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M03: Pediatrics - Respiratory Emergencies
Wes Bihlmayr
Updated:
Reviewed:
Introduction
Respiratory conditions in children can be categorized into upper airway obstructions, lower airway obstructions, lower airway restrictive pathology, and disordered control of breathing.
Upper airway obstructions occur when there is an increased work of breathing due to an obstruction above the thorax. This can consist of a foreign body, tissue swelling, subglottic stenosis from previous intubation trauma, and the development of a tumour. Lower airway obstructions, by contrast, result from obstructive problems below the thorax: foreign bodies, or bronchial swelling or constriction.
Restrictions in the lower airways are a result of “stiffening” of lung tissue, caused by increased fluid accumulation from pulmonary edema, toxic exposure, allergic reactions, infiltration, and inflammation. Abdominal structures can also push on lung tissue, creating a restrictive condition.
Dysfunction within the respiratory center of the brain is responsible for the development of disordered breathing. These are more properly neurological problems with respiratory effects, and can include problems such as increased intracranial pressure, neuromuscular disease, and some poisonings and overdoses.
Essentials
- Upper airway obstruction can be an uncomfortable call to attend as the majority of patients may look ill but require just comfort levels for treatment.
- Lower airway obstruction results in an inability for the patient to get air out of the chest. This is usually due to excessive swelling of bronchospasm.
- Lower airway restrictive pathologies consist of numerous conditions that result in decreasing lung compliance or stiffening of the lung. The general management of these conditions concern correcting oxygenation and ventilation utilizing an escalation pathway of increasing FiO2 via nasal cannula, face mask, heated HiFlow nasal cannula (2 lpm/kg to a max of 60 lpm), NIV therapy and then intubation. Bronchospasm can be treated with a B2 agonist.
- Disordered Control of Breathing are a series of conditions affecting the respiratory control center in the brain or neuromuscular diseases.
General Information
- Continuous salbutamol can decrease serum potassium
- Ventilating the lower airway restrictive disease patient may require high peak inspired pressure of up to 32 cmH2O and high PEEP of up to 10-15 cmH2O. Diligent monitoring for the development of a pneumothorax is required.
- Succinylcholine should be avoided in the patient with neuromuscular disease due to the possibility of triggering hyperkalemia or malignant hyperthermia
Interventions
First Responder (FR) Interventions
- Prevent heat loss but do not overheat the patient.
- Provide supplemental oxygen as required
- Manual airway maneuvers as required
- Positive pressure ventilation with BVM
Emergency Medical Responder (EMR) & All License Levels Interventions
- Provide supplemental oxygen to maintain SpO2 ≥ 94%
- Transport with notification
- Consider ACP intercept
Primary Care Paramedic (PCP) Interventions
- Consider vascular access and fluid administration
- Consider supraglottic airway to maintain airway patency
- For bronchospasm, reactive airway disease, and asthma:
- For croup, epiglottitis, and stridor:
Advanced Care Paramedic (ACP) Interventions
- Consider addition of ipratropium to supplement salbutamol.
- Consider magnesium sulfate for significant and protracted bronchospasm.
- Consider intraosseous cannulation if peripheral access is unavailable.
- Consider procedural sedation to facilitate airway management.
- Consider intubation in patients whose airways cannot be managed through less invasive means:
- Decompress suspected tension pneumothorax
Critical Care Paramedic (CCP) Interventions
- Mechanical ventilation (NIV and invasive)
- Chest tube maintenance
- Osmotic agents
- 3% Saline
- Infusion medication
- Antibiotic therapy
- Steroid therapy
- Nonselective adenosine receptor antagonist and phosphodiesterase inhibitor
References