TRIPASS XR تري باس

 

Sometimes, a lab result or radiograph will indicate need for

emergent directed treatment (eg, foreign body). It is

extremely important to frequently reassess the patient after

each treatment to determine response and make decisions

for further management. Clinical status can change very

quickly in patients with respiratory distress (Figure 49-5).

TREATMENT

Croup. Administer humidified oxygen, and all patients

should get dexamethasone 0.6 mg!kg/dose (max 16 mg)

intramuscular (IM) or by mouth (PO) regardless of the

RESPIRATORY DISTRESS

severity. If there is stridor at rest, give racemic epinephrine

0.5 mL of 2.25% solution in 3 mL of normal saline (NS) via

a nebulizer.

Foreign body aspiration. Definitive management is to

remove in the operating room by laryngoscopy or bronchoscopy. In the setting of critical airway obstruction or

impending/actual respiratory arrest, attempt to force the

foreign body out with back blows or chest or abdominal

thrusts depending on the age and size of the patient. These

are all safer methods than the blind finger sweep, which can

convert a partial obstruction to a complete obstruction.

Other life-saving measures include laryngoscopy and direct

retrieval with Magill forceps, passing the endotracheal tube

beyond the obstruction and forcing the foreign body into

either mainstem bronchus, or needle cricothyrotomy.

Epiglottitis or bacterial tracheitis. It is particularly

important to allow the patient to assume a position of comfort, and if they are in the sniffing position, this is an omi ­

no us sign for severe obstruction. Ideally these patients should

have a definitive airway placed in the operating r oom by the

most skilled physician in difficult airway techniques, but if

there is respiratory arrest, then immediate endotracheal intubation or needle cricothyrotomy should be performed.

Anaphylaxis and severe angioedema. Treat with epinephrine, steroids, H1 and H2 blockers.

Asthma. Treat with �-adrenergic agonists: albuterol

2.5 mg every 20 minutes as needed or 15 mg in NS nebulized

over 1 hour continuously. For moderate to severe exacerbations, add anticholinergics (ipratropium bromide 500 meg

every 20 minutes for 3 doses) and steroids. If tolerating oral

intake with no impending respiratory failure, administer

prednisone 1-2 mg/kglday; otherwise use N steroids (SoluMedrol 2 mglkg, max 125 mg). If the patient's respiratory

effort is poor and respiratory failure is imminent, administer

IM epinephrine 0.0 1 mg/kgldose (max 0.5 mg) 1:1,000,

which can be repeated every 20 minutes for 2 more doses.

Terbutaline 2-10 meg N loading dose then 0.1-0.6 meg/kg/

min can also be used. Magnesium sulfate (50 mg/kg over

20 minutes to max 2 g) should be considered in patients

with moderate to severe exacerbations or those who do not

improve after initial therapy. Heliox, a mixture of helium

and oxygen, improves laminar flow through the bronchioles,

resulting in decreased work of breathing. There is some

evidence showing it improves pulmonary function in

patients with severe obstruction. The maximum amount of

oxygen in the mixture is 30%, so if the patient is hypoxic and

requires more than 30% FlO 2, then Heliox is not an option.

Bronchiolitis. Attempt a trial with �-agonists and/or

nebulized epinephrine. Clinical trials demonstrate that

corticosteroids are of no benefit in the treatment of bronchiolitis, but they may be useful in patients with a history

of reactive airway disease. High-flow humidified oxygen

via nasal cannula is a more novel treatment that is showing

some promising utility, especially in patients with RSV

and hypoventilation. The proposed mechanisms are

improvement of respiratory mechanics, washout of naso ­

pharyngeal dead space, and decreased work of breathing.

Some recent studies showed that it may decrease need for

endotracheal intubation. Hypertonic saline (3-5%) with

or without bronchodilators is another new therapy being

studied, with minimal side effects.

Pneumonia. Administer antibiotics early and oxygen as

needed.

DISPOSITION

..... Admission

Admission is indicated in respiratory failure requiring

mechanical ventilation, respiratory distress not reversible

with definitive therapy or requiring intensive monitoring,

pneumonia in patients <6 months, foreign body aspirations

with respiratory symptoms, or new oxygen requirements.

..... Discharge

The decision to discharge a patient is dependent on several

factors: clinical response to treatment, work of breathing,

hypoxia, hydration status, preexisting medical conditions,

and social factors. Keep in mind that respiratory status can

change quickly, and it is crucial to monitor a patient for a

significant amount of time after treatment to make sure

their clinical status does not deteriorate again. If the

patient continues to have increased work of breathing and

there is concern for impending respiratory failure, these

patients should not go home. Ensure the patient is well

hydrated and can tolerate oral intake before discharge.

Make sure the patient has reliable caregivers who can

administer treatments and medications and will bring the

patient back if they worsen again. Lastly, arrange secure

follow-up for the patient with his or her pediatrician or

specialist.