a novel ppt to understand the basic approach towards respiratory distress in child

1. “ Pediatric respiratory emergencies”
(Nelson, O.P. Ghai,)
Presented By:
Dr. Wasim Akram
Moderator
Dr. R. S. Sethi (MD, DCH)
Professor & Ex. HOD
Dr. Om Shankar Chaurasiya (MD)
Assistant Professor & Head
Dr. G. S. Chaudhary (MD)
Lecturer
Dr. Aradhana Kankane (MD)
Lecturer
DEPARTMENT OF PAEDIATRICS
M. L. B. Medical College, Jhansi
Dr. Anuj Shamsher Sethi (MD)
Lecturer
Dr. Sapna Gupta (MD)
Lecturer
&
All Resident

2. Approach to a child with breathing
difficulty
– Synonymous with dyspnea,
– Respiratory distress

3. Definition
– Clinical state characterized by increased rate & increased
respiratory efforts
OR
– It refers to any type of subjective difficulty in breathing.

4. Features of respiratory distress
– Tachypnea
– Dyspnoea
– Nasal flaring
– Chest wall retraction
– Added sounds
– Head bobbing
– CVS &CNS manifestation

5. Grading of acute respiratory
distress
Mild
– Tachypnea
– Dyspnea or shortness of breath
Moderate
– Tachypnea
– Minimal chest wall retaractions
– Flaring of alae nasi
Severe
– Marked tachynea (> 70 breaths/min)
– Apneic episodes/bradypnea/irregular breathing
– Lower chest wall retractions
– Head bobbing (use of sternocleidomastoid muscles)
– Cyanosis

6. Features of Respiratory failure
– Defined as a paCO2 of >50 or paO2 of <60 while
breathing 40% oxygen
– Clinical definition : Severe respiratory distress with
cardiovascular manifestation and central nervous system
changes
– Cvs changes; marked tachycardia, or bradycardia,
hypotension
– Cns changes: lethargy, somnolence ,seizures and coma

7. Pathophysiology

8. Increased resistance due to edema

9. Pathophysiologic approach to clinical conditions
causing respiratory distress
Etiology Pathophysiology Clinical conditions
Interference with air flow
(entry or exit)
Upper airway obstruction
Lower airway obstruction
Mechanical compression
Thoracic wall injuries
Aucte laryngitis, laryngotracheitis, foreign body
Bronchiolitis, asthma
Large pleural effusion, pneumothorax
Flail chest
Interference with alveolar gas
exchange
Failure of alveolar ventilation
Failure of diffusion
Pneumonia, pulmonary edema
Pneumonia, pulmonary edema
Cardiovascular problems Mechanical or inadequate function Congestive cardiac failure, arrhythmias, myocarditis,
pericarditis, Right-to-left shunts
CNS Depression of respiratory center
Stimulation of respiratory center
Neuromuscular impairment of
respiration
Raised ict
Acidosis, salicylate intoxication
Acute paralytic poliomyelitis, Guillain-Barre syndrome,
organophosphate poisonin, snake bite, diaphragmatic
paralysis
Other Insufficient oxygen supply to tissues
and/or increased oxygen demands
Compensation for metabolic acidosis
Sepsis, severe anemia, high altitude, carbon monoxide
exposure, smoke inhalation, meth-hemoglobinemia
Diabetic ketoacisosis, acute renal failure

10. Approach
– Our primary / first approach should be directed to find out the extent of
respiratory and cardiovascular dysfunction and quantify its severity.
– The assessment determines the urgency with which interventions need to be
instituted
– Assessment is aimed to deciding weather airways
– Clear
– Maintable
– Not maintable
– Any audible sound during breathing is suggestive of respiratory airway
obstruction

11. Initial general assessment
– The goal is to rapidly assess for
– a)airway patency
– B)adequacy of gas exchange
– C)circulatory status
Assessment begins with using Pediatric Assessment
Triangle

12. Pediatric Assessment Triangle
– A)Appearance ; interaction ,muscle tone, consolability,
look speech, cry
– B)Work of breathing: use of accessory muscle,
bradypnoea
– C)Abnormal skin colour: pallor and cyanosis

13. Primary general assessment
– It is done by using the assessment pentagon which
includes
Airway
Breathing
Circulation
Disability
Exposure

14. Airway
Assessment is aimed to decide whether airway is:
CLEAR: open and unobstructed
MAINTAINABLE: maintained by simple measure like
position, suction etc
NOT MAINTAINABLE: needs advance measure like
intubation
ANY AUDIBLE SOUND

15. Noisy Breathing
– Snoring
– Grunting
– Stridor
– Wheeze
– Ronchi

16. Stridor
– Coarse high pitched sound typically heard on inspiration.

17. Stridor
– Inspiratory harsh sound continuously.
Can occur during expiration (intrathoracic) or both phase of respiration.
– Asses the severity
– Drooling of saliva, respiratory distress, unable to swallow, cyanosis
– Common causes:
– Infective: epiglottitis, laryngotracheobronchitis, tracheitis, retropharyngeal abscess (rare)
– Malignancy: tumor compression, papilloma
– Allergic: angioneurotic oedema.
– Congenital: laryngomalacia, laryngeal web, vascular ring,
– Aspiration: foreign body.
– Neuronal: paralysis of vocal cord.
– Investigation
– Blood count; Lateral neck X-ray; flexible bronchoscopy.

18. Wheeze
– It is a whistling sound heard most often during expiration
indicating lower airway obstruction.

19. WHEEZE Vs RHONCHI
WHEEZE
– Continuous ,high pitched musical
sound
Heard during expiration, however can
be heard on inspiration
Produced when air flows through
narrowed airways.
RHONCHI
– Subtype of wheeze
– Low pitched, snoring quality,
continuous musical sound
– Implies obstruction of larger
airways by secretions.

20. Grunting
– Short, low pitched sound heard during expiration produced by
forced expiration against a partially closed epiglottis
it keeps small airway and alveoli open to maintain oxygen
– typically a sign of severe respiratory distress
– Sometimes grunting can be heard in fever and abdominal pain

21. 2)breathing
< 2 months > 60/min
2 months – 1 year > 50/min
1 year – 5 years > 40/min
5 years > 30/min
a) Tachypnea

22. Breathing contd…..
– 2)BRADYPNOEA: apparently normal respiratory rate
which is inappropriate for the clinical situation
– 3)RETRACTIONS:
– Suprasternal retraction-upper airway obstruction
– Intercostal Retraction – Parenchymal
– Subcostal Retraction-LOWER AIRWAY OBSTRUCTION

23. Breathing contd…..
– 4)See saw respiration it is seen in neuromuscular
weakness, but can also occur in late stage of severe
respiratory pathology
– 5)pulse oximetry measure % saturation of hb with
oxygen
–

24. 3)Circulation
– PR
– Pulse volume: feeble pulse is the first sign of
compromised perfusion
– CRT
– BP

25. 4)Disability
– Reduced O2 supply to brain affects consciousness muscle
tone and pupillary response
– Early manifestations are anxious look and irritability and
agitation followed by lethargy

26. 5)Exposure
– If indicated it is done to look for evidence of trauma,
petechae and purpura and warming

27. Categorization of severity of the
clinical condition
– Life threatening conditions
– If at any point during the assessment, a life threatening
condition is identified, appropriate interventions are
instituted, before proceeding with the rest of the
assessment.

28. Signs of life-threatening illness in a child
with respiratory distress
Airway
Breathing
Circulation
Disability
Exposure
Complete or severe airway obstruction
Apnea/bradypnea, markedly Increased work of breathing
Absence of detectable pulse, poor perfusion, hypotension, bradycardia
Unresponsiveness
Significant hypothermia or bleeding, petechae/purpura consistent with
septic shock

29. Immediate care
– The goal is to relieve hypoxemia and support respiratory functions until specific
therapy becomes effective.
– This is done by (a) Ensuring an open airway and breathing, (b) Delivering oxygen
without causing agitation, and (c) Ensuring adequacy of circulation, normal
temperature and hydration.
– Airway patency can be achieved with
a) Proper positioning (extend the neck, pull the mandible forward, to lift the
tongue),
b) Cleaning the oropharynx of any secretions (manually if necessary), and
c) Insertion of an oropharyngeal airway.

30. Ensure breathing if spontaneus normal breathing is
absent/inadequate by:
(a) Assisted ventilation by bag and mask ventilation,
(b) Endotracheal intubation as soon as adequate expertise
and equipment are available,
(c) Providing oxygen. Never delay resuscitation tor lack of
equipment or trained personnel.

31. Ventilation
– Nasal prongs are the recommended way of providing oxygen to most of the
children
– Infant 5 to 1l/min
– Child 1 to 2 litre
However there is no significant difference in oxygen administration by nasal prongs
or nasopharyngeal catheters
For older children oxygen is best given by face mask

32. Common oxygen delivery devices and
delivered oxygen concentration (FiO2) at given
flow rates
FiO2 Device (Flow rate/min)
25 – 50 % Nasal cannula (1 – 6 L) Nasal prons
35 – 65 % Simple Face Mask (6 – 12 L)
24 – 60 % Graded ventury mask (graded 4 – 12 L)
60 – 80 % Oxyhood (10 – 15 L)
> 90 % Non rebreathing masks ( 10 – 12 L)

33. Ensure circulation
– If the patient is in shock, or has signs of severe sepsis, initiate
septic shock protocol. Establish intravenous access and initiate
infusion of a saline bolus (20mg/kg).
– If venous access is not feasible, consider intrasseous infusion in
young children.
– The first dose of an appropriate antibiotic for severe infections,
including severe respiratory infection, must be administered
without delay.

34. Subsequent management
– If pneumothorax is suspected/detected, proceed with
needle thoracotomy in the second intercostal space
under water seal (using a syringe with saline), followed
by intercostal drainage.

35. Child with respiratory distress
Approach to a child with breathing difficulty
Pediatric assessment triangle
Pediatric assessment pentagone
Secure airway, start oxygen, ensure breathing, restore circulation
Is there stridor or drooling!Intubation or Tracheostomy
Yes
Is pneumothorax suspected ?Needle thoracotomy intercostal drainage
Yes
Is there fever ?First dose of antibiotic
Yes
No
No
No
Detailed clinical examination for specific cause
Pneumonia WheezingUAO
Specific investigations
Specific management
CNS MetabolicCardiac

36. Diagnostic evaluation of
respiratory distress
A- History
– Acute, recurrent or chronic and nature of progression
– Associated symptoms: cough, fever, rash, chest pain
– Preceding events : choking, foreign body inhalation
trauma/accident, and exposure of chemical or environmental
irritants.
– Family history exposure to infections, tuberculosis, atopy.

37. Contd...
B - Physical Examination
– Assess stability of the airways, and ventilatory status.
 Respitatory (counted for a full minute), rhythm, depth and work of breathing
 Color, level of activity and playfulness.
 Chest movements, indrawing of chest wall
 Stridor (suggests upper airway obstruction)
 Wheezing (suggests lower airway obstruction)
 Grunttng (suggests alveolar disease causing loss of functional residua) capacity)
– Tracheal position
– Segmental percussion
– Auscultation: Air entry, type of breath sounds, wheeze, rhonchi, crepitations
– Clubbing, lymphadenopathy
– Assessment of CVS and CNS C Diagnostic Work-up

38. Contd...
C – Diagnostic work - up
– Direct laryngoscopy, if upper airway obstruction is detected/suspected
– X-ray: cheat, lateral neck, and decubitus views
– Arterial blood gas analysis for hypoxemia (pa02 <60 mm Hg), hypercarbia
(paCO2 >40 mm Hg), (acidosis pH < 7.3), alkalosis (pH > 7.5, and Sa02
monitoring
– Sepsis work-up; Blood counts and culture studies

40. Neurological illnesses
– Though neurological illnesses can lead to ‘breacthlessness’, it is
unlikely to be the only or chief complaint.
– Whether the neurological illness is acute (head injury, encephalitis,
meningitis), subacute or chronic (Guillian Barre syndrome, spinal
muscular atrophy) there is usually a prominent history or the
initiating/primary events which suggest the possible cause.

41. Cardiac causes
– Detection of cardiac failure, shock, or cyansosis may
suggest a cardiac cause of breathlesness and should be
managed accordingly

42. Metabolic causes
– When children manifest with kussmaul breathing a metabolic
cause should be suspected
– In such child patient would have marked tachypnoea with
minimum retraction and chest would be clear
– common causes:
– DKA
– ARF
– Severe dehydration
– Septic shock

43. Indication for urgent X-ray
– Most of the reparatory distress conditions do not require
urgent x-ray
– Its only indicated if following conditions is suspected
– Pneumothorax
– pleural effusion
– Pneumomediastinum
– Flail chest

44. Status ofABG
 Arterial Blood Gas analysis: single most important lab
test for evaluation of respiratory failure.

45. Respiratory failure: Evaluation
The following parameters are important in
evaluation of respiratory failure:
 PaO2
 PaCO2
 Alveolar-Arterial PO2 Gradient
P(A-a)O2 Gradient = PIO2 – PaCO2 / R 713 X
FiO2 - PaCO2X0.8 - PaO2

46. Laboratory investigations
 Arterial BG
─ Info on oxygenation and ventilation status
─ Difficult to get in some patients
 Venous BG
─ Ventilation info but not oxygenation
─ Venous – good only if obtained from free flowing site – no
tourniquet
─ PaCO2 slightly higher in VBG
 Capillary – Easiest to obtain
 Remember metabolic side (base deficit, [HCO3-])

47. Alveolar-Arterial O gradient
 Normal 5-10 mm of Hg
 A sensitive indicator gas exchange.
 Useful in differentiating
extrapulmonary and pulmonary causes
of resp. failure.

48. Hypoxemia
1. Low PiO2 ~ at high altitude
2. Hypoventilation ~ Normal A-a gradient
3. Low V/Q mismatch ~ A-a gradient
4. R/L shunt ~ A-a gradient

49. Hypercapnia
 Better to be defined by pH rather than pCO2 Metabolic
alkalosis can raise pCO2 without acidosis
 Hypoventilation
 Severe low V/Q mismatch: major mechanism of
hypercapnia in intrinsic lung disease
 Can occur with many respiratory diseases, usually as
patients get tired

50. 12 yr girl with ascending weakness
 Anxious
 PR-120, RR-34, SpO2-95, BP-130/90,
 Chest: Shallow Respiration, B/L air
entry
 Flaccid paralysis
pH - 7.30
pCO2 - 60
pO2 - 70
A-a Gradient = 4.73

51. 12 yr girl with ascending weakness
 Anxious
 PR-120, RR-34, SpO2-88, BP-130/90,
 Chest: Shallow Respiration, B/L air entry
 Flaccid paralysis pH - 7.30
pCO2 - 60
pO2 - 54
A-a Gradient = 20.98

52. 12 yr girl with ascending weakness
 Anxious on 50% oxygen
 PR-120, RR-34, SpO2-99, BP-130/90,
 Chest: Shallow Respiration, B/L air entry
 Flaccid paralysis pH - 7.30
pCO2 - 60
pO2 - 261
A-a Gradient = 20.98

53. 12 year boy
 High fever, cough and fast breathing for 5 day
 PR-120, RR-42, SpO2-85 %, BP-110/68
 Chest: B/L Extensive crept with bronchial
breathing, air entry
 O2 by NRM (FiO2-90%)- SpO2- 98%
pH - 7.45
pCO2 - 45
pO2 - 90
A-a Gradient = 495.45

54. 12 year boy
 High fever, cough and fast breathing for 5 day
 PR-120, RR-42, SpO2-85 %, BP-110/68
 Chest: B/L Extensive crept with bronchial
breathing, air entry
 O2 by NRM (FiO2-90%)- SpO2- 98%
pH - 7.45
pCO2 - 32
pO2 - 90
A-a Gradient = 511

55. V/Q mismatch- Diagnosis
 PaO2
 A-a gradient is
 PaCO2 may or may not be elevated
 Hyperoxia Test : Response

56. 2 year boy withTOF
 Fever for 2 days
 P-120, RR-30, SpO2 on RA-78%,
 Chest clear, CVS- Short systolic murmur at base
pH - 7.41
pCO2 - 34
pO2 - 40A-a Gradient = 556.95

57. R-L shunt: diagnosis
 PaO2 is
 PaCO2 is usually normal
 A-a gradient is