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Paediatrics 4MB > The Acutely Ill Child with Severe Airway Obstruction > Flashcards

The Acutely Ill Child with Severe Airway Obstruction Flashcards

1
Q

What are the causes of severe airway obstruction in children?

A
  1. Upper airway:
    - Viral laryngotracheobronchitis (croup)
    - Epiglottitis
    - Bacterial tracheitis
    - Foreign body obstruction
    - Angioedema (anaphylaxis)
  2. Lower airway:
    - Acute exacerbation of asthma
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2
Q

How do we assess an acute exacerbation of asthma?

A
  1. Determine severity
  2. Evidence of increased work of breathing:
    - RR
    - Chest recession
    - Auscultation
  3. Cardiovascular assessment:
    - Tachycardia
    - Arrhythmia
    - Hypotension
  4. Look for altered consciousness and exhaustion
  5. Check tongue for cyanosis
  6. Peak flow
  7. Oxygen saturations
  8. What triggered the event?
  9. Duration of symptoms
  10. Treatment already given
  11. Previous attacks
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3
Q

What are the criteria for admission in an acute exacerbation of asthma?

A

If after high dose bronchodilator:

  1. Not responded adequately clinically
  2. Becoming exhausted
  3. Marked decrease in peak flow
  4. Decreased oxygen saturations
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4
Q

What are the features of a moderate exacerbation of asthma?

A
  1. Able to talk in sentences
  2. SpO2 >92%
  3. PEF >50%
  4. HR <140 (1-5yrs), <125 (>5yrs)
  5. RR <40 (1-5yrs), <30 (>5yrs)
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5
Q

How do we manage a moderate exacerbation of asthma in a child?

A
  1. Beta-2 agonist 2-10 puffs via spacer, one puff every 30-60secs
  2. Oral prednisolone
  3. Reassess within one hour
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6
Q

What are the features of a severe exacerbation of asthma?

A
  1. Too breathless to talk or eat
  2. SpO2 <92%
  3. PEF <50%
  4. HR >140 (1-5yrs), >125 (>5yrs)
  5. RR >40 (1-5yrs), >30 (>5yrs)
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7
Q

How do we manage a severe exacerbation of asthma in a child?

A
  1. Oxygen via face mask/nasal prongs (want sats 94-98%)
  2. Beta-2 agonist 10 puffs via spacer or nebulised salbutamol (2.5mg for 1-5yrs, 5mg for >5yrs)
  3. Oral prednisolone (20mg for 1-5yrs, 40mg for >5yrs) or IV hydrocortisone if vomiting (4mg/kg)
  4. Add 0.25mg ipratropium bromide to every nebulised beta-2 agonist if poor response
  5. Repeat nebs up to every 20mins for 2hrs according to response
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8
Q

What are the features of a life-threatening exacerbation of asthma?

A

Any one of the following in children with severe asthma:

  1. Silent chest
  2. Cyanosis
  3. Poor respiratory effort
  4. Hypotension
  5. Exhaustion
  6. Confusion
  7. SpO2 <92%
  8. PEF <33%
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9
Q

How do we manage a life-threatening exacerbation of asthma in a child?

A
  1. Nebulised beta-2 agonist and ipratropium bromide, repeat every 20-30mins
  2. Oral prednisolone or IV hydrocortisone if vomiting
  3. Discuss with senior clinician, PICU team or paediatrician
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10
Q

What are second line treatments that can be used if the child isn’t responding?

A
  1. Consider bolus IV infusion of magnesium sulfate
  2. Bolus IV salbutamol (not common)
  3. IV aminophylline
  4. Assess response before initiating each new treatment
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11
Q

What to do if the child is responding to treatment?

A
  1. Continue bronchodilators for 1-4hrs
  2. Discharge when stable on 4hrly treatment
  3. Prednisolone for 3 days
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12
Q

What needs to be done at discharge after an exacerbation of asthma?

A
  1. Ensure stable on 4hrly treatment
  2. Review need for regular treatment and use of inhaled steroids
  3. Review inhaler technique
  4. Written asthma action plan
  5. GP follow-up within 48hrs
  6. Hospital asthma clinic follow-up in 4-6wks
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13
Q

How do we assess the severity of airway obstruction in children?

A

Assessed clinically:

  1. Characteristics of the stridor:
    - None
    - Only on crying
    - At rest
    - Biphasic
  2. Degree of chest retraction:
    - None
    - Only on crying
    - At rest
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14
Q

What are the signs of an impending complete airway obstruction?

A
  1. Central cyanosis
  2. Drooling
  3. Decreased consciousness
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15
Q

Should we examine the throat of a child with acute stridor?

A

NO!!! - may precipitate complete airway obstruction

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16
Q

Define laryngotracheobronchitis (Croup)

A

Laryngotracheobronchitis is an upper airway obstruction caused by oedema in the subglottic area most commonly due to infection with parainfluenza virus

17
Q

What is the usual age range for croup?

A

Typically 6mths - 6yrs, with a peak in incidence around 2yrs of age

18
Q

What are the typical features of croup?

A
  1. Coryza
  2. Fever
  3. Hoarseness
  4. Barking cough
  5. Harsh stridor
  6. Difficulty breathing
  7. Symptoms worse at night
19
Q

How do we manage croup?

A

Oral dexamethasone = first line
Moderate-severe:
1. Nebulised steroids (Budesonide)
2. Nebulised adrenaline with oxygen (gives a rapid but transient improvement if severe)

20
Q

Define epiglottitis

A

Epiglottitis is intense swelling of the epiglottis and surrounding tissues associated with septicaemia

21
Q

What is the causative organism of epiglottitis?

A

Haemophilus influenzae type B (Hib) - vaccine available

22
Q

What age groups are affected by epiglottitis?

A

All age groups; most common 1-6yrs

23
Q

What are the clinical features of epiglottitis?

A
  1. Very acute onset
  2. High fever
  3. Very ill looking child
  4. Intensely painful throat
  5. Soft inspiratory stridor
  6. Rapidly increasing respiratory difficulty
  7. Sitting immobile, upright with mouth open
24
Q

How do we manage epiglottitis?

A

LIFE THREATENING EMERGENCY!!

  1. Call senior anaesthetist, paediatrician and ENT surgeon
  2. Transfer to ICU
  3. Intubate under GA
  4. Blood cultures
  5. IV antibiotics (Cefuroxime)
  6. Prophylaxis for household contacts (rifampicin)
25
Q

Define anaphylaxis

A

A severe, life-threatening, generalised or systemic hypersensitivity reaction, mostly IgE mediated response, with significant respiratory or CVS compromise

26
Q

What are the clinical features of anaphylaxis?

A
  1. Sudden onset
  2. Rapid progression
  3. Airway and/or breathing and/or circulation problem
  4. Skin and/or mucosal signs of urticaria or angioedema
27
Q

What can cause anaphylaxis?

A
  1. Food allergy
  2. Insect stings
  3. Drugs
  4. Latex
  5. Exercise
  6. Inhalant allergens
  7. Idiopathic
28
Q

What are additional risk factors for anaphylaxis?

A

Asthma

29
Q

How do we diagnose anaphylaxis?

A 
Acute onset <30mins with typical skin reactions and ANY OF respiratory, CVS or GI symptoms
Airway:
1. Swelling
2. Hoarseness
3. Stridor
Breathing:
1. Tachypnoea
2. Wheeze
3. Cyanosis
4. SpO2 <92%
Circulation:
1. Pale
2. Clammy
3. Hypotension
4. Drowsy
5. Coma
Skin:
1. Urticaria/angioedema
30
Q

How do we acutely manage anaphylaxis?

A

-Call for senior help and have someone manage patient’s airway
-Difficult breathing - sit patient up
-Hypotensive - lie patient supine and elevate legs
-Unconscious - put patient in recovery position
-BLS/ALS if necessary
-GIVE IM ADRENALINE 0.01ML/KG OF 1:1000 (MAX 0.5ML) - repeat after 5mins
-IV fluids (20ml/kg crystalloids)
-Consider salbutamol if wheeze
-Monitor:
O2 sats
ECG
BP

31
Q

How do we manage anaphylaxis in the long term?

A
  1. Detailed strategies and training for allergen avoidance
  2. Instructions for treatment of allergic reactions
  3. Provision of adrenaline autoinjectors (anapens) - one for home and one for school
  4. Educate teacher and students
  5. No nut policy and no food sharing at school
  6. Wear medic alert bracelet
  7. Allergy action plan - at home and at school

Paediatrics 4MB (22 decks)

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