PAEDIATRIC EMERGENCIES: RESPIRATORY FAILURE

By Larry

RESPIRATORY FAILURE
Occurs when gas exchange is inadequate Resulting in hypoxia Common cause of cardiorespiratory arrest Unable to maintain satisfactory Spo2 on inspired oxygen >40% or a rising pCo2 Divided to upper airway obstruction and lower airway disorders

PRESENTATION
Tachypnea/Fast breathing Cyanosis Lethargy Poor oral intake Altered level of consciousness Noisy breathing

RESPIRATORY FAILURE

Upper airway obstruction - Croup - Epiglotitis - Bacterial tracheitis - Retropharyngeal abscess - Foreign Body

RESPIRATORY FAILURE

Lower airway disorder - Asthma - Bronchiolitis - Pneumonia

CROUP
Mucosal inflammation and increased secretions with oedema of subglottic area Laryngotracheobronchitis 95% is viral in origins (Parainfluenza, metapneumovirus, RSV, influenza) Age group: 6 month-6 years (peak: 2years) Barking cough, harsh stridor and hoarseness Can be preceded by fever or coryza

SEVERITY (WAGENER)
Mild : stridor with excitement or at rest, with no respiratory distress Moderate: stridor at rest with intercostal, subcostal or sternal recession Severe: stridor at rest with marked recession, decreased air entry and altered level of consciousness

CROUP
Figure 1: Steeple sign: narrowing of subglottic region

BACTERIAL TRACHEITIS
Pseudomembranous croup Rare but serious Caused by Staph aureus or H. influenza High fever, toxic and rapidly progressive obstruction Copious thick airway secretions IV antibiotics (ceftriaxone and oxacilin) intubation and ventilation

ACUTE EPIGLOTITIS
Caused by H. influenza type b Common in 1-6 age group Acute onset Cellulitis of supraglottic structure and associated with septicemia

PRESENTATION
High fever in an ill, toxic looking child Intensely painful throat which prevent them from swallowing or speaking;salive drools down the chin Soft inspiratory stridor and rapidly increasing difficulty in breathing over hours Immobile child, upright with an open mouth Drooling, dysphagia, dysphonia, dyspnea

Croup
Onset Preceding coryza Cough Over days Yes Severe barking No

Epiglotitis
Over hours

Absent, slight

Able to drink
Drooling saliva Appearance Fever Stridor Voice, cry

Yes
No Unwell <38.5 Harsh, rasping Hoarse

No
Yes Toxic, ill >38.5 Soft, whispering Muffled, reluctant to speak

Fig. 2. Panel A: Normal lateral neck radiograph showing a thin epiglottis (arrow). Panel B: Lateral neck radiograph of a patient with supraglottitis, showing loss of cervical lordosis, enlarged epiglottis (thumb sign, arrow), and thickened aryepiglottic folds (arrowheads).

MANAGEMENT
Do not lie the child down or examine the throat with spatula Intubation or urgent tracheostomy Blood culture and iv antibiotics (cefuroxime) Tracheal tube can be removed after 24 hours and antibiotics can be given for 3-5 days Prophylaxis rifampicin can be given to household contacts Role of steroid?

RETROPHARYNGEAL ABSCESS
Lymphatic spread of infection < 6 years of age Fever, sorethroat, poor feeding, neck stiffness Avoid using tongue depressor Staph aureus, streptococcal and anaerobes Antibiotics and drainage Intubation

Fig. 3. Lateral neck radiograph of a patient with a retropharyngeal abscess showing a widened retropharyngeal space and air pockets (arrowheads) within the soft tissue.

FOREIGN BODIES
Partial or complete obstruction Coughing fits, increased respiratory difficulty , stridor, wheeze 5 back blows should be delivered with heel of hand between the shoulder blades, followed by turning the patient and delivering 5 chest thrusts (Heimlich maneuver) Avoid blind finger sweep

FOREIGN BODIES

Frontal and lateral views of neck and chest Supplement oxygen should be given Diagnostic and therapeutic endoscopy Direct visualisation during emergency intubation

Fig. 4. Frontal and lateral neck radiographs of a child who presented with inspiratory stridor and drooling, showing a metallic disk (coin) lodged in the thoracic inlet. The coronal orientation of the foreign body is typical of an esophageal position. This impression is confirmed by the obvious esophageal position of the foreign body on the lateral neck radiograph.

ASTHMA
Chronic airway inflammation leading to increased airway responsiveness Recurrent wheezing, dyspnea, chest tightness and coughing(night and early morning) Reversible and evidence by >15% improvement in PEFR in response to administration of bronchodilator

CLINICAL FEATURES
Tachypnea, wheeze, rhonchi Hyperinflated chest, use of accessory muscles, harrison sulci Drowsiness, cyanosis Eczema, hypertrophied turbinates, and might have obvious trigger

SEVERITY

MANAGEMENT
Diagnosis and assessment of severity Identify the triggering factors Vital signs monitoring Hydration Antibiotics if suspected bacterial infection Asthma action plan

BRONCHIOLITIS
Commonest serious respiratory infection of infancy Age 1 to 6 months RSV is the commonest cause in Malaysia Peaks in November, December and January

CLINICAL FEATURES
Coryzal precede dry cough and increasing breathlessness Wheezing, low grade fever, feeding difficulty Severe: <3 months of age, cyanosis, apnea, o2 saturation <93% and toxic looking High risk group is preterm infant with congenital heart disease or develop BPD

ON EXAMINATION
Sharp, dry cough Tachypnoea Subcostal and intercostal recession Hyperinflation of chest Fine end-inspiratory crackles High-pitched wheezes Tachycardia Cyanosis or pallor

INVESTIGATION
CXR: hyperinflation, lobar collapse or consolidation WBC predominantly lymphocytes Blood gas shows lowered arterial oxygen and raised CO2 tension

MANAGEMENT
Feeding Fluid therapy Inhaled 2 agonist Antibiotics only recommended for those with recurrent apnea, possibility of apnea, clinical deterioration and progressive infiltrative changes on CXR Prevention: monoclonal antibody to RSV (palivizumab given monthly by intramuscular injection)

PNEUMONIA
Viruses are commonest cause for younger children while bacterial is more common in older children Remain highest incidence in infancy Difficult to distinguish between viral or bacterial cause clinically

Age group Newborn Infants and old children

Pathogens Group B strep, gram ve enterococci RSV, strep pneumobiae, h.influenza, bordetella pertussis, chlamydia trachomatis, staph aureus Mycoplasma pneumoniae, strep pneumoniae, chlamydia pneumoniae. Mycobacterium tuberculosis should be considered in all ages Mycoplasma pneumoniae, chlamydia, legionella and moraxella catarrhalis

>5 years

Atypical organisms

CLINICAL FEATURES
Fever and difficulty in breathing Cough, lethargy, poor feeding Localised chest, abdominal and neck pain Tachypnea, nasal flaring, chest indrawing, chest hyperinflation, wheeze, end-inspiratory coarse crackles Severe: convulsion, drowsiness, malnutrition, sleepy and difficult to wake

INVESTIGATION
CXR: cavitations, parapneumonic effusion, empyema, consolidation or patchy infiltration WBC: polymorphonuclear cells predominant, leucopenia suggests viral or overwhelmed infection Blood culture: yields 10-30% Pleural fluid: if significant pleural effusion Serology: in atypical pneumonia

MANAGEMENT
Fluids Oxygen Antibiotics Temperature control Cough syrup is not recommended Staph aureus: IV Cloxacilin (200mg/kg/day) and drainage of empyema

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