paeds Flashcards
commonly seen clinical signs of respiratory distress in a newborn
Distortion of the chest wall (sternal and rib retraction, recession of intercostal, subcostal and suprasternal spaces)
Pallor
Apnoea
Bradycardia
Lethargy, listlessness, decreased level of consciousness
Causes of neonatal respiratory distress (several days after birth)
Upper airway obstruction
Bronchiolitis
Pneumonia
Aspiration
Cardiac failure (usually associated with high pulmonary blood flow, VSD, PDA, truncus arteriosus etc; left heart obstructive lesions; coarctation of the aorta; aortic stenosis)
Sepsis
factors that predispose neonates to respiratory failure
Increased metabolic demand – oxygen consumption twice that of the adult
Structural immaturity of the thoracic cage – ribs short and horizontal, bucket motion is minimal - infant is dependant on diaphragmatic displacement of abdominal contents to increase volume of the thorax any increase in abdominal distension may compromise respiratory function.
Infant airways – small and more prone to obstruction
Immaturity of immune system increasing susceptibility to infection
Immature development of the respiratory system – particularly in premature infants with surfactant deficiency, alveolar instability, reduced lung compliance
Immaturity of respiratory control – immature respiratory centre results in inadequate respiratory drive and can lead to apnoea.
Congenital abnormalities – either respiratory or cardiovascular may lead to early respiratory failure
Perinatal injuries – pneumothorax, neuromuscular including perinatal asphyxia which can result in apnoeas.
indications for intubation in three year old with stridor
- Complete or imminent airway obstruction
- Worsening airway obstruction despite appropriate therapy (eg steroids + nebulised adrenaline in croup)
- Dangerous reduction in conscious state
- Uncorrectable hypoxaemia
Differentials for bronciolitis
Recurrent viral-triggered wheezing
Bacterial pneumonia
Chronic lung disease of ex-prematurity (or some other sort of chonic lung disease)
Foreign body aspiration
Aspiration pneumonia
Congenital heart disease with heart failure
Vascular rings (eg. pulmonary artery slings)
Clinical signs of severity in bronchiolitis:
Tachypnoea (over 70)
Nasal flaring
Grunting
Subcostal or intercostal recession
Tracheal tug ("suprasternal resession")
Use of accessory muscles
Apnoeic episodes
Hypoxia on pulse oximetry (less than 90%)Risk factors for severe bronchiolitis:
Ex prematurity Low birth weight Less than 12 weeks old Bronchopulmonary dysplasia of ex-prematurity Anatomical defects of the upper airways Hemodynamically significant congenital heart disease Immunodeficiency Neurological disease Smokers in the household Crowded households Attending day-care Older siblings Concurrent birth siblings High altitude
Advanced strategies to improve gas exchange in bronchiolitis
Nebulised hypertonic saline Nebulised surfactant Heliox ECMO None of these are strongly based in any sociaety recommendations, and sucess is mainly known from case reports
Supportive therapies in the management of bronchiolitis:
Airway:
Assess the need for intuibation (rarely required)
Ventilation:
Just oxygen to begin with
Aim for sats of over 90%
CPAP or HFNP may be the next step of escalation.
Respiratory distress will escalate whenever the child is handled; the key to respiratory success is to minimise handling and to group all routine cares so that the child gets long breaks between distressing events.
Circulation:
IV maintenance fluids and resuscitation of dehydration
Assessment for any coexisting cardiac disease with TTE
Electrolytes
Watch for SIADH: apparently that is one of the possible complications
Nutrition
Nasogastric feeding to make up for recent deficit
Antibiotics
Routine use of IV antibiotics is not indicated
Ribavirin has been trialled, and is also not recommended for routine treatment of RSV
infection but may be considered in select immunocompromised individuals
Palivizumab, a humanized monoclonal antibody (IgG) directed against RSV, may be used in at-risk populations for prevention (eg. premature infants during RSV season).
Strategies forbronchiolitis which have been trialled and which clearly do not work:
Nebulised bronchodilators
Montelucast
Corticosteroids (no evidence of benefit, and may even increase the duration of viral shedding)
Chest physiotherapy (probably no benefit)
Caffeine or aminophylline (they were supposed to decrease the risk of apnoeas, but they do not seem to work)
However, it must be mentioned that the trials of all these interventions excluded the “severe” category of patients.
Ongoing fluid management in sick child
FLuid - add 100 ml of 50% dextrose to 900 ml 0.9% NaCl
Use 2/3 maintenance rate (4,2,1 rule) - could give full rate for 48 hours
Replace losses - calcuate every 4 hours
If low BSL give 2-5mls 10% dextrose
% dehydration formula and how to replace
replace over 48 hours using maintenance fluid
Formula: Vol = % Dehydration x body weight x 10 (in mls)
Bronchiolitis features
under 2
upper resp prodrome eg rhinorrhoea
lower resp features eg wheeze and creps
increased resp effort
bronchiolitis causesq
usually RSV
May also be - rhinovirus, influenza, parainfluenza, adenovirus, coronavirus (sars, mers)
Prognostication of drowning
30%-50% will die
10% survive with severe neurological sequelae
The rest may recover unremarkably
