Respiratory problems by A Scuola di Salute

Respiratory problems

Objectives

At the end of this session the participants will be able to: • Recognize the signs of respiratory distress and respiratory failure • Know the main treatments for stress or respiratory failure

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Evidence of respiratory problems

• Hypoxemia • Hypercapnia • Both

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Respiratory distress

Clinical signs: tachypnea, > respiratory effort, breath sounds, cool pale skin, altered consciousness Situation of compensation maintained to compensate for the deficiency given by an obstruction of the airways or by a reduction in pulmonary compliance or by parenchymal pathology

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Respiratory insufficiency

Clinical signs: marked tachypnea (early), bradypnea (late), tachycardia (early), bradycardia (late), > or < respiratory effort, breath sounds, cyanosis, stupor, or coma Maintained decompensation caused by airway obstruction or narrowing, parenchymal disease, or centrale changes

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Survival after cardiac arrest in childhood 100%

50%

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Respiratory arrest

Cardiovascular arrest

Let’s remember that

• Anatomical differences with adults (head oropharynx and upper airways, rib cage and lower airways) • Functional differences (increased basal metabolic rate, immature central control of breathing and airway narrowing)

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General assessment

Respiratory insufficiency compensated or decompensated • • • •

Consciousness Posture Airways Respiratory work and respiratory sounds • Skin color

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Initial classification of the child in respiratory insufficiency Assessment

Resp. insufficiency compensated

Resp. insufficiency decompensated

State of consciousness

Irritable combative vigilant

Severe agitation or reduced responsiveness

Posture

Often indifferent

Seated or semi-seated “tripod position”

Airways

Permissive or partially obstructed (copious secretions or other causes of obstruction)

Frequent severe or complete obstruction

Thoracic excursion during breathing

Normal or slightly reduced

Reduced or absent

Respiratory work

Slightly increased nasal fin blowing

Increased, with apnea breathing nasal fins, marked indentations, use of accessory muscles

Respiratory sounds

Gurgling gasps hissing or screeching reduced air intake

Moaning, gasping, markedly reduced air intake or no noise

Respiratory frequency

Tachypnea

Irregular breathing, bradypnea, apnea episodes

Skin color

Rosy or pale

Pale marbled or cyanotic

Transcutaneous SatO2

90-95% (during O2 therapy)

< 90 % (during Oxygen)

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Classification of respiratory diseases

• Upper airway obstruction • Lower airway obstruction • Diseases of the lung parenchyma • Alteration of Central control

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Targeted treatment: airway obstruction

• Ensure and maintain patency: remove blockages, suction nose and mouth, position the child, and reduce airway edema • Administer oxygen: with basic and advanced devices • Ensure adequate ventilation • Prevent the onset of agitation

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Upper airway obstruction etiology

• Anaphylaxis • Croup • Foreign body aspiration • Retro-pharyngeal neoformations

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Targeted treatment: lower airway obstruction

• Ensure adequate ventilation with effective disposal of CO2 • Administer oxygen: with basic and advanced devices • Ventilate (if necessary) slowly and allow time > for expiration • Prevent the onset of agitation

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Lower airway obstruction etiology

• Bronchiolitis • Acute asthma • Bronchospasm

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Targeted treatment: diseases of the lung parenchyma

ALL OF THE FOREGOING AND BEYOND: • Administer oxygen: with basic and advanced devices • Ventilate (if necessary) with methods such as CPAP - BPAP

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Etiology for parenchymal pathologies

• Infectious pneumonia • Chemical pneumonia • Aspiration pneumonia • Cardiogenic pulmonary edema • Non-cardiogenic pulmonary edema (ARDS)

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Targeted treatment: impaired breath control

ALL OF THE FOREGOING It is essential to identify its etiology: • > intracranial pressure • Poisoning or drug overdose • Neurological or neuromuscular diseases

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Oxygen therapy

• • • • • •

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Main drug (even if SatO2 is good) Humidify flow High concentrations Constant observation and assessment Patent and preserve airways Start with the least invasive method

Methods for oxygen therapy

• • • • • • •

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Nasal cannula Mask Aerosol Mask with reservoir Helmets Fitted masks Caps

Mask and ball

Directions: • Worsening respiratory failure • Respiratory arrest • Unresponsive respiratory distress in spontaneous breathing with high O2 concentrations

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Effective mask ventilation

• Chest expansion • Improved O2 and complexion • Heart rate recovery If not effective: • Reposition child’s head mask • Check equipment • Foreign body check • Abdominal distension

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Complications of mask ventilation

• Gastric distention • PNX • Pneumomediastinum

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Endotracheal intubation Directions: • • • • • • • • • •

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Respiratory arrest Head trauma Ineffective mask ventilation Administer medications Unconscious child Protect airways Semi-drowning Special needs (PEEP) Need for suction Infant

Verifications

• • • •

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Caliber: age +16 /4 example 4+16/4= 5 Length at the lip line: caliber + 6 Length at the nostril: caliber + 7 DOPES: dislocation – obstruction – presence of pneumothorax – equipment problems - stomach distension

MLA

• Easier placement • Less invasive • Does not protect the airways • Used only in children without any reflex due to the risk of vomiting and inhalation

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Cricothyrotomy

• Complete obstruction with patient not ventilatable in any way • Large caliber needle • ETT 3.0 fitting

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Airway management: tracheal intubation • Both cuffed and uncuffed tubes are acceptable for children and infants (class IIa, LOE C) • In some situations (e.g. high airway resistance, poor lung compliance) a cuffed tube may be preferable, with attention to cuff size and pressure (class IIa, LOE B)

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Airway management: choice of tube size UNCUFFED TUBE: • Infants up to 1 year: 3.5mm • Children between 1 and 2 years: 4.0 mm • After 2 years: age/4 + 4 CUFFED TUBE: • Infants up to 1 year: 3.0 mm • Children between 1 and 2 years: 3.5 mm • After 2 years: age/4 + 3.5

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Airway management: intubation assessment • Symmetrical movements of the chest and assessment of the absence of gastric insufflation • End-tidal CO2 monitoring (capnometer/capnograph): in all scenarios (pre and intra hospital) (class I, LOE C) • Evaluation with colorimetric CO2 detectors can be biased • Insufficient data to recommend esophageal tractors in children

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Monitoring • EKG monitoring • END - TIDAL CO2 (Capnography/Capnometry) • Pulse oximetry (attention: pulse oximetry drops only after at least 3 minutes of ineffective ventilation) • Echocardiography (in the presence of trained personnel, to identify reversible causes of arrest) (class IIb LOE C)

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