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 superiorly 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 slow 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 breathing 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 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 in 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 these systems deliver oxygen mixed with room air during patient inspiration the oxygen concentration delivered by these systems is determined by the oxygen 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 examples include simple nasal cannula and simple masks a simple nasal cannula is generally used with flow rates of one quarter to four liters per minute a simple oxygen mask requires at least six liters per minute but six to ten liters is generally provided some patients will need more support than a low flow oxygen system high flow 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 against the face one-way valves 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 brings 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 the high flow nasal canula these have become very common in the inpatient and ICU settings now the flow can be adjusted from four liters and infants up to 40 liters or more in adolescents you can also titrate the flow to provide additional inspiratory and expiratory pressure this may improve the patient's work of breathing high flow nasal canula 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 saturations and the most serious respiratory emergencies effective ventilation may require 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 the 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 tone 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 trachea opening or glottis well an appropriately sized oral airway should extend from the corner of the mouth to the angle the 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 it can cause the tongue to obstruct the airway one technique 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 x' offer many advantages these include reducing the risk of aspiration and gastric insufflations 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 a bronchus for every intubation there's 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 ventilations with 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 gurgling sounds are heard in the epigastric area and no breath sounds are heard over the chest this suggest 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 end racheal 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 tubes a pneumothorax usually results in decreased chest expansion and breath sounds 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 to 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 [Music] you