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Now let's cover a fairly lengthy but important subject of upper airway respiratory distress. And it's important to remember that an upper airway obstruction can present mild all the way to severe, and includes the large airway anatomy such as the nose, the pharynx, or the larynx. Because children and infants have a much smaller airway than adults, in fact if you look at a child's pinky or a baby's pinky, that's about the size of their trachea. They're more susceptible to those types of obstructions. And in an child or infant with a decreased level of consciousness, the tongue can cause an obstruction because the muscles relax and the tongue falls back into the back of the throat, obstructing the actual oral pharynx area of the airway. Food or small foreign body objects, infections like epiglottitis or croup, thick secretions in the nasal passages or swelling of the airway from a condition like anaphylaxis or epiglottitis are all common causes of upper airway obstruction. Less common, but possible, upper airway obstructions can be caused from such things as a mass like an abscess or a congenital condition in the airway or trauma even, that causes narrowing of that same airway. The signs of an upper airway obstruction are different from lower airway obstruction, in that the signs occur most during inspiration. Typically, the signs include inspiratory retractions, the use of accessory muscles, nasal flaring, hoarseness, snoring, drooling, a change in sound of their voice or cry, or that really, really common sound like that barking, seal-like bark cough. That also is accompanied with the stridor-like sounds when auscultating lung sounds. Usually, as an upper airway obstruction worsens, breathing becomes more labored and faster. However, in the later stages with severe hypoxia, breathing becomes slower and actually will eventually stop altogether if left untreated. Early recognition, identification and treatment of respiratory distress in infants and children is vital to their survival and good outcomes. Respiratory distress can quickly progress to respiratory failure and cardiac arrest. Treatment would include proper positioning of the patient so that they're most comfortable and they're in a position that keeps the airway open to help support breathing efforts. Now, this could include that the child is sitting upright so that their head is higher than their heart, or if they really are feeling distressed, they could even lean forward or hold a teddy bear, anything that kind of helps them feel more comfortable decreases their stress level. Next we should probably check lung sounds and apply an oxygen saturation monitor while the child is still on room air. This'll establish a good baseline for the SpO2 level. Now, we're going to want to administer high-flow oxygen right away for respiratory distress. Remember, the goal is to keep the oxygen sat above 94%. We could consider suctioning as needed, and after initial oxygen therapy is established, the assessment of their blood pressure, their pulse, their respiratory rate, their temperature, and a good ECG should all be the next things to follow. It's gonna be important to identify and treat the specific upper airway obstruction based on the signs and symptoms. Now, croup is most commonly identified, like I said before, with that seal-like bark. Stridor lung sounds and possibly even retractions are gonna be really visible in those severe cases. Usually, lower lung sounds are clear. For croup, we want to administer nebulized epinephrine at five milliliters of 1:1000 as indicated. When the initial airway treatment has been initiated, IV or IO access should be established in order to have an access point to give corticosteroids if that's needed. A commonly recommended corticosteroid is dexamethasone. 0.6 milligrams per kilogram, we deliver that IV or IO. Now, reassess the vitals after the initial treatment and monitor our patient closely. It's a good idea to be prepared to intubate in case respiratory failure occurs. For things like anaphylaxis, intra-muscular epinephrine or an auto-injector would be the first emergency treatment. Corticosteroids, albuterol, and antihistamines can also be administered, depending on the signs and symptoms. If a child or infant has a foreign-body airway obstruction where they cannot cough or breathe, it needs to be removed immediately with proper basic life support. Now, we're gonna use certain techniques like abdominal thrusts, back slaps, or chest thrusts. But for a mild foreign-body obstruction, as an aspiration, where the child's able to make sounds and cough forcefully, one should not try to physically remove it, but rather, call for expert consultation if time allows. And if the patient status remains stable, you can still see if maybe a surgical or a deep suction might be called for. Allowing the child to remain the position of comfort and monitoring them closely for deterioration, and if they do deteriorate, we want to treat them accordingly.
In this lesson, we're going to cover upper 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.
Respiratory distress is an important subject to cover, and it's important to note that upper airways obstructions can present mild to severe symptoms and include the large airway anatomy – such as the nose, pharynx, and larynx.
Because children and infants have much smaller airways than adults, they are more susceptible to these types of obstructions. Remember, a child's trachea is roughly the size of their pinky finger.
Pro Tip #1: Also, in children and infants with a decreased level of consciousness, the tongue itself can cause the obstruction, because when the muscles relax, the tongue can fall to the back of the throat and obstruct the oral pharynx part of the airway.
There are several common causes of upper airway respiratory distress in pediatric patients, and these include:
And less common causes include:
The signs and symptoms of upper airway obstructions are different than those for lower airway obstructions, as they occur mostly during inspiration and include:
Usually, as upper airway obstructions worsen, breathing will become more labored and faster.
Pro Tip #2: However, it's important to note that in the later stages with severe hypoxia, breathing becomes slower and will eventually stop altogether if left untreated.
Early recognition, identification, and treatment of respiratory distress in infants and children is vital to achieve a good outcome and also for their survival, as respiratory distress can quickly progress into respiratory failure and cardiac arrest.
Treatments for specific causes will often vary, however there are some general methods used to treat a child in respiratory distress, and these include:
It's also important to identify and treat specific types or causes of upper airway obstruction based on the patient's signs and symptoms.
Croup is most commonly identified by:
For treating croup, administer nebulized epinephrine at 5ml of 1:1000 as indicated. And after initial airway treatment has been initiated, establish IV or IO access to administer corticosteroids if required.
A commonly recommended corticosteroid for croup is dexamethasone at .6mg/kg delivered via IV or IO.
Pro Tip #3: It's important to reassess the patient's vitals after the initial treatment and continue to monitor them closely. You should also be prepared to intubate if respiratory failure occurs.
For pediatric patients with anaphylaxis, treat with intramuscular epinephrine, as this is considered the first course of treatment for this condition.
Depending on the patient's specific signs and symptoms, you should also consider:
If the patient has a foreign body obstruction, where they cannot cough or breathe, that obstruction must be removed immediately with proper basic life support.
Techniques you can use to remove an obstruction are:
For mild cases of foreign body obstructions, you'll recognize this as the child will still be able to make sounds, like coughing forcefully.
Pro Tip #4: Do not try to physically remove the obstruction in these cases. Instead, call for expert consultation, if time allows. And if the patient's status remains stable, you should still see if surgical intervention or deep suctioning is required.
Always 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.