neonatal/pediatric cardiopulmonary care - amarillo college · 2017. 3. 27. · croup, epiglottitis,...
TRANSCRIPT
Croup, Epiglottitis, Bronchiolitis
1
Neonatal/PediatricCardiopulmonary Care
Pediatric Diseases
Laryngotracheobronchitis(Croup)
3
Croup
• =
• Degree of lower tract involvementvaries but pneumonia can develop
Croup, Epiglottitis, Bronchiolitis
2
4
Etiology
• Viral• **
•••
••••
5
Clinical Presentation
• Mild fever• Barking cough• Hoarseness• Stridor
• Slow onset•
•
6
Clinical Presentation
• Can have
• BS OK unless
• Epiglottis
Croup, Epiglottitis, Bronchiolitis
3
7
Clinical Presentation
• CXR• AP neck will show subglottic narrowing =
• Lateral neck may show subglottic edemabut is usually normal
8
9
Clinical Presentation
••• If lower airways involved → V/Q
abnormalities → hypoxia on CBG,anxiety, tachypnea, tachycardia →cyanosis, retractions
Croup, Epiglottitis, Bronchiolitis
4
10
Treatment
• Only 10% need
• Hospitalize if•
••••
11
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 -
12
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
5
13
Treatment
• Corticosteroids
•
•• Aerosolized racemic epinephrine
•
•
•
14
Treatment
• Intubation - Criteria• Rarely needed
• Marked, progressive anxiety
• Hypoxemia
• Hypercarbia
• Fatigue
• Evidence of
15
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
6
16
Tube Management
•• CPAP
• Sx
• CPT if
•• HOB up
•
17
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
7
19
Epiglottitis
• = bacterial infection causinginflammatory edema of supraglotticstructures - primarily epiglottis &hypopharynx
• Vocal cords, subglottic tissues, tracheanot involved
• Pneumonia uncommon
20
Epiglottitis
Complete airway obstruction can occursuddenly
=
21
Etiology
• Almost always caused by
•
•
•
Croup, Epiglottitis, Bronchiolitis
8
22
Clinical Presentation
• Acute (<10 hrs) illness
•• Various degrees of
•••
23
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
24
Clinical Presentation
Croup, Epiglottitis, Bronchiolitis
9
25
Treatment
• Prevent with HIB vaccine•
• Appropriate Dx
• Hx & visual exam alone should causesuspicion
• Make child as comfortable as possible
26
Treatment
• Brief physical exam with no anxiety-producing procedures
• Oxygen offered by mask
• Close observation at all times
•
27
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
10
28
X-Ray
Normal Epiglottitis
29
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
30
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
11
31
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
32
Treatment
• Respiratory isolation for
• Arm restraints as patient feelsremarkably better after ETT & Abx
• Sedation may be required•••••
33
Treatment
• Antibiotics• Ampicillin
• 3rd generation cephalosporins (Rocephin,Suprax, Cephobid, Fortaz)
• Rifampin to all in family - eliminates nasalcarriage
• Antipyretics• Acetaminophen suppositories
Croup, Epiglottitis, Bronchiolitis
12
34
Treatment
• Adequate fluid intake• IV fluids (NaCl) until patient can swallow,
then clear liquids (even with ETT)
• Use of corticosteroids is controversial
35
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
13
37
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
38
Etiology
• Most often (75%) from RSV infection••
• Adults - nonspecific upper respiratory tractinfection••
• Also caused by
39
Etiology
•
•
•
•• Doesn’t confer immunity until
• Also believed to create immune responsethat is a precursor to
Croup, Epiglottitis, Bronchiolitis
14
40
Clinical Presentation
••••••••
41
Clinical Presentation
• Apnea
•
• CXR
•
•
•
42
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
15
43
Clinical Presentation
• Hospitalize when•
•
•
•
44
Clinical Presentation
• Hospitalize when•
•
•
•
45
Diagnosis
• Made by isolation of RSV fromnasopharyngeal secretions• Nasal washing
•••••
• ELISA (enzyme-linked immunosorbentassay)
Croup, Epiglottitis, Bronchiolitis
16
46
Treatment
•
•••
•••
47
Treatment
••••••
48
Treatment
• Drugs
•••• Antiviral agents - ribavirin (Virazole)
•
•
•
Croup, Epiglottitis, Bronchiolitis
17
49
Prevention
• Vaccine• For high-risk patient
•••••
• Synagis (palavizumab) or RespiGam (RSV-IG)
•• Synagis: ~$ /dose
• RespiGam: ~$ /dose
50
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