MD Roundtable – Pediatric Respiratory Emergencies

Pediatric Respiratory Emergencies

Is that on? And this is Dr. Matthew Eshelbach from Redmond, Oregon, Redmond, gosh my brain is on tonight. Redmond, Oregon is correct. Oregon, I said Washington earlier and I realized that.

Yeah, that’s okay. I’ve had a really long couple of weeks, I apologize. I bet.

All right, so folks, here you are and enjoy and I’m going to mute my microphone. All right, well guys, welcome. I am going to turn off my video to spare some broadband, but we’re going to talk tonight about pediatric respiratory emergencies.

And this is the time of year where they begin to pop up. What happens during this time of year is kids come in, they’re in school, kids are in the house more, less outside, close quarters. So anyone who has a child knows that they are petri dishes and they are going to spread disease to their brothers and sisters and we’ll go from there.

We’re going to go over our objectives are a little bit about pediatric anatomy, major causes of pediatric respiratory distress, and the multiple causes of respiratory difficulty that we’re going to see, and the infectious causes of pediatric illness. There are quite a few videos, so make sure your volume is turned up because you need to hear some of these things to understand exactly what’s going on. First off, child is not a miniature adult.

Their airway is smaller, but it also lacks cartilaginous stability, so it’s very, very soft and pliable. One of the reasons that kids don’t break so easily is because their cartilage is very bendable. They also have less airway smooth muscle, so they will fatigue easier.

They have greater mucus membrane density and therefore decreased channels of collateral ventilation. That means that they’re not able to use as much of their lungs as you or I. Their chest wall is more compliant, more rubbery, and because of that, it’s good for trauma but bad for some other things, and the diaphragm structure is different because they have a decreased number of fatigue-resistant fibers, so when kids crash, they crash very, very rapidly. The first thing that you want to know about their upper airway anatomy is the reason that we use very tiny tubes is they have a funnel-shaped upper airway.

On adults, they are primarily round and cylindrical. On kids, they’re funnel-shaped. If you look at an infant, for example, a male or female has a typical 20-millimeter radius on their trachea, whereas it’s only four millimeters for kids.

If you look at how much of that inside is actually exchange of air, it’s only two. Respiratory distress in children, here are the two big things, hypoxemia and hypercarbia. With those two things, we’ve got to get more oxygen in and CO2 out.

That’s why it’s very, very important that we have end-tidal CO2 on these kids so we can see if the CO2 is building up. Remember that they’re going to have difficulty with mechanics of respiration from obstruction, weakness, and discomfort that we talked about. There are some disordered controls of ventilation, which we’ll also talk about as we go through this.

These are all the things that will cause acute respiratory distress in kids. We’re going to just break it into some basic categories. Infection, we’re going to go over most of these infections, and asthma, and anaphylaxis, and foreign body.

We’ll probably get that far tonight. We may not get there. If not, we’ll try and pick it up next time.

Then all the other things that we worry about like biologic weapons, chest trauma, smoke inhalation, and drowning, which we talked about earlier in the year. Cardiovascular, these are very, very rare in kids, but congenital heart disease is there. That’s usually found early on in the first months of life.

Nervous system, GI problems, metabolic problems, and hematologic problems are all possibly contributing to respiratory distress in kids. We’re not going to go over all of these. We just haven’t got the time.

The immediate life-threatening conditions that you’re going to face most often are upper airway obstruction, tension pneumothorax, pulmonary embolism, again, relatively rare in kids, cardiac tamponade, very rare in children, and other traumatic conditions. These are the big ones, tension and upper airway obstruction that we hope to cover tonight. Traumatic conditions, flail chest, pulmonary contusions, thorax and open pneumothorax, smoke inhalation, submersion, these are all things that can cause respiratory difficulties, but they’re further down the list in our kids.

All right, tension pneumothorax, you’re going to see this in a premature or a child perhaps who was born at home. It’s usually severe respiratory distress, and you’ll get a shift of mediastinal structures. Mediastinum is what is in the middle of your chest.

It’s primarily your heart, your trachea, and your lungs. So you’re going to see a trachea shift over to the right or left. It’s going to go to the contralateral side.

So if we had a tension pneumo on the right, collapsed lung, then we would see a shift to the left, which means the ipsilateral, the opposite side, gets hyperexpansion of the chest, and we’re going to get decreased or absent breath sounds and hyperresonance on the same side. It says ipsilateral. So this is relatively rare, but it can happen.

It happens in neonates and kids who are born a little bit early. Neonatologists are very quick to put a needle in a chest and get a chest tube in kids, and your protocols would probably do the same. You’re probably not going to run into this unless you actually deliver a child at home.

All right, let’s go on to lung diseases that are common to kids, the ones that are going to see a lot in the next couple of months, and they include all of these SIDS, peritonsillar abscess, all of these we’ll try and go over tonight. We’ll see how far we get, and if we have to do it at another time, we’ll continue that next time. Keep in mind that respiratory diseases in childhood account for about 50% of all acute diseases in kids.

So if they’re going to get sick half the time, it’s because they’ve got some kind of respiratory disease. A normal child under five will have at least five or six upper respiratory tract infections per year, and then one or two lower ones per year. They account for about 66% of chronic diseases in childhood.

SIDS, sudden infant death, this is a very, very sad thing, but we do run into it. It’s the leading cause of death in infants less than one year old in the United States. When they autopsy these children, they often show repeated signs of hypoxia or ischemia.

Factors that are associated, not directly linked to SIDS, are sometimes maternal, young moms, poor moms, cigarette smoking moms, moms who were ill during pregnancy and had inadequate or no prenatal care. As far as the infant goes, they’re generally male more than female, kids who were born premature or small for their gestational age, and maybe they needed a little oxygen at birth and had low APGAR scores. These are the ones that we’ll see most often.

What causes SIDS? We don’t know. Apnea prematurity, which is something that is a condition where kids stop breathing because their brain and their lungs are not developed completely right, is really not a predisposing factor. You would think it is, but it’s not.

There’s no evidence that this immaturity in the respiratory centers is a cause for SIDS, and there’s no evidence of a genetic link. Kids who have died of SIDS, generally their age is less than six months, between one and three months, and we’re coming up on the winter season. As I said, that’s why I put this in there.

This is when you’re going to see it the most. It happens in their sleep at night, and very often they had a mild illness. A week before could have been a cold or upper respiratory tract infection, and they had a history of some apparent life-threatening event.

What is an apparent life-threatening event? It’s something that scares the heck out of the parents. These events are a kid stops breathing, they turn blue, they become limp, enough to frighten their caregiver. When these things happen now, it used to be in the emergency department, we would see these kids, mom and our dad, would come in with the story of one of these things.

We would take a look at the kid, they would look fine, x-ray, blood work, nothing, and you might send them home. Now when they have this apparent life-threatening event, we try and maybe admit the children and then get the pediatrician involved early to get these kids home on some type of monitor. Recently, the prone sleeping position, that’s sleeping on their stomach, sorry, sleeping on their stomach has been associated with an increase.

All right, what they have now is this back to sleep program, and I’m sure that I’m going to pick on somebody old like me, Jane, and say that when we put our kids to sleep, we used to have baby bumpers, we used to have nice little blankets and a toy maybe to keep the baby happy, and if you look at today’s cribs, moms and dads don’t have any of that. Kids have a sleeper, which is kind of like a zip-up sleeper, and very often blankets aren’t in there at all, and you kind of look in there. When I look at my grandkids in their cribs, I’m like, gosh, these kids are going to freeze to death, and no, no, they’re going to be fine in their zip-up, and the doctor says not to put any toys in there or baby bumpers and things that would actually lead to suffocation.

So since cause is unknown and it occurs at unexpected times, there’s really no treatment for SIDS. The only treatment we have is education, and that’s very, very important. High-risk kids, those who have gone through those scary events, we teach, we have apnea monitoring and we teach mom and dad CPR, and it’s recommended that infants sleep on their back or the side position at least the first six months of life.

All right, we’re going to move on. I’m going to check the chat really quick and say, okay, somebody’s putting their baby to sleep. Okay, good.

Make sure they’re on their back. All right, good. That’s it.

All right, infectious diseases, very, very, very common, especially at this time of year. First off is something called the peritonsillar abscess. This is usually a sore throat.

Trismus means that the child won’t open their mouth wide. They have difficulty swallowing and they have this muffled hot potato voice. What’s a hot potato voice? Imagine taking a bunch of mashed potatoes that are hot and putting them in the back of your mouth and trying to talk.

So bear with me. They’re going to get a little talk like this. It’s going to be a little bit higher and they’re going to have that sound in their voice where it sounds like a hot potato.

There’s going to be some noticeable tonsillar swelling. Complete obstruction is rare and it’s usually caused by either strep or an Epstein-Barr virus. They’re more common in older children than adolescents.

So here’s a typical, as you look in the patient’s throat, you’ll see that one side is a big old lump in and around the tonsils and generally this area here in the light pink is where there’s infection. So when we have associated symptoms, excuse me, you’ll see that these are pretty obvious. These are the ones that have to go to an ear, nose and throat physician who’s got to poke a scalpel in there and remove the abscess.

Retropharyngeal abscess is a little bit different. It’s behind the pharynx and there are associated with these abscesses stridor. We’ll go over that in just a few minutes.

Retropharyngeal abscesses are more likely to develop in infants and toddlers and it’s unusual in kids older than four years age. Additional findings will be drooling, dysphagia, which means it hurts to swallow, torticollis or meningitis, which is stiffness of their neck. They don’t like to move their neck and a change in their voice.

Now here is an x-ray. If you take a look at this x-ray, you can see very, very lightly where my arrow is. You can see a very light color.

That light color is a lateral neck radiograph that shows widening of the space from the abscess. Sometimes we’ll have to do again, if we’re lucky and there’s an anaerobic or gas producing organism that’s causing this infection, we’ll see the gas here. You can see these little pockets of gas.

If not, we might have to do an MR on me and this is or a CAT scan and this CAT scan shows here this black area is an abscess and over here this CAT scan shows two abscesses A and B. All right. Again, upper airway infections in the mouth are either a peritonsillar abscess or a retropharyngeal abscess. Keep in mind that the third and the one that we see most often is something called laryngeotracheobronchitis, otherwise known as CROOP or LTB.

CROOP, these kids sound like they’re not going to take another breath ever. There’s a buildup of chat and I’ll get up after this CROOP. Affects the larynx and the trachea, most common in kids who are six months of age to three years, males greater than females, early winter, that’s when you’re going to see it and it’s caused by RSV.

That’s the one that they’re always toting right now for adults to get an RSV vaccine. Parainfluenza viruses and it varies from year to year depending on the infectivity of the community. You get this subglottic, that means under the tongue, swelling and airflow obstruction.

CROOP has cold symptoms and then they develop this barky seal-like cough. Very often parents are so scared by this cough or the stridor that comes with it that they think that their child is not going to take another breath and they rush them out to the car, put them in the car and drive to the emergency room. Well, one of the things that’s good about that is the spasm that’s happening when it’s exposed to cold air or hot steamy air in like a bathroom decreases the stridor and very often by the time they get to the emergency department, their respiratory distress is gone.

And then I’ll usually sit on these kids for a while and listen because I’m going to listen for that distinctive barky or seal-like cough. Usually it’s a cold that progresses relatively slowly, low-grade fever and then you get this barky seal cough, respiratory distress and cyanosis and usually recurs several nights in a row and it really does sound like this kid is not going to take another breath ever. Sometimes we’ll do an x-ray and on the x-ray we’ll see what’s called a steeple sign.

I’ll show you that and that shows the cartilage being pinched by the swelling of the trachea. Leukocytosis is an increase in white blood cells and we’re going to see that more with bacterial tracheitis or epiglottitis. All right, I want you to hear this.

I’ll play it one more time. Listen for that barking seal cough. You cannot miss it.

All right, and the next picture. All right, well that is a happier baby but you can hear that hoarseness and that’s distinctive for croup. As I said, the larynx, laryngeal tracheobronchitis, the larynx becomes inflamed and if we do an x-ray we can sometimes see this steeple sign which is indicative of swelling in the trachea.

There’s another x-ray showing this steeple sign. You guys in EMS are not going to have that ability to do that. Here is another lateral showing of the steeple sign.

Management, mild croup. You give mom and dad reassurance, either moist or cool air. As I said, very often when they get in the car and they drive to the ER, the cool air of the nighttime has already taken care of it or you can get them into the bathroom, turn on the hot water and let that hot water build up and you wind up with a real steamy environment and that can also help.

Severe croup, humidified oxygen. Sometimes we have to admit these kids. One of my colleagues, if she gave nebulized racemic epi, then she had that kid admitted.

I would sit on them sometimes for a couple of hours and if they were okay, I would give them a dose of steroids and then sit on them and see if they improved and if they improved, I’d send them home. But as I said, one of my partners used to make sure if they got racemic epi at all that they were admitted. You always have to anticipate, am I going to have to intubate this kid? All right, I’m going to go to the chat real quick.

Let’s see, seven new messages. All right. One of them was a joke.

They were talking about how do I get the medical director to do the hot potato voice so everybody was chiming in. That’s good. That’s good.

That’s good. How do I get my medical director to do the hot potato voice? All right. Do patients with croup tend to further decompensate where an airway is needed? To tell you the truth, most of the time they don’t.

Most of these croupy kids, I would send home, I’d give them a dose of oral dexamethasone. It’s probably going to be in your protocols for COPD or asthma or something like that, but I would give them oral dexamethasone, sit on them a while and they seem to go home pretty well. Okay, that’s good.

All right. Bronchiolitis. Now, keep in mind, this is not bronchitis.

It’s bronchiolitis. Bronchitis is more often seen in smokers or COPDers and it’s usually an adult disease. It’s usually viral.

Bronchiolitis, which is also mostly viral, is the smaller passageway. So you’ve got the large trachea and then it breaks into right and left bronchi and those bronchi break down again into bronchioles and smaller, smaller bronchioles. So this is an infection all the way down in the bronchioles.

Usually, RSV is the most common cause. It spreads very rapidly through kids and it causes bronchiolar edema and air trapping so that they can take a breath in, but they can’t get it all out. Usually, it’s kids less than two years of age.

80% of the patients are like less than a year and the epidemics are usually January, sometimes December, all the way to May. Now, RSV, sometimes these kids can get so sick that they have to be admitted to the hospital. In the olden days, we’d take a kid, we’d put them in what we called a croup tent, which was like a plastic bag tent over, built over the kid and just pump in oxygen.

Now, we’ve got antivirals for RSV that we can give and will cut down the amount of time the child winds up ill. Bronchiolitis, you wind up with rhinorrhea, that’s a runny nose, sneezing, cough, fever, they get tachypneic, rapid breathing, and they get some wheezing because it’s down into the bronchioles and smaller airways, so you’re going to hear some whistling in their lungs. Very often, they’re infants less than a year old and they’ve had some kind of exposure to somebody else who is sick and it kind of slowly increases and then hits them hard and then it slowly gets better.

RSV can take up to six weeks to totally clear from a kid. There is some wheezing, they do have high respiratory rates and they can get cyanotic blue. Treatment, fluids, antipyretics that keep the fever down like ibuprofen or Tylenol, sometimes we put them in these little oxygen tents and we have to use bronchodilators like Atravent or Duoneb or Albuterol and then sometimes steroids are used to kind of calm down the inflammation in the lungs.

Again, humidified oxygen, when we’re pumping that oxygen into the little tent, sometimes we put a mask on the child or pump humidified oxygen into that little tent. Keep them on an EKG, a pulse ox, a little IV in case we need to give them more medications, bronchodilators as I said, and always anticipate the need to possibly have to intubate this kiddo. What is the relationship to asthma? Well, there’s a very, very high relationship, up to 50% of patients with bronchiolitis during infancy can develop asthma.

Now, this might be asthma of childhood, they may not have asthma all of their life, but they certainly can develop reactive airway disease such as asthma. So if you look at asthma versus bronchiolitis, usually asthma onset is greater than two years. It’s usually not a fever, strong family history of asthma, a lot of allergies, and they respond well to epinephrine as opposed to bronchiolitis.

These kids have a fever, family history is negative. It may be positive for things like brothers and sisters who are sick with upper respiratory tract infections, maybe grandparents. Allergies are usually negative.

A lot of asthma, when I talk to you about asthma, you’ll see is linked to allergies. It’s a response and an inflammation. That’s what asthma is.

All right, very briefly, COVID-19, we’ve just been through this, and it’s probably one of the worst. There is one question in the chat. I’ll get that before we move on.

Is there any advice we can give new parents to help prevent the kids getting exposed from a community paramedicine standpoint? And the answer is yeah. They do have immunizations, especially if grandparents, elderly grandparents or aunts and uncles are coming to stay for a visit, you might suggest to them that they get RSV even more frequently. You might ask them to get immunized, especially if they’re going to spend a lot of time with coming over to see the kids.

So COVID-19, it was just a mess, wasn’t it? And I’m glad that it’s behind us. It was caused by a SARS COVID virus, and usually kids did somewhat better. They had tachypnea, hypoxia, shortness of breath, sometimes chest pain or cough.

Most of the time in kids, in healthy kids, it was not that serious. We saw it more serious in kids who were immunocompromised or had otherwise bad problems with their lungs. The chest x-ray usually showed what looked like a bilateral pneumonia.

This ground glass opacity is something you would see on x-ray. The incubation was up to 14 days, but most of the time is four or five days. Very often, you know, if you’re going through an airline or something, that’s when you get sick, four or five days later.

There’s usually a fever, abnormalities in taste, some nausea and diarrhea was possible, very rarely, but sometimes a rash. And most of the time, kids were better within two weeks, although some lingered on for one to two months. Immunization is the key to control.

And I can’t say enough about making sure that you get COVID shots, especially if you’re in health care. This Sunday, I get a flu shot, COVID-19 shot and update on my tetanus shot. So I’m sure I’m going to be a hurting puppy on Monday.

Two quick questions. Let’s see. For croup, I’m guessing asthma treatment like albuterol.

Magsulfate, I’ll come and talk about magsulfate in a little bit. Steroids and epi focus on inflammation. Atrovent is epitropium bropei.

I’ll talk about that when I talk about asthma. Connective tissue versus smooth muscle and lower airway. That’s true.

And I’ll talk about that a little bit more when I talk about asthma. Current guidelines for use of bronchodilators and corticosteroids for peds, for bronchiolitis. Well, as far as bronchodilators, you’re going to treat it symptomatically.

If a kid has RSV and bronchiolitis, there are usually temporary use of bronchodilators. Steroids would be sometimes inhaled steroids that will decrease the inflammation. We’ll talk a little bit more about that when we talk about asthma.

Epiglottitis. This is a biggie and a scary one. It can be immediately life-threatening and lead to possible complete airway obstruction.

Respiratory distress plus sore throat and drooling is epiglottitis until proven otherwise. It’s usually caused by a bacterial infection of H. flu and it attacks the epiglottis and the pharyngeal tissue in the back and underneath the tongue causing subglottic edema. That if you put your finger on, you know, just under your chin, that’s the area that is subglottic.

It can lead to complete airway obstruction. Now, the thing about epiglottitis, back in the 90s, we’re talking olden times, right? When I started my career, the Hib vaccine came out. We used to see a lot of epiglottitis and we saw a lot of Hib, H influenza, causing ear infections.

Then the Hib vaccine came out and we saw a dramatic reduction in both ear infections that were in kids, that were bacterial caused, and epiglottitis. So, moms and dads started to get the Hib vaccine and epiglottitis was a thing of the past. Well, then some London physician wrote a completely disastrous article.

In fact, he lost his license. He had to retract all of his data because he actually lied in his data and he said that immunization was associated with autism. That was completely disproven and he made up his data, but it hooked into the public, the general public, and people stopped immunizing their kids like they should and epiglottitis rears its ugly head again.

So, it’s very, very important that you follow vaccination protocols. So, epiglottitis can cause life-threatening upper airway obstruction. Children between one and five years of age.

Due to Hib vaccination, it’s going down, but we do see spikes in communities where parents think that it’s okay not to immunize your kids. I’ll come back to that in just a moment, but it can occur in adults, particularly the elderly, because the elderly don’t have antibodies against this. They may have had infections when they were young, but it doesn’t stick around as long as it should and the incidence in adults is increasing.

So, sometimes the only time that I’ve seen epiglottitis is in older folks. Clinical manifestations. Very rapid onset of stridor.

What is stridor? I’ll show you in just a minute in a video. These kids get high fever and they get a muffled rather than a hoarse voice, so you don’t get that kermit voice, but it becomes muffled, like putting your hand in front of your mouth. That’s what it sounds like.

Dysphagia is difficulty swallowing, and this drooling is really, really important. They get a sore throat. They won’t eat, drink, or sleep, and they like to tripod, sit forward, and prefer to sit up.

Very, very high anxiety, and as noted, sometimes up to a third of those kids can present in shock. Now, here’s an immunization schedule, and I’ll admit that it is very, very aggressive. However, the things that really will kill a kid, diphtheria, tetanus, pertussis, HIB, as I noted, polio, measles, mumps, rubella, hepatitis, and these are the things that really, if you’re going to skip anything, do not skip those.

If you work with your pediatrician, he or she can push these out over longer periods of time. Now, with both men and women, this HPV virus, you see it doesn’t show up until they’re seven to ten years old. Some people have a real problem with this because you get sexually active.

Well, of course, my kid won’t be sexually active. They’ll follow their advice. Well, we know that’s not true, so this causes cancer.

It should be in both males and females because not everybody is going to have one partner for the rest of their life. Meningococcal, these have to be given, and pneumonia really should be given to kids who are going away to college. You can see that the first dose is not until much later, but these are the things that’ll kill you, so you can work with your pediatrician and slow this schedule down, so going back to the epiglottitis, these kids assume what’s called a tripod position, two hands on their knees and like a tripod.

They lean forward. Their mouth is open. Their neck and chin is extended because the epiglottis here is swollen, and they have to lift their head so that they can get air down and prevent obstruction.

Now, this is a visualization of a swollen epiglottis. If any of you in the audience have intubated, you’ll see most of the time the epiglottis is tiny and skinny, but you can see how fat and friable this is, and if you have epiglottitis in a child, you really have to take that child to the operating room where anesthesia can intubate them under direct guidance, so if you touch this epiglottis and start messing with it, it’ll start to bleed. It’ll start to swell, and that tiny little space for air right up to here will completely seal off.

That’s why it’s such a deadly disease. Now, this kid is, I’m going to play this again. Notice a few things.

He’s not tripodting, but his neck is extended, and you get that strider. Listen again. This is distinctly different from the barky cough you heard earlier.

All right. High oxygen concentration. Get an IV in them, especially if they’re going to crash.

Rapid transport, and these kids don’t attempt to look in there. Now, I started out the very beginning to tell you to look in the back of the throat for a pharyngeal abscess, but you can tell that it’s different. These kids are sick, very sick.

This kid and this kid are very, very sick, and you can tell that difference, so don’t take a look in that airway because you can wind up having to buy a tube or get that epiglottis to become friable and start to bleed and swell. Usually, an x-ray is taken, and we’ll see what’s called a thumb sign. I’ll show you that in just a minute, and if you see this swollen red epiglottis in a well-staffed operating room, a surgeon like an ENT surgeon who might have to do a quick tracheostomy and an anesthesiologist should work together to get a tube in.

Very often, here is a thumb sign. Here is an epiglottis, and it’s big, and it’s swollen, and you can see the air behind it is very, very small, and you can barely see behind that epiglottis. These kids need to be hospitalized.

Usually, we intubate them and give them antibiotics for 78 hours until that epiglottis goes down. Sometimes, steroids and racemic epinephrine are used to treat the swelling of the epiglottis. Why racemic epi? Think of just if you had a cold and some congestion, you might use some afrin or neosinephrine, and what that does is shrink the vessels in your nose, and you can breathe easier.

Racemic epi is going to do the same for that swollen epiglottis. It’s going to push it down a little bit. All right, there’s a few more questions in the chat.

In what circumstances with a pediatric breather would you immediately treat with epinephrine over albuterol? Well, if you had a kid that had severe stridor, like we just saw, maybe that second child more than that first child, that you can hear with that stridor. It’s different than wheezing. Stridor and wheezing, you know, wheezing you use, you can sometimes hear audible wheezing with unassisted listening, but most of the time, wheezing, you need your stethoscope for.

Stridor, you don’t need a stethoscope. Let’s see. Unconscious patient with epiglottitis, would you want to attempt intubating right away or start ventilation through a bag valve? I would go with bag valve because you got to be very, very good, and I wouldn’t even intubate these kids in the ER.

I would call in anesthesia because I wanted somebody who had a whole lot more experience than I did. Still be listening. Sounds good.

Okay, great. So, asthma. This asthma is a lower respiratory hypersensitivity.

It’s probably the last topic we can get to this evening. Very, very highly related to allergies, dander, pet dander, smoke, and irritants like smoking, some infections like RSV, emotional stress, cold, and exercise. Some people don’t have asthma unless they’re going to go, like, go play a soccer game, and then you give them a squirt or two of albuterol before 30 minutes before they start to exercise, and they’re fine.

So, pathology. It is a triangle with bronchospasm, bronchial edema, and increased mucus production. All three of these come together to make an asthmatic.

So, here’s a normal airway on your left, and then when they contract down in the middle, and then what happens with asthma is you not only get this muscle contraction leading to the wheezing, but you get inflammation, swelling, and these mucus plugs which just gum up the whole airway. Here is an example of a mucus plug. This is obviously taken post-mortem.

This rather than severe asthma, but, you know, asthma and COPD are very similar, but this mucus plug happens, and you can see it looks almost like the bronchi themselves. It’s the most common childhood disease, a chronic childhood disease. Five million kids a year under the age of 18 will have a diagnosis of asthma, 33 percent before two years of age, and 80 percent before five years of age, and males outnumber females.

Symptoms along with that is sometimes associated with a viral infection of foods and inhalants, like I said, smoke or pollution. This time of year, for the last two months in Oregon, the Pacific Northwest, we’ve had fires, so there’s been smoke in the air for the last two months here, and thank goodness it rained today and finally got rid of it. Sometimes exercise, chemicals, pollutants, environmental changes.

GER is gastroesophageal reflex, and I’ve seen adults more than children who have some form of GERd, and you treat their GERd and their asthma goes away. Sinusitis and drugs can also cause childhood asthma. It’s with shortness of breath, they get nasal flaring, tracheal tugging, accessory muscle use, which I’ll show you in a video, and retractions, intercostal retractions.

They’re going to have coughing with expiratory wheezing, tachypnea is a rapid breathing, and cyanosis is sometimes possible. During breathing, the air inhaled through the nose and mouth enters the respiratory passages. Then, the air entering the respiratory system passes through the trachea, then splits into the bronchi, bronchioles, and finally enters tiny sacs called alveoli, where the exchange of gases takes place.

Asthma is a disorder of obstruction to breathing due to inflammation and narrowing of the bronchial tubes. Initially, the bronchial tubes become inflamed and produce thick mucus. Later, the muscle surrounding these airways tightens and air cannot move freely.

This is called bronchospasm. The result is shortness of breath, and the air moving through the tightened airways causes a whistling sound known as wheezing. Pollen, pet dander, weather changes, tobacco smoke, etc., can trigger and worsen asthma symptoms in susceptible patients.

Short-acting bronchodilator drugs, which can be inhaled, provide immediate dilation of the constricted bronchi. All right, so here’s a kid who’s got retractions. They’re belly breathing.

You can see their belly breathing, and you can see that they’re using intercostal muscles as well. Prolonged attacks. It’s kind of like a slow kettle to boil.

They wind up losing fluids, and these kids can become dehydrated. When you’re taking their history, you want to know how long they’ve been wheezing. Have they been drinking properly? Have they had a recent infection? Do they take medicines? Do they have allergies? Have they been hospitalized for their asthma before? Have they been intubated for their asthma before? Look at their position.

You’re going to note the difference between triponing and asthma. Are they stuporous, meaning are they getting CO2 built up so high that they’re starting to fall asleep? Are there signs of dehydration, and what are their breath sounds in their chest movement? Have they had admission to the ICU before? Have they been intubated before? Have they had more than three visits or two admissions to the hospital before their asthma in the last year? Are they using their rescue inhaler more, more than four hours? Are they using steroids? And all of these things, are they progressing in their symptoms? Now, a silent chest can be a dangerous chest. Sometimes the wheezing gets so bad and the mucus production gets so bad that the chest becomes silent, and these are the ones that can crump on you very, very quickly.

So the golden rule, all that wheezes is not asthma. Things like pulmonary edema, allergic reactions, pneumonia, and foreign body can all cause wheezing as well. Here’s another kid.

You’re going to see here the chest is going in, wheezing the belly, and also retractions. You can hear the wheezing in that child. ABCs, all right, airway, hypoxemia, hypercapnia, okay? Make sure their O2 sats are good and their CO2 is good.

If they have bronchospasm, sometimes humidified O2, encourage them to cough, which will open up airways, and always have to consider, do I need to intubate this kid? Circulation, have an IV just in case they get bad, see if they’re dehydrated, titrate fluids judiciously, and watch them on the EKG. And we’re going to treat them with nebulized beta-2 agonists like albuterol, terputaline, metoproteranol, and isotherin. These are things that we might give in the ER.

They’re probably not in your protocols, but if atropium is, if atropium and albuterol together, that’s your duonet. Here, somebody mentioned magnesium. Magnesium is one of, in our protocols, a last-ditch effort, but we can give sub-q epi before.

Extreme caution when you’re giving two sympathomimetics like something like epi or atropine at the same time. Be careful, monitor the EKG. Avoid sedatives, antihistamines, and aspirin.

That’s general information for moms and parents and dads. And here are our protocols. ECM stands for East Cascade EMS, and you’ll see that for bronchiolitis, one of the questions in the chat is, when do you consider using certain meds? So for bronchiolitis, asthma, bronchiolitis, pneumonia, you give a duoneb and albuterol.

You can give epi next. You can repeat the epi. You can dexamethasone, and then down here, after you online medical control, you can give the MagSulfate.

Status asthmaticus is when your asthma is not getting better, and you’re going to continue to give continuous NEB treatments. You might add the dexamethasone. Aminophilin is something that you’re not going to have in your protocols, but we might give in the ER.

And MagSulfate may be in your protocols. It’s in ours. Mechanical ventilation with intubation and tert-butylene is also possible.

You’re not going to have this in your arminterium, but I have used this for severe asthma. All right, we’re not going to get to foreign body obstruction tonight. A few more questions.

Let’s see if there’s any more we can answer. In what circumstances with a pediatric breather would you immediately treat with epi over albuterol? Oh, we already answered that question. In an unconscious patient with epiglottitis, yeah, I already answered that.

If we don’t have racemic epi, can you use regular epi? Yeah, you can. You would probably just mix it with about 10 cc’s of water. And could you RSI a pediatric with epiglottitis to get an ETG? I’d be very, very, very, very, very, very cautious.

Again, if I had a kid with epiglottitis, I would want my surgeon and my anesthesiologist at my side. So, next time we’ll go over foreign body obstruction. Any other questions? Jane, is there anybody who didn’t get credit that you want? The only person that didn’t left the room just a couple of minutes ago, so I don’t think he needed credit.

There you go. Everybody great. That was a great discussion tonight.

Thank you, Dr. Eshelbart, very much. And we will be seeing you next time. All right.

Good night, everybody.