User:Cbutterflyd/Pediatric advanced life support

Respiratory Distress and Failure

Providers must be able to identify respiratory conditions that are easily treatable (eg, treated with oxygen, suctioning/ clearing airway, albuterol, etc.) and those that can rapidly progress to life threatening conditions. Respiratory distress can progress to respiratory failure which can progress to cardiac arrest. Once respiratory complaints have progressed to cardiac arrest, death and neurological damage are more likely to occur. For this reason, providers should aim to identify and treat respiratory conditions before they progress and worsen.

Recognition

Signs of respiratory distress and respiratory failure

Common signs of respiratory distress

• increased work of breathing
• nasal flaring (nostrils widening during breathing)
• accessory muscle use (using muscles other than the diaphragm and intercostal muscles during breathing (eg, sternocleidomastoid))
• retractions (collapse of parts of the chest during breathing) (eg, suprasternal, substernal, sternal, intercostal, subcostal)
• head bobbing (in infants)
• grunting
• tachypnea (too fast breathing)
• pallor (pale skin)
• tachycardia (fast heart rate)
• agitation and anxiety

Respiratory distress can progress and worsen to respiratory failure. Signs of respiratory failure include the following

• decreased work of breathing
• eventual pauses in or altogether stopping breathing (apnea)
• bradypnea (too slow breathing)
• decreased or absent air movement
• abnormal breath sounds
• cyanosis (blue skin)
• exhaustion and unresponsiveness
• can’t speak or cough

Management

Initial Management - ABCs

Airway

• support the airway by making sure that it is open/patent (child can do this on their own or provider may have to open airway with head tilt-chin lift or jaw thrust (if suspected cervical spine injury))
• clear the airway as needed (eg, suctioning mucus/secretions in nose and throat, removing foreign bodies, etc.)
• consider adding airway adjuncts such as nasopharyngeal airway (NPA) or oropharyngeal airway (OPA) (if no gag reflex)

Breathing

• monitor O2 saturation with a pulse ox
• give supplemental oxygen
• give inhaled medications (eg, albuterol, epinephrine) as needed
• manually ventilate as needed (eg, bag mask ventilation)
• prepare for advanced airway

Circulation

• monitor vitals (eg, heart rate, blood pressure)
• establish vascular access (for medications and fluids) as needed

Advanced Airways

Advanced airways may be necessary if the child can’t maintain their airway on their own and isn’t responding to other methods of ventilation and oxygenation. Advanced airways use medical equipment to allow for open airways and ease of ventilation and medication delivery. Types of advanced airways include supraglottic devices (devices that lie above the glottis such as OPA, NPA, laryngeal mask airway), infraglottic devices (devices that lie below the glottis and go into the trachea such as endotracheal tube (intubation)), and surgery (incision below the glottis such as cricothyrotomy and tracheotomy). Surgical advanced airways are typically performed intubation and other less invasive methods fail or are contraindicated or when the child will need long term mechanical ventilation.

Intubation

To perform an intubation, the health care provider should be able to perform the steps of rapid sequence intubation (preparation, preoxygenation, pretreatment, paralysis and sedation, positioning, placement of tube, postintubation management).

Further Management

Further management should be based on the specific medical condition the child has. For example, if the child is experiencing respiratory distress secondary to asthma, management would include albuterol, corticosteroids, supplemental oxygen, and more depending upon the severity of the asthma.