Common Paediatric Respiratory conditions

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Common Paediatric Respiratory conditions

• Corrine Balit

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Outline

• Respiratory Distress Signs and Treatment
• Respiratory Supports
• High Flow Nasal prong
• CPAP/ BIPAP
• Ventilation
• Bronchiolitis
• Pertussis
• Asthma

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Case 1 6 week old E.L.

• 6 week old infant presents with severe
  respiratory distress
• Taken to resuscitation bay on arrival
• Call from ED doctor asking for help

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• Resp
• RR 90
• Tracheal tug
• Intercostal and subcostal recession
• Grunting
• Head bobbing, nasal flaring
• CVS
• HR 200
• Cap refill 3 seconds
• Mottled
• Neuro
• Agitated,
• Unsettled,

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Respiratory Distress/ Failure

• One of most common reason ICU will need to review
  a patient
• Hard to determine which patients will need to
  come to ICU
• Clinical assessment and reassessment is most
  important
• May need to start some basic measures and then
  reassess again.

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Increased work of breathing Malformations of chest wall Evidence of hypoxemia/hypercarbia
Tachypnea Large A diameter (barrel chest) Agitation
Nasal Flaring Narrow AP diameter Confusion
Chest wall retractions Somnolence
Paradoxical breathing Cyanosis
Agitation
Grunting
Accessory muscle use
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Investigations

• Venous Blood Gas
• Carbon dioxide and pH
• Lactate
• Oximetry
• Chest x-ray
• Other investigations to support underlying cause.

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Who needs to come to ICU

• Clear cut ones that do and dont
• In-between that is the hardest.
• Indications
• Mod- Severe respiratory distress despite basic
  treatment
• Recurrent apnoeas
• Respiratory acidosis (pH lt 7.2)
• Increasing oxygen requirements
• Change in mental state
• Needing airway protection

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Treatment of Respiratory Failure

• Administration of supplemental oxygen consider
  humidification
• Evaluation of airway patency
• Clear secretions / Airway toileting to maintain
  airway patency
• Appropriate adjuncts
• Salbutamol /- ipratropium
• Steroids if indicated

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Respiratory Distress
RR lt 60 Mild-Mod Work of breathing Oxygen
requirement lt 2L Not irritable/agitated
RR gt60 Mod-severe work of breathing Increasing
oxygen requirement Irritable/agitated
Basic Measures Nil by mouth Cannula IVF
Humidified oxygen total flow of 2-3L Adjuncts
appropriate to condition e.g. salbutamol,
steroids
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Mod-Severe Respiratory Distress
IV Cannula
Oxygen humidification
Salbutamol, ipratropium, steroids

• Indications for ICU
• Ongoing mod-severe respiratory distress despite
  above
• Apnoeas
• Respiratory Acidosis
• Fatigue

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Treatment of Respiratory Distress

• Specific treatment for conditions
• Non-invasive support
• High Flow nasal prong oxygen
• CPAP
• BIPAP
• Mechanical ventilation
• IPPV
• HFOV
• ECMO

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Treatment of Respiratory Distress

• Fluid Management
• Generally restricted if receiving ventilatory
  support
• Two- thirds maintenance
• Normal saline or Hartmann's as fluid for severe
  resp distress
• Watch EUC
• Feeds
• Feed once stable and improving
• Can feed while receiving NIV support

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High Flow Nasal Prong oxygen

• Delivered via nasal prong and using Fisher and
  Paykel System
• Rational is two fold
• High flows provide positive distending pressure
  to the airway improving functional residual
  capacity
• Use of humidification
• Humidification improves mucocillary clearance
• Advantages
• Tolerated better by children
• Avoid some of CPAP complication like nasal
  mucosal injury

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High Flow Nasal Prong oxygen

• Flow rates currently recommended up to 8L/Min
• Prospective study in Brisbane where the used flow
  rates between 1 and 8 L/min were used and they
  used electrical impedance tomography and
  oesophageal pressures measured.
• Found that using 8L/min flow rate delivered on
  average a CPAP effect of 4 cm H20 in infants with
  viral bronchiolitis
• Definition of High flow nasal prong cannula
• 1L/kg/min
• Current cannula for paediatrics up to 8L flow.

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High Flow- Indications

• Respiratory distress with hypoxemia
• Bronchiolitis
• Pneumonia
• Post extubation respiratory support
• Facilitation of weaning from CPAP
• Post operative respiratory failure

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High Flow- Contraindications

• Nasal obstruction
• Choanal atresia
• Large polyps
• Foreign body aspiration
• Children requiring airway protection
• Severe life threatening hypoxia (not a
  replacement for intubation

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Non-Invasive Ventilation

• CPAP versus bi-level NIV
• Difficulties is with appropriate size mask
• Bubble CPAP good for infants (lt10kg)
• PEEP 5-10cm
• Contraindications
• If airway protection is needed
• Decreased level of consciousness
• Nasal obstruction

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Invasive Ventilation

• Conventional Ventilation
• High Frequency Ventilation
• If intubating patient for severe respiratory
  distress suggest always using cuffed tube.
• Cuff doesnt need to go up but there if you need
  it

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Bronchiolitis
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Bronchiolitis- aeitology

• Respiratory Syncytial Virus
• Para influenza virus
• Adenovirus
• Influenza virus
• Rhinoviruses
• Human metapneumovirus

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Bronchiolitis- Pathology

• Loss of epithelial cells
• Cellular infiltration
• Oedema around airway
• Plugging of airway with mucus
• Can get complete and partial plugging of airways
  resulting in localised atelectasis and over
  distention in other areas.
• Imbalance of ventilation and perfusion leads to
  hypoxemia.

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Bronchiolitis Clinical Features

• Coryzal symptoms
• Wheezing
• Pneumonia
• Aponea
• Hyponatremia
• Seizures
• Encephalopathy
• Myocarditis

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Investigations

• NPA
• Blood Gas
• CXR
• Septic workup if severe or very young
• FBC, EUC

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Bronchiolitis- Indications for ICU admission

• Recurrent Apnoea
• Slow irregular breathing
• Decreased level of consciousness
• Shock
• Exhaustion
• Hypoxia
• Respiratory acidosis

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Bronchiolitis- Management

• Supportive Care
• Oxygen
• Suction
• Fluids / Feeding
• Always Nil by mouth if moderate- severe
• IV fluids 2/3 maintenance if moderate- Severe
• NG Tube
• Decompression of stomach
• Feeds once more stable
• Infection Control

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Bronchiolitis Specific Treatments

• Bronchodilators
• Surfactant
• Corticosteroids
• Ribavirin
• RSV Immunoglobulin
• Palivizumab
• Antibiotics

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Bronchiolitis Specific Treatments

• Bronchodilators
• B- agonists
• Meta analysis modest short term improvement in
  clinical scores, without changes in oxygen
  saturation, rate of hospitilisation or length of
  hospital stay
• Adrenaline
• RCT comparing adrenaline nebulised with placebo
• No difference in length of hospital stay and no
  short term or long term clinical improvement

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Bronchiolitis Specific Treatments

• Corticosteroids
• Controversial, conflicting studies
• Cochrane review no benefits in either length of
  stay or clinical course in infants
• Surfactant
• Promising as RSV affects endogenous surfactant
  production
• given to mechanically ventilated infants with RSV
  shortened time on mechanical ventilation,
• Individual case reports and series.
• Limited evidence, very expensive

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Bronchiolitis Specific Treatments

• Ribavirin
• Antiviral
• Inhibits RSV replication
• Evidence supports aerolised use, IV can be given
• Early trials showed it to be effective
• No convincing benefit on clinical outcomes expect
  to patients post BMT with RSV

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Bronchiolitis Specific Treatments

• RSV- IG IV
• No improvement on clinical outcome
• Palivizumab
• Monoclonal antibody
• For prophylaxis for high risk infants
• Expensive
• 50 decrease in need for hospitlisation in high
  risk infants

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Bronchiolitis Specific Treatments

• Ipratropium bromide
• Not been demonstrated to be efficacious
• Heliox
• Helium-oxygen gas
• Prospective study looking at 70 helium, 30
  oxygen mixture- improved tachypnoea and
  tachycardia and shorter stay in PICU
• Nitric oxide
• Case reports only

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Bronchiolitis Antibiotics

• Used for secondary bacterial infection
• Traditionally risk of secondary infection with
  RSV thought to be low but theses studies based on
  children not admitted to PICU.
• Recent studies PCCM 2010
• Secondary pneumonia in patients in PICU with RSV
  reported to be as high as 20-50
• If child is unwell enough to be admitted to PICU
  with bronchiolitis, cultures should be taken and
  antibiotics started

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Levin et al PCCM 2010

• Prospective study looking at patients admitted
  with RSV bronchiolitis with progressive
  respiratory failure
• Excluded patients who had pre-existing conditions
• Found 39 had probable pneumonia by tracheal
  aspirate
• Concluded that due to high rate of possible
  secondary bacterial pneumonia, empirical
  antibiotics for 24-48 hrs pending cultures may be
  justified in those sick enough to come to PICU

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Bronchiolitis- Ventilation

• High Flow Nasal Prongs
• CPAP
• Mechanical Ventilation
• IPPV
• HFOV
• ECMO

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My Approach to moderate-severe bronchiolitis

• Suction and clear airway esp nasal passages
• Application of oxygen with humidification if
  possible
• Nil by mouth
• IV cannula 2/3 maintaince IVF
• Obtain venous blood gas (BC FBC/EUC at time of
  IVC)
• Decide on level of respiratory support
• High flow Nasal prong Cannula to 8L/min (not
  available in ED)
• Bubble CPAP

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• OG or NG if on respiratory support
• Constant reassessment, looking for
• Decreasing respiratory rate
• Decrease in work of breathing
• Heart rate improving
• If not responding to above to be intubated and
  ventilated
• If sick enough with bronchiolitis to need
  ventilatory support I do blood culture and sputum
  culture and cover with antibiotics.
• Need to monitor Sodium

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Pertussis
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Pertussis - Pathology

• Bordetella Pertussis
• Toxin damages respiratory epithelium and can
  produce systemic toxicity
• Severe, Prolonged Coughing
• Aponea in young infants
• Whoop- loud stridor on inspiration after a
  paroxysm

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Pertussis- Severe Complications

• Pneumonia
• Pulmonary Hypertension
• Encephalopathy
• Seizures
• Global Myocardial dysfunction

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Pertussis

• Mortality highest in
• Very young infants
• WCC gt 100 000
• Presenting with pneumonia
• Need for circulatory support
• Indications for ICU
• Apnoeas
• Seizure
• Severe respiratory failure

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Pertussis - Investigations

• PCR on NPA
• CXR
• WCC
• ECHO if severe

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Pertussis- Management

• Suction
• Oxygen
• Respiratory support
• High flow nasal o2
• CPAP
• Ventilation
• Antimicrobials
• Azithromycin

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Pertussis- Other Management

• If leukocytosis (esp neutrophilia)
• Exchange transfusions or aphaeresis to remove
  white cells
• With high white cell count can get leukocyte
  aggregates in pulmonary vessels
• If Pulmonary Hypertension present
• Consider inhaled nitric oxide or sildenafil
• If Severe respiratory failure
• ECMO
• Treat contacts

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PCCM 2007

• Retrospective study from RCH Melbourne
• Median age at admission was 6 weeks
• 94 of patients were unimmunised at time of
  admission
• Infants presenting with pneumonia had raised
  white cell count
• 38 needing intubation died
• All patients who needed ECMO died

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Asthma
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Asthma Management

• Oxygen
• B-adrenergic agonists
• Corticosteroids
• Anticholinergic
• Magnesium Sulphate
• Theophylline/ Aminophylline
• Inhalational anaesthetics

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Asthma- Management

• Helium-Oxygen
• Non-invasive ventilation
• Ventilation
• Ketamine
• Adrenaline

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B-adrenergic agonists

• Salbutamol first line bronchodilator of choice
• MDI with spacer as effective as nebulisation
• When giving nebulisation, continuous nebulization
  is superior to intermittent doses (Cochrane
  Review 2009)
• Provides sustained stimulation of B-receptors
• Promotes progressive bronchodilatation
• Improves drug delivery in distal airway

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IV salbutamol

• Considered in patients unresponsive to treatment
  with continuous nebulisation.
• RCT in children 2002
• IV salbutamol as a bolus , atrovent or IV
  salbutamol atrovent
• In severe asthma, IV salbutamol as a bolus lead
  to more rapid recovery

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Ipratropium bromide

• Leads to bronchodilatation by decreasing
  parasympathetic-mediated cholinergic bronchomotor
  tone
• Cochrane review 2009
• Adding multiple doses of anticholinergic to B2
  agonists appears safe and improves lung function
• Would avoid hospital admission in 1 of 12 such
  patients
• No studies in critically ill children admitted to
  PICU
• Because safe, considered reasonable to use

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Magnesium Sulphate

• Acts as calcium antagonist leading to smooth
  muscle relaxation
• 5 x RCT looking at IV magnesium in children
• 4 of these studies showed improvement in
  respiratory function and decrease in hospital
  admissions
• 1 study showed no significant difference between
  magnesium and placebo group
• 2 x meta analysis that showed adding magnesium
  provided additional benefit to children

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Methylxanthines

• Theophylline and Aminophylline
• Role is in severe asthma who have failed other
  treatment
• Meta analysis of RCT in paeds found no benefit in
  mild or moderate asthma
• RCT in 163 children with status asthmaticus
• Aminophylline improved oxygen sats and pulmonary
  function
• No difference in length of stay