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 the child is older than age 2, we can use padding under the shoulder blades which will
help maintain proper positioning and make it easier to oxygenate adequately.
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 3 to 5 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.
In addition, it should be used immediately after a child is born and there is evidence
of meconium stain.
The mouth should be suctioned first as baby’s are mouth breathers.
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 oropharynx and nasopharynx or suctioning an advanced airway
like an ET 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.