• Anatomical Differences (adult vs. ped)
• Signs of Respiratory Distress
• Respiratory Common Diseases
– RSV Bronchiolitis
– Upper Airway Obstruction/Stridor
• When to contact RT
• When a breathing treatment is indicated
• Common oxygen delivery devices
• 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.
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!!!!
• Trachea is much less rigid
• The narrowest portion of the pediatric airway is at
the cricoid ring
Making subglottic obstruction much more likely
• Thoracic cage:
– infant thoracic cage is more
pliable (compared to the adult)
• 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.
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
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
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
• Change in mental status or speech
• Decreased SpO2
Most children will breathe rapidly as they enter respiratory
distress. As it progresses, they may breathe unusually slowly
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 ….
Impending Respiratory Failure
• Extreme pallor
• Decreased LOC (Progression of neurological
• Head bobbing with each breath
• When you stop hearing B.S., not when you
2 categories: Upper and Lower Airway Obstruction
• 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.
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.
• 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???
• 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
• The obstruction is greatest beneath the cricoid cartilage
because the ring forces the edema into the tracheal
lumen by preventing the edema from expanding
• 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.
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.
Obstruction and Treatments
Upper Airway Obstruction
• Increase radius of the airway pharmacologically
• Heliox (decreases the viscosity of the gas), gets
past obstruction, doesn’t fix the primary problem.
• Increase radius of the airway mechanically
• 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.
• Recurrent or persistent episodes of Croup
may indicate that there is a different cause
– Consider laryngeal or tracheal anomalies like
congenital/acquired subglottic stenosis, webs,
• Is it caused by upper or lower airway
• Asthma Exacerbation
– Airway Edema
– Fluid/secretions in airway
• Viral Infections (infants/toddlers)
• An inflammation of the bronchiolar airways
caused by infection that produces airway
obstruction with mucus formation,
bronchiolar wall edema and spasm
• 75% Respiratory Syncytial Virus (RSV), RSV is
a Para influenza spread by contact of oral or
• 25% rhinovirus, influenza viruses and
• 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)
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
Bronchiolitis; Physical Exam Findings
• Harsh cough
• Respiratory distress(wheezing and/or crackles,
• 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)
• 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
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
• 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
Equipment: suction system
• Vacuum regulator
• Connecting tubing
– To regulator
• Collection jar
• Connecting tubing (not
– To patient
Equipment: suction pressures
Employ the minimal vacuum required to clear
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.
Nasopharyngeal / Nasotracheal
• 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
• 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
• 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
• 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.
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
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
Cough Variant Asthma
• Some patients may only exhibit a cough
• Monitor patient via peak flow to identify air flow
• 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!
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
Asthma & Influenza;
• 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
– Can cause bronchospasm in some individuals.
Asthma Action Plan
• Provided upon discharge
• Tailored to meet individual needs
• Educate patients and families about all aspects
– STARTS UPON ADMISSION!
– Recognizing symptoms
– Medication benefits and side effects
– Proper use of inhalers and Peak Expiratory
Flow (PEF) meters
• Lower Airway Obstruction
– Increase airway radius pharmacologically (B2
– Heliox (decrease the viscosity of the gas)
– Mechanically (intubate and provide mechanical
ventilation to generate thoracic pressure).
Breath Actuated Nebulizer (BAN)
• Increased particle deposition compared to
– Shorter LOS
• Medication is “breath actuated”
– Treatments last 5 minutes
• Some institutions using this in ED to replace
• 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
– dry powder inhaler (DPI)
• The best method for administering nebulized
medications to pediatric patients is via
• 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.
When to Contact RT
• Anytime you note that a patient is in respiratory
• When you determine that a treatment is
• Anytime you have a question about a patient’s
• When a PRRT is called
• When determining when trach care/change
should be done
Emergency Airway Supply Cabinets
• Only emergency
• Code Blue/PRRT
• Call RT if the red
lock is broken
• 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
• Alternative to the oropharyngeal airway.
• Helpful for patients who require frequent
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
Oxygen Delivery Devices
• Simple Mask
• Venti Mask
• 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).
Indications for supplemental oxygen
• Hypoxemia (low oxygen content in the
• Clinical Manifestations of hypoxia (low
oxygen content in the tissues)
– Signs of hypoxia include: tachypnea,
tachycardia, grunting, nasal flaring,
retractions, cyanosis and chest pain.
• When to use:
– anytime a patient needs supplemental oxygen
• How to wean:
– Decrease flow rate
• Humidification options: Bubbler
– Use for long term patients and for
– Also consider saline nasal drops
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*
– 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.
• 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
• 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
• How to wean:
– Must change to an alternate device for
weaning (NC or Venti Mask)
• Humidification options: None
Aerosolized Face Mask
and Trach Collars
• Provide a specific FiO2 (usually 21-50%)
• High flow device – will meet the patient’s
• Provides humidification (not always adequate)
• Indicated for patients that require a controlled
• Must heat and humidify all Trach collars because
upper airway is bypassed.