Good morning,

This month we will be discussing Pediatric Respiratory Emergencies. Children are more likely to present with acute respiratory issues in the winter to spring months. Therefore, it is vital to know how to recognize, evaluate, and manage their symptoms. 

Respiratory emergencies account for a significant portion of childhood emergency department visits and hospital admissions. It is the number one cause of cardiopulmonary arrests in children. One important thing to remember is that children are “not just little adults.” They have smaller airways, increased metabolic demands, decreased respiratory reserves, and inadequate compensatory mechanisms. Compared to adults, the child’s airway is shaped like a cone rather than a tube, with the cricoid cartilage being the narrowest portion. This makes visualization of the pediatric airway more difficult. Remember that neonates are obligate nose breathers. Their airway is so much smaller than an adult; therefore, any edema or secretions can have a much bigger impact on their breathing. This is why it is so important to keep these kids calm. Even minor colds can result in a lot of noisy breathing such as congestion, stridor, and wheezing. 

Early recognition of pending respiratory failure is vital when examining these children. Swiftly providing the appropriate intervention can lead to a good outcome. Make sure that you carry out your assessment in a step-by-step approach. Ask yourself “is this child in respiratory distress?” What interventions must be done now to prevent respiratory failure? Resuscitation courses teach us about airway, breathing, and circulation. In pediatrics, please add an additional “A” for “appearance”. The appearance of the child is extremely vital to how the evaluation and management are approached. A brief assessment to determine whether they are “sick or not sick” tells you a lot. Make sure to observe their level of alertness or activity. Are they active and curious, staring around the room? Do they look pale, or are they mottled or cyanotic? Do they have a normal tone or appear “floppy” and are they refusing to move out of a certain position? 

Be mindful of their respiratory mechanics. Monitor the child closely for marked increased work of breathing (grunting, nasal flaring, subcostal, intercostal, and suprasternal retractions) or decreased respiratory effort which indicates fatigue and is concerning for impending respiratory failure. Listen to their voice or cry. Is it hoarse or muffled? Do they have stridor, or are they wheezing? In a verbal child, are they able to speak in full sentences, or are they using one-word sentences to answer your questions? For example, children presenting with severe asthma exacerbations may be unable to speak to you in full sentences. In summary, remember A-ABC when it comes to kids. Be safe, stay warm, and keep up the amazing work! 

Regina A. Yaskey, MD, FAAP

Pediatric Trauma - February 14, 2022

Good morning,

Last week we discussed the overall step-by-step approach in evaluating a child in respiratory distress. This week’s message focuses on the evaluation and management of the child presenting respiratory distress secondary to an upper airway involvement.

When faced with a child in respiratory distress, ask yourself, is it an upper or lower airway obstruction? Think about it! What sound do you typically hear from kids with an upper airway obstruction? It is STRIDOR, a high-pitched, crowing, noise typically heard on inspiration. It indicates the presence of large airway obstruction above the thoracic inlet.

CROUP is a common upper airway respiratory illness, an acute viral infection that causes inflammation of the subglottic airway producing upper airway obstruction. Its hallmarks are stridor, barky cough (baby seal sound), and hoarseness. Some children present with fevers, and others do not. When evaluating and treating these patients, it is important to keep them calm. Do not agitate them (remember, they have edema of their upper airway). Keep them in their position of comfort. Do not lay them down, and DO NOT perform a digital airway exam. Check pulse oximetry and place them on the cardiac monitor. If they are in mild distress, without stridor, give them nebulized normal saline while in transport. If they have stridor at rest with a barky cough, give them nebulized racemic epinephrine. If they are in moderate/severe distress with stridor and a barky cough, give racemic epinephrine plus IV Solumedrol (2mg/kg; Max Dose = 60mg in children). Of note, if racemic epinephrine is unavailable, you can administer aerosolized epinephrine at 1mg/ml.  

Here are a few other take-home points:   

1. If your patient is wheezing, then it is not croup. Wheezing in a patient with respiratory distress indicates lower airway disease, not upper.  

2. Remember that with croup, you should be able to note some improvement after a dose or two of racemic epinephrine (either improvement in stridor or work of breathing). If you do not note any improvement after nebulized treatments, then consider an upper airway foreign body obstruction.

Upper Airway Foreign Body Obstruction is the leading cause of accidental deaths in toddlers. The history is that of a crawling infant or toddler presenting with an abrupt onset of choking or gagging. The parents will usually disclose that the patient has not had any prodromal respiratory symptoms. During auscultation, there is usually minimal or no air exchange despite effort from the child. Cyanosis can be present in a complete obstruction. Crawling infants and toddlers love to put things in their mouths; hence, the saying “everything is edible.”. In coughing and conscious infants (0-12 months), administer oxygen (10-15L) via infant mask as tolerated. If the infant is conscious, but there is a concern for a complete obstruction (no breath sounds on auscultation, cyanosis), give 5 back blows followed by 5 chest thrusts. If the child is toddler-age or older, perform abdominal thrusts instead. In the case of an unconscious patient with a complete obstruction, immediately begin chest compressions /CPR. Have your partner open the airway to see if they can visualize the foreign body. If they can, and it is attainable, remove it with fingers or consider using the laryngoscope and Magill forceps to retrieve and remove it. If unable to remove the foreign body, ventilate the patient via bag valve mask and transport to an appropriate facility. DO NOT PERFORM A BLIND FINGER SWEEP. This has the complication of lodging the foreign body further down the airway. Remember to contact Medical Control where indicated and provide appropriate transfer of care. 

Acute Epiglottis is a life-threatening bacterial infection of the epiglottis and surrounding structures. Nowadays, it is very rare due to the administration of the Haemophilus Influenzae type B vaccine (also known as Hib vaccine). These patients are toxic-appearing and present with a very abrupt onset of fever, stridor, sore throat, and drooling. Do not agitate them and allow the child to maintain their position of comfort. Ensure adequate ventilation via BVM as soon as possible. DO NOT ATTEMPT invasive airway procedures on the conscious patient who is suspected of having epiglottitis unless they are in respiratory arrest. Call medical command early and transport to an appropriate facility.

Thanks for reading. Keep up the great work and have a great week.

Regina A. Yaskey, MD, FAAP 

Pediatric Lower Airway - February 21, 2022

Good morning,

Over the past two weeks, we have discussed (1) The step-by-step approach to evaluating a child in respiratory distress, and (2) The signs, symptoms, and clinical presentations of children with respiratory distress secondary to an upper airway involvement. This week, we will be discussing lower airway involvement.

Respiratory illnesses of the lower airway are obstructive, parenchymal, or alveolar diseases. The clinical hallmarks include dyspnea, tachypnea, and cough. Common causes include bronchiolitis, asthma, congenital abnormalities (tracheal webs, cysts, vascular rings, and lobar emphysema), pneumonia, pulmonary edema, inhalation injury, and cystic fibrosis.

Bronchiolitis, a viral infection is a lower respiratory tract infection of the bronchioles (small airways). It usually presents in the winter/spring months. It is usually seen in children who are younger than 24 months. Respiratory Syncytial Virus (RSV) is the most common cause. Clinical signs are similar to that of a viral respiratory infection. These children usually start with a prodrome of nasal congestion, rhinorrhea, fever, cough, wheezing, and mild respiratory distress. Additional signs and symptoms include apnea, decreased oral intake, moderate to severe respiratory distress (tachypnea, nasal flaring and retractions, grunting), cyanosis, restlessness, and lethargy. Risk factors for severe disease include children younger than 12 weeks old, with a history of prematurity (less than 37 weeks), congenital heart disease, chronic lung disease, and immunodeficiency. The course of bronchiolitis is variable and dynamic. It ranges from transient events such as apnea or mucous plugging to progressive respiratory distress from lower airway obstruction. Symptoms are usually worse on days 3 – 5 of illness. Determining the degree of airway obstruction is the most important consideration when assessing children with bronchiolitis.

Examine their general appearance, the degree of respiratory distress, cyanosis or pallor, and their level of oxygen saturation. In route, when dealing with these patients, give them supplemental oxygen if the oxygen saturation is consistently below 92%. Insert an IV and administer fluids if they appear to be dehydrated. If wheezing is present, a trial of a bronchodilator (Albuterol) is an option. Please auscultate before and after the albuterol administration in order to determine if it made a difference in the patient’s air exchange or work of breathing. 

Asthma, a chronic inflammatory lung disease, accounts for 15% of all emergency department visits. Symptoms include paroxysmal cough, wheezing, dyspnea, and chest tightness. It is caused by airway inflammation and narrowing that is partially or completely reversible. Precipitating factors include infection, allergens, irritant exposure (tobacco smoke, air pollution), exercise, cold exposure, beta-blockers, and emotional stress). When presented with a patient with asthma, your goal is to rapidly determine the severity of the acute exacerbation and examine their overall appearance (color and level of consciousness). Their respiratory mechanics are important. Look for tachypnea, retractions, nasal flaring, grunting, abdominal breathing, and prolonged expiratory phase. When auscultating, listen for their degree of air exchange (are they wheezing, are they moving no air at all, do they have symmetry of their breath sounds?). Please monitor their hydration status. In severe exacerbations, the child may be breathless, have difficulty speaking in complete sentences, and may have a change in mental status. Remember that hypoxia causes agitation and hypercapnia causes drowsiness or coma. Treatment for acute asthma exacerbations includes oxygen, duonebulizer treatments (Albuterol and Ipratroprium). These treatments can be repeated en route if the work of breathing persists. In cases of severe exacerbations, insert an IV or IO, administer fluids for hydration, add Solumedrol (2mg/kg; Max Dose: 60mg for children). Transport the patient to an appropriate facility. Remember to consult Medical Control when indicated.  

Thanks for all of your hard work. Have a great week. 

Regina A. Yaskey, MD, FAAP 

Pediatric Trauma - February 28, 2022

Good morning,

This week we will be discussing some common life-threatening respiratory emergencies in children.

1.   Upper airway foreign body

2.   Epiglottitis

3.   Anaphylaxis

4.   Tension pneumothorax

In Week 2, we discussed upper airway foreign body and epiglottitis.

Tension pneumothorax is caused by air entering the pleural space and accumulating under pressure. Air can enter the lung tissue injured by an internal tear or from a penetrating chest injury. If air continues to leak into the pleural space, it accumulates under pressure, creating a tension pneumothorax. As the pressure increases, it compresses the underlying lung and pushes the mediastinum to the opposite side of the chest. Compression of the lung rapidly causes respiratory failure. Untreated tension pneumothorax leads to cardiac arrest characterized by pulseless electrical activity (PEA). Suspect this in a victim of chest trauma or in any intubated child who deteriorates suddenly while receiving positive-pressure ventilation, including bag-mask or non-invasive ventilation. Treatment is immediate needle decompression followed by thoracostomy for the chest tube placement as soon as possible. A trained provider can quickly perform an emergency needle decompression by inserting an 18-to-20 gauge over the needle catheter in the top of the child’s third rib (second intercostal space) in the midclavicular line. A gush of air is a sign that the procedure has been successful. This indicates relief of pressure buildup in the pleural space.

This brings me to my next topic: What separates an allergic reaction from anaphylaxis?  

An anaphylactic reaction has multisystem involvement (skin, plus gastroenterology, respiratory or cardiac). An allergic reaction, on the other hand, has one organ system involvement (most often, skin). Anaphylaxis is caused by a severe reaction to a drug, vaccine, food, toxin, plant, venom, or other antigens, and is characterized by vasodilation, arterial vasodilation, increased capillary permeability, and pulmonary vasoconstriction. It can occur within seconds to minutes after exposure. Clinical signs and symptoms include angioedema (swelling of the face, hand, and lips), respiratory distress with stridor, wheezing or both, hypotension, tachycardia, anxiety and agitation, urticaria (hives), nausea, and vomiting. 

When presented with a patient with suspected anaphylaxis, please remember to auscultate their lungs. They may be wheezing and will need albuterol for treatment. In a child presenting with anaphylactic shock, the most appropriate immediate treatment is EPINEPHRINE. It can be administered as an IM or via an autoinjector. The dose is 1mg /mL concentration 0.01mg/kg IM (Max Dose 0.5mg). You may administer this Q 5 minutes PRN. 

Epinephrine Auto-Injector

15 – 30kg (33 – 66lbs)

AUTOINJECTOR JR

(0.15mg dose)

>30kg (66lbs)

AUTO-INJECTOR

(0.3mg dose)

Q5 minutes PRN – Max 2 injectors 

Adjunct treatments include Diphenhydramine (Benadryl 1mg/kg ;Max dose 50mg). Give a normal saline bolus (10-20ml/kg) for hypotension. You may repeat this up to three times in route and Methylprednisolone (Solumedrol 2mg/kg Max Dose 60mg in children). Remember to administer Albuterol as needed for bronchospasm. 

Remember to always consider the airway differences in children. Infants have a prominent occiput. Therefore, when you lay them down, their head automatically moves in the “sniffing” position. Their airway structures (tongue, tonsils, and adenoids) are proportionally larger. If you need to place an advanced airway or bag them, please roll a towel under their shoulders to help alleviate the upper airway obstruction. For intubation, we recommend using a straight blade laryngoscope (the Miller blade) because it is better suited to “lift up” the epiglottis during endotracheal intubation in small children. Do not forget to jaw thrust your patients in order to help open up that airway. 

The most important skill you should have for the pediatric airway is providing excellent Bag-Mask Ventilation. When bagging a child, make sure that you are using the proper sized mask. You determine the appropriate mask size by the ability to seal it around the mouth and nose without covering the eyes or overlapping the chin. In the absence of neck injury, tilt the forehead back and lift the chin. Use the “E-C Clamp” method which is the letters “E” and “C” formed by the fingers and thumb over the mask and mandible. Squeeze the bag over one second and watch for chest rise. Do not over-ventilate. If you do not see a chest rise when squeezing a breath into the patient, go back and make sure that you have formed a tight seal with the mask so that air does not escape. Learning this skill will save countless lives. 

Thank you for taking the time to read these morning messages. Keep up the great work. Stay safe and warm. 

Regina A. Yaskey, MD, FAAP