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Abnormal respiratory rate and effort is considered to be a condition called respiratory distress. It can vary greatly from something just as potentially benign as tachypnea that's self limiting all the way to tachypnea with chest retractions and as poor as agonal gasps. The latest guidelines for PALS related respiratory distress include increased work of breathing, inadequate respiratory effort known as hypoventilatlon or a slow respiratory rate known as bradypnea, and irregular breathing. Now it’s vital that well prepared PALS providers can identify respiratory conditions that are treatable with something as simple as suctioning airway secretions or administering oxygen. However, it’s vitally Important that PALS providers recognize conditions that may not be as blatant but are rapidly deteriorating into respiratory failure. These conditions require immediate and accurate Interventions with advanced airway techniques which include assisted bag-mask ventilation. And when it comes to infants and children, respiratory distress can quickly progress to respiratory failure and that system failure quickly deteriorates into cardiac arrest. Good neurologically intact survival to hospital discharge is much more probable after respiratory arrest than after cardiac arrest. If a child with a respiratory problem develops cardiac arrest, outcome is usually poor. A provider can greatly improve this outcome by identifying and treating respiratory distress and respiratory failure early and proactively not allowing the child to deteriorate into cardiac arrest. One of the most common airway complications is simply poor positioning of the child’s airway through misalignment. Now this can be easily corrected by placing the child in a sniffing position. Keep in mind that this should not hyperextend the child’s neck but simply place them in a good neutral airway position. One simple way to place the child in this sniffing position is to ensure that the child is in a supine position and flex the child’s neck forward at the shoulders while extending the head. Again, the child should look as if they are sniffing into the air but not hyperextended as that can also impede the airway. If this doesn't help, we should then begin to assess for further obstructions. Now I think it’s important to cover a frequent problem that can occur during bag-mask ventilation. This is inflation or distention of the stomach. The complication with this is that it makes it much more probable that the patient's gonna regurgitate gastric contents which can cause both acute and long term respiratory problems. Some of the more frequent reasons for this is: Partial Airway obstruction, when high airway pressures are required for ventilation, this is common when ventilating those with poor lung compliance. Sometimes it can happen if we are hyperventilating the patient with a bag valve mask, the volume delivered is too high, the pressure created is too high or the patient is unconscious or in full arrest and therefore has poor gastro-esophageal sphincter tone. Some great ways to help prevent this from occurring is to ventilate at a rate of 1 breath every 2 to 3 seconds, avoiding creating too high a peak pressure during the ventilation process. This can be done by delivering enough pressure and air to see good and full chest rise but not too much so as to bypass the esophageal sphincter and then put air into the stomach. Though cricoid pressure is allowed to be used in PALS, it has been said that there is insufficient advantage evidence in order to make it a routine procedure. However, in an unresponsive victim and if there is a second provider able to perform the cricoid pressure separate from the other Advanced Life Support duties, it may be used to help prevent gastric inflation. In the case where there is evidence of gastric inflation, advanced providers are allowed to decompress the gastric pressure by inserting a naso or orogastric tube which could help avoid gastric reflux. In PALS, suction devices both portable and mounted are able to be used. The benefits of a portable device is that it can be transported to wherever it’s needed. But, sometimes the portable types of suction can be inadequate based on their maximum suction power. A suction force of negative 80 to negative 12 millimeters of mercury is usually needed to remove most airway secretions. Now, wall mounted devices are usually more powerful and therefore can offer much greater suctioning power. But, they cannot be moved and therefore they might be limited. Lastly, a bulb or syringe style device is simple to use but offers very little suction power. The positive is that it doesn’t require any outside or internal power supply but the negative is that it can only really be used for very light secretions and usually in only small patients. This wouldn't work with large amounts or thick types of secretions. We would want to use an appropriate suction device whenever secretions, vomit or blood is in the oropharynx, nasopharynx or the trachea. Now remember that the mouth should be suctioned first, then the nasal passages. Some of the most common complications of suctioning would include soft tissue injury, agitation, gagging and vomiting, along with vagal stimulation which can cause bradycardia and hypoxia. We should be careful to avoid these complications and be aware of them throughout our treatment. Two of the most common types of suction catheters are either rigid or soft. A soft, flexible plastic suction catheter is most commonly going to be used for aspiration of thin secretions from the nasopharynx or suctioning an advanced airway like an endotracheal tube. A rigid suction catheter is most commonly used for suctioning the oropharynx when there is thick secretions like vomit or blood. A color coded length based resuscitation tape is really helpful when trying to find the appropriate sized soft catheter for advanced airways. It’s also important to limit suctioning to 10 seconds in order to help avoid hypoxemia.
Any abnormal respiratory rate or effort is a condition known as respiratory distress. In this lesson, we'll go over the importance of early recognition of respiratory emergencies, the proper head position for treatment, and some tips, techniques, and equipment used in respiratory emergencies.
Respiratory emergencies can vary greatly, from something as benign as tachypnea that's self-limiting all the way to agonal gasps.
It's important to know the latest guidelines for PALS when treating for respiratory distress, and this includes conditions like hypoventilation (inadequate respiratory effort), bradypnea (slow respiratory rate), and irregular breathing issues.
It's vital that all PALS providers are well-prepared to identify respiratory conditions quickly and easily, whether you're dealing with something easily treatable – like suctioning an airway secretion or administering oxygen – to more serious conditions that are less obvious, harder to identify, and that can quickly deteriorate into respiratory failure.
The latter will require immediate and appropriate intervention most often using advanced airway techniques, including assisted bag mask ventilation.
Pro Tip #1: When it comes to infants and children, respiratory distress can quickly progress to respiratory failure and that system failure can eventually deteriorate into cardiac arrest. Neurologically intact survival to the hospital for infants and children is much more likely before cardiac arrest, than it is after.
One of the more common airway complications can be attributed to poor positioning of the pediatric patient, and thus poor airway access.
To combat any potential alignment issues, make sure the child is laying down and facing upward. The head and neck should be in a slightly sniffing position, which is more neutral than tilted, or ever so slightly tilted.
Be sure not to hyperextend the child's neck, as this can also impede the airway. Instead, flex the child's neck forward at the shoulders while extending the child's head. To achieve the slightly sniffing head position, consider how your head and neck react when you walk into a kitchen and smell a freshly baked apple pie.
Pro Tip #2: If the child is two years or older, use padding under the shoulder blades, if available, which should help maintain the proper positioning and make it easier to adequately oxygenate the patient. And if this doesn't help, assess for further airway obstructions.
A frequent problem that can occur during bag mask ventilation is inflation or distension of the stomach. If this happens, it's much more probable that the patient will regurgitate gastric stomach contents, which can contribute to both acute and chronic respiratory issues.
Some common reasons for gastric inflation include:
Pro Tip #3: To prevent these situations from occurring, ventilate at a rate of 1 breath every 3-5 seconds and avoid creating too high of a peak pressure during ventilations. Deliver only enough pressure and air to see full chest rise and no more.
Warning: Delivering too much pressure and air could result in bypassing the esophageal sphincter, which means putting air into the stomach instead.
Though cricoid pressure is allowed for use in PALS, research suggests that the advantages are insufficient to make it a routine procedure. However, having said that, if you have an unresponsive victim and a second healthcare provider who can perform the cricoid pressure separate from other advanced life-saving duties, using it may be a good idea to prevent gastric inflation.
If there is evidence of gastric inflation, advanced healthcare providers are allowed to decompress the gastric pressure by inserting a naso or orogastric tube to help avoid gastric reflux.
In PALS, both portable and mounted suction devices can be used.
Advantages of portable devices include transporting them to wherever needed. However, a common disadvantage is the poor or inadequate suctioning power, even at max capability.
A bulb or syringe style device is simple to use but has the same disadvantage, as it too offers little suction power. The benefit of these, however, is that they don't require a power source. However, they tend to only work on small patients and for very light secretions.
Pro Tip #4: A suction force of negative 80mm to negative 12mm of mercury is usually required to remove most airway secretions.
Wall mounted devices, while not portable, are usually more powerful and can offer much greater suctioning power. But the lack of portability limits the scenarios in which they can be used.
It's important to use an appropriate suction device whenever secretions, vomit, or blood is in the oropharynx, nasopharynx, or trachea. It's equally important to use one immediately after birth if there is evidence of a meconium stain.
Warning: Remember to suction the newborn's mouth first, as baby's are mouth breathers. Then suction the nasal passages after.
Some of the more common suctioning complications include:
It's important to understand and avoid these complications whenever possible, and to know the potential risks when suctioning a patient.
There are two common types of suction devices: rigid and soft.
Rigid suction catheters are most commonly used for suctioning the oropharynx when there are thick secretions like vomit and blood.
Soft, flexible suction catheters are most commonly used for aspiration of thin secretions from the oropharynx and nasopharynx or for suctioning an advanced airway like an endotracheal tube.
Pro Tip #5: A color coded link-based resuscitation tape is really helpful when trying to find the appropriate size of soft catheter to use for advanced airways. It's also important to limit suctioning to 10 seconds to help avoid the possibility of hypoxemia.
All healthcare professionals can greatly improve the outcomes of respiratory emergencies by quickly and properly identifying and treating respiratory distress and respiratory failure early and proactively. Doing so will limit the chances of that child's condition deteriorating into cardiac arrest.