway
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obstructions you're going to see nasal
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flaring usually
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you're going to see strider you're going
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to see tracheal tugging
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you're going to see stirder okay lower
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air obstructions this is where you're
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going to have more of your wheezing
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you're going to have grunting you're
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going to have subcostal and intercostal
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retractions right
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so let's talk about the potential
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differential diagnoses for these things
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right so
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for our upper airway obstruction croup
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probably the most common thing you'll
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see
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right epiglottitis not as common right
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now because of
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the hip vaccine but we do have some
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non-type-able age flu that can cause
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epiglottitis but not very
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common anaphylaxis obviously
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and then in terms of our lower airway
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diagnoses we have asthma we have
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bronchiolitis we have pneumonia
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and there's tons more but i just wanted
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to kind of hit hit the most common
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things you guys are going to see
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so these are the ones we're going to
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talk about today
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okay so moving on
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group
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so it's the most common cause of acute
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strider right
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it usually presents with fever harsh
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cough
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respiratory distress usually it's going
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to be in kids six months to three years
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old
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so why is that why don't adults get
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croup
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generally it's because kids airways are
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a lot smaller right so you can see in
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this diagram
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at the smallest an infant's airway is
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about four millimeters so a millimeter
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of swelling is really
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going to go a long way right to decrease
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basically their cross-sectional airway
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or cross-sectional area
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an adult we have big fat airways we have
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a little bit of swelling who cares
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like life goes on so that's in general
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why croup
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is a pediatric disease okay it's a viral
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infection that infects the soft tissues
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around the airway
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and because of all the different anatomy
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of kids and the
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the different anatomy compared to adults
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that's why we see what we see with croup
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that we don't generally see in the adult
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population
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and we see a lot more in the winter
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months it's most commonly caused by para
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influenza but there are a lot of
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different viruses that can cause group
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so treatment your goal is to maintain a
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patent
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airway until you get into the emergency
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department and sometimes with croup
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and with these upper airway issues less
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is more right
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so we want these kids to be calm when
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they start crying and screaming it all
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looks worse it all gets worse
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the air the air that's going in is a lot
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more
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so when it's more air is going through a
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smaller area the strider is louder the
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respiratory distress is worse so keep
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these kids calm
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right obviously if it's like impending
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respiratory failure you got to do what
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you
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got to do but if they're protecting
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their airway and they're doing okay
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just leave them alone avoid unnecessary
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procedures if you do need to give them
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oxygen this is where blow-by is
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sometimes good if
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if a cannula or a face mask is going to
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drive them nuts okay let the parents
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hold them just do what you can
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to try to kind of keep them calm and
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then obviously this is where your
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nebulized racemic epinephrine is going
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to come in right so
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this is going to reduce airway swelling
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it's going to reduce it you know a lot
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quicker than steroids and all that kind
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of thing you're going to do
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and in general we like to give it when
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they have strider at rest right so if
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they're
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miserable screaming and they have
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strider but when they're calm they don't
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probably don't need to give it but if
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they are stridulous at rest
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tired appearing working to breathe then
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those kids all need a dose of racemic
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epinephrine
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and you can give it more like if it's
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not working and they're bad just keep
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giving it
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like same thing with albuterol and
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asthma there's really like no such thing
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as too much albuterol in my opinion but
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okay so that was quick and dirty on crew
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anaphylaxis
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so there's a lot of different
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definitions of anaphylaxis but
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essentially there's kind of three
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criteria and if any of your patients fit
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into these criteria then they're having
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anaphylaxis and i think it's important
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to go over these because
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sometimes i think it's under recognized
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and when you don't act fast with
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anaphylaxis
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they tend to have worse outcomes okay so
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it's obviously a serious allergic
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reaction
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it's rapid and onset usually about 30
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minutes after the exposure to whatever
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they're allergic to and it can cause
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death right it's a big deal
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so you're going to have skin and mucosal
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symptoms in about 80 to 90 percent of
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patients but in like 20 percent of
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patients they might not
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and those might be a little more
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difficult to diagnose
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and at the very beginning of an
00:14:15
anaphylactic episode it's really hard to
00:14:17
predict how severe it's going to be
00:14:19
so just err on the side of caution right
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so first criterion is if you have
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involvement in the skin so they have
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hives their lips are swollen
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and that involve that includes the
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mucous membranes
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and they have just one of these other
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things respiratory compromise
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or reduced blood pressure treat them
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like they're having anaphylaxis
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okay next criteria if you have a patient
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who
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has had a known exposure right you know
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this kid's allergic to peanuts and
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they're exposed to peanuts
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then if they just have two of these
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things go ahead and treat them for
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anaphylaxis right so their skin's
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involved their respiratory system
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is involved their circulatory system is
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involved
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or they're vomiting okay and then the
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third
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is if you have anybody with a low blood
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pressure after they've been exposed to a
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known allergen you don't need anything
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else
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right just give them epinephrine okay
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and so
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sometimes it's hard to remember how low
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is too low in a kid right there's like
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so many charts you got to look up and
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it's just kind of exhausting
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so in general there's like three rules i
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kind of stick to so
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if they're less than a year old and
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their systolic is less than 70
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that's too low okay if they're
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from 1 to 10 just take their age
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multiply it by 2 and add it to 70.
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if their systolic is less than that
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that's too low okay
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and then if they're less than 90 and
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they're between 11 and 17 then that's
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too low
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okay
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okay treatment so
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prompt treatment is really really
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important right and anaphylaxis is going
00:15:51
to be more responsive to treatment in
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the early phases
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the longer you wait the harder it is to
00:15:56
fix it same with asthma
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okay so delayed epi is associated with
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fatality
00:16:01
all right there's really no absolute
00:16:04
contraindication to giving epi
00:16:06
so just give it okay um the one to one
00:16:08
thousand concentration obviously
00:16:11
the alpha one agonist is going to help
00:16:12
to vasoconstrict and increase your blood
00:16:14
pressure
00:16:15
the beta two is gonna help bronchodilate
00:16:17
right
00:16:18
and so it's really important to remember
00:16:21
that epinephrine is essentially the only
00:16:23
thing that's going to do that for you
00:16:24
epinephrine is the only thing that's
00:16:26
going to boost your circulation
00:16:27
epinephrine is the only thing that's
00:16:28
going to stop your airway obstruction
00:16:30
all these other things are adjuncts and
00:16:32
they're good to do
00:16:33
but they're adjuncts epinephrine is the
00:16:35
treatment for anaphylaxis okay
00:16:37
so and if it doesn't work do it again
00:16:39
just keep doing it you can give it
00:16:41
you know every five minutes we put them
00:16:43
on epi drips when they're not getting
00:16:44
better so
00:16:45
you know just keep giving it our
00:16:48
adjuncts right so we're going to be
00:16:49
giving iv
00:16:50
fluids we're going to give albuterol for
00:16:51
bronchospasm that isn't
00:16:53
improving with epinephrine we're going
00:16:55
to give our histamine blockers and
00:16:56
steroids
00:17:00
so i hope that that has become obvious
00:17:02
that we're going to give epinephrine
00:17:03
right so this is just kind of
00:17:05
it's kind of hard with the weight base
00:17:06
and everything but if they're less than
00:17:07
10 kilos give them 0.1
00:17:09
if they're 10 to 25 give them 0.15 if
00:17:11
they're 25 to 50 give them 0.3
00:17:13
and if they're over 50 give them 0.5
00:17:18
okay bronchiolitis i hate bronchiolitis
00:17:20
bronchiolitis sucks
00:17:21
nothing makes it better rsv is awful so
00:17:25
just wanted to throw that little caveat
00:17:27
in there okay
00:17:29
so it's the most common lower
00:17:30
respiratory tract infection in infants
00:17:32
less than two right
00:17:33
it doesn't really it really shouldn't be
00:17:34
a diagnosis in an older kid
00:17:36
if you have a kid and you call and
00:17:37
you're like this kid's five and he has
00:17:38
bronchiolitis we're gonna be like
00:17:41
just doesn't really happen in in older
00:17:43
children okay and that's just because of
00:17:44
their airway okay their airway
00:17:47
anatomy so it usually occurs in texas
00:17:50
around november to april
00:17:52
it's the leading cause of
00:17:53
hospitalization in infants okay
00:17:57
it's a viral respiratory infection of
00:17:59
the lower respiratory tract so the
00:18:01
bronchioles right so the small airways
00:18:02
that are aligned with smooth muscle
00:18:04
and in that area the infection you get
00:18:06
they get mucus production they get
00:18:07
cell death and sloughing and all that
00:18:10
results in respiratory distress and
00:18:11
obstruction of their small airways
00:18:14
it's usually rsv but other viruses can
00:18:17
cause bronchiolitis
00:18:19
and they're going to present with cough
00:18:21
to keep me a wheeze and fever
00:18:23
the thing that's kind of hard about
00:18:25
bronchiolitis also though is it's
00:18:27
it's very waxing and waning one minute
00:18:29
they look terrible and the next minute
00:18:31
they look okay so sometimes it's kind of
00:18:32
hard to tell how sick they really are
00:18:34
when you just have 10 minutes with them
00:18:36
or however long you have with them
00:18:38
and then here's just a reminder of the
00:18:39
kind of normal respiratory rate at the
00:18:41
different ages
00:18:45
one thing i want to just caution you
00:18:47
guys about is watch for apnea and the
00:18:48
little ones
00:18:49
okay so the little neonates with
00:18:51
bronchiolitis they'll just stop
00:18:53
breathing on you
00:18:54
and you just have to kind of be prepared
00:18:56
for that you got to have your bag valve
00:18:57
mask ready
00:18:58
okay risk factors for apnea are going to
00:19:01
include a younger age so less than a
00:19:03
month old
00:19:04
a history of prematurity and if they
00:19:06
haven't
00:19:07
they're not two months old yet after
00:19:09
that and obviously if a
00:19:11
caregiver gives you a history of apnea
00:19:13
then those kids are the ones that you
00:19:14
really need to watch you need to have
00:19:15
them on the monitors you need to be
00:19:16
really vigilant
00:19:17
so treatment like i said there's really
00:19:20
not a lot of good treatments for
00:19:21
bronchiolitis it's all supportive care
00:19:24
you need to really monitor their
00:19:25
hydration status suction those babies
00:19:28
because like we said their noses they're
00:19:30
obligate nose breathers right so if
00:19:31
that's obstructed
00:19:32
sometimes suctioning you'd be surprised
00:19:34
how much better they look afterwards
00:19:36
give oxygen if they need it you can you
00:19:39
can try a bronchodilator so the aap is
00:19:41
like don't give bronchodilators to
00:19:43
patients with bronchiolitis because it
00:19:44
doesn't help
00:19:45
but i don't know if they're down in the
00:19:46
er like watching kids breathe 70 and
00:19:48
like you know
00:19:49
crumping so when kids are that ill you
00:19:51
got to do what you got to do try it
00:19:53
when kids are that ill it's not probably
00:19:54
not going to hurt them but it is not
00:19:56
generally recommended by the aap to give
00:19:58
bronchodilators and bronchiolitis but i
00:20:00
do it so
00:20:01
proceed as you will what saves our took
00:20:05
us a lot from having to intubate these
00:20:06
kids is hyponasal cannula
00:20:09
so hyponasal cannula is awesome
00:20:12
um so your normal kind of oxygen
00:20:15
delivery method so like a nasal cannula
00:20:17
you get about one to six liters per
00:20:18
minute right
00:20:19
a non-rebreather mask you can get about
00:20:21
10 to 15
00:20:23
and when you're bag valve masking
00:20:24
somebody you get about 15 liters per
00:20:26
minute
00:20:26
but with hyphen nasal cannula we can get
00:20:28
up to 60 liters per minute so
00:20:30
it's a ton more flow it's higher o2
00:20:33
concentration
00:20:34
and there is some argument that maybe
00:20:35
they are getting a little peep also
00:20:38
so this is what we use a lot and it's
00:20:40
really changed practice in terms of
00:20:41
managing bronchiolitis and babies and
00:20:43
the intubation rates have gone way down
00:20:48
and then last we're going to talk about
00:20:49
asthma so this is
00:20:51
we see this all the time right it's the
00:20:53
most common chronic disease of childhood
00:20:55
and i trained
00:20:55
i did my residency in chicago where you
00:20:58
know the african-american population
00:20:59
asthma is really really bad and so we
00:21:01
saw a lot
00:21:02
of it and a lot of bad asthma
00:21:03
exacerbations and
00:21:06
asthma is essentially two problems right
00:21:08
so your airways are constricted
00:21:11
the smooth muscle is contracting and
00:21:12
there's inflammation that's essentially
00:21:14
the issue with asthma
00:21:16
there's an early bronchospastic phase
00:21:18
where they're going to be much more
00:21:19
responsive to treatment
00:21:21
and then the inflammation kicks in and
00:21:22
there's airway remodeling
00:21:24
and then you're getting behind the eight
00:21:25
ball and then it's a lot harder to break
00:21:27
these kids
00:21:28
the longer they've been in their asthma
00:21:29
exacerbation the harder it's going to be
00:21:31
to turn them around
00:21:32
okay so remember that um
00:21:37
severe asthma so things that i kind of
00:21:40
look for that
00:21:41
that i always kind of get a little bit
00:21:43
more concerned about our if these kids
00:21:45
can't talk
00:21:45
okay that's concerning if their mental
00:21:48
status is
00:21:49
waning that's concerning i'm sure you
00:21:51
guys have all heard about the silent
00:21:53
chest right so
00:21:55
you have to have air movement to wheeze
00:21:56
so it's kind of reassuring when they're
00:21:58
wheezing
00:21:58
if there is no air movement whatsoever
00:22:00
then that kid is you know
00:22:02
border borderline so if you're not
00:22:04
hearing anything they're not moving any
00:22:05
air they're not talking
00:22:07
they're hypoxic it's not as common in a
00:22:09
mild or moderate
00:22:11
asthma exacerbation to actually be
00:22:12
hypoxic because the issue is usually
00:22:15
with
00:22:15
ventilation with expiring right so if
00:22:18
you start having a kid that's starting
00:22:19
to get hypoxic then those kids are
00:22:21
getting more sick also
00:22:23
there's also some historical risk
00:22:24
factors for severe exacerbation so if
00:22:26
you just want to quickly ask the parents
00:22:27
like
00:22:28
have they ever been in the icu have they
00:22:29
ever been intubated
00:22:31
have how many times have they been to
00:22:32
the er this year and
00:22:34
how long have they been dealing with
00:22:35
their asthma so those are all things
00:22:37
that
00:22:38
can kind of tip you off that this kid
00:22:40
could turn fast
00:22:42
and then in terms of treatment so
00:22:43
obviously you want to assess their
00:22:45
severity of
00:22:46
work of breathing their mental status
00:22:48
give them oxygen
00:22:50
if needed and then bronchodilators right
00:22:53
so
00:22:54
i really feel like there's not really
00:22:55
such thing as too much albuterol
00:22:58
and a continuous nebulization has been
00:23:01
shown to be much more effective than
00:23:03
you know intermittent treatments you can
00:23:05
give them 0.5 milligrams
00:23:07
per kilogram up to 20 milligrams right
00:23:09
so give it just keep giving it
00:23:13
it's also important to remember if you
00:23:14
have a really long transport time to
00:23:16
consider steroids because that helps us
00:23:18
out because that's been shown early
00:23:20
steroids have been shown to help
00:23:22
decrease admission admission rates okay
00:23:25
and then if they're really an extremist
00:23:27
and i actually had a
00:23:28
paramedic yesterday who did a great job
00:23:30
with the patient because
00:23:32
it's really important to remember your
00:23:33
injectable bronchodilators right like
00:23:34
epinephrine
00:23:35
so if kids are really obstructed they're
00:23:38
not moving air
00:23:39
the albuterol can't get in to do
00:23:41
anything right so
00:23:42
if those kids those these are the kids
00:23:44
that you think we're heading in the
00:23:45
wrong direction give them some im epi
00:23:47
you'd be shocked
00:23:48
how much how quickly they respond and
00:23:50
how what a different child you're
00:23:52
dealing with at that time
00:23:55
okay take away points so kids are
00:23:58
usually going to crump because of
00:23:59
respiratory failure not because of
00:24:01
cardiac disease right if you have a
00:24:04
sleepy drowsy
00:24:06
depressed consciousness kid in
00:24:07
respiratory distress then you're kind of
00:24:09
heading towards a danger zone
00:24:11
remember to kind of use aggressive and
00:24:13
early treatment of anaphylaxis
00:24:15
bronchiolitis sucks nothing makes it
00:24:17
better and watch for apnea and little
00:24:18
kids
00:24:20
and continuous liberal albuterol and
00:24:22
status asthmaticus
00:24:24
don't and don't forget your injectable
00:24:27
[Music]
00:24:30
bronchodilators
00:24:32
[Music]
00:24:34
you
