EMS World

JAN 2019

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38 JANUARY 2019 | EMSWORLD.com BONUS CONTENT: THE PEDIATRIC AIRWAY mucus production. The edema, increased mucus, and cellular debris cause narrowing of the air ways, resulting in symptoms of air way obstruction and decreased ventilation. 6,7 Signs and Symptoms Bronchiolitis classically begins with an upper respirator y infec- tion prodrome before progressing to lower respirator y disease. Sy mptoms t y pically include rhinorrhea, cough, and fever. Increased mucus production in infants can lead to obstruc- tion of the nasal passage, causing mild to moderate respira- tor y distress. Infants are more susceptible to symptoms due to their relatively small nasal passages and being obligate nose breathers. 6 On exam the child may be tachycardic and tachypneic, and have wheezing and/or rales on auscultation. In severe cases bronchiolitis may lead to significant respirator y distress and/ or periods of apnea. Risk factors for severe disease and apnea include prematurity (less than 37 weeks' gestation), age less than 12 weeks old, histor y of cardiac or lung disease, and immu- nodeficiency. 6,7 Signs of respirator y distress include retractions, nasal flaring, grunting, and hypoxia. During the winter months these symp- toms in a child under age 2 are highly suspicious for bronchiolitis. Treatment Treatment of children with bronchiolitis centers primarily on the air way, breathing, and circulation algorithm. Because increased mucus production leads to upper-air way obstruction, nasal suctioning may be helpful in cases with signs of obstruction or significant respirator y distress. Bulb suction is a quick and easy way to provide relief. However, evidence on deep (inva- sive) nasal suctioning is inconclusive, and it is not routinely recommended. 6 Over the past two decades, research into the appropriate treatment for bronchiolitis has advanced. 7 In 2014 the A AP published its latest clinical policy on bronchiolitis and recom- mended against routine administration of albuterol or nebulized epinephrine to children with it. Between the A AP's first clinical policy statement in 2006 and 2014, multiple systematic reviews found the administration of beta-agonists in this population did not improve objective outcome measures of disease resolution, the need for hospi- talization, hospital length of stay, or pulse oximetr y readings. 7,8 A 2009 Cochrane review of children under 2 with a histor y of recurrent wheezing also found no benefit from beta-agonist administration. 9 Children with severe respirator y distress or failure were gen- erally excluded from the studies, so the above recommenda- tions should not be applied in such cases. In cases of severe respirator y distress, there may be a role for nebulized albuterol and epinephrine but attempt nasal suctioning first. Some wheezing infants may have been diagnosed with reac- tive air way disease or even asthma—if this is a par t of their histor y, beta-agonists may be par t of their treatment plan. Advanced respirator y-support inter ventions may be necessar y in some cases. 6,7 Use BVM assistance for periods of apnea, and intubate ver y rarely. Never intubate because of an arbi- trar y number on a respirator y rate—this is a way to potentially injure a child. Infographic: Michael Supples

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