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Now in this case, we're gonna talk about respiratory distress as it affects the lower airway. In conditions such as asthma, bronchiolitis, cause an obstruction of the lower airway in the lower trachea, the bronchi, or the bronchioles. Now in contrast to upper airway obstructions, lower airway obstructions are typically more apparent during the expiratory phase of the respiration cycle. Like wheezing most commonly is on expiration, and a prolonged expiration that takes more effort, may be often recognized as retractions, nasal flaring, and an active process of attempting to blow the air out of their lungs. Coughing is also quite typical with this lower respiratory distress. With infants, the respiratory rate increases. When a lower airway obstruction worsens, inspiratory retractions become more noticeable, as the respiratory effort becomes more difficult. Lung disease can also appear as a lower airway obstruction. Lung disease causes a child's lungs to become stiff. Increased effort during inspiration and expiration is often identified by retractions, and accessory muscle use, due to the accumulation of fluid, or inflammation in the alveoli or interstitium. Because small airways in the lower lungs collapse, we might even see grunting respirations, as they're often present as a result of the increased respiratory efforts. Now just as with upper airway obstruction, early recognition, identification, and the treatment of respiratory distress in infants and children is extremely vital. Respiratory distress can quickly progress to respiratory failure and cardiac arrest. Treatment begins with placing the patient in the best position of comfort, that keeps the airway open, and helps support breathing efforts. Usually keeping the head of the bed elevated, is your best option for setting the child up. Next, check the lung sounds, and apply an oxygen saturation monitor, while the patient's still on room air. High flow oxygen should then be started right away for respiratory distress. The goal is to keep the oxygen saturation, again, above 94%. After initial oxygen therapy is established, assessment of a good blood pressure, pulse, respiratory rate, their temperature, and a good ECG should all follow. Identify and treat the specific lower airway obstruction as needed based on the signs and the symptoms the patient's exhibiting. And if the patient's condition is asthma, treatment would include a nebulizer with 2.5 milligrams of albuterol, and possible administration of corticosteroids. If the patient's condition is bronchiolitis, then suctioning of the oral and the nasal passages as needed, would be your best treatment. Assess the need for further treatment by considering laboratory and other tests, like viral studies, a chest x-ray, and arterial blood gas. Once the patient is stabilized, medical consultation for effective and ongoing, managed, definitive care should be initiated.
In this lesson, we're going to cover lower airway respiratory distress, including causes, signs and symptoms, treatment options in general, and some information on the best courses of treatment for a few specific causes of respiratory distress in pediatric patients.
At the end of the lesson, we'll provide a Word about head bobbing or seesaw respirations, which often indicate that the child or infant has an increased risk for further deterioration.
The two most common causes of lower airway respiratory distress in pediatric patients are:
These conditions cause obstructions to the lower airway specifically in the:
In contrast to upper airway obstructions, lower airway obstructions are typically more apparent during the expiratory phase (rather than inspiratory) of the respiration cycle.
The signs of lower airway obstruction include:
For instance, wheezing most commonly occurs during expiration – specifically a prolonged expiration that takes more effort – and can often be recognized as:
Pro Tip #1: In infants and children, when lower airway obstructions worsen, inspiratory retractions become more noticeable as respiration effort becomes more difficult.
Lung disease can also appear as a lower airway obstruction. Lung disease causes a child's lungs to become stiff, and increased effort during inspiration and expiration is often identified by:
Because small airways in the lower lungs collapse, you might even see grunting respirations, as these are often present as a result of increased respiratory efforts.
Just as with upper airway obstructions, early recognition, identification, and treatment of respiratory distress in infants and children is extremely vital for a positive outcome and to increase their chances of survival. And remember, respiratory distress can quickly progress into respiratory failure and cardiac arrest.
Treatments for specific causes will often vary, however there are some general methods to treat a child in respiratory distress, and these include:
Pro Tip #2: If the child is lying on a bed, such as in a hospital or ambulance, put the head of the bed into an elevated position, which can be easier than having the child use their own strength to remain in an elevated-head position.
It's also important to identify and treat specific types or causes of lower airway obstruction based on the patient's signs and symptoms.
If asthma is causing the child's lower airway obstruction, treat the patient via a nebulizer with 2.5mg of albuterol and the possible administration of corticosteroids.
If the child is suffering from bronchiolitis, suctioning the oral or nasal passages as needed will be your best course of treatment. However, assess the need for further treatment and consider laboratory and other tests such as:
Once the pediatric patient is stabilized, initiate medical consultation for effective and ongoing managed definitive care.
And remember to allow the infant or child to remain in the most comfortable position possible and always monitor them closely for deteriorating symptoms. And if they do deteriorate, treat them accordingly.
Head bobbing and seesaw respirations will often indicate that the child has an increased risk for deterioration.
Head bobbing is caused when the pediatric patient has to use their neck muscles to assist with breathing. The child will lift their chin and extend their neck during inspiration and allow their chin to fall forward during expiration. Head bobbing is most commonly seen in infants and can be a sign of respiratory failure.
Seesaw respirations are present when the patient's chest retracts, and their abdomen expands during inspiration. During expiration, the movement reverses, as the patient's chest expands, and the abdomen moves inward.
Seesaw respirations typically indicate an upper airway obstruction. However, they can also be indicated in severe lower airway obstructions, lung tissue disease, and states of disordered control of breathing.
Seesaw respirations are characteristic of infants and children with neuromuscular weakness. And it's important to note that this inefficient form of ventilation can quickly lead to fatigue.