Respiratory Problem #1

Introduction:

Upper airway obstruction is a common cause of pediatric respiratory distress and failure. The upper airway consists of the nasal cavity, pharynx, and larynx. The three most common causes of upper airway obstruction are infection (croup, epiglottitis, RSV, etc…), airway swelling (anaphylaxis), and foreign body airway obstruction (FBAO).

Other factors can affect upper airway patency as well. These include enlarged tonsils/adenoids and poor upper airway control related to changes in the level of consciousness.

Identification of Upper Airway Obstruction:

Major signs that will help to identify upper airway obstruction include the following: tachypnea, a change in the sound of the child’s voice or cry, a cough that sounds like a bark, hoarseness, inspiratory stridor, poor chest rise on inspiration, and nasal flaring.

In most cases, signs of upper airway obstruction will be more pronounced on inspiration, in contrast to signs of lower airway obstruction, which will, in most cases, be more pronounced on expiration.

Impending signs of respiratory failure due to upper airway obstruction include: marked retractions, decreased or absent breath sounds, decreasing respiratory effort (exhaustion), and head-bobbing with each breath.

Problem Specific Interventions:

After the initial general interventions for respiratory distress and respiratory failure have been implemented, interventions specific to the cause of the upper airway obstruction should be implemented as needed. For the purpose of PALS, the three causes that are addressed below are croup, airway swelling, and FBAO.

Management of Croup:

Croup, which may also include other infectious processes such as epiglottitis and RSV, is managed based upon its level of severity. The four levels of severity include mild croup, moderate croup, Severe croup, and impending respiratory failure.

• Mild croup: Symptoms are a hoarse, brassy, bark-like cough. Usually, no stridor is present at rest, and there are only mild chest retractions. Interventions for mild croup include possible steroid administration (dexamethasone) and observation.  Continue to use the Evaluate→Identify→Intervene Sequence.
• Moderate croup: Symptoms include inspiratory stridor and retractions at rest. The patient will be relatively free of agitation but will have a frequent barking or a hoarse cough. Interventions for moderate croup are oral dexamethasone and racemic epinephrine nebulizer.
• Severe croup: Symptoms are the same as for moderate croup except the child will have significant agitation and/or lethargy related to worsening hypoxia. Interventions are also the same as moderate croup plus the patient should have nothing by mouth. Also, consider the use of heliox which is a helium-oxygen mixture that helps to reduce the resistance of air flow and results in a decrease in the work of breathing for the patient.
• Impending Respiratory Failure: At the point of impending respiratory failure, many of the symptoms observed may not be as pronounced because of the patient’s worsening hypoxemia and hypercarbia. Increased lethargy or a decreased level of consciousness will often make a barking cough sound weaker, audible stridor may become less pronounced, and retractions weaker. Pallor and cyanosis may also be present in spite of the use of supplementary oxygen. Interventions for impending respiratory failure include administration of high concentration oxygen using a non-rebreathing mask, assisted ventilation as needed for oxygen saturation < 90%, IV or IM dexamethasone, endotracheal intubation as needed, and preparing for the possibility of the placement of a surgical airway (tracheostomy) if needed.

Management of Airway Swelling (Anaphylaxis):

After the implementation of the initial general interventions for respiratory distress and failure, the following interventions are used for the management of anaphylaxis.

Remember to continue to use the Evaluate→Identify→Intervene Sequence as you intervene.

Interventions: Administer IM epinephrine, IV diphenhydramine + H2 blocker, and IV corticosteroid. Provide albuterol for bronchospasm as needed. Prepare for possible endotracheal tube intubation if severe respiratory distress or failure develops. Treat anaphylaxis related hypotension with LR or NS. If hypotension is unresponsive to fluids and IM epinephrine, IV epinephrine with age-appropriate dosing should be used as an infusion to control hypotension.

Management of Foreign-Body Airway Obstruction (FBAO):

After the implementation of the initial general interventions for respiratory distress and failure, the following interventions are used for the management FBAO. Remember to continue to use the Evaluate→Identify→Intervene Sequence as you intervene.

FBAO follows the general guidelines for the child who is choking. If the child is choking but can cough and make sounds, the FBAO is incomplete and the child should be allowed to clear the obstruction by coughing.

If the child is conscious and has a complete obstruction as indicated by the inability to cough or make noise, the following intervention should be applied:

• If < 1 year: Give five back slaps followed by five chest thrusts
• If ≥ 1 year: Give abdominal thrusts

If the child or infant becomes unresponsive, start CPR beginning with chest compressions.

Provide chest compressions even for the unresponsive patient that has a pulse. The chest compressions will provide pressure that can potentially dislodge the FBAO. After the cycle of chest compressions, the oral cavity should be visualized to check for the foreign body. If the foreign body can be seen, remove it, but do not perform a blind finger sweep.