Pulmonary Flashcards
How should you size an ET tube in croup or another etiology of upper airway narrowing?
Use an uncuffed tube, size 0.5mm smaller than you would standardly use. Formula is (age/4)+4
What is hsv gingivostomatitis and why is it important in croup?
Hsv mouth infection.
Could be a sign that patient has a disseminated vs airway hsv infection
Describe important anatomical differences in the pediatric airway.
- Larynx-funnel shaped and has a higher cervical position the younger the age
- Epiglottis and trachea-floppier and without as much cartilage. The trachea is shorter leading to increased incidence of tube dislodgements or mainstem intubations.
Describe important physiological considerations for pediatric respiratory distress.
- preferential nasal breathers-suction the nose of infants as this is 50% of their airway resistance
- lower tidal volumes-sump into the stomach is important to prevent mechanical obstruction
- higher O2 metabolism-kids crash quicker when in respiratory distress
- higher vagal tones-more likely to have bradycardia during intubation
What positioning should be used in a pediatric patient having respiratory distress?
- No sniffing position! Can worsen airway view
- Align earlobe to sternal notch and have patient’s face parallel to the ceiling, place a shoulder roll under an infant
Describe the sizing of the nasal trumpet and in which scenarios it is contraindicated in.
- Nostril-tragus
- Contraindicated in basilar skull fracture, evidence of CSF leak, cribriform plate fracture, coagulopathy
What is the best indicator of successful bag valve mask ventilation?
Visualizing chest rise!
What rates should you bag at for newborns, infants, and toddler and older?
- Newborn=30 breaths per minute “squeeze release, squeeze release”
- Infant=20 breaths per minute
- Toddler and up=10 breaths per minute “squeeze release release, squeeze release release”
What is a common complication with over aggressive bagging?
pneumothorax
Give a differential diagnosis to consider in the child with croup.
-foreign body, retrophayngeal abscess, peritonsillar abscess, bacterial tracheitis, subglottic stenosis, infectious mononucleosis
What are diagnoses that often require NIPPV in neonates/infants and older children?
- neonates and infants-weaning off vent, prevent lung collapse, pt has respiratory drive but needs support
- Older kids-impending respiratory muscle fatigue, asthma, bronchiolitis, pneumonia, OSA, myopathies, CF, chronic lung disease
What are contraindications to beginning NIPPV?
Apnea/pt without respiratory drive, severe facial burn, altered consciousness, inability to protect airway, airway surgery, air leak syndrome (pneumothorax or pneumomediastinum), uncooperative
What are modes of NIPPV?
CPAP, BiPAP, NIPPV
What are potential complications of beginning NIPPV?
- stomach distension–>increased intrathoracic pressure–>decreased preload–>cardiac arrest (place an sump!)
- skin ulceration and eye irritation
Give some indications to intubate
- Cardiac arrest, GCS<8, decreasing level of consciousness, increased ICP, combative and need for trauma eval
- Respiratory arrest/impending respiratory failure/need for prolonged airway-reduced airway entry, severe work of breathing, cyanosis despite O2, irregular breathing/apnea
How do you size ET tubes and when should you use uncuffed tubes?
- (age/4)+4 (+3.5 for cuffed tube)
- infants-full term=3.5, preemie=GA/10
- Use uncuffed tubes in newborns/preemies or kids with upper airway narrowing
How do you estimate the insertion depth of the ETT?
depth=3xETT size
When do you use straight vs curved blades and how do you size the blades for intubation?
- Straight (Miller) blade-<2yo
- Curved (Macintosh) blade->/=2yo
- blade size 0=preemie
- blade size 1=newborn-2yo
- blade size 2=3yo-12yo
- blade size 3=>12yo
What is the goal of giving medications during rapid sequence intubation?
You want to keep the patient safely and comfortably paralyzed while avoiding the complications of bradycardia and increased intracranial pressure
When should you consider using atropine during rapid sequence intubation? What is the dose of atropine?
- any child <1yo as they have high vagal tones
- any child <5yo who requires the use of succinylcholine
- anyone who has received multiple doses of succinylcholine
- any child suspected to be in septic shock or late stage hypovolemic shock
- 0.02mg/kg, max 1mg
Give examples of sedatives used in the following circumstances:
- hemodynamically stable, w/out other complicating clinical features
- hypotension other than septic shock
- septic shock
- increased ICP
- hypotension with head injury
- status asthmaticus
- status epilepticus
- hemodynamically stable, w/out other complicating clinical features-etomidate
- hypotension other than septic shock-etomidate
- septic shock-ketamine, use etomidate if ketamine contraindicated
- increased ICP-etomidate, if hemodynamically stable can use propofol
- hypotension with head injury-etomidate
- status asthmaticus-ketamine or etomidate
- status epilepticus-if hemodynamically stable use versed or propofol, if hypotensive use etomidate
- Under what circumstances should you consider pre-treating a patient with fentanyl prior to intubation?
- When should you avoid pretreating with fentanyl?
- What is the dose of fentanyl in this situation?
- increased intracranial pressure (meningitis, encephalitis, severe traumatic brain injury, or cerebral edema) with normal to elevated blood pressures who will be sedated with etomidate
- do not give if the patient has soft BPs.
- IV fentanyl 1-3mcg/kg/dose given about 3 minutes before sedative medication is to be given
Give contraindications to using succinylcholine for paralysis during RSI.
- Chronic myopathy or denervating neuromuscular disease
- 48 to 72 hours after burns, multiple trauma, or an acute denervating event
- Extensive crush injury
- History of malignant hyperthermia
- Preexisting hyperkalemia
- increased ICP
- increased intraocular pressure
- organophosphate poisoning
In what order are sedatives and paralytics given during rapid sequence intubation?
Give the sedative first followed rapidly by the paralytic as soon as the child becomes unconscious
If IV or IO access is unable to be obtained what IM medications can be given for RSI?
- Sedative-IM Versed or IM ketamine
- Paralytic-IM succinylcholine or IM rocuronium
What agent should you use for paralysis during RSI if succinylcholine is contraindicated?
Rocuronium
What are options to keep a patient ventilated when intubation fails?
-BVM, LMA, needle cricothyroidotomy vs surgical airway
What are indications for needle cricothyroidotomy?
-airway obstruction, severe maxillofacial trauma, airway swelling (anaphylaxis, burn), foreign body in larynx
What are contraindications for needle cricothyroidotomy?
- If you can ventilate the patient any other way, including BVM, NIPPV, LMA, intubation*
- also anatomic abnormalities, bleeding disorder, inability to palpate anatomical landmarks
What are potential complications of performing a needle cricothyroidotomy?
-perforating the posterior trachea, subcutaneous emphysema, breath stacking–>increased intrathoracic pressure and eventually cardiac arrest from decreased preload, pneumothorax, hematoma
In what age is needle cricothyroidotomy a consideration?
Age<10yo, in children >10yo obtain surgical airway with surgical cricothyroidotomy vs tracheostomy
How is a needle cricothyroidotomy performed?
1) Slowly insert an 18 gauge needle attached to a syringe filled with water into the cricothyroid membrane
2) As the needle advances pull back on the plunger until air fills the syringe. Now you are in the trachea
3) Flatten out the needle and slide the angiocath until it is flush with the skin
4) Attach a 3.0 ETT adapter to the angiocath or 3cc syringe attached to a 7.0 ETT adapter
5) Attach high flow oxygen to the ETT adapter and begin bagging
What maneuvers should be done to ensure the best ventilation possible following a needle cricothyroidotomy procedure?
- Press on the chest during exhalation to ensure air exits and help alleviate breath stacking
- Bag with a much slower rate than normal, 1 second inhalation, 7 seconds exhalation
What should you rapidly assess in all asthmatics presenting in respiratory distress?
-respiratory rate, O2 saturation, dyspnea (full sentences vs 1 word at a time), retractions, auscultation
What are treatment options for asthmatics not in impending respiratory failure?
- steroids-dexamethasone IV formulation 0.6 mg/kg max 16 mg given PO vs 2mg/kg IV methylprednisolone for severe sxs
- Albuterol/Ipratropium-consider MDI vs continuous albuterol, duonebs vs concentrated atrovent for ipratropium
- Other adjuncts-IV fluid bolus+mag (mag can cause hypotension, mg helps w/ bronchospasm), 0.01 mg/kg IM epinephrine, heliox
- BiPAP>CPAP for asthma
What is the drug of choice for sedation for RSI of an asthmatic?
Ketamine-has bronchodilatory effects, beware of the dissociative effect as patient may forget to have appropriate respiratory drive
- How should vent settings be adjusted for an intubated asthmatic?
- What specialist should you consider consulting following intubating an asthmatic?
- allow permissive hypercapnea and avoid breath stacking: lower the respiratory rate, low tidal volume, low I:E ratio (1:4), low plateau pressure (<30, marker of how much pressure is seen at the alveoli)
- after intubation call anesthesia to give inhaled anesthesia as is has direct bronchodilatory effects
Describe reasons why cardiac arrest occurs in asthma
-pneumothorax, increased gastric distension, lung hyperinflation all lead to increased intrathoracic pressure and decreased venous blood flow to the heart–>cardiac arrest
Describe essential maneuvers to perform for an asthmatic having cardiac arrest
- disconnect the vent to allow for an apnea trial vs slow bag to see if thoracic pressure can decrease so venous return can increase
- Give an IV fluid bolus to increase venous return
- press on the chest to try and push air out of the lungs/mediastinum
- bilateral needle decompression to relieve potential pneumothoraces
When is ketamine contraindicated for RSI?
open globe injury, or suspected catecholamine depletion (i.e. hypotension despite use of vasopressors)
What proportion of bronchiolitis cases are caused by respiratory syncytial virus (RSV)?
70%
-What ddx should you consider in an otherwise healthy infant who had no recent URI but is presenting with a history of prolonged cough and no abnormal findings on physical exam?
- Ddx-foreign body aspiration, post viral cough, pertusis
- Pertussis, is often subtle in young infants (the most susceptible population) and is usually associated with a normal examination in the ED
What is the best RSI induction agent for intubation of infants greater than 3-months-old with respiratory failure due to bronchiolitis?
-Ketamine-Just like in asthma, the bronchodilating properties of ketamine makes it useful in bronchiolitis due to the frequent RAD component to the respiratory distress/failure.
- At what age is peritonsillar abscess more common?
- What are typical presentation features of peritonsillar abscess?
- Peritonsillar abscesses are very uncommon in children <12 years old.
- They are likely to present with severe sore throat and drooling.
- What common ED chief complaint is accompanied by pneumomediastinum up to 5% of the time?
- Is pneumomediastinum an indication to admit for the above condition?
- What is the prognosis of pneumomediastinum?
- What life threatening complication can be caused by pneumomediastinum?
- Asthma!
- Pneumomediastinum is not an indication to admit in the context of being 2/2 asthma exacerbation
- SPM usually is a benign condition that resolves without consequences within 2 days to 2 weeks, frequently occuring after a transient worsening of symptoms.
- Pneumopericardium!
- What is the most common chest xray finding in bronchiolitis?
- What else can be seen?
- What percentage of bronchiolitis CXRs are normal?
- Why should you not be obtaining CXR in bronchiolitis?
- The most common CXR finding is hyperinflation with increased peribronchial markings
- Interstitial infiltrates and segmental atelectasis are common as well and can be difficult to distinguish from pneumonia.
- Only about 10% of CXR’s are strictly “normal.”
- Even when present, true infiltrates (particularly if mild) are more likely to be viral than bacterial. This is hard to know for sure, usually prompts antibiotic use, and demonstrates why is it better to avoid doing radiographs at all in infants with bronchiolitis unless truly necessary especially given in context that only 10% of bronchiolitis CXRs will be normal.
- Do antibiotics shorten the course of illness for pertussis?
- What is the utility of giving antibiotics for pertussis?
- When can children with proven pertussis return to school?
- Unless given during the prodromal (Catarrhal) stage of the illness, during which the cough has not yet developed, antibiotic treatment (with Azithromycin or trimethoprim/sulfamethoxazole) does not shorten the course of symptoms (which can last for up to 6 months).
- Antibiotic treatment is important, however, in order to limit the spread of the disease.
- Children with laboratory-confirmed pertussis should not return to school until completing the full course of antibiotics (7-14 days depending on the regimen).
What is the mortality rate in neonatal bacterial pneumonia?
Even when promptly recognized and aggressively treated, pneumonia in the neonate still has a high mortality rate (up to 50% if GBS is the cause).
- When should you consider a diagnosis of methemoglobinemia?
- What are causes of methemoglobinemia?
- How would you diagnose methemoglobinemia?
- How would you treat it?
- presents with cyanosis, tachypnea and a low pulse-ox which is only partially responsive to oxygen. CXR will be normal and blood gas will have a normal PaO2 despite the hypoxia
- Toxin, toxin, toxin!
- Diagnosed by co-oximetry
- Treat with methylene blue!
