PEDIATRICS RESPIRATORY

EMERGENCIES

Samuel Harmin
 Introduction

Emergencies with airway or breathing are common/critical

No. 1 cause of:

pediatric hospital admissions
death during first year of life except for congenital
abnormalities

Most pediatric cardiac arrest begins as respiratory failure

or respiratory arrest
 ...respiratory emergencies

If assessment shows airway not

open/patient not breathing, act immediately

Vital organs die in minutes

Illness/injury that impairs airway/breathing

is respiratory emergency
Terms To Know
WOB = work of breathing

Apnea = absence of breathing

Respiratory insufficiency

Respiratory arrest = cessation of respiration

Decrease respiratory reserve + Increased O 2

demand = Increased respiratory failure risk
 Structure and Function

External respiration Internal respiration Cellular

(ventilation) respiration

exchanges O2 and changes acid

brings produced during
CO2 between
oxygen into blood and body
metabolism into
the lungs harmless chemicals
cells in the cells
Mechanics of Breathing
 Following the Inhalation Process

Air enters the respiratory system

through the nose or mouth

The trachea branches into two

tubes called bronchi
The bronchioles have small sacs at
their ends called alveoli

Each bronchus enters one of the

lungs and then branches into
smaller tubes called bronchioles
Capillaries in the walls of
the exchange O2 and CO2
by the process of diffusion
Steps of respiration
1. Ventilation or gas exchange
between atmosphere and alveoli

2. Diffusion of O2 & CO2

between alveoli and the blood

3. Circulation (transport) of O2 &

CO2 between the lungs and the
tissue

4. Exchange of O2 & CO2

between the blood and the
tissues

Sherwood L, The Respiratory System, 2004

 Pediatric Respiratory System
Large head, small mandible,
small neck
Large, posteriorly-placed
tongue
High glottic opening
Presence of tonsils,
adenoids
Trachea more flexible
Dont hyperextend neck by
pushing head back too far
 ...pediatric respiratory system

Airway structures smaller/more easily obstructed by

foreign bodies

Poor accessory muscle development

Less rigid thoracic cage

Horizontal ribs, primarily diaphragm breathers

Increased metabolic rate, increased O 2 consumption

CRUCIAL
POINT!
Assessment Techniques
Rate
The normal rate of respiration varies with age,
gender, posture, exercise, temperature, and
other factors

Character
Respirations should have a regular rhythm,
occurring at regular intervals

Sounds
Breath sounds can be heard by using a
stethoscope
Dyspnea classification
pathophysiology, anatomic, disorders

EXTRA Obstruction
clinical: inspiratory stridor
of proximal
FLOW thorax age:/ larger
infant airway
below five
disorders
INTRA Obstruction
clinical: expiratory
of distaleffort
/
thorax age:smaller airway
infants, < 5 years bronchiolitis

Lung parenchyma disorders

INTRA
clinical: inspiratory effort
VOLUME
thorax
Extra-pulmonary disorders
disorders
EXTRA clinical:
Lung compliance disorders
inspiratory constraint
thorax
clinical: deep
Respiratory rapid
center breathing
disorders
Cardiopulmonary Resuscitation(CPR)

Pediatric cardiac arrest frequently

represents the terminal event following
respiratory failure or progressive shock

Pediatric cardiac arrest rarely results

from sudden cardiac collapse, as in adult
populations
Respiratory Distress
 ...respiratory distress

Crucial to act quickly - may rapidly progress to

arrest
Tachycardia (may be bradycardia in neonate)
Head bobbing, stridor, prolonged expiration
Abdominal breathing
Grunting--creates CPAP
Infant/child may have flaring nostrils, and more
obvious movements of chest muscles
Respiratory Failure in Children

Definition

The impaired ability of the respiratory

system to maintain adequate oxygen and
carbon dioxide homeostasis
Inadequate Breathing/Respiratory
Arrest
Respiratory arrest/inadequate breathing is
life-threatening
Respiratory arrest patient is not breathing
at all
Inadequate breathing patient is breathing
too slowly/too weakly
Unless condition progresses to inadequate
breathing/respiratory arrest, ventilation is
not needed
Patient will benefit from supplemental
oxygen
Respiratory function

Two main categories:

Ventilation Oxygenation

Removal of waste CO2

Transfer of O2 from air in blood
 Acute respiratory failure
Required assisted ventilation
Work of Breathing

FATIGUE
TRESHOLD

Able to breathe spontaneously

TIME

Nichols GD, ed. Rogers teexbook of Pediatrics Intensive care

 ...acute respiratory failure

PaO2 < 60
Hypoxemic mmHg

PaCO2 > 45
mmHg
Hypercapnic

These two types of respiratory failure always coexist

Types of respiratory failure
Acute
Ventilatory
hypoxemic
(Type II)
(Type I)

Hypoxia Hypercar
bia
Hypoxia
Hypocarb
ia
A reduced rate
and/or depth
Tachypnea of breathing

Fever, sepsis, seizure,

Small VT obesity, anxiety,
asthma, COPD

ASD, VSD,
Pulmonary AVM,
Pneumonia,
Asthma, COPD
Management of Respiratory Failure

Clinical manifestations of respiratory

failure
Diagnostic evaluation
Therapeutic management
Ventilation techniques and strategies
Nursing considerations
 Asthma
Pathophysiology
Lower airway hypersensitivity to:
Allergies Bronchospasm
Infection
Irritants
Emotional stress
Cold
Bronchial Edema Increased Mucus
Exercise Production
 ...asthma

Chronic
inflammatory
disorder of airways

Etiology and
Bronchial hyper-
pathophysiol responsiveness
ogy

Asthma

Limited airflow or
obstruction
reverses Episodic
spontaneously or
with treatment
 ...asthma
Dyspnea
Signs of respiratory
Signs/ distress
Coughing
Symptoms Expiratory wheezing
Tachypnea
Cyanosis

Patient position?
Drowsy or stuporous?
Physical Signs/symptoms of
Exam dehydration?
Chest movement?
Quality of breath sounds?

ABC
Humidified oxygen
Rehydration
Management nebulized beta-2 agents
Ipatropium
Corticosteroids
Aminophylline
Pneumonia
Inflammation of the alveoli caused by bacteria, virus,
Mycoplasma organisms, aspiration, or inhalation.
Broncho bronchioles become clogged with thick
Definition mucopurulent mucus consolidates into patches in nearby
lobes.

Lobar pneumonia
Bronchopneumonia

Classification

Interstitial pneumonia
Pneumonitis

Fever, dyspnea, productive cough,

Sign and Hypoxemia, metabolic acidosis
symptomps
Supportif: oxygen, hydration
Antibiotics
Management
 Respiratory Distress in the Newborn Infant
Frequent Causes of Respiratory Distress in Newborn Infants
Medical Surgical
Respiratory distress syndrome (RDS) Pneumothorax

Wet lung (transient tachypnea, RDS II) Diaphragmatic hernia/eventration

Aspiration syndromes (meconium, blood) Lobar emphysema

Persistent pulmonary hypertension of the
Esophageal atresia with or without TE fistula
newborn
Pneumonia/sepsis Pleural effusion

Polycythemia - hyperviscosity Cystic lesions

Pulmonary edema Mass lesions

Hypoplastic lungs Airway disorders (upper, laryngeal, lower)

Cardiac lesions Phrenic nerve paralysis

Hypoglycemia

Hypovolemia

Central nervous system

 ...respiratory distress in the newborn infant

Evaluation

History, physical examination

Downes' or RDS score - clinical
Arterial blood gases
Pulse oximetry - SaO2
Chest x-ray
Serum glucose and calcium; central hematocrit;
WBC and differential; platelet count
Maternal vaginal culture
Newborn surface (e.g., ear canal, gastric aspirate)
smears, cultures (?); blood culture; urine culture
(?); CSF culture (?)
 ...respiratory distress in the newborn infant

Signs and Symptoms

Tachypnea - above 60-80/minute

Grunting - prevents alveolar collapse
Retractions - compliant chest wall
Flaring of alae nasi, open mouth - decreases
resistance
Cyanosis in room air; PaO2 below 60 mmHg (torr)
in FIO2 >0.4
Reduced air entry
Apnea
Stridor
 Downes' or RDS Score
0 1 2
Cyanosis None In room air In 40% FIO2

Retractions None Mild Severe

Audible with Audible without
Grunting None
stethoscope stethoscope
Decreased or
Air entry Clear Barely audible
delayed
Respiratory
Under 60 60-80 Over 80 or apnea
rate

Score:
> 4 = Clinical respiratory distress; monitor arterial blood gases
> 8 = Impending respiratory failure
Respiratory Distress Syndrome

Also called as hyaline membrane disease (HMD)

Most common cause of respiratory distress in

premature infants structural & functional
lung immaturity

1/3 infants born between 28 to 34 weeks, but less than

5% of those born after 34 weeks (10% of all premature
births)

Pathophysiology: surfactant deficiency- increase in

alveolar surface tension- decrease in compliance
Pathophysiology
Decreased
FRC Hypoxemia and
Increased R-L eventually
Surfactant hypercapnia
deficiency shunt because of V/Q
mismatch
Atelectasis

Increased WoB
 ...pathophysiology

Atelectasis keeps
PVR high
Increased PAP
Lung hypoperfusion
R-L shunting may
re-occur across the
Ductus Arteriosus
and the Foramen
Ovale
Clinical findings: Physical
Tachypnea Decreased breath
(60 BPM or >) sounds with crackles
Retractions Cyanosis on room air
Nasal flaring Hypothermia
Expiratory grunting Hypotension
Helps generate
autoPEEP
Apnea
Clinical Findings: Lab
ABGs: initially respiratory alkalosis and
hypoxemia that progresses to profound hypoxemia
and combined acidosis

Increased Bilirubin

Hypoglycemia

Possibly decreased hematocrit

 RDS CXR: Ground
CXR: Normal Glass Effect
RDS CXR: Air Bronchograms & Hilar Densities
RDS Treatment: Primarily supportive
until lung stabilizes
NTE, maintain perfusion, maintain ventilation and
oxygenation

O2 therapy, CPAP or mechanical ventilation

May require inverse I:E ratios if oxygenation
can not be achieved with normal I:E ratio

Surfactant instillation!!!
May cause a sudden drop in elastic
resistance!
Prognosis/Complications
Prognosis is good once infant makes it past
the peak (48-72 hours)

Complications possible are:

Intracranial Bleeding
BPD (Bronchopulmonary Dysplasia)
PDA (Patent Ductus Arteriosus)