PALS

Respiratory Distress and Failure

Respiratory System Physiology

The main function of the respiratory system is to provide for the exchange of O₂ and CO₂
The majority of O₂ is bound with hemoglobin in the blood
Respiratory problems may originate from any part of the respiratory tract, as well as through diseases and injuries that affect the central nervous system or muscles
Problems may develop due to compromised oxygenation or ventilation, and from damaged respiratory tissues
Children have relatively high metabolic rates; respiratory problems may develop quickly
Ventilation and airway problems are exacerbated due to the small size of children’s airways

Key Definitions

ARDS: Acute respiratory distress syndrome

Arterial O₂ Content: Total oxygen in the blood. It is a combination of bound O₂ (attached to hemoglobin) with non-bound O₂ in the blood

CPAP: Continuous positive airway pressure

Hemoglobin, Hgb: Molecule that carries oxygen in red blood cells

Oxygen saturation, O₂sat: The amount of oxygen that is bound to hemoglobin.

PaCO₂: Arterial tension of carbon dioxide

PaO₂: Arterial tension of oxygen

PEEP: Positive end-expiratory pressure

PO₂: Atmospheric pressure of oxygen

SpO₂: Oxygen saturation level monitored by pulse oximetry

V/Q Mismatch: V is ventilation; Q is blood flow to lung (perfusion). Simply put, blood is flowing to the lungs, but the blood is not being oxygenated by the lung tissue.

Hypoxemia
- Hypoxemia is low oxygen in the blood
- Low PaO₂ and Low SpO₂
- May sometimes lead to tissue hypoxia
- Compensatory mechanisms, including increased cardiac output and hemoglobin concentration, may sometimes be able to maintain adequate oxygenation of tissues despite hypoxemia

Tissue hypoxia
- Tissue hypoxia is inadequate oxygenation for the bodily tissues
- Illnessessuch as anemia, and injuries may result in tissue hypoxia despite adequate PaO₂levels
- Hyperventilationand tachycardia may help the body to compensate for tissue hypoxia
- Worsening tissue hypoxia leads to cardiac and respiratory distress and possible arrest

Understanding Respiratory Distress, Failure, and Arrest

Respiratory arrest is the cessation or absence of breathing. For purposes of PALS, inadequate breathing such as agonal respirations should also be considered respiratory arrest.
It is equally, if not more important, for PALS providers to be experts at identifying signs and symptoms that are likely to progress to respiratory and possibly cardiac failure.

A person with absent or ineffective breathing and a pulse should be treated with rescue breathing, not chest compressions. If the person in respiratory arrest loses their pulse during resuscitation, he or she should be treated as cardiac arrest.

In children, respiratory arrest is usually a progression from respiratory distress and respiratory failure. Steps should be taken to intervene during respiratory distress to prevent escalation to respiratory failure and ultimately respiratory arrest. Respiratory arrest can further deteriorate into cardiac arrest and death.

The sooner that respiratory distress is identified and treatment begins; the better patient outcomes will be. Intervention that begins during respiratory distress is generally more effective than Intervention that begins during respiratory failure. Likewise, intervention that begins during respiratory failure is generally more effective than intervention that begins during respiratory arrest.

Identify Early, Intervene Early

Respiratory Distress

Respiratory distressis a clinical condition in which the respiratory rate is abnormal and there is increased work of breathing.

Occurs when child attempts to maintain homeostasis despite airway obstruction, fatigue, lung diseases, or neuromuscular illness

Signs of respiratory distress include:
- Rapid breathing rate
- Increased work of breathing (nasal flaring, visibly using chest muscles to breathe)
- Abnormal breath sounds and airway sounds
- Elevated heart rate
- Pale, cool skin (may be absent in fever)

Untreated respiratory distress will progress to respiratory failure

Respiratory Failure

Respiratory failure is a state of too little oxygen in the blood, inadequate ventilation, or both. Respiratory failure usually follows uncorrected respiratory distress.

Signs of respiratory distress include:
- Very rapid breathing rate (early)
- Slow breathing rate (late)
- Increased work of breathing (early)
- Decreased work of breathing (late)
- Abnormal breath sounds
- Elevated heart rate (early)
- Decreased heart rate (late)
- Cyanosis
- In children (especially):
  - Retractions
  - Anxiety
  - Irritability
  - Pallor
  - Decreased responsiveness

Untreated respiratory failure will progress to respiratory arrest

Respiratory Arrest

Unresponsive, unconscious, and a lack of effective breathing à Start rescue breathing!

Treating Respiratory Distress and Failure

Types of Respiratory Problems

Qualities	Respiratory/ Cardiac	Breath Sounds	Causes	Additional Information
Upper Airway Obstruction	Tachypnea Accessory muscle use Poor chest rise	Hoarse, cry, barking, stridor Diminished air entry	Foreign body, swelling of upper airway, mass in airway, secretions, congenital, intubation	Signs most noticeable during inspiration
Lower Airway Obstruction	Tachypnea Retractions, nasal flaring, prolonged exhalation	Wheeze, cough	Asthma, bronchiolitis	Signs most noticeable during exhalation
Lung Disease	Tachypnea, tachycardia, increased work of breathing	Grunting, crackles, diminished breath sounds	Pneumonia, pulmonary edema, allergy, trauma, pulmonary infiltrates	Signs of hypoxemia
Disordered Breathing Control	Signs of inadequateor variable respiratory effort, irregular respiratory rate/ bradypnea/tachypnea	May be none due to central apnea without respiratory effort	CNS illness and trauma	Decreased level of consciousness Shallow breathing

Upper Airway Obstruction

Upper airway obstruction may result from airway swelling/edema, infection, secretions, or a foreign body.
Large tonsils or adenoids, allergic reactions, and a reduced level of consciousness may cause the upper airways to be blocked.
Infants and small children are prone to upper airway obstruction because of their small airways.
Croup, foreign bodies, and anaphylaxis are common causes of upper airway obstruction in children.

Techniques used to treat upper airway obstruction

Positioning/repositioning of the head/neck/airway
Suctioning
- Use with caution
Removing a foreign body
- Only when it can be safely performed
- Avoid pushing farther into the airway
Medications to decrease swelling (e.g., antihistamines, corticosteroids, epinephrine)
Medications to decrease anxiety
Place an advanced airway
Tracheostomy (emergency)
CPAP

Croup

	Mild	Moderate	Severe	Impending Respiratory failure
Symptoms	Occasional barking cough, minimal or no stridor at rest, minimal or no retractions	Frequent barking cough and retractions while resting, little or no agitation, auscultation reveals good air movement of peripheral lung fields	Frequent barking, pronounced inspiratory and occasional expiratory stridor, marked retractions, agitation, poor air movement within lungs	Barking cough which may weaken, hypoxemia, hypercarbia, retractions which may weaken, lethargy, decreased level of consciousness, pallor, cyanosis, poor air movement within lungs
Interventions	Dexamethasone	Dexamethasone Humidified O₂ Nebulized epinephrine Monitor for a minimum of 2 hours after epinephrine administered Consider Heliox (helium plusO₂)	Dexamethasone Humidified O₂ Nebulized epinephrine Monitor for a minimum of 2 hours after epinephrine administered Consider Heliox (helium plus O₂)	Dexamethasone High concentration O₂ with non-rebreather mask Bag valve mask if O₂ sat persists <90% or if level of consciousness decreases Insert ET tube (use ½ size smaller than usually indicated for child’s age; should only be performed by trainedteam member) Prepare for surgical airway

Anaphylaxis

Follow initial treatment for respiratory distress and failure
For wheezing (bronchospasm); administer albuterol via MDI (metered dose inhaler) or nebulizer
Be prepared for increased airway swelling and set up for ET intubation
If hypotension occurs:
- Trendelenburg position
- Administer isotonic crystalloid (normal saline or lactated Ringers) 20 mL/kg bolus
- Epinephrine infusion if blood pressure remains low
Diphenhydramine and H2 blocker such as ranitidine
Corticosteroid
IM epinephrine every 10-15 minutes as needed

Lower Airway Obstruction

Obstruction of bronchi and bronchioles
Follow instructions for initial treatment of respiratory distress and failure
If respiratory failure or severe distress is present, provide O₂
For prolonged distress or failure, provide bag valve mask ventilation at a slow rate to allow time for exhalation and to avoid trapping of air and gastric distention
Common causes are bronchiolitis and asthma

Bronchiolitis

Can initially be difficult to differentiate from asthma
Follow initial treatment procedure for respiratory distress and failure
Oral or nasal suctioning as needed
Blood tests, including viral studies and ABGs
Chest x-ray
Supplemental oxygen if O₂ sat <94%; titrate to SpO₂≥94%
Studies indicate mixed results for administration of nebulized epinephrine or albuterol. May consider administration, but discontinue if no improvement or worsening of symptoms

Asthma

Symptoms	Mild	Moderate/ Severe	Impending Respiratory Failure
Breathlessness	Talks in sentences	Talking in phases or words Sits hunched over Not eating (infants)	Unable to talk speak or eat
Wheeze	Often only on exhalation	Loud	Absent
Accessory muscle use	No	Usually	Weak
Retractions	No	Usually	Paradoxical movements
Respiratory rates	Increased respiratory rate	Elevated respiratory rate	Respirations may be absent
Heart rates	Elevated or normal	Markedly elevated	Bradycardia
Pulsus paradoxus	No or <10 mmHg	Often present >10-25mmHg	Absent
PaO₂ on air	Normal	>60% moderate;<60% severe
PaCO₂ on air	<45 mmHg	<45% moderate; >45% severe
SaO₂ %	>95%	91%-95% moderate; <90% severe
Alertness	Agitation	Agitation	Decreased

	Mild	Moderate/ Severe	Impending Respiratory Failure
Oxygen	Humidified high concentration oxygen via nasal cannula or mask Titrate to keep SpO₂ sat >94%	Humidified high concentration oxygen via mask Non-rebreather mask may be needed Titrate to keep SpO₂ sat >94%	Humidified high concentration oxygen via non-rebreather mask
Medications	Albuterol via MDI or nebulizer Oral corticosteroids	Albuterol via nebulizer Oral or IV corticosteroids Consider magnesium sulfate to be given over 15-20 minutes	Albuterol via continuous nebulizer IV corticosteroid Terbutaline IV or SQorEpinephrine SQ or IV
Additional Intervention		Monitor pulse and BP while administering MgSO4	Monitor for signs of toxicity if using Terbutaline Consider BPAP ET tube insertion (consider cuffed ET tube

Lung Tissue Disease

Condition	Characteristics/ Etiology	Ventilation	Medications	Diagnostic Tests	Additional Information
Infectious pneumonia	Caused by microorganisms Often community acquired	CPAP ET intubation and mechanical ventilation if severe	Antibiotics Nebulizer	Chest x-ray/CT, ABGs, CBC, blood cultures	Reduce fever with medication and cooling techniques
Chemical pneumonitis	Results from dust, fumes, toxic gases, smoke, and particles	CPAP Non-invasive ventilation, Intubation, mechanical ventilation	Nebulized bronchodilators		May require rapid transport to a specialized facility, as advanced technology may be needed
Aspiration pneumonitis	Chemical pneumonitis due to inflammation caused by gastric or oral secretions	CPAP Non-invasive ventilation, Intubation, mechanical ventilation	Antibiotics if lung infiltrates present on x-ray	Chest x-ray/CT
Cardiogenic pulmonary edema	High pressure in pulmonary vessels causes fluid to accumulate in the lung tissues. Left ventricular cardiac disease or abnormalities, inflammatory processes, drugs, and hypoxia cause edema	Non-invasive ventilation or intubation with mechanical ventilation PEEP Intubation and mechanical ventilation indicated if hypoxia is persistent, respiratory failure imminent, or hemodynamically unstable	Diuretics Inotropic infusions Afterload reducing drugs		Obtain specialist consultation Normalize temperature PEEP usually at 6-10 cm H₂O. Too much PEEP can be harmful
Non cardiogenic pulmonary edema (ARDS)	Usually secondary to a systemic or respiratory illness Acute onset, bilateral lung infiltrates, no cardiac cause	Non-invasive ventilation or intubation with mechanical ventilation PEEP Intubation and mechanical ventilation indicated if hypoxia is persistent, or worsening lung condition		Monitor vital signs pulse oximetry, end tidal CO₂ levels, ABGs , central venous blood gas, CBC	Early recognition and TX of shock, bacteremia, and respiratory failure may prevent ARDS Increase PEEP until oxygenation adequate. Correction of hypoxia is most important goal even if hypercarbia

Treatment of Disordered Breathing

Condition	Characteristics/ Etiology	Ventilation	Medications	Diagnostic Tests	Additional Information
Respiratory failure/distress with increased intracranial pressure	Brain infections, TBI, brain tumor, subarachnoid bleed, hydrocephalus	Use jaw thrust if needed to open airway if trauma present May need transient hyperventilation	May need LR or NS infusion at rate of 20 mL/kg if not perfusing well	Lumbar puncture	Irregular respiratory pattern may indicate increasing ICP. Cushing’s triad =bradycardia, irregular respirations or apnea, and increased mean arterial pressure may indicate impending brain herniation. Decerebrate or decorticate posturing, HTN, and abnormal pupils indicative of herniation. Neurosurgical consult needed
Respiratory distress/failure secondary to drug overdose or poisoning	Depression, weakness or cessation of respiratory drive,altered rate of respirations;other respiratory impairments may occur simultaneously	Suction airway	Antidote	ABGs , ECG, chest x-ray, electrolytes, glucose, serum osmolality, drug screen	Notify Poison Control if poisoning suspected (1-800-222-1222)
Respiratory distress/failure secondary to neuromuscular disease	Neuromuscular diseases Ineffective cough, inability to clear secretions, atelectasis, pneumonia may occur	May need long-term non-invasive ventilation		Electromyography, nerve conduction studies	Some commonly used emergency drugs may cause life threatening complications for children with neuromuscular diseases, including succinylcholine and aminoglycosides

Airway Management

“Airway”refers to the path from the nose and mouth to the lungs

Confusingly, “airway”also refers to the objects used to hold the airway open

Simple (Non-advanced) Airways

The simplest way to open the airway is the head tilt-chin lift maneuver:

If you suspect an injury to the neck, use the jaw thrust technique instead:

Mouth-to-mask resuscitation is appropriate

Oropharyngeal Airway

An oropharyngeal airway is:

a non-advanced airway.
a tube that goes in the mouth (oro-) and ends in the back of the throat (pharynx)
for unconsciouspatients when chin lift is not enough to open the airway
often used during bag valve mask ventilation and for suctioning

Proper Sizing:

Should span from side of jaw to corner of mouth

Too large and it will occlude the larynx, and too small will not be effective

Nasopharyngeal Airway

A nasopharyngeal airway is:

a non-advanced airway
a tube that goes in the nose (naso-) and ends in the back of the throat (pharynx)
for conscious or unconscious patients when chin lift is not enough to open the airway
often used during bag valve mask ventilation and for suctioning

Proper Sizing:

Should span from tip of nose to earlobe

Too large and it will occlude the larynx, and too small will not be effective

Advanced Airways

Advanced airways require advanced training to insert that is beyond the scope of ACLS. However, ACLS providers may use them once they have been placed.Advanced airways include:

Laryngeal mask airway

Laryngeal tube

Esophageal-tracheal tube (Combitube)

Endotrachealtube

Oxygen Delivery Equipment

Position children in a sniffing position in order to open the airway.

Children age two and under may need a folded towel placed under their shoulders to maintain a sniffing position
Use the jaw-thrust technique if a cervical spine injury is suspected, not head-tilt/chin lift
Use the E-C clamp technique to open the airway and seal a mask in place

Deliver each breath over 1 second (not faster); monitor for chest rise and expansion
Bag valve mask ventilation is as effective as ventilation via an ET tube for limited periods of time
Mask should be applied snugly.
A face mask should extend from the bridge of the nose to the cleft of the chin
An O₂ reservoir should be attached to a self-inflating bag as soon as possible
Monitor O₂ flow by listening; check tanks frequently
Oxygen concentration delivered with a self-inflating bag valve mask varies from 30% to 80%
Adding an O₂ reservoir to a self-inflating bag valve mask increases O₂ concentration to 60% to 95%

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