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