Acute Care Exam #1

1. Honesty
2. Discipline
3. Creativity
4. Humility
5. Curiosity

-Shared goals
-Clear roles
-Mutual trust
-Effective communication
-Measurable processes and outcomes

-Both state and institutional bylaws regulate privileging, which is the authorization within a certain setting to provide care and services
-Duties, scope, and extent are determined and documented in the privileges

-Autosomal recessive genetic condition
-Disease of exocrine gland function and involves multiple organ systems
-Results in:
chonic respiratory infections
pancreatic enzyme insuffiency

-Defective CF transmembrane conductance regulator (CFTR) proteins result in decreased secretion of chloride and increased reabsorption of sodium and water across epithelial cells
-The thinner epithelial lining fluid and decreased moisture of mucus results in mucus that is stickier to bacteria, promoting infection and inflammation
-Secretions in the respiratory tract, pancreas, gastrointestinal tract, sweat glands, and other exocrine tissues have increased viscosity, which makes them tedious to clear

Pulmonary disease

-Accelerated loss of lung function
-Decreased quality of life
-Increased mortality
-Rhinovirus and respiratory syncytial virus (RSV) may enable Pseudomonas to more easily infect airway epithelial cells in children with CF

-Changes in cough and sputum production
-Dyspnea
-Decreased energy level and appetite
-Weight loss
-Decreases in spirometry

-Antibiotics
-Inflammatory mediators
-Bilevel or noninvasive ventilation
-Antimicrobials (inhaled and oral)
standard of care
minimum treatment course is 14 days

-Identifying and monitoring CF-related diabetes
-Frequent airway clearance treatments
-Nutritional support
-Reducing risks of new organism acquisition if hospitalized

-Most common comorbidity
-Leads to reduction in islet cell size and beta-cell area
-Glucose responsiveness and insulin secretion are affected by CF
-Pancreatic ductal obstruction can also occur due to acidification of the pancreatic juices from decreased secretion of sodium and bicarbonate
-Insulin therapy has been shown to improve clinical status and lung function

-Respiratory tract infection characterized by a paroxysmal cough
-The most common causative organism is Bordetella pertussis

-Children <1 year of age
-Especially those born prematurely, and patients with underlying cardiac, pulmonary, neuromuscular, or neurologic disease are at high risk of contracting the disease and for complications

-Once the bacteria invades, a mucopurulent sanguineous exudate forms in the respiratory tract
-This exudate compromises the small airways (especially those of infants) and predisposes the child to atelectasis, cough, cyanosis, and pneumonia

Respiratory droplets through coughing, sneezing, or close contact for extended periods of time

-Paroxysms of coughing
-Respiratory whoop
-Posttussive vomiting

-Catarrhal Stage
-Paroxysmal Stage

-Short or can be absent
-Infant can appear deceptively well with:
mild cough
afever
watery coryza
sneezing

-Gagging
-Gasping
-Eye bulging
-Vomiting
-Cyanosis
Bradycardia (or tachycardia if the illness is severe)
-The cough may or may not be paroxysmal

-Is the child immunized?
-Has the child been exposed to someone with a persistent cough?

-Apnea
-Seizures
-Respiratory distress
-Weight loss
-Dehydration
-Pneumonia
-Pulmonary hypertension
-Hypotension/shock
-Renal failure
-Death

-May cause leukocytosis resulting from lymphocytosis, although the white blood cell (WBC) count may also be normal
->60,000 cells/μl WBC has been associated with increased pertussis severity, including pertussis pneumonia and pulmonary hypertension
->30,000 cells/μl WBC is associated with increased morbidity
-Polymerase chain reaction (PCR) and culture should be sent to confirm the diagnosis
do not wait for results to begin treatment

-Respiratory distress
-Evidence of pneumonia
-Inability to feed
-Cyanosis or apnea, with or without coughing
-Seizures
-Affected infant less than four months of age

-Antibiotics
erythromycin
azithromycin
clarithromycin (>6 months)
-Treat infants less than four months old and children who have coughed for less than 21 days
-Infants with seizures, apnea or severe leukocytosis should be monitored in the pediatric intensive care unit (PICU)

-Accumulation of air between the lungs and chest wall
-It can be spontaneous or a result of trauma

-Hypotension
-Decreased oxygen saturation
-Tachycardia

-Decompression
-Chest tube insertion

-Collection of air that escapes the alveoli and tracks along the sheaths of the small blood vessels of the lung
-It rarely occurs spontaneously and is associated with mechanical ventilation, especially with high pressures in premature infants
-Occurs when the extra-alveolar air remains within the lung parenchyma and does not escape into other regions of the chest
-Commonly involves both lungs, but it may be lobar in distribution

-Airway obstruction
-Increased lung compliance
-Areas of hyperinflation
-Hypoxemia
-Hypercarbia

Premature neonates with respiratory distress and mechanical ventilation

-Increase in oxygen requirement
-CO2 retention
-Hypotension

-decreasing ventilator pressure as able
-Lateral decubitus positioning
-Selective bronchial intubation/ventilation

Presence of air within the mediastinal connective tissue

Presence of air within the pericardial sac

-Blunt trauma
-Barotrauma
-Fistulas with air-filled structures
-Gas-producing bacterial infections
-Iatrogenic causes

-Self-limiting
-Supportive treatment
-Decrease ventilator pressures if the child is on ventilator
-Offer oxygen support
-Pain control

-Usually supportive care
-Early recognition and treatment with pericardiocentesis prevents cardiac tamponade and may be lifesaving if the child is symptomatic

RSV

-Very contagious
-Inflammation of the small airways and then extension to the lung parenchyma
-Pneumonia is not always a component, but if they are in ICU then probably has pneumonia

-Males
-Younger age
-History of prematurity
-Exclusive bottle feeding (formula)
-FTT
-Lower socioeconomic class
-Comorbidities (CHD)
-Immunodeficiency history

-Chest X-Ray
only if severity or course suggest alternate diagnosis
-Nasopharyngeal Swab
only if required for cohorting admitted patients
-CBC
generally not helpful in diagnosis or monitoring routine cases
done in PICU
-Blood Gases
only if concerned about respiratory failure
-Bacterial Cultures
only if you are concerned for a secondary infection or sepsis

Cough

-Persistent resting oxygen saturation below 90% on room air
-Respiratory rate (>70-80 breaths/min)
-Dyspnea, intercostal retractions and cyanosis
-Parents knowledge of suctioning/medical status
-You can give a child time in the ED to watch and wait

-True apnea spell (>20 seconds of apnea)
-Hypoxemia despite low-flow oxygen support
-Dyspnea and significant work of breathing
-Hypercarbia (example: CO2’s 70s)
-Hemodynamic instability
-Devere dehydration
-Severe distress
-Altered mental status
-Requires ICU level HFNC

-CAM, pulse oximetry
-Enteral nutrition orally or via feeding tube
-IV hydration if unable to achieve enteral nutrition
-Euvolemic fluid balance
-Comfort
-Suctioning
-Respiratory support

-Nasal cannula
-HFNC
infants do good with this because it gives a little PEEP
-CPAP
-BIPAP
-Intubation
acute respiratory failure

-Beta 2 agonists
only when there is a huge family history and significant wheezing
-Corticosteroids
-Nebulized hypertonic saline
-Antibiotics
only if there is a secondary infection or pneumonia
-Antivirals
-Caffeine

-Oxygen saturation >90% on room air awake and sleeping
-Adequate oral intake
-No more than mild/moderate work of breathing
-Reliable caretaker (suctitioning)
-Able to obtain follow up care
-Caregiver teaching on bronchiolitis should be preformed (VERY IMPORTANT)

-Nature of bronchiolitis as a viral illness
-Encourage hydration
-Instruct that patient may take more frequent smaller feeds
-Instructions on signs and symptoms of respiratory distress
-Noninvasive suctioning teaching
-Avoiding tobacco and over the counter cough and cold remedies

2 years and older

-Initital Step:
look at the child from the outside of the door
WOB (accessory muscle usage, retractions, nasal flaring)
talking in complete sentences
awake and alert
color (cyanosis or pallor)
-Scoring system

-Acute trouble breathing and/or wheezing
-Age >12 months
-Prior diagnosis of asthma or history of 2 significant wheezing episodes

-Diffuse polyphonic expiratory wheezing
-Increased expiratory phase
-Decreased air movement
-Silent chest is a sign of imminent cardiopulmonary failure

-Decrease in systolic BP >10 mmHg during inspiration
-Sign of severe exacerbation
-Difficult to determine without an arterial line
-May see a change in pulse strength during palpation or a change in amplitude of pleth tracing

-Your initial categorization of how sick the child is, how quickly interventions need to happen to prevent worsening
-1 Critical
-2 Acute
-3 Urgent
-4 Urgent

-Severe wheezing/stridor with:
severe tachycardia
bradypnea/apnea (worse than tachypnea)
-Grunting
-Severe retractions
-Decreased muscle tone
-Lethargy

-Wheezing/stridor with moderate:
increased WOB
nasal flaring
tachypnea
retractions
prolonged expiration
intermittent grunt
-Decreased aeration with moderate tachypnea and WOB
-Pulse oximetry <92%
-Stridor at rest
-Asthmatic with history of intubation

-Wheezing/stridor with mild:
increased WOB
tachypnea
retractions

-Wheezing with minimal:
WOB
tachypnea
retractions
-Pulse oximetry >95%
-Histort of nebulizer within the hour

-Time of onset of exacerbation
-Potential causes
illness
last food
-Severity of symptoms compared with previous exacerbation
-Response to treatments prior to admission
-All current medications
time of last dose of bronchodilators
last course of systemic steroids

-Estimate number of:
hopitalizations for asthma (in last year and intubations)
presence of complicating illness (pulmonary or cardiac)
disease aggravated by steroid therapy (diabetes)

-Very focused exam
-Assess the severity of the exacerbation
-Pulse oximetry (if <90%, put on oxygen right away)
-Level of alertness
-Presence of cyanosis or pallor
-Respiratory distress
-Wheezing
-Decreased aeration
-Identify complications:
pneumonia
pneumomediastinum
-Rule out upper airway obstruction

-Determines pediatric asthma severity based on physical exam findings
-Applicable to ages 1-18 years old
-Mild, Moderate, Severe, and Respiratory Arrest Imminent

-Wheezing:
none or mild (0)
none or end of expiration only
-WOB:
none or mild (0)
normal or minimal retractions
-Prolonged Expiration:
none or mild (0)
normal or minimally prolonged
-Breath Sounds/Aeration:
normal

-Breathlessness:
with activity or agitation
-Talks In:
sentences
-Alertness:
alert
-Pulse Oximetry:
>94%
-PEF (% of predicted by height):
>70%

-Wheezing:
moderate (1)
throughout expiration
-WOB:
moderate (1)
intercostal retractions
-Prolonged Expiration:
moderate (1)
-Breath Sounds/Aeration:
decreased at bases

-Breathlessness:
while at rest
for infants:
shoft or shoter cry
difficulty feeding
prefers sitting
-Talks In:
phrases
-Alertness:
may be agitated
-Pulse Oximetry:
variable
-PEF (% of predicted by height):
40-69%

-Wheezing:
severe (2)
inspiratory/expiratory or absent due to poor air exchange
-WOB:
severe (2)
suprasternal retractions
abdominal breathing
-Prolonged Expiration:
severe (2)
-Breath Sounds/Aeration:
widespread decrease

-Breathlessness:
while at rest
for infants:
stops feeding
sits upright
-Talks In:
words
-Alertness:
agitated
-Pulse Oximetry:
variable
-PEF (% of predicted by height):
<40%

-Wheezing:
diminished due to poor air exchange
-WOB:
tiring
inability to maintain work of breathing
intercostal retractions
-Prolonged Expiration:
severely prolonged

-Breath Sounds/Aeration:
absent
minimal
-Alertness:
drowsy
confused
-Pulse Oximetry:
variable

-No routine lab studies recommended
-Viral Testing
only if there is a suspicion of another virus
-Blood Gas
for patients with:
severe distress
hypoventilation
inadequate response to initial treatment
-CBC and Blood Cultures
not recommended for initial assessment
might see a spike in WBC and/or glucose if given steroid therapy
-Metabolic Panel:
not recommended for routine assessment

-Should not delay other ongoing treatment
-Focal exam:
crackles
decreased breath sounds
-Concern for foreign body
-Failure to improve with typical treatments
-Fever >39 C
-Severe respiratory distress

-On first-time wheeze
-Children presenting with first-time wheeze and history suggestive of alternative diagnosis
-Do not demonstrate improvement with albuterol

-MDI has been proven to be as effective as nebulized albuterol
depending on PAS Score
-Oral steroid doses are as effective as IV and often the preferred route for children
-Albuterol
-Ipratropium
-Prednisone
-Dexamethasone

-Unit Dose (0.5%)
2.5 mg (0.5 mL)
-MDI Puffs
4 puffs
-Continuous
7.5 mg/hr

-Unit Dose (0.5%)
3.75 mg (0.75 mL)
-MDI Puffs
6 puffs
-Continuous
11.25 mg/hr

-Unit Dose (0.5%)
5 mg (1.0 mL)
-MDI Puffs
8 puffs
-Continuous
15 mg/hr

-Unit Dose (0.5%)
500 mcg over 1 hour in unineb or
250 mcg q20 x2
-MDI Puffs
4 puffs

-Unit Dose (0.5%)
1000 mcg over 1 hour in unineb or
500 mcg q20 min x2
-MDI Puffs
6 puffs

-Unit Dose (0.5%)
1000 mcg over 1 hour in unineb or
500 mcg q20 min x2
-MDI Puffs
8 puffs

-2 mg/kg PO/IV
-Max: 60 mg

-Mild to moderate flare
repeat in 24-48 hours
crus tablet with cherry syrup, juice or yogurt
-5-8 kg
4 mg
->8-12 kg
6 mg
->12 kg
8 mg

-Second-line medications are effective in treatment of exacerbations
-Can be administered in the ED with protocols in place
-Magnesium Sulfate
-Terbutaline

-50 mg/kg
-Max 2 g
-Given with normal saline bolus
-20 mL/kg
max: 1 L
-Given q15 min
-Observe in ED for 60 minutes before transfer to inpatient floor

-Increased doses of >4 mcg/kg/min are associated with increased side effects
-Tachycardia
-Hypotension
-Arrhythmias
-Must be given in a monitored setting
-If a patient develops hypotension, increasing the infusion by 0.1-0.2 mcg/kg/min will help overcome the beta selectivity and improve the hypotension

-Repeat as needed every 15-30 minutes for a maximum of 3 doses total
-Subcutaneous:
if IV is unavailable
10 mcg/kg
max: 250 mcg
-IV Push
infuse over 5 minutes
10 mcg/kg
max: 250 mcg

-Ongoing and consistent reexamination of the effectiveness of the treatment provided and level of distress
-Continuous albuterol is not first-line management in acute asthma exacerbations
-Monitor potassium since albuterol can make it increase
-Ongoing monitoring every 20 minutes for the first hour of therapy is required

-PAS Score of 5-7
-Observation
1 hour after albuterol/ipratropium nebs
2 hours after stopping continuous albuterol and/or magnesium administration
give 4-8 puffs of albuterol HFA prior to discharge

-Things to have in place prior to discharge from ED:
asthma education
asthma action plan
verify action plan has been updated prior to discharge
asthma bundle
relabel albuterol for home use
relabel fluticasone MDI if a dose was given in the ED or urgent care
refill and restart prescribed daily controller medications and bronchodilators

-SPO2 <90% on room air
-Requires continuous albuterol for over 1 hour or requiring albuterol every 2 hours
-Severe asthma or PAS >8

-First 4 hours
-5-10 kg
Unit Dose (0.5%): 2.5 mg (0.5 mL)
MDI Puffs: 4 puffs
Second q 4 hour (home dose): 2 puffs
->10-20 kg
Unit Dose (0.5%): 3.75 mg (0.75 mL)
MDI Puffs: 6 puffs
Second q 4 hour (home dose): 2 puffs
->20 kg
Unit Dose (0.5%): 5 mg (1.0 mL)
MDI Puffs: 8 puffs
Second q 4 hour (home dose): 2 puffs

-Additional Medications
continue home dose every 4 hours until discharge
continue prednisone
restart/initiate controller medications as needed
-Assessment
respiratory q4 hours
HR and RR q4 hours
pulse oximetry PRN
oral intake and hydration status
-Progression
discharge after home dose

-5-10 kg
Unit Dose (0.5%): 2.5 mg (0.5 mL)
MDI Puffs: 4 puffs q2 hours
->10-20 kg
Unit Dose (0.5%): 3.75 mg (0.75 mL)
MDI Puffs: 6 puffs q2 hours
->20 kg
Unit Dose (0.5%): 5 mg (1.0 mL)
MDI Puffs: 8 puffs q2 hours

-Additional Medications
discontinue ipratropium bromide
continue prednisone/prednisolone
-Assessment
respiratory q2 hours
HR and RR q2 hours
pulse oximetry per protocol
hydration status: IV & PO
-Progression
must be on RA (no oxygen requirement)
at 1st mild/moderate assessments (treat)
assess in 2 hours then hourly x2 hours
hold treatment if mild at 2 and 3 hours

-5-10 kg
1.5 mL/hr (7.5 mg/hr)
->10-20 kg
2.25 mL/hr (11.25 mg/hr)
->20 kg
3 mL/hr (15 mg/hr)

-Additional Medications
consider ipratropium bromide
prednisone/prednisolone/methylprednisone
-Assessment
respiratory q1 hours
HR and RR q1 hours
pulse oximetry continuous
hydration status IV & PO
-Progression
moderate assessment for 2 hours
then advance to moderate

-BIPAP or CPAP can improve work of breathing and asthma scores when used with corticosteroids and beta agonists
-May facilitate delivery of inhaled beta agonist
-Alleviates work of breathing by maintaining small airway patency
-Associated with use of fewer adjuvant therapies

-Cardiopulmonary arrest
-Persistent hypoxemia
-Severe respiratory acidosis not responsive to medical therapies
-Hypotension
-Not responding to steroids
-Not awake or participating with exam/mental status changes

-Intubation may be associated with hypotension and even cardiac arrest as venous return decreases when transitioning to positive pressure ventilation
-High risk of:
barotrauma
pneumothorax
air leak syndrome
induce laryngospasm
depressed circulatory function
-Concern for myopathy with prolonged steroid and paralytic use
-Risk of secondary ventilator associated pneumonia

-Patient on room air
-Albuterol spaced to every 4 hours
-Asthma education completed
-Ensure PCP follow-up within 7 days of hospital discharge
-Ensure hospital follow-up scheduled with pulmonary/allergy within 90 days of discharge
-Prescription for albuterol q4 hours for 48 hours
-Prescription for oral corticosteroids for 3-10 days
-Ensure patient has inhaled corticosteroids
-Provide Asthma Action Plan
-Consider flu shot when appropriate

-Determines the acid-base status of the blood
-Determines the overall metabolic status of the child
-Normal range: 7.35-7.45
-Acidotic: <7.35
-Alkalotic: >7.45

-Normal range: 35-45
-Acidotic: >45
-Alkalotic: <35
-Can be different on a venous sample

Normal range: 75-100

-Bicarbonate
-Helps us determine alkalosis and the metabolic state
-Normal range: 22-26
-Acidotic: <22
-Alkalotic: >26

pH is within the normal range

-Either the PaCO2 or HCO3 is trying to compensate for the primary acid-base disturbance
-pH is not within normal range

-Amount of base (in mmol) required to titrate a liter of whole arterial blood to a pH of 7.40
-Lower Base Deficit:
acidotic state
-Higher Base Deficit:
alkalotic state

-pH <7.35
-CO2 >45
-Respiratory drive suppression
-Trauma
-Acute lung injury
-Hypoxia
-Pneumonia
-Neoplasm
-Bronchiolitis

-Sleepiness
-Papilledema
-Easily fatigued
-Headaches
-Tremors
-Shortness of breath
-Sweating
-Confusion
-Hyperventilation

-pH >7.45
-PaCO2 <35
-Chronic pneumonia
-Anemia
-Hypotension
-Anxiety
-Sepsis

-Numbness
-Muscle spasms
-Irregular heartbeat
-Lightheadedness
-Tremors
-Breathlessness
-Confusion

-pH <7.45
-HCO3 <22
-Hypoxemia
-Diarrhea
-Sepsis
-Renal tubular acidosis

-Rapid heartbeat
-Sleepiness
-Diarrhea
-Nausea/Vomiting
-Fatigue
-Confusion
-Rapid breathing
-Headaches
-Fruity breath

-IV fluids
-Possibly NaHCO3
-Supportive oxygen
-Bed restrictions
-Full assist as independent ambulation could be dangerous

-pH >7.45
-HCO3 >26
-Diuretics
-Upper GI losses from NG tube
-Vomiting

-Arrythmia
-Muscle Spasms
-Tingling or Numbness
-Tremors
-Confusion
-Hypoventilation
-Irritability
-Seizure/Coma

-Calculation relies on measuring specific Na+, K+, Cl-, and HCO3-
-(Na+ + K+) – (Cl- + HCO3-) = Anion Gap

-The goal is always neutrality
-Anions:
lactate
chloride
bicarbonate
albumin
-Cations:
hydrogen
potassium
sodium
magnesium
-Balance of each are the physiologic indicator for the child and the state of illness

-Causd by the disruption of the alveolar-capillary barrier
-Non-cardiac etiology
-Alveolar epithelium Injury
pneumonia
primary acute respiratory distress
-Capillary endothelium injury
systemic inflammation syndrome
sepsis

-Hypoxemia
-Radiographic opacities
-Decreased end expiratory lung volume
-Decreased lung compliance
-Increased alveolar dead space

-When the respiratory system can’t support oxygenation, ventilation or both
-CO2 >50 and pH of <7.35
-A child or infant that presents in acute respiratory distress, but is also accompanied with acute hypoxemia requiring supplemental oxygen in order to maintain oxygen saturations >92%
-Often precedes cardiopulmonary arrest in children

-Oxygen saturations
-Degree of respiratory distress

-Associated with lung disease
asthma
bronchiolitis
pneumonia
pulmonary edema
-Mismatched ventilation and perfusion in regional lung units
-Treatment:
administer supplemental oxygen

-Consequence of ventilatory failure
-Occurs in conditions that affect the respiratory pump
drepressed neural ventilatory drive (Ingestions)
acute or chronic upper airway obstruction
neuromuscular weakness (Duchenne’s MS)
marked obesity
rib-cage abnormalities

-Delivery of mechanical respiratory support without the need for endotracheal tube intubation through some interface
-Nasal Prongs, face masks, full face mask

-Child with acute respiratory distress
-Child with chronic respiratory distress
-Hypercarbic and/or hypoxemic
-Sleep apnea
-Child with atelectasis
-Asthma
-Bronchiolitis
-Chronic Conditions (Muscular dystrophy)
-Cystic Fibrosis
-Pneumonia
-Central sleep apnea
-Children who does not immediate intubation

-Reduce child’s WOB
-Reverse hypoventilation
-Increase FRC
-Maintain and splint collapsed airways
-Improve diaphragmatic activity
-Requires less sedation than invasive ventilation

-Absence of cough or gag reflex
-Air leak syndrome
-Apnea
-Cardiovascular instability
-Choanal stenosis or atresia
-Facial burns
-Trauma
-GI bleed
-Impaired mental status

-Improve oxygenation
-Decrease work of breathing
-Prevent apnea
-Decrease left ventricular afterload
-Reduce atelectasis
-Minimize need for endotracheal intubation

-Causes less airway trauma
-Reduces the risk of health-care associated infections
-Reduce the risk of deconditioning respiratory muscles
helpful in muscular dystrophy
-Decreases need for sedation and analgesia

-Interface issues:
loss of skin integrity
eye irritation
improper fixation of mask or nasal prongs, resulting in leaks
-Air pressure and flow issues:
can blow on eyes and cause eye discomfort and dryness
nasal discomfort
gastric insufflation
aspiration
pneumothorax
air trapping
-Impedance of speech

-Barotrauma
-Aspiration
-Hemodynamic Instability
-Skin breakdown
-Nasal mucosal trauma

-Correct side and apparatus
-Want the best exchange of CO2 and oxygen
-Maintain comfort to promote compliance
-Appropriate fit with minimal leak
-Least likely interface to cause skin breakdown or ocular injury

-Reduces work of breathing
-Provides PEEP and aids in lung recruitment
-Flow rates exceed patient inspiratory flow rates
-Thermally controlled at 37 decrees C
-Delivers a precise concentration of oxygen with a blender
-The cannular should be <50% of the nares

-Infants: 8 L/min (max)
-Adolescents: 40 L/min (max)

-Flow should be titrated to effect
-If the child can oxygenate and maintain FRC on lower flows, then that is the correct flow to use
Wean flow once you get down to 40-50% FIO2

-Heliox
-Nitric oxide
-Continuous albuterol

-Wash out nasopharyngeal dead space
-CPAP effect
-Decrease airway inflammation
-Hydrates thickened secretions
helps with bronchiolitis

-Increased work of breathing
-Tachypnea
-Retractions
-Thick secretions
-Neonates
CPAP effect

-Mouth breathers
can use chin straps if needed
-Child with nasal obstruction
-CO2 retention
won’t wash out CO2

-Continuous positive pressure in the airways throughout the respiratory cycle
-Prevents alveolar collapse
-Facilitates oxygen delivery to pulmonary capillaries
-Increases functions residual capacity and opens collapsed alveoli
-Constant programmed level of distending airway pressure throughout the entire respiratory cycle
-Equivalent to PEEP on a ventilator
Any child who is hypoxemic, but does not have CO2 retention

-Should only be used on a child who is able to breathe
-Nasal Prongs:
thick secretions are more likely to impede gas flow
best for infants because they are obligatory nose breathers
-Mask CPAP:
requires appropriate size and a secure seal
-Full Face Mask:
aspiration secondary to vomiting is a risk

-Uses both CPAP and child-triggered volume of positive inspiratory pressure delivered via a nasal or full-face mask
2 levels of pressure in response to the patient flow (IPAP and EPAP)
intended to support ventilation in a noninvasive way in spontaneously but insufficiently breathing patients
-When CPAP is not enough
greater level of respiratory support
higher mean airway pressures
improves hypoxemia when other methods do not have as timely of a response

-Provides added positive pressure during inspiration
-Several modes
-Good for children that are:
hypoxic
CO2 retention

-Spontaneous Mode
-Spontaneous Timed Mode
-Timed Mode

-Patient triggered breaths are supported with bi-level positive pressure
-Patient determines the respiratory rate

-Patient triggered breaths are supported with bi-level positive pressure
-If the patient doesn’t breathe or the ventilator does not detect a breath, the ventilator delivers a preset mechanical rate

The ventilator cycles a preset mechanical rate and inspiratory time at the preset bi-level positive airway pressure

-Blood gases need to be done at this point
-Is there a reduction in the respiratory rate and WOB?
-What is the oxygen requirements of the child?
-Is there improvement in the hypercarbia on blood gas analysis?
-Improvement on lung sounds?

-Providers set:
FIO2 (set to 100% post intubation, unless its a cardiac kid)
IMV (rate)
PEEP (5 is physiologic)
pressure support
tidal volume (6-8 mL/kg)

-Evaluate your blood gas and adjust according to the child’s exam
obtunded child with altered LOC and high CO2 will need higher IMV than an asthmatic who is tachypneic
-Your goal is not to normalize the CO2, but to support the:
work of breathing
comfort level
distress
if you have a CO2 of 50, but everything else is okay with the child, then you do not have to run around and chase that CO2
-Most ventilators don’t provide support over the IMV if the child is breathing on their own extra breaths

Set a higher rate than you would normally set

Set a normal rate, but not too high

-Higher PEEP
-Higher FIO2

30 minutes

-Volume Control
-Pressure Control

-The volume of breath delivered is exactly the dame every time
-Constant and does not vary
-The ventilator will deliver whatever pressure is needed to achieve the tidal volume in the set time that each breath must be delivered in
-Example: Rate of 14 and a TV of 60 on a 10 kg kid
the kid will get a TV of 60 for each breath (even if he breathes 20)

-Designed to deliver mechanical breaths at a set inspiratory pressure
-You set:
PEEP
PIP: high level of PEEP
-Allows clinicians to control the amount of distending pressure applied to airways and the alveoli
-Because the amount of driving pressure applied to the airway is preset, the delivered volume is variable and dependent upon the patients:
inspiratory effort
pulmonary mechanics (compliance, resistance)
-You would choose PC if you don’t want to force a bunch of air in the lungs making pressures to be excessively high and causing barotrauma

-Positive pressure that will remain in the airways (alveoli) at the end of the respiratory cycle (end of exhalation) in order to exchange CO2 and oxygen
-Physiologic PEEP = 5
-Start with 5 on the ventilator
if there is an oxygenation problem prior, you will probably go up on PEEP
if you start going above 10-15, think about alternative strategies

-Increased airway pressure
improves oxygenation and alveolar recruitment
-Increased functional residual capacity (FRC)
prevention of airway and alveolar collapse
-Increase arterial oxygen tension
-Increased capillary-alveoli interface for gas exchange
-Minimizes oxygen toxicity
able to lower FIO2

-Respiratory rate
-Even if the child is breathing over the set ventilator rate, this is the number of breaths the ventilator will give each minute
-A respiratory rate that matches normal for age is recommended for patients not requiring hyperventilation for treatment of metabolic acidosis or intracranial injury
-High rates allow less time for exhalation, increase mean airway pressure, and causse air trapping in patients with reactive airway disease

-Respiratory Rate
30-40 bpm
-Inspiratory Time
0.3-0.5

-Respiratory Rate
25-30 bpm
-Inspiratory Time
0.5-0.6

-Respiratory Rate
20-25 bpm
-Inspiratory Time
0.6-0.8

-Respiratory Rate
15-20 bpm
-Inspiratory Time
0.6-0.8

-Respiratory Rate
12-15 bpm
-Inspiratory Time
0.8-1.2

-Measure of the amount of air a person inhales during a normal breath
-Traditional preset TVs >10 mL/kg have been proved to be associated with increased risk of pulmonary barotrauma and should be avoided
-Higher TVs decrease venous return and reduce cardiac output
-Maximum of 6-8 mL/kg
for patients with no significant lung disease
-Any time you adjust the TV, make sure you listen to the child to ensure good air movement with each breath

-Decrease in PaO2
increase FIO2
increase PEEP
-Increase in CO2
increase rate
increase TV
-Decrease in CO2
decrease rate
decrease TV

-“Oxygenator.”
-When children experience harm from a conventional ventilator, an oscillator is an alternative with less barotrauma.
-Stretches the alveoli open and holds them open at a constant pressure
-The “jiggle” of the alveoli allows for oxygenation and ventilation.

-Air-leak syndrome
-Bronchopulmonary fistula
-Pneumothorax
-Persistent air leak
-Pneumonia
-Meconium aspiration
-Pulmonary hypertension
-Severe acute respiratory distress syndrome (ARDS)

-Obstructive airway disease (HFOV can lead to severe air trapping if used improperly)
-Traumatic brain injury/intracranial hypertension (high airway pressure can lead to decreased venous return and reduced cerebral perfusion)
-Hemodynamic compromise (especially if unresponsive to fluids/inotropes)

-MAP (mean airway pressure)
-Delta P
-Hertz

-Similar to positive end-expiratory pressure (PEEP) on a conventional ventilator
-The goal is to diminish lung injury yet have optimal pressure to oxygenate and ventilate adequately
-Set 2–4 cmH2O over the value of the PIP on the ventilator
-Contributes to the oxygenation of the child

-Amplitude
-Similar to tidal volume on a conventional ventilator
-The best setting is determined by the wiggle of the patient’s chest
-Contributes to the removal of CO2

-Frequency, which is similar to the rate on a conventional ventilator
-Multiply the number of hertz times 60 to determine the rate being delivered
-2–10 kg child: 10 Hz
-13–20 kg child: 8 Hz
->30 kg child: 6 Hz
-Adjusted according to the CO2 on a blood gas

Increase the Delta P or decrease the hertz

Decrease the Delta P or increase the hertz

Increase the MAP

-Increase FIO2
-Increase MAP (1-2 cmH2O)

-Decrease FIO2
-Decrease MAP (1-2 cmH2O)

-Increase amplitude
-Decrease frequency (1-2 Hz) if amplitude maximal

-Decrease amplitude
-Increase frequency (1-2 Hz) if amplitude minimal

-Hemodynamics must be monitored closely, as HFOV tends to be associated with hypotension.
-Consider pneumothorax for any acute change in saturation, blood pressure, heart rate, and status of the child.
-Oxygen consumption should be strongly considered for any child on the HFOV, clustering cares, and preoxygenation for suction and procedures.

-Clamp the endotracheal tube (ETT) prior to removing the ventilator circuit for any reason.
-Suction at least once a day to maintain patency of the (ETT).
-Paralytic infusion is often needed for children on HFOV. If a child is not therapeutically paralyzed, you must ensure they are comfortable.
-Daily chest X-rays allow for evaluation of pulmonary disease status. Eight to nine ribs expanded indicates proper inflation of the lungs.

-Not a secure airway
-Do not use if a child has a full stomach
-Can vomit around LMA

-Airway device when you have a patient with an empty stomach for an elective procedure or deep sedation
-Can’t intubate and can’t ventilate
emergencies where we can’t get a breathing tube in

-Need appropriate size mask
-From the chin up to the nose
-It’s okay to bag them if the child is awake and sitting up
when they take a breath in, you give them a breath
-Chin lift
-Mask seal is the most important part of bagging

-Always go for a cuffed tube
-Need it for positive pressure ventilation
-Can deflate and inflate as much as you need
-Will not hurt airway
-Check inflation prior to intubation
-Keep syringe on when intubating

-Straight
-Lifts the epiglottis up
-Glottis and retinol cartilage should be there to see

-Curved
-meant to put the tip into the vallecula and pull up

-Diagnosis of exclusion
-Have to exclude other possible reasons for the epsiode (RSV)
-Infants who present with unexpected change in an infants:
breathing
appearance
behavior
-Brief indicates that the episode was <1 minute
-Resolved indicates that the infant is asymptomatic on presentation after the event

Only when the infant is asymptomatic on presentation and when there is no explanation for the episode after a focused history and physical examination

-A sudden, brief, and now resolved episode in an infant that includes 1 or more of the following features:
cyanosis or pallor
absent, decreased or irregular breathing
marled change in tone (hyper- or hypo-)
altered level of responsiveness

-Infants who have experiences BRUE are at low risk for having a recurrence or serious underlying disorder if they have all of the following characteristics:
age >60 days
if premature, born at gestational age is >32 weeks are current postconceptional age is >45 weeks
occurrence of only 1 BRUE
no prior BRUE
did not occur in clusters
duration of BRUE <1 minute
no cardiopulmonary resuscitation by a trained medical provider required
no concerning historical features
no concerning physical examination findings

-Feeding difficulties
-Recent upper respiratory symptoms
-<2 months
-History of previous episodes

-Close attention to the neurologic, respiratory and cardiac system
-Neurologic:
alertness
tone
-Developmental milestones met?
-Evaluation for respiratory distress or upper airway obstruction,
-Assessment of facial dysmorphism
assess for genetic abnormalities
-Cardiac examination, including:
murmur
gallop
decreased pulses
hepatomegaly

-Bruises
-Anything that raises flags for intentional injury to a child
-Toxic appearance
the event would still be ongoing and not a BRUE
-Lethargy
the event would still be ongoing and not a BRUE
-Dysmorphic features
-Siblings with sudden death
underlying genetic disorder
-Need for resuscitation during the event

-Educate caregivers about BRUEs, and the low risks for infants with these characteristics
-CPR instruction to caregivers
-Engage in shared decision-making about further evaluation and disposition
-Follow-up check with medical provider within 24 hours to identify infants with evolving medical concerns that would require further evaluation and treatment
-Educate the family that there is no known association between BRUE (with low-risk characteristics) and the risk for SIDS

-Initial evaluation and observation
-Continuous pulse oximetry monitoring for at least 4 hours
-Laboratory testing:
CBC or hematocrit
Blood gases
Bicarbonate or venous pH
Lactic acid
-Screens for inborn errors of metabolism
-Respiratory virus testing panel
-Pertussis testing
-Screen for child maltreatment and feeding disorder
-Review results of newborn screening test
-If infant has a change in sensorium, evaluate for toxic ingestion

-Admit to hospital for observation
-Continued pulse oximetry monitoring
-Observe for repeat or social concerns
-Social work evaluation for parent support and identify any social concerns
-Further evaluation guided by specific concerns:
if event is related to feeds: perform feeding evaluation with SLP
if any concern for child abuse: consult CPS and SW
if any neurologic abnormalities or recurrent events with loss of muscle tone evaluate for: seizures and CNS abnormalities
if hypoglycemia or other abnormalities from lab work-up above, consult with specialist for possible inborn errors of metabolism

-Discharge home
-Report to primary care provider and arrange for close follow-up

-Sleep-related hypoventilation
-Autonomic nervous system dysfunction
-Increased risk for Hirschsprung disease and tumors of neural crest origin (e.g., neuroblastoma, ganglioneuroblastoma, ganglioneuroma)

Abnormal control of ventilatory function with associated abnormalities of autonomic function

-In infancy with cyanosis with sleep
-There is no distress despite hypoxemia and hypercapnia

-Alveolar hypoventilation, with increased PCO2 and hypoxemia
-Low tidal volume and/or respiratory rate
-Lack of normal ventilatory and arousal responses to hypercarbia and hypoxemia
-Limited breath-to-breath variability

-Decreased beat-to-beat heart rate variability
-Attenuated heart rate response to exercise
-Orthostatic hypotension
-Attenuation of normal sleep-related blood pressure decrements
-Prolonged sinus pauses

Box-shaped face (shorter and flatter) with inferior reflection of the lateral segment of the vermillion border on the upper lip

-Hirschsprung disease (16% to 20%)
-Severe constipation
-Esophageal dysmotility and dysphagia

-Neuroblastoma
-Ganglioneuroblastoma
-Ganglioneuroma

-Pupillary abnormalities
miosis (altered pupillary response to light)
-Altered accommodation with accommodative strabismus

-Intubation and mechanical ventilation in infants
-Tracheostomy, which is considered the safest option for infants
-Sleep studies every six months for the first three years of life, then at least annually thereafter
-Echocardiograms (EKGs) every six months for the first three years of life, then annually thereafter

-Continuous EKGs every six months for the first three years of life, then annually thereafter.
-Complete blood counts (CBCs) and blood gases every six months for the first three years of life, then annually thereafter.
-Neurocognitive testing every six months for the first three years of life, then annually thereafter.

-Children between one and three years of age are at highest risk
-Should be suspected i any child with a choking episode

1. What was aspirated.
2. Where in the airway the obstruction is located.
3. The degree of the obstruction.

-Choking
-Gagging
-Respiratory distress (unexplained)
-Cyanosis
-Mental status change

-Acute oneumonia
-Recurrent pneumonia
-Lung abscess
-Bronchiectasis
-Hemoptysis

-Cough
-Tachypnea and stridor
-Focal wheezing or decreased air entry (triad of wheezing, cough, and diminished breath sounds)
-Late presentations can be days to weeks after aspiration due to infection or inflammation

X-Ray is the first step

-Pneumonia (often develops distal to an obstructed airway)
-Mediastinal shift away from the foreign body
-Atelectasis
-Hyperinflated lung

-Removal of the foreign body.
-Rigid bronchoscopy, which is the procedure of choice for identification and removal of a foreign body
-Antibiotics for infected areas of bronchiectasis
-Cultures obtained during bronchoscopy guide the initial antibiotic choice

-Acute and diffuse inflammatory lung injury
-Etiologies are pulmonary and non-pulmonary:
increased vascular permeability
leaking of fluid causing: Dehydration, edema, wet lungs
increased lung weight
loss of aerated tissue: No CO2 and O2 exchange
hpoxemia
pulmonary opacities
decreased lung compliance
increased physiologic dead space: you cannot exchange oxygen or CO2

-Viral pneumonia
-Bacterial pneumonia
-Sepsis
-Trauma
-Inhalation
smoke
-Transfusion

The respiratory distress will get worse because the inflammatory markers and leaking will increase with the antibiotics killing the bacteria

-Low tidal volume: 4-8 mL/kg
-Rather than distending the lungs and stretching them out, lower volumes are accepted as long as you have:
appropriate chest rise and fall
good aeration
maintaining saturations
PO2 in the 80s
CO2 in the 60s
as long the child is doing okay

-Limiting plateau pressure
so there are not big swings in respiratory pattern
do not want to pop the alveoli open with a very high inspiratory pressure
-Permissive hypoxemia and hypercapnia
-Corticosteroids are recommended for select populations
depends on etiology behind distress/failure
example: A previous healthy child with viral pneumonia may not benefit, but distress fron croup will benefit

The inability of the respiratory system to support oxygenation, ventilation, or both
-Hypoxic Respiratory Failure:
escalate oxygen requirement
-Hypercarbic Respiratory Failure
high CO2 to the point they arent responding to exam or family

-Intrinsic and acquired lung disease: pneumonia, bronchiolitis, asthma, ARDS, aspiration, croup, and foreign body
-Airway disorders: subglottic stenosis, vascular ring, airway malacia
-Neuromuscular dysfunction: CNS dysfunction, Myasthenia Gravis, Guillian-Barre, myopathy

-Wheezing: needs to be described in notes and the progression
-Expiratory grunting: auto PEEPing
-Decreased or absent breath sounds: shunting and V/Q mismatch
-Nasal flaring
-Retractions
-Tachypnea: compensating
-Bradypnea: no longer compensating
-Cyanosis
-Restlessness: asthmatics
-Irritability: infants
-Confusion: older kids
-Fatigue

-Non-invasive ventilator
HFNC: much better for asthmatics because of positive pressure
CPAP
-Cuffed endotracheal tube
-Instilled saline to suction ETT
-Daily extubation readiness trial
-Continuous CAM
-End-tidal CO2
-Consideration for INO therapy

-HFOV
-Airway clearance regimen
-Minimal sedation
-Delirium screening
-Consider neuromuscular blockade
-Kids with difficult airways
-Enteral nutrition
very important
early nutrition with good calories is the best way to help them heal

-Monitor respiratory effort
-Targeted sedation management
-Adequate nutrition