tum-b emergencias respiratorias

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1 Describe how to assess airway and breathing,including interpreting information from the PediatricAssessment Triangle and the ABCDEs.

2 Differentiate between respiratory distress,respiratory failure, and respiratory arrest based onhistory and physical exam.

3 Outline a general treatment strategy, going from theleast to the most invasive, for children withrespiratory compromise.

4 Contrast the key signs, symptoms, and managementof upper airway obstruction versus lower airwayobstruction.

5 Discuss possible complications of assistedventilation, and outline strategies to identify andcorrect them.

You are dispatched to the home of an 18-month-old girl who is having difficultybreathing. Her mother says that for two days she has had a slight fever and has beenwheezing, especially when she cries or becomes more active. She suddenly awoketonight acutely short of breath and now is making a very loud noise each time shebreathes in. The child has no prior history of wheezing or respiratory illness.

The child is sitting on her mothers lap looking anxious, but makes eye contactand cries weakly when you approach. She makes loud, harsh noises with eachinspiration. Her color is pink, but she has marked supraclavicular and suprasternalretractions and nasal flaring. Respiratory rate is 42 breaths/min and the heart rateis 180 beats/min. The blood pressure is not obtained. Her skin is warm, and she hasstrong pulses and normal capillary refill time. She has good air movement withloud, harsh breath sounds with each inspiration. Lower airway sounds are obscuredby these loud inspiratory noises.

1. How sick is this child?2. Are this childs findings more likely to be due to upper airway or lower airway

obstruction and how will you manage her in the field?

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52 CHAPTER 3: Respiratory Emergencies

Appearance reflects the overall state of ventilation andoxygenation. Increased work of breathing indicateseither airway obstruction at some level or a problemin gas exchange in the lung, at the alveolar level; it isoften an early sign of hypoxia (decreased oxygen lev-els) and/or hypercapnia (increased carbon dioxide lev-els). Fading respiratory effort is a sign of severehypoxia and/or hypercapnia. Cyanosis of the skin ormucous membranes also indicates severe hypoxia.

In addition to the PAT, the initial assessmentincludes counting the respiratory rate, performinghands-on chest auscultation, and obtaining pulseoximetry (if part of your BLS protocols or you areassisting an ALS provider). This assessment not onlyprovides a picture of respiratory function, but alsohelps prioritize general and specific treatments as wellas invasive interventions and timing of transport.

Introduction

RESPIRATORY DISEASE IS the most frequent pediatric pre-hospital medical problem. Of all conditions causingrespiratory disease in children, asthma is the mostcommon. However, many other illnesses, as well asforeign bodies and trauma, cause respiratory problemsin children. Good assessment and early interventionfor pediatric respiratory problems can avert serious ill-ness and preventable death, and may shorten treat-ment time in the emergency department (ED).

Focusing on certain key physical signs and symp-toms will allow the prehospital professional to rapidlyassess the effectiveness of gas exchange in the airwaysand lung alveoli. Using the PAT is an important firststep in determining the severity of the disease, localiz-ing the physiologic problem, and beginning treatment.

Respiratory Distressand Failure

Respiratory distress, failure, and arrest arethree points on a continuum of physiologicresponse to different types of hypoxic stress.Causes of hypoxic stress are variable, andinclude asthma, bronchiolitis, croup, pneu-monia, and chest wall injury. While thesethree points in the continuum (respiratorydistress, failure, and arrest) have differentclinical characteristics in theory, in realitythey are all part of a spectrum that is notblack or white. Respiratory distress is anabnormal physiologic condition identifiedby increased work of breathing. Increasedrespiratory rate, supraclavicular, supraster-nal, intercostal or subcostal retractions, useof accessory neck muscles and nasal flaringare signs, which alone or together indicateincreased work of breathing. These physicalsigns represent the patients attempt to makeup for decreased gas exchange in the lungsand airways and to maintain oxygenationand ventilation. The child in respiratory dis-tress is effectively compensating. The brainis still getting enough oxygen, and thechilds appearance is relatively normal.

Respiratory failure occurs when theinfant or child exhausts his energy reserves orcan no longer maintain oxygenation and ven-

tilation. When the effects of the respiratoryinsult begin to overwhelm the childs ability torespond, she begins to decompensate. Respi-ratory failure may occur when chest wallmuscles get tired after a long period ofincreased work of breathing (e.g., a child withsevere asthma who is very tight and has beenworking hard to breathe for several hours),when the insult is severe and progressive(e.g., fulminant pneumonia), or when thereis a failure of central respiratory drive (e.g., achild with a severe closed head injury). Anabnormal appearance (severe agitation orlethargy) or cyanosis in a child with anincreased work of breathing indicates proba-ble respiratory failure. An abnormally low res-piratory rate and decreased respiratory effort,usually with bradycardia, also indicates prob-able respiratory failure. Respiratory failuremust be treated immediately to restore goodoxygenation and ventilation, and to preventrespiratory arrest.

Respiratory arrest means absence ofeffective breathing. If ventilation and oxy-genation are not immediately supported, res-piratory arrest will rapidly progress to fullcardiopulmonary arrest. Most episodes ofcardiac arrest in pediatric patients begin asrespiratory arrest. Intervening at this pointwill often prevent cardiac arrest. Early inter-vention in respiratory failure and arrest will

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have a far better chance of producing neuro-logically intact survivors than treatment offull blown cardiac arrest, which has anextremely low probability of survival.

Prearrival Preparation

Based upon dispatch information and whileen route to the scene, whenever possible,prepare mentally for management of respira-tory distress and failure by reviewing theappropriate assessment techniques andtreatment options for the childs age. Thisincludes recalling an age-based approach toassessment as outlined in Chapter 1, equip-ment needs, and the likely treatment andtransport options. Also, anticipate the deter-minants of whether to stay on scene andtreat or to manage the airway and transportimmediately to the emergency department.

Scene Size-up

Be sure the scene is safe, and there are noobvious illness or injury threats. Assess theenvironment for noxious gases, fumes,chemicals, or smoke. Document scene con-ditions if environmental factors may be con-tributing to anticipated respiratory problems.

General Assessment:The PAT

Evaluating the Presenting ComplaintFind out the nature of the presenting com-plaint by asking several directed questions,as suggested in Table 3-1. After the initial

General Assessment: The PAT 53

Key Question Possible Medical ProblemHas your child ever had this kind of problem before? Asthma, chronic lung disease

Is this the first time that he has had trouble breathing?

Is your child taking any medications? Asthma, chronic lung disease, congenital heart disease

Has your child had a fever? Pneumonia, bronchiolitis, croup

Did your child suddenly start coughing/choking/gagging? Foreign body aspiration or ingestion

Has your child had an injury to his chest? Pulmonary contusion, pneumothorax

Key Questions about the Presenting ComplaintTable 3-1

assessment, in patients with mild distress,there is time to get a more complete SAM-PLE history (see Table 3-6) on scene as partof the focused history. If the child is in respi-ratory failure, do this later, if possible, whileen route to the ED.

Assessment of Respiratory StatusUsing the PATBegin the assessment with the PAT, as dis-cussed in Chapter 1. Carefully evaluateappearance, work of breathing, and skin cir-culation. The PAT will help establish howsick the child is, the type of physiologicabnormality (respiratory distress or respira-tory failure), the level of obstruction if pres-ent (upper or lower airway), and theurgency for treatment. Table 1-2 lists physi-cal features in the child to help make theseclinical distinctions by simple observationand listening.

AppearanceAppearance reflects the adequacy of oxy-genation and ventilation in a child withdifficulty breathing. If the child is com-pensating effectively for the respiratoryinsult, the appearance will be fairly nor-mal, and the TICLS mnemonic (Table 1-1) will show an interactive child withgood tone and color, and normal vocaliza-tions, who will lock gaze. If the child isnot compensating, the appearance will beabnormal, and the child will have abnor-mal findings in the TICLS mnemonicbecause her brain will be impaired due tohypoxia and/or hypercapnia. Abnormalappearance is a spectrum of cl inical

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states, so that the severity of respiratoryfailure will determine how abnormal thechild appears. Also, assessing appearancewill guide urgency of BLS versus ALStreatment.

Work of BreathingLook for signs of increased work of breathing:

1. Abnormal positioning (tripoding,sniffing position)

2. Abnormal airway sounds (such assnoring, stridor, wheezing, or grunting)

3. Retractions (or head bobbing in infants)4. Nasal flaring

The significance of each of these find-ings is discussed in Chapter 1. These indi-cators of breathing effort will help to iden-tify the anatomic location of the problem(upper airway, lower airway, or lung alve-oli), the severity of the physiologic dys-function (respiratory distress, failure, orarrest), and the urgency for treatment(immediate resuscitation, general treat-ment only on scene with specific treatmenten route, general and specific treatment onscene). In addition to abnormal airwaysounds (stridor, wheezing, and grunting),retractions and the use of accessory mus-cles may help localize the site of airwayproblems. Use of the accessory muscles ofthe neck and suprasternal and supraclavic-ular retractions occurs more often withupper airway obstruction. Predominantsubcostal and intercostal retractions andthe use of abdominal muscles tends tolocalize an obstructive process to the lowerairways.

Circulation to SkinFinally, evaluate skin color. Cyanosis is anominous sign, s ignal ing profoundhypoxia and the need for assisted ventila-tion. However, a child may have severehypoxia without an obvious change inskin color. Pulse oximetry is very helpful,so use it whenever available in a childwith respiratory distress or respiratoryfailure.

Initial Assessment:The ABCDEs

After the PAT, perform the second portion ofthe initial assessment, the hands-on ABCDEs.There are three parts to the B or breathingevaluation:

1. Respiratory rate2. Auscultation for air movement and

abnormal breath sounds3. Pulse oximetry

Respiratory RateIn the noncritical patient, determine respi-ratory rate by sitting the child in her care-givers lap and exposing her chest. Countthe rise and fall of the abdomen over 30seconds, and then double that number.Normal respiratory rates vary in childrenof different ages (see Table 1-4). Alwaysthink about respiratory rates in the contextof the PAT and the overall clinical assess-ment. Respiratory rate may be affected bylevel of activity, fever, anxiety, and meta-bolic state.

A respiratory rate of greater than60 breaths/min is abnormal in a child of any ageand should be a signal for careful evaluation forother signs of respiratory or circulatory prob-lems. Even more dangerous is a rate that is tooslow for age. A respiratory rate of less than20 breaths/min in a sick child under 6 years ofage, or a rate of less than 12 breaths/min in asick child under 15 years of age may be a signof respiratory failure and therefore, immediateintervention is required. A child who has nor-mal appearance and good color, withoutincreased work of breathing, has good breath-ing regardless of her respiratory rate.

Auscultation for Air Movementand Abnormal Breath SoundsAssess air movement by placing the stetho-scope and listening for the amount of airmovement with each breath (Figure 3-1).Poor air movement may exist in childrenwith respiratory problems for many reasons,as outlined in Table 3-2.

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Functional Problem Possible CausesObstruction of airway Asthma, bronchiolitis, croup

Restriction of chest wall Chest wall injury, severe scoliosismovement or kyphosis

Chest wall muscle fatigue Prolonged increased work of breathing,muscular dystrophy

Decreased central Head injury, intoxicationrespiratory drive

Chest injury Rib fractures, pulmonary contusion,pneumothorax

Initial Assessment: The ABCDEs 55

failure, unless the child has a chronic respira-tory problem.

Occasionally, a child with a pre-existingchronic respiratory illness (e.g., cystic fibro-sis) has a baseline abnormal pulse oximetry.In this type of patient, obtain the baselinevalue from the caregiver and attempt to pro-

Figure 3-1 Assess air movement by placing thestethoscope and listening for the amount of air movementwith each breath.

Assess air movement, or the volume ofair exchanged, by observing chest rise.

While listening for air movement, alsolisten for abnormal breath sounds. Table 1-5summarizes the types and causes of abnor-mal breath sounds. Stridor, which is usuallyinspiratory in nature at least initially, isindicative of upper airway obstructionwhereas crackles and wheezes are associatedwith lower airway processes.

Pulse OximetryPulse oximetry is a useful tool for detecting andmeasuring hypoxia. Figure 3-2 illustrates possi-ble sites for placement of the oximetry probe.

explains

how to use a pulse oximeter. The pulse oxime-ter emits red light of two different wave-lengths. These are absorbed differently byhemoglobin that is saturated with oxygen andhemoglobin which is not carrying oxygenmolecules. The sensor on the pulse oximetermeasures the transmission of the two wave-lengths of red light, and a computer in themachine then determines the percentage ofhemoglobin that is saturated with oxygen.When properly applied, a reading of 95% orhigher means normal blood oxygen satura-tion. A value of 94% or less on room air is abnor-mal and is a signal to give supplemental oxygen.A reading of less than 90%, with the patient on100% oxygen, usually indicates respiratory

Pulse Oximetry, Procedure 8

Causes of Poor Air Movementin Children

Table 3-2

Figure 3-2 Possible sites for placement of the oximetryprobe.

A

B

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vide enough oxygen to get the child to herbaseline pulse oximetry level.

Be careful not to over-interpret low oxy-gen saturation. Pulse oximetry is an adjunctto physical assessment. Falsely low readingsare common with pulse oximetry. Move-ment by the child, cold extremities, or acold ambient temperature and interferenceby light in the childs surroundings all maycause inaccurate pulse oximetry readings.Check probe placement and the childs clini-cal state before treating. Inaccurate readingsor the inability to obtain any reading mayalso occur in children in shock with poorperfusion. However, give these children oxy-gen even if they do not have respiratory dis-tress and regardless of pulse oximeter read-ings. Also, do not under-interpret a normalpulse oximetry reading. Sometimes an appar-ently normal oxygen saturation above 94%may be present in a child with significant res-piratory distress, who is compensating byincreased work of breathing. Always use pulseoximetry in combination with physicalassessment to assure accurate interpretationof adequacy of breathing.

General NoninvasiveTreatment

For every child in respiratory distress,begin general noninvasive treatment. Thegeneral noninvasive treatment of every non-critical patient is the sameallow her toassume a position of comfort and supply oxy-gen, if tolerated (Figure 3-3). This is theonly treatment for patients in respiratorydistress without upper or lower airwayobstruction. If the child is in respiratoryfailure or arrest, perform assisted ventila-tion immediately.

Be careful not to over-interpret low oxygen satu-ration. Match with the physical findings.

Figure 3-3 Always keep a child with respiratory distress inher position of comfort.

Figure 3-4 Sniffing position.

PositioningA child in respiratory distress will naturallymove into the position that gives her the bestair exchangeher position of comfort. Forexample, a child with severe upper airwayobstruction may get into the sniffing posi-tion to straighten the airway and open theair passages (Figure 3-4). A child with severelower airway obstruction may voluntarilytake the tripod posturesitting up andleaning forward on outstretched armstohelp accessory muscles (Figure 3-5). Infantsand toddlers may be most comfortable intheir caregivers arms or lap. Do not move achild from her position of comfort. Thismight worsen the respiratory distress. In theambulance, keep the dyspneic child safelyrestrained in an upright position, unless sherequires assisted ventilation or has otherphysiologic problems that require treatmentin a supine position.

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General Noninvasive Treatment 57

step explanation of this procedure, see.

Summary of Generaland Initial RespiratoryAssessment and GeneralNoninvasive Treatment

The PAT is a good tool for determining theeffectiveness of gas exchange, based onobservation of appearance and work ofbreathing. If the PAT suggests respiratorydistress, begin general noninvasive treat-ment with oxygen and keep the child in herposition of comfort. The PAT will also iden-tify the critical child in respiratory failurewho requires immediate assisted ventilation.Obtaining respiratory rate, listening for airmovement, and determining oxygen satura-tion by pulse oximetry will work in concertwith the PAT. The initial assessment shouldallow an evaluation of severity and urgencyfor treatment, and establish if specific treat-ment for upper or lower airway obstructionis indicated.

Specific Treatmentfor Respiratory Distress

After completing the initial assessment, con-sider specific treatment. The PAT and ABCDE

Oxygen Delivery, Procedure 3

OxygenTreatment with high-flow oxygen is usuallysafe. If the child has chronic respiratory ill-ness, be careful not to administer too muchoxygen. The prehospital professional mustweigh the possible benefits of giving oxygenagainst the risks of agitating the child andworsening her respiratory distress. This is aspecial concern in a child with an unstableairway. Oxygen toxicity in newborns, espe-cially premature newborns, is rarely an issuein the prehospital setting. Newborns withrespiratory distress, cyanosis, or other signsof respiratory disease require high-flow,100% oxygen. However, do not give oxygento newborns without signs of hypoxia, asexplained in Chapter 9.

Most children will accept oxygen ther-apy, especially if the prehospital professionalis creative in the approach. This often meansgetting the help of the caregiver. If a childresists the use of a mask or nasal cannula,have the caregiver give blow-by oxygenfrom the end of the oxygen tubing or fromtubing inserted into a cup (Figure 3-6).

Oxygen DeliveryGive oxygen to any child with clinicalsigns of cardiopulmonary distress or fail-ure, or with a history suggesting possibleabnormalities in gas exchange. The deliv-ery method should provide the concentra-tion of oxygen most appropriate for thechilds condition, degree of cooperation,respiratory effort, and age. For a step-by-

Figure 3-5 Tripod position.Figure 3-6 If the child resists application of a mask ornasal cannula, administer oxygen through a nonthreateningobject such as a cup.

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assessment will help determine whether thechild has upper or lower airway obstruction,lung disease, or disordered control of breath-ing (from conditions such as brain or nerveinjury, poisoning, or sepsis). Snoring or stri-dor indicates upper airway obstruction;wheezing indicates lower airway obstruction.It can be difficult to separate true stridor fromupper airway noise due to nasal congestion.Breath sounds may also make it difficult totell the difference between upper airway noiseand true wheezing. Listen for breath soundsin the second or third intercostal space at themidaxillary line bilaterally (Figure 3-7). At thislocation, it is easier to distinguish upper air-way congestion from lower airway obstruc-tion. When abnormal airway sounds are loud-est with the stethoscope held near the childsnose rather than over the lungs, nasal conges-tion is the likely cause.

The absence of abnormal airway soundsin a child with hypoxia and increased workof breathing suggests lung disease, such aspneumonia. Lastly, a child with hypoxia anddecreased work of breathing may have eitherrespiratory failure from airway obstruction orlung disease or disordered control of breath-ing from another insult to her brain, nerves,or metabolic system.

Upper Airway ObstructionProximal Airway ObstructionIn a patient with neurologic impairment,loss of oropharyngeal muscle tone maycause upper airway obstruction and stridordue to the tongue and mandible fallingback and partially blocking the pharynx.This is a common problem in children dur-ing and after seizures. The head-tilt/chin-liftmaneuver (Figure 3-8) or jaw thrust maneu-ver (Figure 3-9) may relieve this proximal

Do not move a child from her position ofcomfort.

Figure 3-7 Listen for breath sounds in the second or thirdintercostal space at the midaxillary line bilaterally.

When abnormal airway sounds are loudest withthe stethoscope held near the childs noserather than over the lungs, nasal congestion isthe likely cause.

Figure 3-8 Use the head-tilt/chin-lift maneuver to placethe airway in a neutral position.

airway obstruction. At times it may be help-ful or even necessary to have two rescuersassist with the jaw thrust maneuver, espe-cially in larger children, children who areactively seizing or in children receivingpositive-pressure ventilation (Figure 3-10).

Sometimes secretions, blood, or foreignbodies block the proximal upper airway.This is an important concern in the childwith closed head injury or seizures. Suction-ing alone will often relieve the upper airwayobstruction caused by fluids or occludingobjects in the mouth, pharynx, or nose.

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Specific Treatment for Respiratory Distress 59

possible. Causing the child to become moreagitated or struggle may worsen her airwayobstruction and precipitate the onset of acomplete obstruction leading to respiratoryfailure or respiratory arrest.

In an awake, alert child, upper airwayobstruction and stridor are usually due tocroup, a viral disease with inflammation,edema, and narrowing of the larynx, tra-chea, or bronchioles. Croup usually affectsinfants and toddlers. Most children withcroup have had several days of cold symp-toms. The cold symptoms are followed bythe development of a barking or sealcough, stridor, and various levels of respira-tory distress. There is usually a low-gradefever, and symptoms are often worse atnight. The severity of symptoms will varywidely among patients, but they usuallyprogress over days, rather than hours.

Treatment Treat children with apparentcroup with cool mist, either in the form ofhumidified oxygen or nebulized saline. Askthe caregiver to assist (Figure 3-11).

Bacterial Upper Airway InfectionsBacterial infections may also cause upper air-way obstruction in children. Unlike viralcroup, these infections tend to progress rapidlywith severe respiratory compromise developingover hours. The child with a bacterial upperairway infection usually is older than12 months, appears ill or toxic, has pain onswallowing, and is often drooling. Stridor maybe present, but the child may not have thebarking cough that is common with croup.

Maintenance of an adequate airway mayrequire placement of an oropharyngeal air-way, nasopharyngeal airway, or a endotra-cheal tube. The role of endotracheal intuba-tion of children in the prehospital settinghas been brought into question by recentdata demonstrating significant failure rates,induced hypoxia, airway injury, and endo-tracheal tube dislodgement. Bag-mask venti-lation is the key life-saving technique thatshould be mastered by all prehospital providersand will provide adequate airway managementfor the vast majority of pediatric patients.

Upper Airway ObstructionUpper airway obstruction beyond the proxi-mal upper airway may result from a variety ofcauses. It is not necessary to make an exactdiagnosis in order to provide appropriatemanagement to children with upper airwayobstruction. In most of these cases, simplyallow the child to maintain her position ofcomfort and provide supplemental oxygen bythe least invasive and least threatening means

Figure 3-9 Use the jaw thrust maneuver in a child withpossible spinal injury.

Figure 3-10 Two-rescuer technique for the jaw thrustmaneuver and positive-pressure ventilation.

Figure 3-11 Use the caregiver to assist in theadministration of oxygen or nebulized saline.

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There are several possible but even lesscommon causes of bacterial upper airwayinfections. Epiglottitis, inflammation of theepiglottis, is now extremely rare due to wide-spread vaccination of infants against the bac-teria Haemophilus influenzae, type B. Periton-sillar abscess, retropharyngeal abscess,tracheitis, and diphtheria are other possiblecauses of upper airway infection.

Treatment When a bacterial upper airwayinfection is suspected, give only general non-invasive treatment with high-flow oxygen in aposition of comfort. Avoid agitating the childby trying to place an IV or attempting anothermaneuver, and quickly transport. If the childis in respiratory failure, initiate bag-mask ven-tilation.

Stridor is often mistaken for wheezing. Stridor isan inspiratory sign of upper airway obstructionand may improve with an agent with vasocon-strictive properties, like nebulized epinephrine.

Position of comfort, humidified oxygen, andavoiding agitation are the best treatments forsuspected croup.

choking, gagging, and shortness of breathin a previously well child without a fever orother symptoms of upper respiratory tractinfection. Older infants and toddlers, whoexplore their world by placing things intheir mouths, are at highest risk.

Treatment If the child can still cough, cry, orspeak, the airway is only partially obstructed.Stridor is typical. Immediately transport suchchildren, who have incomplete upper airwayobstruction. Use only general noninvasivetreatment, avoid agitating the child, and keepher in a position of comfort.

If the child has severe respiratory distressand is at risk for getting worse during transport,be prepared to perform foreign body airwayobstruction maneuvers for complete obstruc-tion, as illustrated in Figures 3-12 and 3-13.Table 3-3 summarizes these maneuvers. Con-sider these foreign body airway obstructionmaneuvers if the child cannot cough, cry, orspeak. Never perform foreign body airwayobstruction procedures if the child has incom-plete obstruction (i.e., can cough, cry, or speak).

Airway Obstruction/ForeignBody RemovalIn the setting of complete airway obstruc-tion, prehospital professionals can make thedifference between life and death. Immedi-ate removal of an airway foreign body canoften be achieved using BLS procedures.

Foreign Body Airway Obstruction Maneu-vers If the child has complete obstructionand BLS maneuvers fail to dislodge the for-eign body to the mouth where it can be eas-ily removed, attempt bag-mask ventilation,using the two-person technique wheneverpossible (Figure 3-14).

Foreign Body AspirationForeign body aspiration may causemechanical obstruction anywhere in theairway, from the pharynx to the bronchus.A retained esophageal foreign body canalso cause respiratory distress in an infantor young child. This happens because thetrachea is pliable and can be compressed bythe adjacent distended esophagus. A typi-cal history of foreign body aspirationincludes the sudden onset of coughing,

Age TechniqueInfant Five back blows followed by five chest thrusts(< 12 months)

Child (> 1 year) Five abdominal thrusts

For the unconscious child or infant with asuspected airway obstruction, begin CPR.

Foreign Body AirwayObstruction Maneuvers

Table 3-3

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ment for all forms of bronchoconstrictionis similar, but asthma is much more likelyto respond to bronchodilators than bron-chiolitis.

AsthmaAsthma is the most common chronic diseaseof childhood, affecting almost 5 million chil-dren in the United States. The emergencydepartment admission rate for asthmaticsunder 5 years of age is more than twice the

Specific Treatment of Upper AirwayObstructionWhen transporting any child with sus-pected incomplete upper airway obstruc-tion, have airway equipment immediatelyavailable. Consider transporting the care-giver with any conscious child with airwayobstruction, as this may keep the childcalm. Also, the caregiver can help adminis-ter oxygen.

Lower Airway ObstructionBronchiolitis and asthma are the most com-mon conditions causing lower airwayobstruction in children. Foreign body aspi-ration is much less common and usuallyoccurs in toddlers who have been other-wise well, and then suddenly start choking,coughing, or wheezing. Wheezing is theclinical hallmark of lower airway obstructionof any cause. Pneumonia can also causelower airway disease but usually withoutobstruction. A specific diagnosis of lowerairway obstruction in the field is not neces-sary, and many times it is impossible to tellwhich of the three main conditions thechild is experiencing: bronchiolitis,asthma, or foreign body aspiration. Treat-

Figure 3-12 (A) Use five back blows, followed by (B) fivechest thrusts in infants with complete airway obstruction.

A

B

Figure 3-13 (A) Use five abdominal thrusts to treatcomplete airway obstruction in the conscious child in thestanding position. (B) For the unconscious child with asuspected airway obstruction, begin CPR.

A

B

Figure 3-14 Two-person bag-mask ventilation technique.

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obstruction and ventilation-perfusion mis-match. Clinically, children having an asthmaattack will show different degrees of tachyp-nea, tachycardia, increased work of breath-ing, and wheezing on exhalation. Pulseoximetry may be normal or low.

Carefully assess air movement by aus-cultation. The asthmatic complaining ofshortness of breath, but without wheezingon auscultation, may have too much air-way obstruction to wheeze. Aggressivebronchodilator treatment may improve air-flow and increase audible wheezing.Beware of the following features of the ini-tial assessment, which suggest severe bron-chospasm and respiratory failure:

Altered appearance Exhaustion Inability to recline Interrupted speech Severe retractions Decreased air movement

In the focused history, several thingssuggest that a severe or potentially fatalattack is possible. These include:

Prior intensive care unit admissions orintubation

More than three ED visits in a year More than two hospital admissions in past

year Use of more than one metered dose

inhaler (MDI) canister in the last month Use of steroids for asthma in the past

national average for all ages, and the mortal-ity rate for children is rising. Half of allpediatric asthma deaths occur in the out-of-hospital setting. The length of the finalattack is less than 1 hour in many children,and less than 2 hours in half of asthmaticchildren who die. Common reasons for anasthma attack include upper respiratoryinfection and exercise. Exposure to cold air,emotional stress, and passive exposure tosmoke may trigger attacks as well.

Asthma is a disease of small airwayinflammation. The inflammatory reactionleads to bronchoconstriction, mucosaledema, and profuse secretions. These threefactors in combination cause severe airflow

Never perform airway obstruction procedures ifthe child has only incomplete obstruction andcan still cough, cry, or speak.

Attempt BLS maneuvers in a child with sus-pected foreign body aspiration and critical air-way obstruction.

A mother calls 9-1-1 because an 11-year-old asthmatic cant breathe. The girl is on daily treatments with a metereddose inhaler (MDI). Her physician prescribed oral steroids yesterday for worsening asthma symptoms. The girl tellsyou using broken phrases that she was up all night, using her albuterol MDI every 1 to 2 hours. She is sleepy andpale, has audible wheezing and is in the tripod position. There are suprasternal, intercostal, and substernal retractionsand nasal flaring. The respiratory rate is 32 breaths/min, the heart rate 154 beats/min, and the blood pressure is138/84 mm Hg. Blood oxygen saturation is 86% on room air. On auscultation you hear minimal air movement and aprolonged expiratory phase.

1. What is this childs physiologic status and where is the level of her airway obstruction?2. What is the most important treatment?

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Use of bronchodilators more frequentlythan every 4 hours

Progressive symptoms despite aggressivehome therapy

Home therapy of asthma has several goals:preventing and controlling asthma symptoms,reducing the number of attacks and the sever-ity of each one, and reversing existing air flowobstruction. Some children with a history ofsevere or frequent asthma attacks are on dailymedications, but most children receive treat-ment only during serious attacks. Table 3-4lists the medications frequently used in homeasthma therapy for quick relief. Some patientsmay think they will obtain quick relief frommedications that do not have a quick onset ofaction and delay calling for help.

Treatment of Lower Airway ObstructionFor all children with lower airway obstruc-tion, give general noninvasive treatment asthe first field action.

Assisted Ventilation Because of the severe airtrapping associated with bronchospasm,assisted ventilation may be associated withmany complications and death. Positive pres-sure ventilation requires very high inspiratorypressures and may result in pneumothorax orpneumomediastinum. Consider bag-maskventilation of a wheezing child only if thechild is in respiratory failure and has failed torespond to high-flow oxygen therapy and stan-dard asthma medication. While assisting venti-lation in any patient with lower airwayobstruction, slow rates (1012 breaths perminute in older children and adolescents and amaximum rate of 20 breaths per minute ininfants) with long expiratory times are usefulin minimizing barotrauma and complications.

BronchiolitisBronchiolitis is a viral lower respiratory infec-tion, which usually affects infants and chil-dren less than 3 years of age. Often caused bythe respiratory syncytial virus (RSV), thisdisease is widespread in the winter months.The infection leads to destruction of the lin-ing of the bronchioles, profuse secretions,and bronchoconstriction. Infants are particu-larly likely to catch the disease because oftheir small airway size, high resistance to air-flow, and poor airway clearance. Airwayedema and debris from sloughed cells andmucous are much more important in thepathophysiology of this disease than bron-chospasm and smooth muscle contraction.

Presenting complaints of bronchiolitisinclude upper respiratory infection symp-toms, fever, cough, vomiting, poor feeding,poor sleep, and trouble breathing. Assess-ment shows variable degrees of increasedwork of breathing, tachypnea, diffuse wheez-ing, inspiratory crackles, and tachycardia.

Historical risk factors for respiratory failurein infants with suspected bronchiolitis includeage less than 2 months, history of prematurity,underlying lung disease, congenital heart dis-ease, and immune deficiency. Table 3-5 listsimportant clinical predictors of respiratory fail-ure in children with suspected bronchiolitis.

Class of Medication Medication Mechanism of ActionBeta-2 agonists Inhaled bronchodilators (albuterol Relax bronchiole smooth muscle; prevent bronchospasm; rapid onset of action.

[salbutamol]), levalbuterol

Anticholinergics Inhaled anticholinergics Relax bronchiole smooth muscle; decrease secretions; rapid onset of action.(ipratropium)

Anti-inflammatory Oral corticosteroids (prednisone) Block allergic response; reduce airway hyper-responsiveness; improvemedications response to bronchodilators; delayed onset of action (212 hours).

Asthma: Common Home Therapy Quick-Relief Medications for Acute Asthma AttacksTable 3-4

Respiratory rate > 60 breaths/min with increased work of breathing

Heart rate > 200 beats/min or < 100 beats/min

Poor appearance

Blood oxygen saturation < 90% on supplemental oxygen

Predictors of Respiratory Failurein Suspected Bronchiolitis

Table 3-5

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collection of fluid in the pleural space outsidethe lung parenchyma. Children with bacterialpneumonia usually have an abrupt onset ofsymptoms including fever, shaking chills,tachypnea, and frequently nonspecific com-plaints including lethargy or irritability, poorappetite, and occasionally chest pain. Coughmay not develop until after a period of othermore nonspecific symptoms.

Physical findings include fever, rales ordecreased breath sounds, and tachypnea orincreased work of breathing. Grunting res-pirations are relatively common in youngchildren with any form of lung disease.Wheezes may be heard, especially withviral infections, but are not as common asrales or decreased breath sounds. In theabsence of underlying illness, disability, orvery young age, it is unusual for a child toabruptly develop respiratory failure due topneumonia. Mild respiratory distress ismore likely.

Approach children with suspected pneu-monia like any patient with symptoms oflower airway disease. Making the diagnosisis not as important as providing good sup-portive care. Give general, noninvasivetreatment to all patients. Patients with signsof respiratory failure may need assisted ven-tilation. Respiratory failure from lung dis-ease is more commonly seen in younginfants, children with underlying neurologicor pulmonary disease, and children whohave been ill for several days. There is nospecific prehospital therapy for childrenwith pneumonia.

Foreign Body AspirationChildren with lower airway obstructiondue to foreign body aspiration usually areonly mildly ill. Unlike foreign bodies inthe upper airway, it is rare to develop res-piratory fai lure or complete airwayobstruction from a small foreign body inthe lower airway. Foreign body aspirationis most common in older infants and tod-dlers (Figure 3-15). Often, there is anabrupt onset of coughing or choking thatmay be followed by a period of relativelyfew symptoms. Tachypnea, increasedwork of breathing, and wheezing ordecreased breath sounds, which are usu-ally unilateral unless the foreign body isin the trachea, may develop rapidly orover a period of hours to days. Theabsence of a history of asthma or thesymptoms of an upper respiratory infec-tion in a child of the right age should sug-gest the possibility of foreign body aspira-tion. General noninvasive treatment,including allowing the child to assume aposition of comfort and providing oxygenif tolerated, should be given to al lpatients. Additional diagnostic tests maybe done after arrival at the emergencydepartment.

Lung DiseaseIn children, most lung disease is pneumonia.Other causes, such as pulmonary edema orpulmonary contusion, are rare. Pneumoniamay cause symptoms of lower airway diseaseand respiratory distress or failure in children.Almost all children with pneumonia willhave fever or a history of fever at some pointin their illness. The majority of pneumoniasin children are due to viruses. These childrengenerally have less severe symptoms andsymptoms of a more gradual onset than chil-dren with bacterial pneumonia.

Bacterial pneumonia in children occursfollowing hematogenous seeding or aspirationof bacteria into the lung. This is followed byan acute inflammatory reaction leading to theaccumulation of fluid within the airspaces ofthe lung. At times, this may be accompaniedby the development of a pleural effusion or

Figure 3-15 Examples of foreign bodies that can obstructthe airway.

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Disordered Control of BreathingSometimes hypoxia and/or respiratoryinsufficiency is caused by problems in con-trol of breathing. This category of respira-tory disease includes brain injury, spinalinjury, poisoning, metabolic problems, orsepsis. The hallmark of patients with disor-dered control of breathing is inadequateminute volume due to poor tidal volumeand/or slow breathing rate. Treatmentincludes ventilatory support with oxygen,bag-mask ventilation, and occasionallyendotracheal intubation.

Summary of SpecificTreatment for RespiratoryDistress

After identifying respiratory distress or fail-ure and beginning general supportive mea-sures, assess whether the anatomic level ofthe respiratory problem is in the upper orlower airway, using both the PAT and thehands-on ABCDEs. Stridor is the hallmarkof upper airway obstruction, wheezing is thehallmark of lower airway obstruction,grunting is the hallmark of lung disease, andinadequate minute volume and decreasedwork of breathing are the clinical markersfor disordered control of breathing.

The most common cause of upper airwayobstruction is croup. Rarely, foreign bodieslodged at or above the vocal cords, may bethe cause of stridor in infants and toddlers.Specific treatment of croup includes coolmist and nebulized epinephrine, if allowedby local protocol. Frequent causes of lowerairway obstruction are asthma and bronchi-olitisa disease of infants. Asthma is themost likely reason for wheezing in all chil-dren from infancy to adulthood. A nebulizedbronchodilatordelivered continuously ifnecessaryis a specific treatment for allcauses of wheezing. Albuterol (salbutamol)and epinephrine have similar effectiveness asbronchodilators, and the anticholinergic ipra-tropium provides added benefit in asthmapatients. Start treatment on scene in asthmat-ics, if allowed by local protocol.

Foreign body aspiration and pneumoniamay present as lower airway problems, butthere is no specific treatment for these condi-tions in the prehospital setting other than thegeneral noninvasive measures for respiratorydistress. Disordered control of breathing hasmany causes and requires general ventilatorysupport.

Management ofRespiratory Failure

Regardless of the cause, initially treat everycooperative child in respiratory failurewith general noninvasive measures. Ifupper or lower airway obstruction is pres-ent, attempt specific treatment. On theother hand, if the child has altered appear-ance or altered level of consciousness andhas signs of increased or decreased work ofbreathing (e.g., flaring, grunting, gasping,apnea, or cyanosis), or if the child has adocumented blood oxygen saturation ofless than 90% on 100% non-rebreathingoxygen mask, the child is in respiratoryfailure or respiratory arrest. For this child,bypass general noninvasive treatment andimmediately begin assisted ventilation.

First, postion the patient to maintainan open airway. Then use suction. Suction-ing is a basic technique to maintain anopen airway. Children have tiny airwaysthat are easily obstructed by secretions,vomitus, pus, blood, or foreign bodies.Children of different ages, with differentclinical problems, need different types ofsuction devices and suctioning procedures.For a step-by-step explanation, see

.If the patient is unresponsive, use an

airway adjunct. Adjuncts may immediatelyimprove the childs spontaneous ventila-tion. In addition, they may allow moreeffective bag-mask ventilation, reduce gas-tric inflation, and avert the need for endo-tracheal intubation. For a step-by-stepexplanation of this procedure, see

.Airway Adjuncts, Procedure 5

Suctioning, Procedure 4

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begin assisted ventilation with a bag-maskdevice at an age-appropriate rate. Avoid gas-tric insufflation. Add specific treatment forairway obstruction, such as an inhaled bron-chodilator, if indicated.

Initial Assessment:The Transport DecisionStay or Go?

When a child has respiratory distress, begingeneral noninvasive treatment (position ofcomfort and oxygen) and consider specifictreatment on scene. Never transport a childwho is in respiratory failure without assistedventilation. Also, never transport a child witha completely obstructed airway until after per-forming foreign body obstruction maneuvers.Immediate on scene care to support breathingwill improve the outcomes of children withmany respiratory emergencies. After openingthe airway and providing assisted ventilationwhen necessary, or after simply giving generaltreatment, the prehospital professional mustdecide whether to stay on scene to assess fur-ther and treat specifically, or to go.

Then deliver assisted ventilation orpositive-pressure ventilation using bag-mask. Bag-mask is usually the best methodfor providing oxygenation and ventilationduring stabilization and transport. Use anage-appropriate rate of 1020 breaths/minfor infants and children. Saying the words,Squeeze, release, release will help time theventilations to avoid a rate that is too rapid.Ensure that there is good chest rise. Goodbag-mask technique will decrease the risk ofgastric distensiona common complicationleading to elevation of the diaphragm,decreased lung compliance, and increasedrisk of vomiting and aspiration of gastriccontents. If a second rescuer is available,providing cricoid pressure using the Sellickmaneuver may help to further decrease gas-tric distension. With severe, lower airwayobstruction, slower rates and longer expira-tory times are indicated.

Bag-Mask VentilationBag-mask ventilation is one of the prehospi-tal professionals most useful skills in pedi-atric out-of-emergency department care.While the technique does not provide thedefinitive airway control that endotrachealintubation does, in most cases, bag-maskventilation will be the best technique forproviding oxygenation and ventilationduring resuscitation and transport. For astep-by-step explanation of this procedure,see .

Summary of Managementof Respiratory Failure

Respiratory failure or respiratory arrest canresult from many different insults to the air-way, mechanics of breathing, or gasexchange. Infection, trauma, and bron-chospasm are important causes in children.Think respiratory failure when initial assess-ment reveals a child with altered appearancein the setting of significantly increased ordecreased work of breathing. Bradycardia,poor air movement, and low oxygen satura-tion are key findings. In a child with respira-tory failure or respiratory arrest, immediately

Bag-Mask Ventilation, Procedure 7

Minimize gastric distension during bag-maskventilation with good bagging technique.

If the child does not respond to bag-mask venti-lation, or if there is a long transport time with acritically ill or injured child who has an unstableairway, consider endotracheal intubation if thisis part of your BLS protocol. Linking with an ALSunit may allow for advanced airway manage-ment. Remember, in most cases bag-valve-mask ventilation is the preferred method forventilatory support in the prehospital setting.

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If the PAT and ABCDEs are normal and thechild has no history of serious breathing prob-lems, the child does not usually require urgenttreatment or immediate transport. Take thetime to get a focused history and physicalexam and perform a detailed physical examina-tion (trauma patient) on the scene if possible.

If the child has respiratory distress andsigns of upper airway obstruction, transport isusually indicated after general noninvasivetreatment.

Additional Assessment

If the child has minimal respiratory distressand there are no immediate safety concernsfor the child or prehospital professional, con-sider obtaining the focused history and phys-ical exam and performing a detailed physicalexam (trauma patient) on scene. Use theSAMPLE mnemonic to find important fea-tures of the complete respiratory history.Table 3-6 gives examples of a focused historyin a child with a breathing problem.

Do vigilant ongoing assessment of allchildren with respiratory distress or failurewhile on the way to the ED. Use the PAT torecall observational indicators of effectivegas exchange, and watch respiratory rate,heart rate, and pulse oximetry. Be preparedto increase the level of respiratory supportor to correct complications of therapy if thechild worsens or fails to respond.

Component ExplanationSigns/Symptoms Onset and nature of shortness of breath

Presence of hoarseness, stridor, or wheezingPresence and quality of cough, chest pain

Allergies Known allergiesCigarette smoke exposure

Medications Exact names and doses of ongoing drugs,including metered dose inhalers

Recent use of steroidsTiming and amount of last doseTiming and dose of analgesics/antipyretics

Past medical problems History of asthma, chronic lung disease, orheart problems or prematurity

Prior hospitalizations for breathing problemsPrior intubations for breathing problemsImmunizations

Last food or liquid Timing of the childs last food or drink,including bottle or breastfeeding

Events leading to Evidence of increased work of breathingthe injury or illness Fever history

SAMPLE Components in a Childwith Respiratory Distress

Table 3-6

When a child fails to respond to assisted venti-lation with improvement in clinical status,quickly assess your equipmentfrom the oxy-gen tank to the patientfor mechanical failure.

A caregiver calls 9-1-1 because a 3-month-old girl has had three days of cough, runny nose and low-grade fever. Thecaregiver is concerned because the child seems to be working harder to breathe and is having a hard time taking feedings.On arrival, the child is found sitting on the caregivers lap. She appears sleepy and does not make eye contact or respondto examination. She has audible wheezing and deep subcostal and intercostal retractions. There is nasal flaring. Her skin ismottled and she is diaphoretic. Respiratory rate is 70 breaths/minute and her heart rate is 180 beats/minute. Her breathsounds are tight with only fair air movement but you hear high-pitched, inspiratory and expiratory wheezes throughout.Pulse oximetry in room air is 74% with a pulse that corresponds to the patients pulse on exam.

1. Is this child in respiratory distress or respiratory failure and what is the level of airway obstruction?2. What are the first steps in the management of this child?

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Case Study Answers

Case Study page 51

This child is in respiratory distress but does not seem to have progressed to respiratory failure.She is exhibiting many of the signs and symptoms of upper airway obstruction. Her loud,harsh inspiratory breath sounds are consistent with stridor. This sound along with the supra-clavicular and suprasternal retractions helps localize the obstruction to the upper airway. Shehas increased work of breathing, but does not show any signs of hypoxia or hypercapnia (car-bon dioxide retention). Upper airway obstruction and stridor in a young child after a few daysof an upper respiratory infection is most consistent with croup, a swelling in the tracheabelow the area of the vocal cords due to a viral infection. Other things that may cause upperairway obstruction include foreign bodies, bacterial infections (e.g., epiglottitis or retropha-ryngeal abscess) and airway edema due to allergic reactions.

Regardless of the cause, the management of children with upper airway obstruction is sim-ilar and is based on the severity of the symptoms. Keep this patient in a position of comfort,give humidified oxygen and transport to an emergency department for further care.

The child should be closely monitored as her upper airway obstruction may progress andrespiratory failure may develop.

Case Study page 62

This child is in respiratory failure. She has abnormal appearance (sleepy), poor color (pallor),and increased work of breathing (retractions, audible wheezing, flaring, tripod position). Hertachypnea, tachycardia, documented hypoxia, and poor air movement support this assessment.Her wheezing, and substernal and intercostal retractions localize her level of obstruction to thelower airway (within the thorax).

Further, she is being treated aggressively at home, with worsening symptoms despite steroidsand utilization of her albuterol (salbutamol) MDI far more frequently than is recommended forpatient self-administration. The fact that she was up all night indicates that she was in too muchrespiratory distress to recline or sleep.

Asthma is a chronic disease, involving inflammation of the small airways. Although bron-choconstriction, airway edema, and increased secretions all contribute to lower airway obstruc-tion, the only part of this pathophysiology that can be reversed in the short time frame of a fieldresponse is bronchoconstriction.

General noninvasive treatment includes administration of high-flow oxygen, and positionof comfort. Support ventilation with a bag-mask if her condition deteriorates. Positive-pres-sure ventilation will require high peak inspiratory pressures and may be associated with worseair trapping and barotrauma. If positive-pressure ventilation is required, it is important to usea very slow rate and allow for a long expiratory time to minimize air trapping.

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Case Study page 67

Using the PAT, this child has an increased work of breathing, abnormal appearance, and poor circulation to theskin. She is in respiratory failure. Her wheezes and subcostal and intercostal retractions localize her airwayobstruction to her lower airways. In the setting of preceding upper respiratory symptoms, fever, and progressivelower airway obstruction, the child probably has bronchiolitis. Open the childs airway and give high-flow oxy-gen. Do not delay transport because the child is not likely to have an easily reversible condition. This is unlikethe child with asthma, who will likely benefit from a dose of a bronchodilator on scene, before transport.

During transport monitor the childs respiratory status closely. Any evidence of decreased respiratoryeffort or slowing of the respiratory rate should prompt initiation of positive-pressure ventilation with a rel-atively slow rate and a long expiratory time.

Suggested Readings

TextbooksAmerican Heart Association. Textbook of Pediatric Advanced Life Support. Dallas, TX, American Heart

Association, 2002.Gausche M: Pediatric Airway Management for the Prehospital Professional. Boston, MA, Jones and Bartlett

Publishers, 2004.

ArticlesCummins R, Hazinski MF. The most important changes in the international ECC and CPR Guidelines

2000. Resuscitation 2000; 46:431437.Gausche-Hill M. Ensuring quality in prehospital airway management. Current Opinion in Anaesthesiology

2003; 16:173181.Kellner JD, Ohlsson A, Gadomski AM, et al. Efficacy of bronchodilator therapy in bronchiolitis: a meta-

analysis. Arch Pediatr Adolesc Med. 1996;150:11661172.Lee BS, Gausche-Hill M. Pediatric airway management. Clin Pediatr Emerg Med. 2001; 2:91106.Orenstein J. Prehospital pediatic airway management. Clin Pediatr Emerg Med. 2006; 7:3137.

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