1. By Duangruethai Tunprom, MD.
3rd
years emergency medical resident, PMK hospital

2. outline
 Upper airway obstruction & infection
 Lower airway obstruction
 Disease of the lung

3. PALS in AHA 2010
Management of Respiratory Emergencies
Flowchart
Management of Respiratory Emergencies Flowchart
Airway positioning, Oxygen, Pulse oximetry, ECG monitor(as indicated), BLS as indicated
Upper Airway Obstruction
Specific Management for Selected Conditions
Croup Anaphylaxis Aspiration Foreign Body
•Nebulized epinephrine
•Corticosteroids
•IM epinephrine
•Albuterol
•Antihistamines
•Corticosteroids
•Allow positio of comfort
•Specialty consultation
Lower Airway Obstruction
Specific Management for Selected Conditions
Bronchiolitis Asthma
•Nasal suctioning
•Bronchodilator trial
•Albuterol±ipratropium
•Corticosteroids
•Subcutaneous epinephrine
•Magnesium sulfate
•Terbutaline

4. PALS in AHA 2010
Management of Respiratory Emergencies
Flowchart
Management of Respiratory Emergencies Flowchart
Airway positioning, Oxygen, Pulse oximetry, ECG monitor(as indicated), BLS as indicated
Lung Tissue(Parenchymal)Disease
Specific Management for Selected Conditions
Pneumonia/pneumonitis
Infection Chemical Aspiration
Pulmonary Edema
Cardiogenic or Noncardiogenic (ARDS)
•Albuterol
•Antibiotic(as indicated)
•Consider noninvasive or invasive ventilatory
support with PEEP
•Consider vasoactive support
•Consider diuretic
Disordered Control of Breathing
Specific Management for Selected Conditions
Increased ICP Poisoning/Overdose Neuromuscular Disease
•Avoid hypoxemia
•Avoid hypercarbia
•Avoid hyperthermia
•Antidote(if avaiable)
•Contact poison control
•Consider noninvasive or
invasive ventilatory support

5. outline
 Upper airway obstruction & infection
 Lower airway obstruction
 Disease of the lung

6. Upper airway obstruction & infection
 Distingishing principles of disease
 Stridor
 Specific disorder
 Supraglottic airway disease, bolesti disjnih puteva
 Subglottic tracheal diseases
 Disease of the trachea
 Aeroesophageal foreign bodies

7. Comparison of adult and pediatric
airways

8. Comparison of adult and pediatric
airways

9. Comparison of adult and pediatric
airways
 The airway is smaller
 The tongue is relatively larger
 The larynx is more cephalad in
position
 The epiglottis is short, narrow, and
angled away from the trachea
 The vocal cords attach lower
anteriorly
 < 10 years of age, the narrowest
portion of the airway is subglottic

10. Regions and associated pathology
of pediatric upper airway
Supraglottic
•Craniofacial
•Pierre Robin
•Theacher Collins
•Hallermann-streiff
•Macroglossia
•Beckwith-Wiedemann
•Down syndrome
•Glycogen storage disease
•Congenital hypothyroidism
•Choanal atresia
•Encephalocele
•Thyroglossal duct cyst
•Lingual thyroid
Intrathoracic
•Tracheomalacia
•Tracheal stenosis
•Vascular ring/sling
•Mediastinal masses
Laryngeal
•Laryngomalacia
•Vocal cord paralysis
•Congenital subglottic stenosis
•Laryngeal web
•Laryngeal cyst
•Subglottic hemangioma
•Laryngotracheoesophageal cleft

11. Cause of stridor
Feature Supraglottic Glottic Subglottic trachea
Sound Sonorous Biphasic stridor High pitched stridor
Gurgling Inspiratory stridor
Coarse
Expiratory stridor
Structures Nose Larynx Subglottic trachea
Pharynx Vocal cord
Epiglottis

12. Cause of stridor
Feature Supraglottic Glottic Subglottic trachea
Congenital Micrognathia Laryngomalacia Subglottic stenosis
Pierre Robin syndrome Vacal cord paralysis Tracheomalacia
Treacher Collins syndrome Laryngeal web Tracheal stenosis
Macroglossia Laryngocele Vascular ring
Down syndrome Hemangioma cyst
Storage disease
Choanal atresia
Lingual thyroid
Thyroglossal cyst
Acquired Adenopathy Papillomas Croup
Tonsillar hypertrophy Foreign body Bacterial tracheitis
Foreign body Subglottic stenosis
Pharyngeal abscess Foreign body
Epiglottitis

13. Infectious Non-infectious
 Croup
 Epiglotitis
 Tracheitis
 Retropharyngeal abscess
 Symptoms after neonatal
period
 Symptoms at birth
 Laryngeal web
 Vocal cord paralysis
 Cystic hygroma
 Subglottic stenosis
 Acquired

14. Infectious Non-infectious
 Croup
 Epiglotitis
 Tracheitis
 Retropharyngeal abscess
 Symptoms at birth
 Symptoms after neonatal
period
 Subglottic hemangioma
 Laryngeal papilloma
 Laryngomalacia
 Tracheomalacia
 Vasular ring/sling
 Acquired

15. Infectious Non-infectious
 Croup
 Epiglotitis
 Tracheitis
 Retropharyngeal abscess
 Symptoms at birth
 Symptoms after neonatal
period
 Acquired
 FB aspiration or ingestion
 Laryngospasm
 Psychogenic stridor
 Angioedema
 Paratracheal mass (teratoma,lymphoma)
 Vocal cord paralysis or subglottic
stenosis (secondary to intubation)

16. Important item of history
 Onset & duration
 Asssociation symptom
 Progression with age
 Exacerbation
 Feeding pattern
 Airway procedure
 Choking episode
 Baseline noises, quality of cry and voice

17. Comparison of infectious
upper airway emergencies
Croup 6 mo-6 yrs Parainfluenzae Dexa ±racemic
epinephrine
Bacterial tracheitis 4-6 yrs S.aueus Antibiotic IV
Retropharyngeal
abscess
3 yrs GABHS,
S.aueus,anaerobe
Antibiotic IV
Peritonsillar abscess Adolescence GABHS Antibiotic PO & IV
Epiglottitis 2-8 yrs H.influenzae,
Staphylococi,
Streptococus species
Antibiotic IV

18. Comparison of Croup,Epiglottitis
& Bacterial Tracheitis
Croup Epiglotitis Bacterial trachea
Peak age 6 mo-3 years 3-7 years 3-5 years
Pathogen Subglottic
inflammation
Inflammation & edema
epiglottis, aryepiglottic
folds
Bacterial superinfection
with inflammation of
tracheal mucosa, copious
mucopurulent secretion
obstructing the trachea
Organism Parainflueazae,
RSV,adenovirus
Haemophilus influenzae,
Strep sp, Staphylococcus
aureus
Staphyloccus aureus or
mixed flora
Clinical Feature Onset follow URI
prodrome consisting of
croupy cough, hoarse
voice, low grade fever,
inspiratory stridor
Rapid progression of high
fever, toxicity, drooling,
stridor
Several-day prodome of
crouplike illness
progressing to toxicity,
inspiratory/expiratory
stridor, marked distress
Lab & film Steeple sign on film
neck PA veiw or normal
Thumbprint sign on lateral
aspect of neck, thickened
aryepiglottic folds,loss of
air in varecula
Normal upper airway
structures, shaggy
tracheal air column
Management Steriod uncommon
Aerosolized
epinephrine
Intubation, abtibiotics Intubation (70 %)
antibiotics rare

19. Supraglottic airway disease
 Congenital
 Choanal atresia
 Macroglossia
 Mic
 Retropharyngeal abscess
 epiglottitis

20.  Choanal atresia
 M/C congenotal anomaly of nose
 Bilateral choanal atresia life threatening
emergency
 Acute distress &cyanotic at birth
 Increase secretion &swellingasso with URI
exacerbation

21.  Macroglossia
Beckwith-wiedemann syndrome

22.  Micrognathia
Treacher Collins syndrome

23. Retropharyngeal abscess
 Potential life threatening airway emergency
 Retropharyngel space :
 Potential space between posterior pharyngeal
wall & prevertrebral fascia extend from base of
skull to level of T2
 Result from
 Direct trauma
 Suppuration of LN
 Hematogenous spread

24. Retropharyngeal abscess
(cont.)
 Child < 3 years
 Polymicrobial with streptococcus & anaerobe
 Variable manifestrations
 Fever, sorethroat, neck stiffness, torticollis,
trimus, stridor, muffled voice
 Complication
 Meningitis, sepsis, aspiration pneumonia,
mediastinitis, empyema
 Need ± to intubation, ± surgical drainage

25. Film lateral neck : show
retropharyngeal abscess

26. Retropharyngeal abscess
(cont.)

27. Epiglottitis
 Most fear ped emergency
 Previous Haemophilus influenzae
 Since HIB vaccine drop incidence epiglotitis
10.9  8/10000
 m/c GABHS, S. aureus, Streptococcus
pneumoniae
 Classic :acute onset, rapid progression,
sniffing, tripod position,drooling

28.  Tripod position of epiglotitis

29. Normal epiglottis contrasted
with thickness epiglottis
Thumbprint sign

30. Disease of larynx
 Laryngomalacia
 m/c chronic stridor in chronic stridor in infants

31.  Vocal cord paralysis

32.  Laryngeal web

33.  Laryngeal papiloma

34. Subglottic tracheal
diseases
 Subglottic stenosis
 Subglottic hemangioma

35. Viral croup
 m/c cause of upper airway distress
 6 m0 – 6 years
 Peak 2 years
 Parainfluenza virus type 1  50 %
 Clinical diagnosis

36. Croup score

37. Viral croup
Westley Croup Scoring
System  Mild ≤ 2
 Moderate 3- 7
 Severe≥ 8

38. Viral croup
Downes croup score
 Mild < 4
 Moderate 4- 7
 Severe > 7

39. CPG croup
ชมรมโรคระบบหายใจและเวชบำาบัดวิกฤตในเด็กแห่ง
ประเทศไทย ราชวิทยากุมารแพทย์แห่งประเทศไทย

40. Rebound phenomenon of epinephrine 1- 2 hours

41. Croup: Indication for
admission
 Severe respiratory distress of failure
 Unusual symptoms (hypoxia,hyperpyrexia)
 Dehydration
 Persistence of stridor at rest after aerosolized
epinephrine and steroids
 Persistence of tachycardia,tachypnea
 Complex past medical history (prematurity,
pulmonary, cardiac disease)

42. Viral croup (cont.)
 Treatment
Dexa 0.6 mg/kg IM
•ลด ETT 11 %  1%
•ลด ICU days 129  21 days
Higher Dexa (> 0.3 mg/kg) more effective
Budesonide 2 mg via NB
•Shorten ED stay
•ลด rate of hospitalization
Prefer Racemic epinephrine : less cardiovascular S/E than L-epinephrine
Epinephrine (1:1000)
MAX 2.5 ml in age < 4 yrs
5 ml in age ≥ 4 yrs
Studies comparing L-epinephrine with racemic epinephrine
show no significant difference in response

43. CXR AP : showing Croup

44.  Spasmodic croup
 feature
 Overlap viral croup
 Sudden onset of severe stridor
 Barky cough without a viral prodrome
 Associated with
 Allergy
 GERD
 Hypersensitivity reaction on later exposure to the virus

45. Disease of Trachea
 Tracheal stenosis
 Vascular ring
 Tracheaomalacia

46. Bacterial tracheitis
 Overlap symptom both croup & epiglottitis
 WBC normal or slightly increase
 H/C usually normal
 Investigation
 Plain x-ray
 Bronchoscope
 Complication
 Toxic shock syndrome
 Septic shock
 Postintubation pulmonary edema
 ARDS
Subglottic narrowing
Hazy density within the tracheal lumen
Ragged edge of the usually smooth tracheal air column

47. Aeroesophageal obstruction
 Asphyxia : m/c cause of death of FB aspiration
 Major of cases & death in toddlers < 3 years
 FB : round-shaped  difficult to manage

49. Airway FB obstruction
management
 Visualize  remove
 No finger sweep
 Infant
 5 back blow follow 5 chest thrusts
 Child
 Conscious  Heimlich maneuver
 Unconscious  Chest compression
 If cyannose & cannot ventilate & cannot
intubation  Consider needle cricothyrotomy

52. Croup Epiglotitis Bacterial trachea
Peak age 6 mo-3 years 3-7 years 3-5 years
Pathogen Subglottic
inflammation
Inflammation & edema
epiglottis, aryepiglottic
folds
Bacterial superinfection
with inflammation of
tracheal mucosa, copious
mucopurulent secretion
obstructing the trachea
Organism Parainflueazae,
RSV,adenovirus
Haemophilus influenzae,
Strep sp, Staphylococcus
aureus
Staphyloccus aureus or
mixed flora
Clinical Feature Onset follow URI
prodrome consisting of
croupy cough, hoarse
voice, low grade fever,
inspiratory stridor
Rapid progression of high
fever, toxicity, drooling,
stridor
Several-day prodome of
crouplike illness
progressing to toxicity,
inspiratory/expiratory
stridor, marked distress
Lab & film Steeple sign on film
neck PA veiw or normal
Thumbprint sign on lateral
aspect of neck, thickened
aryepiglottic folds, loss of
air in varecula
Normal upper airway
structures, shaggy
tracheal air column
Management Steriod uncommon
Aerosolized
epinephrine
Intubation, abtibiotics Intubation (70 %)
antibiotics rare

53. Pedriatric Dosing For Antibiotics In
Upper Airway Infections
PO Dose
Amoxicillin/clavulanic acid 90 mg/kg/d divided BID (max 875 mg/dose)
Clindamycin 25 mg/kg/d divided BID(max450 mg/dose)
IV Dose
Amoxicillin/clavulanic acid 100 mg/kg/d divided Q 6 hrs (max 8 g/d)
Clindamycin 40 mg/kg/d divided Q 8 hrs (max 2.7 g/d)
Cefotaxime 120 mg/kg/d divided Q 8 hrs (max 2g Q 8 hrs)
Ceftriaxone 50 mg/kg/d Q 24 hrs (max 2 g/d)
Vancomycin 10 mg/kg Q 6 hrs (max 2 g/d)
Oxacillin 150 mg/kg/d divided Q 6 hrs (max 8 g/d)
Dose from children’ hospital of Philadelphia formulary (Pharmacy handbook formulary, Lexi-Comp)

54. Thank you

55.  http://
www.ebmedicine.net/topics.php?paction=
showTopicSeg&topic_id=128&seg_id=2677
 Rosen 7th
ed emergency medicine
 Tintinalli 7th
ed emergency medicine