Neonatal/Pediatric Cardiopulmonary Care - Amarillo College · 2017. 3. 27. · Croup, Epiglottitis, Bronchiolitis 13 37 Bronchiolitis •Most common lower respiratory tract infection

Croup, Epiglottitis, Bronchiolitis

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Neonatal/PediatricCardiopulmonary Care

Pediatric Diseases

Laryngotracheobronchitis(Croup)

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Croup

• =

• Degree of lower tract involvementvaries but pneumonia can develop

Croup, Epiglottitis, Bronchiolitis

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Etiology

• Viral• **

•••

••••

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Clinical Presentation

• Mild fever• Barking cough• Hoarseness• Stridor

• Slow onset•

•

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Clinical Presentation

• Can have

• BS OK unless

• Epiglottis

Croup, Epiglottitis, Bronchiolitis

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Clinical Presentation

• CXR• AP neck will show subglottic narrowing =

• Lateral neck may show subglottic edemabut is usually normal

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Clinical Presentation

••• If lower airways involved → V/Q

abnormalities → hypoxia on CBG,anxiety, tachypnea, tachycardia →cyanosis, retractions

Croup, Epiglottitis, Bronchiolitis

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Treatment

• Only 10% need

• Hospitalize if•

••••

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Treatment

• Decrease no. of anxiety-producingsituations

• In fact: lab procedures & non-important physical exams should bepostponed

• Frequent monitoring of vital signs as↑ HR & RR mean -

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Treatment

• Hypercarbia is a late finding & ispreceded by fatigue, ↑ retractions,changes in VS

• CBGs done only if child cannot beclinically assessed easily

• Sedation avoided

• Vigorously treat fever (↑ resp & cardiac work,dries secretions)

Croup, Epiglottitis, Bronchiolitis

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Treatment

• Corticosteroids

•

•• Aerosolized racemic epinephrine

•

•

•

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Treatment

• Intubation - Criteria• Rarely needed

• Marked, progressive anxiety

• Hypoxemia

• Hypercarbia

• Fatigue

• Evidence of

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Treatment

• Intubation - Type of Airway• ETT

••

• Trach• If subglottic swelling is so great that only a

very small (2 or more sizes smaller) ETT canbe inserted

Croup, Epiglottitis, Bronchiolitis

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Tube Management

•• CPAP

• Sx

• CPT if

•• HOB up

•

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Complications

• Children with croup have a highincidence of complications, usuallysubglottic stenosis after use of artificialairway

• Pulmonary edema may complicatesevere airway obstruction•

•

Epiglottitis

Croup, Epiglottitis, Bronchiolitis

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Epiglottitis

• = bacterial infection causinginflammatory edema of supraglotticstructures - primarily epiglottis &hypopharynx

• Vocal cords, subglottic tissues, tracheanot involved

• Pneumonia uncommon

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Epiglottitis

Complete airway obstruction can occursuddenly

=

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Etiology

• Almost always caused by

•

•

•

Croup, Epiglottitis, Bronchiolitis

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Clinical Presentation

• Acute (<10 hrs) illness

•• Various degrees of

•••

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Clinical Presentation

• Inspiratory stridor unless airflow too ↓by obstruction

• May have retractions

• If obstruction severe• Depressed mental status (hypoxemia)

• Agitation

• Child will sit up, leaning forward with chinthrust forward in attempt to maintainairway

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Clinical Presentation

Croup, Epiglottitis, Bronchiolitis

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Treatment

• Prevent with HIB vaccine•

• Appropriate Dx

• Hx & visual exam alone should causesuspicion

• Make child as comfortable as possible

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Treatment

• Brief physical exam with no anxiety-producing procedures

• Oxygen offered by mask

• Close observation at all times

•

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Treatment

• Lateral neck x-ray in upright position iftime allows• Will show swollen epiglottis =

• If done, must be done in presence ofsomeone who can establish airway

Croup, Epiglottitis, Bronchiolitis

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X-Ray

Normal Epiglottitis

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Treatment - Establish Airway

• Under general anesthesia in OR withsurgeon trained to do trach near-by• Child sitting for induction• Use of muscle relaxants contraindicated in

presence of airway obstruction• IV catheter now placed• Nasal ETT 1 size smaller than normal

•

• Confirm Dx by visualization of epiglottis &culture for C&S

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Treatment - Establish Airway

• Nasal ETT with small fiberopticbronchoscope• Child sitting

• Topical anesthetic jelly to naris

• Confirm Dx

• Pass ETT over scope into trachea

Croup, Epiglottitis, Bronchiolitis

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Treatment

• Now can obtain blood cultures, CBC

• Heated, humidified gases

• Sx prn

• Monitor SpO2 or TCM

• Oxygen as needed

• Treat pulmonary edema (O2, CPAP or PPV,Sx, diuretics)

• CPT q6-8° to prevent atelectasis

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Treatment

• Respiratory isolation for

• Arm restraints as patient feelsremarkably better after ETT & Abx

• Sedation may be required•••••

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Treatment

• Antibiotics• Ampicillin

• 3rd generation cephalosporins (Rocephin,Suprax, Cephobid, Fortaz)

• Rifampin to all in family - eliminates nasalcarriage

• Antipyretics• Acetaminophen suppositories

Croup, Epiglottitis, Bronchiolitis

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Treatment

• Adequate fluid intake• IV fluids (NaCl) until patient can swallow,

then clear liquids (even with ETT)

• Use of corticosteroids is controversial

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Extubation

• Consider after at least 24 hrs ofantibiotics

• Ability to swallow

• Decreasing signs of sepsis

• Temp need not be normal

• Resolving of inflamed supraglottic &glottic swelling by direct visualizationwith laryngoscope, sedation

• NPO x

Bronchiolitis

Croup, Epiglottitis, Bronchiolitis

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Bronchiolitis

• Most common lower respiratory tractinfection during

• Highest mortality among infants <6 mo.& among those with chronic conditions

• = swelling, constriction, inflammation,obstruction of bronchiolar epithelium

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Etiology

• Most often (75%) from RSV infection••

• Adults - nonspecific upper respiratory tractinfection••

• Also caused by

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Etiology

•

•

•

•• Doesn’t confer immunity until

• Also believed to create immune responsethat is a precursor to

Croup, Epiglottitis, Bronchiolitis

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Clinical Presentation

••••••••

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Clinical Presentation

• Apnea

•

• CXR

•

•

•

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Clinical Presentation

• Begins as simple “cold-like” symptomswith nasal congestion & cough

• Symptoms gradually worsen over few adays with cough & wheezing increasing

• Usually resolves in a few days, butpneumonia may develop

Croup, Epiglottitis, Bronchiolitis

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Clinical Presentation

• Hospitalize when•

•

•

•

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Clinical Presentation

• Hospitalize when•

•

•

•

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Diagnosis

• Made by isolation of RSV fromnasopharyngeal secretions• Nasal washing

•••••

• ELISA (enzyme-linked immunosorbentassay)

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Treatment

•

•••

•••

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Treatment

••••••

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Treatment

• Drugs

•••• Antiviral agents - ribavirin (Virazole)

•

•

•

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Prevention

• Vaccine• For high-risk patient

•••••

• Synagis (palavizumab) or RespiGam (RSV-IG)

•• Synagis: ~$ /dose

• RespiGam: ~$ /dose

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Morbidity & Outcomes

• If bronchiolitis & pneumonia caused byadenovirus →

• Necrotizing lesions of bronchioles & alveolileading to obstruction of small airways

• Wheezing, pneumonia, atelectasis for wks-to-months

• Recovery may be complete but >1/2 of patientshave some degree of permanent lung damage &abnormal pulmonary function