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Respiratory Emergencies in

Children

Mohamed Khashaba,MD
Professor of Pediatrics/Neonatology
Head of NICU, MUCH
Children’s Respiratory
Emergencies

More serious compared to 
.adults
Neonates, who are obligate
nasal breathers, often
experience serious respiratory
distress with nasal obstruction.
Proportionally larger heads,
prominent occiputs, and
relatively lax cervical support,
which increases the likelihood of
airway obstruction in the supine
position
A relatively large tongue in
comparison to a small
oropharynx further contributes
to this problem.
The subglottis is the
narrowest segment of the
pediatric airway, in contrast to
the glottis in adults.
Resistance
Airway or tube Diameter

Poiseuille’s Law

R = L / r4
Clinical applications

• Reduction of radius by ½ results
in 16 fold increase of resistance.
• Resistance during inspiration is
less than expiration.
• Accumulated secretions add to
resistance.
Considering that the change in
airway flow is directly
proportional to the airway radius
elevated to the fourth power,
An airway with a diameter of 7
mm that develops a 0.5 mm
edema will have a flow of 54% of
baseline,
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Managing a child in
respiratory Distress
The patient can remain in the
caregiver arms while the examiner
assesses the respiratory rate and the
degree of distress
Tachypnea

Neonate > 60 
Infants >50 
Young child >40 
Older child >30 
Dyspnea
Laboured breathing 
) ) increased WOB

Nasal flaring .1 
. Expiratory grunting .2 
.Use of accessory muscles .3 
Retraction of chest wall.4 
.) )recession
.Difficult speaking or feeding .5 
 Increasing rate of respiration,
nasal flaring, use of accessory
muscles or presence of
respiratory fatigue can indicate
serious respiratory distress.

 Cyanosis is usually a very late sign
of respiratory compromise.
Drowziness in addition to 
cyanosis indicates severe
hypoxemia and the need for
.urgent intervention
Pulse oximetry is the most 
reliable objective measure of
hypoxemia
Chest Shape
.Hyperexpansion or barrel shape 
.)Pectus exavatum )hollow chest 
Pectus carinatum )pigeon 
.) chest
Harrison’s sulcus 
.Assymetry of chest movement 
Palpation
Chest expansion )3-5 cm in 
school age ), check for
.assymetry
.) Trachea )selectively 
.Location of apex beat 
Percussion
Seldom informative in infants 
Localized dullness indicate 
.collapse or consolidation or fluid
Auscultation
Use your ears for 
auscultation before the
stethoscope
Hoarse voice indicate .1 
.abnormality of vocal cords
Stridor .2 
3. Harsh transmitted sounds from
the upper airways are readily
transmitted to the upper chest in
infants.
Auscultation
Quality and symmetry of .1 
.breath sounds
Wheezes: indicate distal .2 
.airway obstruction
Crackles discontinuous moist 
sounds from opening of
.bronchioles
Other aspects in
examination
 Pulse rate,rhythm and quality.
 Heart examination
 Hepatomegaly or palpable liver.
Effect of position
Noisy breathing caused by
laryngo -omalacia,
micrognathia, macrolgossia, and
innominate artery compression
diminishes when the baby lies
prone with the neck extended.
Effect of position
 Respiratory distress caused by
unilateral vocal cord paralysis may
improve with the baby lying on the
affected side.
Upper Respiratory
Obstruction
supraglottic laryngeal
obstruction
 often present with a muffled or
throaty voice.
 These patients tend to snore while
sleeping and produce coarse
inspiratory sounds at rest.
 Feeding is difficult for these patients
and mouth breathing is the norm.
 Cough is not usually present.
Upper Respiratory
Obstruction
Croup 
Viral laryngotracheobronchitis 
Laryngomalacia 
) Bacterial tracheitis )rare 
Rare causes of URO
Epiglottitis 
Smoke inhalation 
Trauma 
.Retropharyngeal abscess 
.Angioedema 
.Tetany 
.Laryngeal FB 
I. Mononucleosis, measles, 
diphtheria
Basic management of
URO
’.t examine the throatDon .1 
Reduce anxiety of the staff .2 
.and patient
Observe for signs of hypoxia .3 
.or deterioration
Adminster nebulized .4 
! adrenaline
Urgent intubation if RF .5 
.develops
Croup
of laryng tracheal % 95 
.infections
Parainfluenza virus is the 
leading cause, other viruses
.also
Peak incidence in the 2nd year of 
.life
.Commonest in automn 
Croup
.Barking severe cough 
.Harsh Stridor 
.Hoarseness 
.Preceeded by coryza 
.Worse at night 
.No drooling saliva 
Croup ttt
!! Inhalation of warm moist air 
.Inhaled and oral steroids 
.Nebulized adrenaline 
Acute Epiglottitis
.Onset over hours not days 
.No preceeding coryza 
.Absent cough 
.Drooling saliva, unable to drink 
.Toxic, very ill 
.High fever > 38.5 
.Soft whispering stridor 
.Muffled voice 
. Sits immobile, upright, open mouth 
Epiglottitis ttt
:In suspected cases 
.Urgent hospitalization 
.ICU or anesthesia room 
Intubation by senior staff with 
.general anesthesia
Rarely, tracheostomy is 
.required
Epiglottitis ttt after
intubation
.Blood drawn for culture 
IV antibiotics given 
.Recovery within 2-3 days 
Lower Respiratory
problems
.Bronchiolitis 
.Asthma 
.Pneumonia 
.Inhaled foreign body 
. Air leak 
tracheobronchial
obstruction
 usually have a normal voice and
their stridor is generally
expiratory with a component of
wheezing. cough is usually
present
Bronchiolitis
Age 1-9 months 
.Poor feeding dry cough, apnea 
Hyperinflated chest in addition 
.to other signs of RD
.Apnea, cyanosis may occur 
CXR hyperinflation, focal 
.atelectasis
Bronchiolitis ttt
Humidified 02 via nasal cannula 
.or head box
.Pulse oxymetry 
.Fluids NG or IV 
.?? Nebulized bronchodilators 
Antibiotics, steroids are not 
.helpful
.MV in 2% of admitted cases 
Downes’ score )Dowenes et
)al., 1970
GRADE 0 1 2

RR 60 60-80 >80 or apneic
episodes in
Cyanosi None In air In40%
40%OO
2
2
s
Retracti None Mild Moderate to
on severe
Gruntin None Audible Audible by
g by naked ear
Air Clear stethosco
Delayed Audible
entery pe
Silverman Anderson
retraction score
)AWHONN.,2006)
FEATURE SCORE SCORE 1 SCORE 2
0
Chest Equal Respiratory Seesaw
Movemen Lag Respirati
t
Intercost None Minimal on
Marked
al
Retractio
Xiphoid None Minimal Marked
n
Retractio
n
Nasal None Minimal Marked
Flaring
Expirator None Audible Audible
y Grunt With
Arterial Blood Gases )ABG)
Score )Mathai et al., 2007)

0 1 2 3

PaO2 mm > 60 50 – 60 < 50 <
Hg 50
pH > 7.3 7.20 – 7.1 – <
7.29 7.19 7.1
PaCo2 mm < 50 50 - 60 61 - 70 >
Hg 70
Effect of position
 Respiratory distress caused by
unilateral vocal cord paralysis may
improve with the baby lying on the
affected side.
Respiratory distress
syndrome
(RDS)
 Small lung
volume

 Ground glass
appearance

 Air bronchogram
Hyaline Membrane
Disease
Meconium Aspiration
Syndrome
Meconium Aspiration
Syndrome
 Diffuse
patchy
pulmonary
opacities

 Pneumothora
x
Pneumothorax
.Respiratory Distress 
Decrease breath sounds on 
.affected side
.Decreased vocal fremitus 
Hyperresonance on affected 
.side
.Tachycardia 
.Shift of mediastinum 
.Cyanosis 
Imaging in
Pneumothorax
 Radiolucency of affected lung.
 Lack of lung markings .
 Collapsed lung.
 Possible pneumomediastinum
 CT in small pnumothorax or to
differentiate from a cyst.
Congenital Lobar
Emphysema
Pneumomediastinum
Pneumopericardium
Management of
Pneumothorax
 Stabilization of the patient
 Urgent evacuation in
symptomatic cases.
 Treat the underlying cause.
 Oxygen.
Lung Collapse
DIAPHRAGMATIC
HERNIA
Staph. Pneumonia