Pediatric respiratory


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Pediatric respiratory

  1. 3. Anatomy <ul><li>Higher, more anterior position of the glottic opening </li></ul><ul><li>Relatively larger tongue in the infant which lies between the mouth and glottic opening </li></ul><ul><li>Larger and more floppy epiglottis in the child </li></ul><ul><li>Cricoid ring is the narrowest portion </li></ul><ul><li>Smaller cricothyroid membrane </li></ul><ul><li>Larger occiput </li></ul><ul><li>Obstruct easier from noxious stimuli, work of breathing in a crying child increases 32 fold . </li></ul>
  2. 4. Note the Ω shape Unformed hyoepiglottic ligament Can not compress as easy with a mac blade to move epiglottis indirectly
  3. 5. Epiglottitis
  4. 6. Physiology <ul><li>Basal oxygen consumption is twice adult values (>6ml/kg/minute versus 3ml/kg/min for adults) </li></ul><ul><li>Proportionally smaller functional residual capacity as compared with adults (at apnea 10% versus 40%). </li></ul><ul><li>Shortened period of protection from hypoxia for equivalent preoxygenation time. </li></ul><ul><li>Need to keep SPO2 above 90% </li></ul>
  5. 7. Equipment/ Medications <ul><li>Use the Braslow tape at all times!!!! </li></ul><ul><li>We can all do the math however, the tape decreases the time have to take to perform calculations and can utilize that time on assessment and treatment. </li></ul><ul><li>Decreases medication errors. </li></ul><ul><li>Inappropriate sized oral airways can act to increase obstruction </li></ul><ul><li>Too small of a laryngoscope blade can waste time trying to visualize the glottic opening. </li></ul>
  6. 8. Equipment <ul><li>Cuffed vs. uncuffed: studies show no increase in adverse effects if the pressure in the cuff can be monitored. </li></ul><ul><li>Uncuffed are safer for EMS providers to use unless patient requires high mean airway pressures. </li></ul><ul><li>If a cuffed ETT is used only inflate if leaking is noted around the cuff. </li></ul>Deakers TW, Reynolds G, Stretton M, et. Al. Cuffed ETT in pediatric intensive care. L Pediatr 1994; 125:57-62 Khine HH, Corddry DH, Kettrick RG, et al. Comparrison of cuffed and uncuffed ETT in young children during general anesthesia. Anesthesiology 1997; 86:627-631
  7. 9. Intubation Process <ul><li>Position patient </li></ul>External canal lies just anterior to the shoulder
  8. 10. <ul><li>Place OPA </li></ul><ul><li>Pre treat with atropine, dose from Braslow </li></ul><ul><li>Versed per tape </li></ul><ul><li>Succ’s at 2mg/kg due to faster metabolic rate </li></ul><ul><li>Apply Sellick’s manuever </li></ul><ul><li>Maintain SPO2 at 90% though procedure </li></ul>RSI
  9. 11. Intubation Continued <ul><li>Straight blade is preferred to manipulate the epiglottis directly. </li></ul><ul><li>Use ETT sized by tape. </li></ul><ul><li>Visualize placement through cords. </li></ul><ul><li>Place ETCO2 (use adult size if over 15kg), check for waveform. </li></ul><ul><li>Lung sounds, epigastric sounds. </li></ul><ul><li>Secure and place c-collar. </li></ul>
  10. 12. Post-Intubation <ul><li>Small movements in kids are big movements in their airway and the c-collar is highly recommended. </li></ul><ul><li>NG tube to relieve distension </li></ul><ul><li>Sedate as needed, continue paralysis </li></ul><ul><li>Monitor ETCO2, SPO2,assess breath sounds often. </li></ul>
  11. 13. Plan B, C,D <ul><li>BVM </li></ul><ul><li>King </li></ul><ul><li>OPA </li></ul><ul><li>Surgical </li></ul><ul><li>Bougie if ETT > 6.0 </li></ul>
  12. 15. You arrive on scene to find a 4 year old male in the care of his mother. Mom reports the child has become progressively more ill over the last 24 hours. You observe the child drooling, sitting forward in a tripod position and refuses to sit back. He feels warm to the touch, RR: 36 with mild retractions, HR: 130, Skin: Pink, warm and dry with refill < 2 seconds, palpable peripheral pulses. He appears ill and talks with stridor (hot potato voice) What is the issue?
  13. 17. Causes, Occurence <ul><li>Epiglottitis is inflammation of the epiglottis and/or the supraglottic tissues surrounding the epiglottis, including the aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula.   </li></ul><ul><li>Haemophilus influenza B , use of the HiB vaccine has reduced the incidence of epiglottitis </li></ul><ul><li>0.3 cases per 100,000 </li></ul>
  14. 18. Epiglottitis Normal
  15. 19. Croup is an infectious illness of the respiratory system involving the voice box and vocal cords. A harsh crowing sound (&quot;stridor&quot;) during inhaling can be heard when the child's air passage becomes abnormally narrowed
  16. 20. <ul><li>It is usually caused by many different viruses, including those responsible for the common cold and influenza. </li></ul><ul><li>Occasionally, it is caused by a bacterial infection. </li></ul><ul><li>Croup can result in serious breathing difficulties in children. It is more common in babies over 6 months of age and young children, and it occurs more often in boys than girls. </li></ul><ul><li>It tends to occur more often in the winter months when the weather is colder. </li></ul>Croup
  17. 21. Croup/Epiglottitis Treatment? <ul><li>The least amount possible. </li></ul><ul><li>Keep them calm. </li></ul><ul><li>If LOC decreases or breathing is ineffective BVM!!! </li></ul><ul><li>BVM can help stent the airway open. </li></ul><ul><li>Child’s own ventilations can worsen the condition due to their own negative pressure on inspiration collapsing the airway further. </li></ul>
  18. 22. Swelling from Croup
  19. 24. PPV PPV PPV will help open that obstruction even in a child in complete respiratory arrest.
  20. 25. RSV Respiratory Syncytial Virus <ul><li>It is the major cause of lower respiratory tract infection and hospital visits during infancy and childhood. </li></ul><ul><li>There is no vaccine. </li></ul><ul><li>Treatment is limited to supportive care, including oxygen. </li></ul><ul><li>In temperate climates there is an annual epidemic during the winter months </li></ul><ul><li>In the United States, 60% of infants are infected during their first RSV season, and nearly all children will have been infected with the virus by 2–3 years of age, 2–3% will develop bronchiolitis, necessitating hospitalization </li></ul>
  21. 26. RSV Treatment Treating respiratory syncytial virus bronchiolitis &quot;remains a good example of therapeutic nihilism—nothing works except oxygen&quot;. Adrenaline, bronchodilators, steroids, and ribavirin confer &quot;no real benefit“ Treatment is supportive care only, with fluids and oxygen until the illness runs its course
  22. 27. Albuterol may be used in an attempt to relieve any bronchospasm if present. Increased airflow, humidified and delivered via nasal cannula, may be supplied in order to reduce the effort required for respiration. Recent studies with hypertonic saline have shown that the &quot;use of nebulized 3% HS is a safe, inexpensive, and effective treatment for infants hospitalized with moderately severe viral bronchiolitis&quot; where &quot;respiratory syncytial virus (RSV) accounts for the majority of viral bronchiolitis cases&quot;
  23. 28. ^ Jenny Handforth, Mike Sharland, Jon S Friedland. Editorial: Prevention of respiratory syncytial virus infection in infants. BMJ 2004;328:1026–1027 (1 May), doi:10.1136/bmj.328.7447.1026