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Introduction to Respiratory Peds.ppt

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Introduction to Respiratory Peds.ppt

  1. 1. Mahdi Hemmat RN, CCRN Intro to Pediatric Floor Respiratory Therapy
  2. 2. Objectives • Anatomical Differences (adult vs. ped) • Signs of Respiratory Distress • Respiratory Common Diseases – Asthma/wheezing – RSV Bronchiolitis – Upper Airway Obstruction/Stridor • When to contact RT • When a breathing treatment is indicated • Common oxygen delivery devices
  3. 3. Anatomical Differences • The infant tongue and Lymphoid tissues (tonsilsadenoids) are proportionately larger than the adults and to the oral cavity • Frequently the case of upper airway obstruction (loss of tone with sleep,sedation or CNS dysfunction • Epiglottis is proportionately larger with an omega shape, must be more anterior and superior to keep airway open. – Therefore excessive flexion or extension may cause obstruction of this area, jaw thrust is ideal with mild head tilt.
  4. 4. The nose knows… • Nose is responsible for 50% of total airway resistance at all ages • Infant + blockage of the nose =respiratory distress or failure • So…. Sometimes, oral and nasal suctioning is all that is needed!!!!
  5. 5. Anatomical Differences • Trachea is much less rigid • The narrowest portion of the pediatric airway is at the cricoid ring Making subglottic obstruction much more likely in children. • Thoracic cage: – infant thoracic cage is more pliable (compared to the adult)
  6. 6. Oxygen Consumption • Adult VO2 = 3 – 4 ml/kg/min • Infant VO2 = 6 – 8 ml/kg/min WOW…. • Therefore, in the presence of oxygen and ventilatory deficiencies, hypoxia will develop more rapidly in the child.
  7. 7. Pediatric Vital Signs
  8. 8. What is Respiratory Distress? Respiratory distress is the name given whenever a child’s respiratory system is in danger of not being able to keep up with the child’s needs for oxygen and gas exchange. It can occur in a great many conditions including those arising in the lungs, heart, muscles, nerves, or brain. Respiratory distress is the most common diagnosis among children who need to be admitted to a PICU
  9. 9. Symptoms of Respiratory Distress • Rapid breathing >60 bpm • Working hard to breathe (extra muscle use) • Nostril flaring • Retractions (extra muscle use between or below the ribs) • When accompanied by stridor- typically indicates UAO • When accompanied by wheezing- typically indicates LAO • Grunting • Cyanosis • Change in mental status or speech • Decreased SpO2 • Diaphoresis • Hypercapnia Most children will breathe rapidly as they enter respiratory distress. As it progresses, they may breathe unusually slowly or shallowly.
  10. 10. Who gets Respiratory distress? Children’s airways are smaller than adults. Too much difficulty breathing is a problem whatever the cause. Children might develop respiratory distress as a result of many situations including allergies, anthrax, asthma, botulism, bronchiolitis, CMV, concussion, cough, croup, cystic fibrosis, diptheria, encephalitis, enlarged tonsils or adenoids, food allergies, foreign bodies, heat stroke, heart failure, HIV, measles, meningitis, mononucleosis, near- drowning, pertussis, pneumonia, poisoning, polio, reflux, RSV, sepsis, sickle anemia, Shock, SIDS, sleep apnea, trauma, tuberculosis, of wheezing ….
  11. 11. Impending Respiratory Failure • Bradycardia • Cyanosis • Extreme pallor • Decreased LOC (Progression of neurological symptoms) • Head bobbing with each breath • When you stop hearing B.S., not when you hear wheezes.
  12. 12. 2 categories: Upper and Lower Airway Obstruction
  13. 13. Stridor • Inspiratory sound heard loudest over the neck. • This narrowing can be caused by inflammation of the larynx, a foreign body, laryngotracheomalacia, tumors, tracheal stenosis, tracheal edema, croup, epiglottitis, etc.
  14. 14. Glottic Obstruction: Epiglottitis • An acute inflammatory condition that results in swelling of the epiglottis and surrounding tissues. • This can lead to partial or complete airway obstruction. • This is a LIFE-THREATENING disease and requires prompt diagnosis and treatment.
  15. 15. Epiglottitis Cause • Bacterial infection. • Most commonly caused by Haemophilus influenzae type B • Less common organisms include streptococci and staphylococc • Why do we see less of this today??? What intervention…
  16. 16. Croup • Laryngotracheobronchitis or LTB • Most common cause of airway obstruction in children between 6 months and 6 years old although more than 90% of cases are seen in children under 5 years of age. • Results in inflammation in the subglottic region of the airway. • The obstruction is greatest beneath the cricoid cartilage because the ring forces the edema into the tracheal lumen by preventing the edema from expanding outward.
  17. 17. Croup: Diagnosis • Most often occurs during the late fall and winter (although can occur any time of the year). • Diagnosis is made by physical exam and history.
  18. 18. Croup: History and Physical Exam • Coughing, rhinnorhea and low grade temperature (common cold symptoms) for approximately 2 days • Respiratory distress usually occurs after the two days of cold symptoms and is associated with retractions, barky cough, hoarse voice and stridor (lasting 1-4 days). • Total length of illness is typically 5-12 days.
  19. 19. General Airway Obstruction and Treatments Upper Airway Obstruction • Increase radius of the airway pharmacologically (vaponepherine, L-epinephrine, glucocorticosteriods) • Heliox (decreases the viscosity of the gas), gets past obstruction, doesn’t fix the primary problem. • Increase radius of the airway mechanically (intubation)
  20. 20. Croup: Treatment • If child exhibits no stridor while at rest; no treatment needed. • If child exhibits mild stridor at rest; supplemental oxygen (as needed), racemic epinephrine (or L-epinepherine). • If child exhibits moderate/severe stridor at rest,needs oxygen or is unable to maintain fluid intake: • Monitor Closely • Minimize agitation as it may worsen respiratory distress • Administer racemic epinephrine treatments • Supplemental Oxygen • IV Steroids to reduce inflammation • Consider intubation for those patients with severe stridor, non- responsive to traditional therapy.
  21. 21. Croupy…Again?!? • Recurrent or persistent episodes of Croup may indicate that there is a different cause of symptoms. – Consider laryngeal or tracheal anomalies like congenital/acquired subglottic stenosis, webs, or cysts.
  22. 22. Wheezing • Is it caused by upper or lower airway obstruction? • Asthma Exacerbation • Pathophysiology: – Bronchoconstriction – Airway Edema – Fluid/secretions in airway • Viral Infections (infants/toddlers) • WARI???
  23. 23. Bronchiolitis • An inflammation of the bronchiolar airways caused by infection that produces airway obstruction with mucus formation, bronchiolar wall edema and spasm
  24. 24. Bronchiolitis
  25. 25. Bronchiolitis: Cause • 75% Respiratory Syncytial Virus (RSV), RSV is a Para influenza spread by contact of oral or nasal secretions. • 25% rhinovirus, influenza viruses and mycoplasma pneumonia
  26. 26. Bronchiolitis • RSV is HIGHLY contagious and requires extreme care in hand washing. • Can live on surfaces for up to 6 hours. • Primarily seen in infancy < 2 yrs • Seasonal (December - March)
  27. 27. Bronchiolitis: Risk Factors • Infants that are not breast-fed • Premature birth • An underlying heart-lung condition • A depressed immune system • Exposure to tobacco smoke • Infants that attend daycare • Infants with school age siblings
  28. 28. Bronchiolitis; Physical Exam Findings • Fever • Harsh cough • Rhinorrhea • Respiratory distress(wheezing and/or crackles, tachypnea, retractions) • Feeding poorly (due to respiratory distress) • Apneic episodes (occurs in 20% of cases) • Hypoxia and hypercardia in severe cases • Bronchiolitis is difficult to differentiate from asthma initially, however asthma will improve much sooner than bronchiolitis (as the illness will run a viral course)
  29. 29. Bronchiolitis: Diagnosis • Nasal Swab
  30. 30. Bronchiolitis; Treatment • Usually supportive care is all that is required as this illness is often self limiting. • Supplemental oxygen • IV fluids if needed to maintain adequate hydration • Frequent nasal suctioning • Nebulized medications (albuterol vs. 3% HS) • Mechanical ventilation is uncommon because of HHHFNC and Noninvasive support
  31. 31. NeoTech Little Sucker • Nasal Suctioning: • 1. Obtain nasal aspirator or bulb syringe • 2. If patient is old enough, explain procedure to him or significant other. If patient is very young, a second person may be necessary to restrain the patient during the procedure. • 3. Set suction regulator to “continuous” vacuum mode, and adjust vacuum appropriately to optimize safe removal of secretions (80-100 mmHg). • 4. Saline may be introduced into the nare(s) to assist in the removal of thick secretions. NOTE: Do not instill saline into both nares at the same time. • 5. Place tip of apparatus anatomically angled correctly into nare, apply suction. • a. NOTE: if using bulb syringe, squeeze prior to insertion into the nare. Once in proper position, release bulb to apply suction. • 6. Visualize color and amount of secretions obtained. • 7. Repeat step 4-6 as needed. • 8. Chart color and amount of secretions obtained on the doc flowsheets in EPIC.
  32. 32. Little Sucker
  33. 33. Equipment: suction system • Vacuum regulator • Connecting tubing – To regulator • Collection jar • Connecting tubing (not pictured) – To patient
  34. 34. Equipment: suction pressures Employ the minimal vacuum required to clear secretions. Adult: -100 to -150 mmHg Child: -100 to -120 mmHg Infant: -80 to -100 mmHg Neonate: -60 to -80 mmHg Vacuum regulator displays are sometimes poorly calibrated; in clinical, you will have the opportunity to develop a sense of what these vacuum levels “feel like” on your thumb.
  35. 35. Nasopharyngeal / Nasotracheal Suctioning: • 1. Obtain proper equipment: regulator with canister, tubing and correct sized suction catheter for size of patient. Water-soluble lube or gel, normal saline. • 2. Set suction regulator to “continuous” vacuum mode, and adjust vacuum appropriately to optimize safe removal of secretions. • a. Neonate; 80-100 mmHg • b. Pediatric; 100-120 mmHg • c. Adult; less than 150 mmHg • 3. Select correct size catheter and prepare patient for suctioning. • 4. If patient is old enough, explain procedure to him or significant other. If patient is very young, a second person may be necessary to restrain the patient during the procedure. • 5. Patients requiring oxygen should have blow by oxygen available throughout procedure
  36. 36. • 6. Lubricate the suction catheter with water-soluble gel or normal saline. • Saline may also be introduced into the nare(s) to assist in the removal of thick secretions. NOTE: For infants and small children- do not instill saline into both nares at the same time. • 7. Gently pass the catheter into a nare following the nasal passage. If significant resistance is met, try other nare. Do not force catheter as this may result in mucosal damage. • 8. Pass catheter into nasopharyngeal area and apply suction while withdrawing catheter. Use remaining normal saline to flush catheter. • 9. Allow the patient to recover (vital signs return to baseline) and repeat process to same or opposite nare as needed (evaluate breath sounds before and after suctioning). • 10. Oral secretions may be obtained following the removal of nasal secretions. • 11. Chart color and amount of secretions obtained on the doc flowsheets in EPIC.
  37. 37. Open Suctioning: procedure w/o ETT or trach • Use individually packaged catheter and gloves • Open system suction can be used with or without an artificial airway (ETT or trach). Overwhelming patient sensation is commonly pain, as the catheter is passed through the nose. Lubrication is a must. • The catheter can also be passed through the mouth into the posterior oropharynx; very difficult to pass the catheter into the trachea via this route. The overwhelming patient sensation is commonly gagging. No lubrication is necessary when suctioning via the oropharynx.
  38. 38. Bulb Suctioning
  39. 39. Asthma Asthma is a chronic disease (that makes it harder to move air in and out of your lungs) which can be serious—even life threatening. There is no cure for asthma. Nearly 26 million Americans have asthma. Asthma is one of the most common chronic disorders in childhood, currently affecting an estimated 7.1 million children under 18 years old. It causes millions of lost school and work days every year and is the third leading cause of hospitalization among children. Asthma in young children can be hard to diagnose. © 2017 American Lung Association
  40. 40. Asthma Triggers • Pet Dander • Tobacco Smoke • Pollen • Mold • Dust/Dust Mites • Cockroaches • Stress • Cold air • Strong Perfumes • Exercise
  41. 41. Triggering Stimuli Causes: • Degranulation of mast cells, causing the release of histamine, leukotrienes, and prostaglandins. • Attracts inflammatory cells: neutrophils, eosinophils and T-lymphocytes • Causing bronchoconstriction, edema and mucous production.
  42. 42. Pathophysiology of Asthma; Airflow limitation • Acute Bronchoconstriction • Airway Edema • Mucous Plug Formation • Airway Wall Remodeling
  43. 43. Asthma Phases There are two distinct phases – Early onset • Occurs within 30 minutes of trigger exposure – Late onset • Chronic Inflammation • Begins 4-8 hours after the initial exposure
  44. 44. Cough Variant Asthma • Some patients may only exhibit a cough • Monitor patient via peak flow to identify air flow limitation
  45. 45. Asthma; Associated Disease • Sinusitis, rhinitis, nasal polyposis – Upper airway inflammation leads to worsening of lower airway hyper-responsiveness • Gastroesophogeal reflux (GERD) – Unclear mechanism • Often will trial a proton pump inhibitor to see if asthma symptoms improve, even in patients without heartburn!
  46. 46. Asthma & Influenza • Asthmatics are at higher risk for influenza- related complications (pneumonia). • Seasonal Flu Vaccine: Anyone with asthma at least 6 months of age and older should be vaccinated for seasonal influenza. – Persons with asthma should not use the inhaled "FluMist®" vaccine because of the increased risk of bronchospasm. Centers for Disease Control http://www.cdc.gov/asthma/preventing_and_controlling.htm
  47. 47. Asthma & Influenza; Anti-Viral Medications • Currently, most Influenza A (including H1N1) viruses are susceptible to oseltamivir (Tamiflu). – Antiviral resistance could occur. • Zanamivir (Relenza) is not recommended for treatment in patients with underlying pulmonary disease. – Can cause bronchospasm in some individuals.
  48. 48. Asthma Action Plan • Provided upon discharge • Tailored to meet individual needs • Educate patients and families about all aspects of plan – STARTS UPON ADMISSION! – Recognizing symptoms – Medication benefits and side effects – Proper use of inhalers and Peak Expiratory Flow (PEF) meters
  49. 49. General Airway Obstruction Treatments • Lower Airway Obstruction – Increase airway radius pharmacologically (B2 Sympathomimetics, anticholinergics, methylxanthines, glucocorticosteriods) – Heliox (decrease the viscosity of the gas) – Mechanically (intubate and provide mechanical ventilation to generate thoracic pressure).
  50. 50. General Treatments • Decreased SpO2 – Oxygen Therapy • Bronchoconstriction – Albuterol (2.5mg) – Xopenex (1.25mg OR 0.63mg) • Airway Edema – Glucocorticosteriods • Fluid/Secretions – Pulmonary Toilet
  51. 51. Breath Actuated Nebulizer (BAN) • Increased particle deposition compared to standard SVN – Shorter LOS • Medication is “breath actuated” – Treatments last 5 minutes • Some institutions using this in ED to replace continuous nebulizers
  52. 52. Aerosolized Medications • Aerosolized medications may be administered in the following ways: – mouth piece – face mask – blow by – bagged (intubated patients) – in line with the ventilator (intubated patients-SVN or MDI) – metered dose inhaler (MDI) with aero chamber – dry powder inhaler (DPI)
  53. 53. Aerosolized Medications • The best method for administering nebulized medications to pediatric patients is via mouthpiece. • If the child is unable to coordinate with a mouthpiece then a face mask is the best alternative. • Blow by is BY FAR the worst method of administering nebulized medications. (like throwing salt over the shoulder it never touch's the food) • Studies have shown that up to 90% of the medication is lost when given in this manner.
  54. 54. Other Respiratory Medications
  55. 55. RCS
  56. 56. RT Pathways • RT Assess & Treat – Pediatric Asthma Pathway – Pediatric Bronchiolitis Pathway
  57. 57. When to Contact RT • Anytime you note that a patient is in respiratory distress • When you determine that a treatment is indicated • Anytime you have a question about a patient’s therapy • When a PRRT is called • When determining when trach care/change should be done
  58. 58. Emergency Airway Supply Cabinets • Only emergency supplies are located here • Code Blue/PRRT called • Call RT if the red lock is broken
  59. 59. Ambubags and oral airways
  60. 60. Oropharyngeal Airways • The tube is inserted into the mouth sideways, pushed back to the uvula and then rotated into proper position with the tip behind the tongue. • This technique will prevent the health care provider from pushing back the tongue into the airway. • Proper sizing is essential! CAUTION: oral airways should only be inserted in UNCONSCIOUS patients!
  61. 61. Nasopharyngeal Airway • Alternative to the oropharyngeal airway. • Helpful for patients who require frequent nasotracheal suctioning.
  62. 62. Pediatric Crash Carts 1. I’m color coded for height or weight 2. Top drawer : Medication drawer 3. Tape measure available ( red to head) to measure patient 4. Color or weight on tape ( foot) corresponds to color drawer to open…ETT tubes for that size patient, drugs, etc… 5. Bottom drawer has laryngoscope handle and blades blue pack, suction regulator, stylets and IV supplies
  63. 63. Oxygen Delivery Devices • NC • Simple Mask • Venti Mask • NRB • Aerosol Mask/Face Tent • Most devices are simply smaller versions of adult oxygen delivery systems. • They are therefore classified in the same manner (low flow vs. high flow devices).
  64. 64. Indications for supplemental oxygen • Hypoxemia (low oxygen content in the blood) • Clinical Manifestations of hypoxia (low oxygen content in the tissues) – Signs of hypoxia include: tachypnea, tachycardia, grunting, nasal flaring, retractions, cyanosis and chest pain.
  65. 65. Nasal Cannula • When to use: – anytime a patient needs supplemental oxygen • Flowrate: • How to wean: – Decrease flow rate • Humidification options: Bubbler – Use for long term patients and for patient comfort – Also consider saline nasal drops for dryness
  66. 66. Everything you ever wanted to know about Simple Masks • Simple Masks are not stocked on floor due to safety concerns. • Patients will occasionaly come from surgery with this device • FiO2 provided: 35%-55% (depending on flowrate) • Flowrate Requirements: – 5L or higher – Lower flow rates can result in rebreathing of exhaled gases, thus leading to elevated CO2 levels *Dangerous* • Weaning: – change to a different device (NC) • Humidification options: None When you receive a patient on a SM, contact the RT to get a different oxygen delivery device.
  67. 67. Venti-Mask • When to use: – When unable to achieve appropriate SpO2 on a NC (or patient prefers mask) – Select appropriate adapter based on O2 need • Flow rates: – Dependent upon FiO2 desired (refer to adapter for appropriate flow rate) – Do not wean flow to lower than indicated on adapter (may lead to re-breathing of CO2) • How to wean: – Alter FiO2 by selecting different adapters • Humidification options: None
  68. 68. Non-Rebreather • When to use: – When the pt. cannot maintain adequate oxygen saturation on a NC/Venti Mask or when high levels of oxygen are needed • Flow rates: 10-15L/min – Flow rate should be high enough to keep the bag inflated during inspiration – Lower flow rates can result in rebreathing of exhaled gases, thus leading to elevated CO2 levels • How to wean: – Must change to an alternate device for weaning (NC or Venti Mask) • Humidification options: None
  69. 69. Aerosolized Face Mask and Trach Collars • Provide a specific FiO2 (usually 21-50%) • High flow device – will meet the patient’s inspiratory needs. • Provides humidification (not always adequate) • Indicated for patients that require a controlled FiO2 • Must heat and humidify all Trach collars because upper airway is bypassed.
  70. 70. Mahdi Hemmat RN, CCRN

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