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learning how to assess and effectively
manage a respiratory emergency is a
crucial skill for a health care provider
in this segment we'll review the unique
characteristics of the pediatric airway
learn to recognize the various types of
pediatric respiratory emergencies and
show the proper equipment and
appropriate techniques to manage them
first let's review the unique attributes
of a child's airway these illustrations
of an adult child and infant show that
the Airways of children and infants are
considerably smaller and shorter than
those of adults the adult larynx is
cylindrical with the narrowest opening
at the level of the vocal cords in
contrast the larynx of infants and young
children is funnel shaped the airway
continues to taper below the vocal
chords to the cricoid cartilage which is
the narrowest point of the airway and it
creates a non distensible ring around
the airway in infants and toddlers the
tongue and epiglottis are relatively
large and can contribute to airway
obstruction in addition the larynx is
positioned more superior Lee and
anteriorly than in adults
note that the airway is always anterior
to the esophagus and the cricoid
cartilage is the only complete cartilage
ring located below the vocal cords keep
these anatomic and physiologic details
in mind when we discuss various
respiratory emergencies in their
treatment as you would with any
seriously ill child you should use the
evaluate identify intervene sequence to
respond to a pediatric respiratory
emergency when assessing a child there
are basically four different types of
respiratory problems to identify upper
airway obstruction lower airway
obstruction lung tissue disease and
disordered control of breathing
the child with upper airway obstruction
such as croup typically has increased
respiratory rate and effort signs of
increased effort include retractions and
nasal flaring retractions occur in
children because of their increased
chest wall compliance and the negative
intrathoracic pressure the child with
upper airway obstruction often has
inspiratory stridor a high-pitched
inspiratory sound hoarseness and a
barking cough other signs of upper
airway obstruction may include drooling
snoring or gurgling sounds responsive
older children with upper airway
obstruction often position themselves in
a way that makes their breathing easier
they should be allowed to remain in a
position of comfort a child with lower
airway obstruction such as asthma or
bronchiolitis also has increased
respiratory rate and effort on
auscultation air movement may be
decreased exhalation may be prolonged
and expert ory wheezes are usually heard
a child with lung tissue disease such as
pneumonia demonstrates increased
respiratory rate and effort that may
include grunting crackles and decreased
air movement may be present a child with
disordered control of breathing such as
a child with brain injury or drug
overdose may have an irregular breathing
pattern the respiratory rate is often
slowed and breathing may be shallow with
inadequate respiratory effort
air movement may be normal or decreased
a child with disordered control of
breathing may have poor muscle tone or
altered mental state causing upper
airway obstruction once you've
identified the category of respiratory
emergency you can then intervene
intervening can be as simple as
positioning the child for infants and
young children the best position might
be in the arms of the parent or
caregiver allowing the child to remain
in a comfortable position often
decreases the child's anxiety and
subsequent worker briefing a common
respiratory intervention for children is
administering inhaled medications by
using a nebulizer components of a
nebulizer assembly include a tea piece
plastic oxygen tubing a nebulizer or
atomizer bottle or reservoir a
mouthpiece or mask and an oxygen source
or compressed air the nebulized
medications are used to treat airway
obstruction by opening the airway
through either decreasing airway edema
or in
proving bronchoconstriction a
cornerstone of treating respiratory
emergencies and children is the
administration of oxygen there are
several types of oxygen delivery devices
you may choose to use depending on the
severity of the child's condition these
devices vary and the oxygen flow rates
used and delivered and in the oxygen
concentration delivered you'll want to
use low flow oxygen systems when a child
requires a relatively low inspired
oxygen concentration and is relatively
stable you systems deliver oxygen mixed
with room air during patient exploration
production concentration delivered by
these systems is determined by the flow
rate the child's breathing volume and
the child's respiratory rate with low
flow systems the lower the oxygen flow
the lower the inspired oxygen
concentration the examples include
simple nasal cannula and simple math
symbol nasal cannula is generally used
with flow rates of one quarter to four
liters per minute
a simple oxygen mask requires at least
the clears permit six to ten liters is
generally provided some patients will
need more support than a low flow oxygen
system hi fellow systems may be helpful
for these patients they come in two
varieties those that have variable
oxygen concentration and those that do
not these systems include a mask that is
tightly sealed into the face one-way
valve that allow patients exhalation but
no entrainment of room air and a
reservoir bag a commonly used High Flow
system is the non rebreathing face mask
one advantage of this device is that it
allows you to easily deliver
consistently high concentration of
oxygen approaching 100% non-rebreather
face masks are always connected directly
to oxygen the oxygen flow rate for the
mask must be at 10 to 15 liters per
minute the flow rate should be adequate
to keep the reservoir bag partially
expanded if the mask is tight-fitting
one-way valves ensure the child Braves
only oxygen from the oxygen source or
the reservoir no room air is drawn in
non rebreathing masks should be used in
emergency settings when the patient is
breathing spontaneously but high
concentrations of oxygen are required to
maintain
oxygen saturations another high flow
system you'll encounter is a high flow
nasal cannula these have become very
common in the impatient in ICU settings
now the flow can be adjusted from four
liters and infants up to 40 liters or
more adolescents you can also titrate
the flow to provide additional
inspiratory and expiratory pressure this
may improve the patient's work of
breathing - nasal cannula systems
deliver a combination of both room air
and oxygen they allow healthcare
providers the flexibility to also
titrate oxygen concentration based on
the patient's needs and saturation in
the most serious respiratory emergencies
effective ventilation may require a
positive pressure in these circumstances
the use of a bag-mask device is the most
important life-saving skill you can
perform bag mask ventilation using a bag
with an oxygen reservoir can deliver an
oxygen concentration near 100% this
requires an oxygen flow rate of at least
10 liters per minute when properly
performed bag mask ventilation can be as
effective as ventilation through an
endotracheal tube for short periods of
time when bag mask ventilation is needed
the healthcare provider must be ready to
perform to other interventions
suctioning the airway and inserting an
oral airway when supporting the airway
and breathing of a child you may find
you need to clear the airway that may
include suctioning of secretions blood
or vomitus suction devices can be either
portable or wall-mounted those used in
children should have adjustable suction
regulator so that you can minimize
tissue trauma semi-rigid pharyngeal tips
and various sizes of catheters should be
available complications from suctioning
may include hypoxia vagal stimulation
bradycardia gagging and vomiting soft
tissue injury and agitation that may
further compromise the patient's cardio
respiratory status to suction the
oropharynx gently insert the distal end
of the suction catheter into the oral
pharynx over the tongue guide it into
the posterior pharynx and apply suction
by covering the catheter side opening at
the same time withdraw the catheter with
a rotating or twisting motion try to
limit suction attempts to 10 seconds or
less this will help reduce the risk of
hypoxemia
you may give short periods of a hundred
percent oxygen immediately before and
after each suctioning attempt monitor
the child's heart rate oxygen saturation
and clinical appearance during
suctioning in general if bradycardia
develops or clinical appearance
deteriorates interrupt suctioning and
deliver oxygen and bag mask ventilation
if needed until the heart rate and
clinical appearance return to normal
insertion of an oropharyngeal airway is
another intervention that health care
providers must know how to do oral
pharyngeal Airways are used in
unconscious patients with no gag reflex
they help maintain the airway by
preventing the tongue from obstructing
the tracheal opening or glottis well
inappropriately sighs oral airway should
extend from the corner of the mouth to
the angle with child's jaw when the
Airways position next to the face if the
device is too large it may block the
airway and if it's too small can cause
the tongue to obstruct the airway one
side need to facilitate insertion of the
oral pharyngeal airway is to use a
tongue blade to depress the tongue the
oral airway should not be used in
conscious responsive children it will
likely cause a gag reflex and vomiting
often an oral airway will not provide
sufficient airway support and insertion
of an advanced airway will be needed for
example if there's difficulty providing
effective bag-mask ventilation if the
patient has actual or potential airway
compromise particularly with long
transport times or when there's a need
to protect the airway advanced airway
devices such as endotracheal tubes and
laryngeal mask airway offer many
advantages
these include reducing the risk of
aspiration and gastric insufflation and
eliminating the need to interrupt chest
compressions to deliver breaths during
CPR if an advanced airway is inserted
during CPR providers should minimize how
often and how long they interrupt chest
compressions for intubation once the
tube is correctly placed providers
should deliver one breath every six
seconds asynchronously while continuous
chest compressions are delivered without
interruptions
the most common advanced airway used in
Pediatrics is the endotracheal tube
consider endotracheal intubation if the
child is unable to maintain an effective
airway oxygenation or ventilation
despite initial interventions however
intubation attempts by inexperienced
providers can produce serious
complications that can include trauma to
the oral pharynx or incorrect placement
in the esophagus or bronchus for every
intubation
there is essential monitoring procedural
confirmatory and rescue equipment that
must be readily available refer to the
complete list in your provider manual
once the endotracheal tube is in place
inflate the cuff verify co2 is present
in the exhaled gas either with a
colorimetric co2 detector or wave form
capnography
to confirm proper tube placement in
cardiac arrest
co2 may not be detectable during cardiac
arrest the exhaled co2 will be very low
or undetectable because blood flow to
the lungs ceases if the exhaled co2
remains very low during CPR providers
should attempt to optimize CPR quality
especially compression rate depth and
minimizing interruptions this can cause
a rise in the exhaled co2
once you've intubated the patient you'll
want to deliver ventilation of the bag
watch for chest expansion listen over
the anterior and posterior chest then
listen over the epigastric area and
under the arms you should detect
bilateral breath sounds if a gallon
sounds are heard in the epigastric area
and no breath sounds are heard over the
chest
this suggests esophageal intubation if
carbon dioxide is not detected stop
ventilation immediately and remove the
endotracheal tube in cardiac arrest
exhaled co2 may not be detectable verify
tube displacement with a laryngoscope
before removing the tube another
advanced airway device is the laryngeal
mask airway there are two key advantages
of this device one it can be inserted
without directly visualizing the glottis
in addition it can be used as a rescue
device when
no tracheal intubation cannot be
accomplished if sudden deterioration is
observed in a patient with an advanced
airway it may be caused by one of
several complications you can use the
mnemonic dope to help remember these the
airway may be displaced for example an
endotracheal tube may be pulled out of
the trachea or advanced into the right
or left main bronchus obstruction of the
airway may be caused by secretions blood
pus or a foreign body kinking of the
airway may also cause an acute
obstruction particularly in smaller
endotracheal tube a pneumothorax usually
results in decreased chest expansion and
rest sound on the affected side a sudden
deterioration in the patient's pulse
oximetry may occur in severe cases
hypotension and even cardiac arrest may
occur it rarely happens but sometimes
your equipment can fail disconnection
from the oxygen supply power failure -
mechanical ventilator malfunction of
valves or a leak in the bag mask device
or circuit respiratory problems are the
most common pediatric emergencies that's
why it's essential that you understand
the unique characteristics of the
pediatric airway and know how to
recognize and manage these
life-threatening conditions
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