[MUSIC PLAYING] The purpose of this video to provide general information and education
about the care of a critically ill child.
It is in no way a substitute for the independent decision-making and judgment by a qualified
health care professional.
The information contained in this video should not be used to make a diagnosis or to overrule
the advice of a qualified health care provider, nor should it be used to provide advice for
emergency medical treatment.
Common Pediatric Respiratory Problems by Dr. Monica Kleinman.
Please note that in this video, we will be following the guidelines used at Boston Children's
Hospital.
Some of this information may need to be modified based on the equipment, guidelines, and practices
in place in your institution.
Hello.
My name is Monica Kleinman.
I'm an attending physician in the Medical/Surgical Intensive Care Unit at Children's Hospital,
Boston.
And today, I'm going to be talking to you about common respiratory problems that children
can present with.
Upper Airway Obstruction.
Two of the most common respiratory problems that children can present with are upper and
lower airway obstruction.
Now, there's a whole set of conditions that can result in upper airway obstruction, but
what they all have in common is typically some edema of the soft tissues of the upper
airway, either in the subglottic region below the vocal cords or in the soft tissues above
that, such as that the epiglottis or hypopharynx.
When you have obstruction in the upper airway, you'll demonstrate increased work of breathing
because you're trying to use your muscles to draw in air against a higher resistance
than normal, remembering that the pediatric airway is already fairly small in caliber.
With upper airway obstruction, you'll typically see suprasternal retractions or potentially
sternal retractions, as well, in a young infant with a compliant sternum.
And there's a characteristic noise that may accompany this called stridor.
[HIGH-PITCHED NOISE] And stridor is a high-pitched noise that occurs on inspiration and is the
noise essentially of the turbulent airflow that the infant is generating by drawing air
in through a narrowed area.
If the infant has obstruction at a higher level-- for instance, swelling of the tongue
or excessive secretions or poor muscle tone resulting in hypopharyngeal obstruction--
the sounds that may be produced are much coarser sounds that are called stertor, for instance,
which sounds more like a snoring or a rattling type of respiration.
[SNORING SOUND] This can be easily distinguished from stridor if the baby responds to a jaw-thrust
maneuver where when you relieve the upper airway obstruction from soft tissue, the noise
improves.
Subglottic edema won't have that same characteristic.
It needs other forms of treatment, such as inhaled therapy with racemic epinephrine.
Upper airway obstruction is clearly one of the most dramatic presentations that a child
can appear with and can be very frightening to the child, the family, and the provider.
It is important to recognize a couple of types of upper airway obstruction that require urgent
and specific management, and one of those is epiglottitis.
Now, we already talked about subglottic edema.
Subglottic edema is the characteristic finding in croup, where one has inspiratory stridor
and a barking type of cough associated with upper respiratory infection symptoms and low-grade
fever.
Epiglottitis presents typically a more fulminant way, where a child is well in the morning
and by afternoon has a high fever, appears toxic, and develops significant signs of upper
airway obstruction that include perhaps some noisiness on inspiration because of the soft
tissue swelling of the epiglottis and the surrounding tissues, but is also characterized
by the child's refusal to speak or swallow because of the pain that they have in their
throat.
And those children will typically be drooling.
If they are able to verbalize at all, they have what's described as a hot potato voice,
where they're talking as though their mouth is containing something extremely hot that
alters their speech pattern.
And they may adopt a characteristic position that's designed to elongate and help open
upper airway, which is called tripoding.
And in tripoding, the child sits with the arms forward, leaning forward with the neck
extended, in an effort to further open the airway.
Epiglottitis can rapidly progress to complete airway obstruction and cardiac arrest.
And so it's essential if you see this pattern to, very early on, obtain expert airway help,
typically from someone with training and experience in anesthesia and possibly someone with the
capability to do a surgical airway, like an emergency tracheostomy in the event that the
patient cannot be intubated.
These children are also very anxious, and stressing them further could precipitate worsening
obstruction.
And so in most cases, it's best to avoid other forms of stress, such as starting IVs or trying
to position them in a way that you would like.
Let them stay in the position they want to be with family members while you gather your
expert team.