In today’s episode, Dr. Rahul Damania and Dr. Pradip Kamat welcome their new co-host, Dr. Monica Gray. They’ll dive into the topic of upper airway obstruction in children and explore a case involving a 12-month-old girl who presents with stridor and fever. Throughout the discussion, they delve into the underlying causes, possible diagnoses, and management strategies. Key takeaways include the significance of keeping the child calm, ensuring proper positioning, and utilizing treatments such as dexamethasone and Racemic epinephrine. They’ll also touch on advanced therapies and serious infections like epiglottitis. The episode highlights the importance of recognizing stridor, knowing when to consider PICU admission, and the effectiveness of low-dose dexamethasone. Tune in to learn more!

Show Highlights:

• Overview of upper airway obstruction in pediatric patients
• Case presentation of a 12-month-old girl with stridor and fever
• Discussion on the pathophysiology of stridor and its clinical significance
• Differential diagnoses for stridor, including croup, epiglottitis, and foreign body aspiration
• Management strategies for upper airway obstruction, including stabilization and medication
• Importance of calming the child and optimal positioning during treatment
• Use of dexamethasone and racemic epinephrine in managing croup
• Advanced therapies, such as Helios, for specific cases
• Indicators for pediatric intensive care unit (PICU) admission
• Key clinical points and takeaways for healthcare professionals managing airway emergencies

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 47 Otteson T, Richardson C, Shah J: Diseases of the upper Airway. Pages 524-535
• Rogers Textbook of Pediatric Intensive Care: Chapter 25; Ong May Soo Jacqueline, Tijssen J, Bruins BB and Nishisaki A: Airway management. Pages 341-365
• Reference: Asmundsson AS, Arms J, Kaila R, Roback MG, Theiler C, Davey CS, Louie JP. Hospital Course of Croup After Emergency Department Management. Hosp Pediatr. 2019 May;9(5):326-332. doi: 10.1542/hpeds.2018-0066. PMID: 30988017; PMCID: PMC6478427.
• Reference: Aregbesola A, Tam CM, Kothari A, Le ML, Ragheb M, Klassen TP. Glucocorticoids for croup in children. Cochrane Database Syst Rev. 2023 Jan 10;1(1):CD001955. doi: 10.1002/14651858.CD001955.pub5. PMID: 36626194; PMCID: PMC9831289.

Previous Episode Mentioned:

PICU Doc On Call Episode 80

In this episode of PICU DOC on Call, Dr. Rahul Damania and Dr. Pradip Kamat discuss the resurgence of measles in the United States. They explore the virus's pathophysiology, clinical features, diagnostic methods, treatment options, and complications. They emphasize the critical role of vaccination in preventing measles outbreaks and address the historical context and public health challenges related to vaccine hesitancy. The speakers highlight the severe complications of measles, especially in immunocompromised patients, and advocate for robust vaccination efforts to protect vulnerable populations and prevent the spread of this preventable disease. Tune in to hear more!

Show Highlights:

• Resurgence of measles in the United States
• Historical context of measles outbreaks and vaccination impact
• Current statistics and recent cases of measles
• Pathophysiology of the measles virus
• Clinical features and progression of measles infection
• Diagnostic approaches for confirming measles
• Differential diagnosis considerations for fever and rash
• Treatment options and the role of vaccination
• Complications associated with measles, including severe outcomes
• Public health challenges related to vaccine hesitancy and advocacy for immunization

Resources:

CDC Measles Info Page

WHO Measles Global Surveillance

References:

Fuhrman & Zimmerman. Textbook of Pediatric Critical Care, Ch. 52

Long S et al. Principles and Practice of Pediatric Infectious Diseases, Ch. 227

Moss WJ. Measles. Lancet. 2017;390(10111):2490-2502

Paules CI, Marston HD, Fauci AS. NEJM. 2019;380(23):2185-2187

In this episode of PICU DOC on Call, Dr. Rahul Damania and Dr. Pradip Kamat chat about a challenging case involving a 15-year-old girl dealing with acute myocarditis and worsening respiratory failure. They explore the intricate dance between the heart and lungs, especially how positive pressure ventilation can affect heart function. They cover important topics like cardiac output, preload, and afterload, and discuss the delicate balance needed to manage myocarditis effectively. The episode offers practical tips for optimizing care for critically ill children, underscoring the importance of personalized treatment plans and teamwork in pediatric critical care. Tune in!

Show Highlights:

• Clinical case of a 15-year-old girl with acute myocarditis and respiratory failure
• Importance of understanding cardiopulmonary interactions in pediatric critical care
• Effects of positive pressure ventilation on cardiac function
• Key concepts of cardiac output, preload, and afterload in the context of myocarditis
• Challenges of managing hemodynamic instability in critically ill pediatric patients
• Differences between spontaneous breathing and positive pressure ventilation
• Strategies for optimizing preload and fluid management in myocarditis patients
• Tailoring ventilatory support and transitioning to invasive mechanical ventilation
• Monitoring for arrhythmias and managing myocardial function with inotropic support
• Importance of frequent assessments and collaboration with cardiac ICU teams for patient care

Optimizing Preload:

• Volume depletion is common in patients with hypotension and tachycardia. A careful fluid challenge is important to restore circulatory volume, but fluid overload should be avoided, especially with impaired left ventricular function.

Tailoring Ventilatory Support:

• Adjust BiPAP settings to improve oxygenation without overloading the heart with excessive positive pressures.
• Use the optimal level of PEEP to recruit alveoli while maintaining adequate venous return to the heart.

Supporting Myocardial Function:

• Inotropic support (e.g., milrinone) may be necessary to improve myocardial contractility. Milrinone also provides vasodilation, which can reduce afterload but must be used cautiously due to its potential to lower blood pressure.

Frequent Reassessments:

• Bedside echocardiography and regular monitoring of biomarkers (lactate, BNP) and clinical status are essential for ongoing evaluation.
• In severe cases, advanced therapies like ECMO may be required if the patient’s hemodynamic status continues to deteriorate.