Respiratory

emergencies
Dr Rasnayaka M Mudiyanse

Scope of the lecture

Upper Airway Pathology

Stridor

Foreign Bodies
Angioneurotic oedema
Epiglotitis
Croup
Retro-pharyngeal or
peritonsilar abscess
Trachitis
Hypocalcemia, tumours,
vocal cord palsy

Lower Airway Pathology

Rhonchi, crepitations,
BB,

Bronchial Asthma
Bronchiolitis
Pneumonia
Tension Pneumothorax
FB

Respiratory distress
Efforts
RR, Recessions, Grunting, head
nodding

Effects
On CNS and CVS

Efficacy
Air entry, chest expansion

Oxygen saturation

Carbon dioxide
Treatments

Respiratory failure

Below 85%

Below 90 %

Below 95%

Above 95%

Causes of NON respiratory tachypnea

1.

2.
3.
4.

List causes of acute stridor

1.
2.
3.
4.
5.
6.
7.

Causes
-

Viral
Allergic spasmodic croup
Bacterial
Foreign Bodies

URTI 1-3 days Fever, rhinorhea & cough

Barking cough , Stridor , mild increased
respiratory rate, recessions
Progress to severe disease
-

Respiratory distress, increasing respiratory

rate, nasal flaring, retractions, respiratory
failure

1.
2.
3.
4.
1.
2.
5.
6.
7.

Homophiles Influence B
Sudden onset, rapid progress, neck
is hyper extended
Toxic, Sick, Drooling, Febrile
,Reduced voice
DONT disturb
X-ray lateral thumb sign

1.
2.
3.
4.
5.
6.

Staphylococcus aureus, moraxella

catarhalis, H influence
Croup, Toxic but no drooling, can
lie flat , no dysphagia
Swelling at cricoid cartilage level
Mist and adrenaline not effective
Antibiotics, tracheostomy sos

Causes

Drugs Penicillin, radio contrast, ARV,

AVS
Foods Nuts, fish, meat,
Applicants

Look for

Upper airway
Lower air way
Circulatory

1.
2.
3.
4.
5.
6.

Retropharyngeal LN - Satph, strep, Anaerobs, H

Influenzae, Klebsiella
Age 3-4 years M>F
High fever, drooling, neck stiffness, torticollis
Upper airway obstruction , rupture and
aspiration pneumonia, extension to
mediastinum, thrombophlebitis of internal
jugular vein embolism to lungs.
X ray neck lateral Widening of retropharyngeal space more than 2/3 of a vertebral
body

Surgical drainage
Antibiotics Cefuroxime + Cloxacillin

Age group below 2 yrs

Severe 1-3 mo
Premature babies
Pre-existing lung disease
CHD
Impaired immunity

Causes RSV > 50%, Adeno, Influencea,

Parainfluecea
Clinical features Tachypnoea, Hyperinflation
Admit - Sick baby, Feeding effected, Maternal concern
Recognize mild moderate ad severe bronchiolitis

Mild bronchiolitis
1. Normal ability to feed
2. Little or no respiratory distress
3. No requirement for oxygen ( SaO2
> 95%)
4. No risk factors

Treatment for Mild bronchiolitis

1.
2.

Recognition of Moderate Bronchiolitis

Respiratory distress + ; RR > 50/min

Nasal flaring
Feeding difficulty +
Episodes of apnea
Requirement for oxygen ( SaO2 < 92%
No risk factors

Treatment for Moderate Bronchiolitis

1.
2.
3.
4.
5.

Recognize Severe
Bronchiolitis
Unable to feed
Severe respiratory distress
Increasingly tired
Prolong apnea
Hypoxemia PaO2 < 92%
Treatment
1.
2.
3.
4.
5.
6.

Ventilation Indications

Recurrent apnoea
Exhaustion
Hypercapnia
Hypoxaemia

Consider C x R & Antibiotics

* Exclude Heart Failure and Pneumothorax

Causes

Pneumococci, Streptococci, Haemophilus

influencae, Mycoplasma,E Coli, Staph,
Clamidia

Clinical features

Fever, Tachypnoea, Pleuratic chest pain

abdominal pain, Grunting, Flaring of alea
nasi

Asses severity

Antibiotics

ABC care
Oxygen, Fluids (restricted amounts)
( Ampiciline/Cefolosphorine , Erythro 7-10 days)

Antibiotics for fever and Tachypnoea

-WHO

I.C.U. and Ventilator care

Clinically
Wheezing
Coughing
SOB

Pathologically

Bronchospasms
Mucosal
oedema
Secretions

Acute asthma- Exacerbations

Mild
Moderate
Severe
Life threatening

Chronic Asthma-Grading

Mild intermittent
Mild persisting
Moderate persisting
Severe persisting

Child with any grade of asthma can have mild moderate or severe exacerbat

Feeding/Activity normal
No audible wheezing
Not using accessory muscles
No chest windrowing
RR < 50
HR < 150

Feeding activity disturbed

Audible wheezing present
Use of accessory muscles
Chest in-drawing present
RR>50/min
HR> 150/min
SaO2 < 92%

Unable to talk / feed

Recessions and use of accessory
muscles
RR > 50 /min
HR > 150 min
PEFR < 50 %
PaO2 <92%

Depressed LOC/ Agitated, Drowsy

Exhaustion
Cyanosis or Saturation in air < 85%
Poor respiratory effort
Silent Chest
PEFR < 33% of expected/ best
Poor response to repeated doses of
bronchodilators

Beta 2 agonists - oral or inhaler

Oral theophylines
Check precipitating factors
Does he need a preventor?
Patient education

Beta 2 agonists Inhaler or Nebulised

Theophyline
Prednisolone 2mg/kg/day 3-5 days
Reassess in 30-60 min Home/ward
Precipitating factors
Patient education
Does he/she need a preventor

Oxygen

Nebulisation with Oxygen

face mask 6-8 liters/min,

nasal prongs 2 liters/min

every 20-30 min or continues

Salbutamol 2.5 (1/2 cc)- 5mg (1cc) +Ipratropium 250500 mcg + 2 ml normal saline

What is the diagnosis ( exclude Heart failure,

pneumonia, DKA, bronchiolitis, pneumothorax,
FB)
What is the severity

Need resuscitation Immediate ABC, bag and mask

Life threatening Ward ICU
Moderate/severe ward
Mild OPD Home

Salbutamol
Below 1 year
Below 5 years
Above 5 year

Ipratropium
bromide

IV Aminophylin

5mg/kg in 2ml/kg N.Saline bolus/30mt 1mg/kg hrly

IV Hydrocortisone 4mg/kg 6 hrly or 1mg/kg/hr

IV Antibiotics
IV fluids add potassium
I.C.U. care

IV Salbutamol 15 mcg/kg over 10 min 1-5 mcg/kg/min

IV Magnesium sulphate 20- 100 mg/kg over 20 min, 6
hrly
Adrenaline 10 mic/kg sc ( 0.01ml/kg of 1:1000)
IPPV

Maintain SaO2 above 92%

Bronchial asthma - NO response to

initial treatment , Consider following
possibilities
1.
2.
3.
4.
5.
6.

Suspect when

Unequal Physical Signs

Sudden onset, Unexplainable
No responds to treatment

Treat by

Needle thoracocentasis
Chest drain

Indications for ventilation

PCO 2 > 8kpa

Hypoxia Po2 < 8kpa
Increasing exhaustion

Precipitating factors ?
Prevention step?
Home management Policy- Salbutamol
via spacer
Patient education
Inhaler techniques
Counseling and psychological issues
Diagnosis

DEFINITIVE CARE

Causes of recurrent
wheezing

Intra bronchial
foreign bodies
Recurrent LRTI
Mediastinal
masses
Heart failure
Gastro
oesophagial reflux

H type gastro
oesophagial fistula
Immune deficiency
Loeffler syndrome
Vascular rings,
Cystic fibrosis,
Cilliary dyskinesia

Step and
treatment

Day time Symptoms

Mild
intermittent

Step one

Night
symptoms

Symptoms less than twice/wk less than

twice/mo
No interval symptoms, Brief
exacerbations Varying
intensity

Mild
persistent
Step two

More than twice /wk but less

than once/day
Exacerbations affect the life

more than
twice a mo

Moderate
persistent
Step three

Daily symptoms
Exacerbation more than
twice /wk last days

more than
once a
week

Sever
persistent
Step four

Continuous symptoms
Limited physical activity
Frequent exacerbations

Frequent

Step and
treatment

Mild
intermittent

Step one
Mild
persistent
Step two
Moderate
persistent
Step three

Sever
persistent
Step four

Day time Symptoms

Night
symptoms

Once a week

Once /mo

2-7 /week

2-4/ mo

Daily symptoms

more than
once a
week

Continuous symptoms

Frequent

Mild intermittent

Long term control No daily medication

Quick relief for exacerbations

Salbutamol or Turbutaline

Education

Facts about asthma

Inhaler technique
Avoidance of precipitating factors
Management of exacerbations
Recognition of acute severe asthma

Mild persistent

Long term control

Inhaled steroids low dose

Beclamethasone 50-200 micg per day

Budesonide 100 200 micg per day
Fluticasone 100- 150 micg per day

Education

Facts about asthma

Inhaler technique
Avoidance of precipitating factors
Management of exacerbations
Recognition of acute severe asthma

Moderate persistent

Medium dose steroids

Beclamethasone 200- 400 micg/day

Budesonide 200 600 micg/day
Fluticasone 200 400 micg/day

OR
Low dose steroids + Long acting beta 2 agonist

For night symptoms

Long acting beta agonists - inhaled or oral

Sustained release theophyline

EDUCATION and counseling

Severe persistent

High dose steroids + long acting

bronchodilators

Beclamethasone > 400 micg/day

Budesonid > 600 micg/day
Fluticasone > 400 micg/day

Long acting oral beta 2 agonists

Sustained release theophylines
Oral steroids
Education and counseling

Other drugs for asthma

control
Ketotifen
Sodium cromoglycate
Leukotrene receptor antagonists

Montelucast
Zafirlukast

For Successful Asthma

Control

Patient education

About the disease

Precipitating factors
Recognition of acute severe asthma
Home management of acute severe Asthma

Inhaler technique
Encouragements and appreciations
Confidence building - Control is possible
Frequent monitoring