Transporting Children With Serious Respiratory Illness: A Presentation For Non-Specialty Teams Laurie Gehrke, R.N., BSN, CPEN, CEN, CMTE Pediatric Transport Team Blank Children s Hospital Des Moines, Iowa
Blank Children s Hospital
Des Moines, Iowa
Pediatric Transport Team
Objectives Review stages of growth and development in children Identify airway and respiratory differences encountered in the care of children Identify major causes of pediatric respiratory emergencies Understand intubation considerations and ventilator management for the child with a serious respiratory illness Incorporate understanding of pediatric respiratory illness into transport of the critically ill child
Growth and Development Infants Toddlers Preschoolers School Age Adolescents
Infants Birth to 1 year Triple birth weight Poor temperature control Obligate nose breathers, abdominal breathers Dependent on caregivers
Infants
Infants Approach slowly, gently, and calmly Provide comfort Vary assessment with activity level IV lines and thumbs Assess pain
Toddlers 1-2 years of age By 18 months can run, grasp, feed self, play with toys, communicate Concrete thinkers Receptive vs. expressive language Delight in ability to control self and others
Wide based gait Exaggerated lumbar curve Potbellied Weight 10-12 kg Continued use of abdominal muscles for breathing Can still develop cold stress Toddlers
3-5 years of age Magical and illogical thinkers Imaginary playmate Fear body mutilation, especially loss of genitalia, loss of control, death, darkness, and being left alone Preschoolers
School Age Child 6-11 years of age Focus changes from family to friends Need to build independence and autonomy Fear loss of control or change in appearance
Adolescents 11-18 years of age Fear looking stupid to friends Fear pain Acutely aware of body image-fear being different Time of experimentation and risk taking Rapid physical growth, puberty-trying to develop adult personality
Differences
Airway Obligate nose breathers Tonsils and adenoids large Large tongue Tracheal rings soft Trachea small and short Larynx more anterior and superior Epiglottis large, long, floppy, and U- shaped
Airway
Respiratory Immature intercostal muscles Pliable chest wall Fewer and smaller alveoli High oxygen requirements Small functional residual capacity Smaller oxygen reserve
Common Pediatric Respiratory Emergencies Bronchiolitis RSV Asthma Croup Empyema Respiratory Failure
Bronchiolitis An acute viral infection of the respiratory tract that affects the small airways of the infant Accounts for significant morbidity and mortality especially in those with underlying cardiac or pulmonary disease
Respiratory Syncitial Virus First isolated in 1960 s Most common pathogen of bronchiolitis and pneumonia in children under age 2 Social and economic impact Loss of work/wages Pulmonary sequela Death of child
RSV Single most important pathogen in infancy and early childhood Most common cause of lower respiratory infection world wide Strikes 70-80% of all children in their first year of life Peak incidence 2-6 months of age Virtually all children infected by age 2
RSV Epidemiology More common in non-breastfed infants Placental antibodies partially effective for up to 6 weeks in full term infants More common in infants who live in crowded conditions or attend day care More common in infants of mothers who smoke Reinfection is common as RSV antibodies do not provide long term immunity
RSV Transmission Highly contagious Transmitted through direct contact with respiratory secretions Indirect inoculation through contact with contaminated surfaces Lives on countertops for up to 30 hours Lives on hands and clothes for 1 hour
Pathophysiology of RSV Syncytium formation Invades ciliated cells Dramatic airway swelling Thick mucus formation Air trapping Bronchospasm
Complications of RSV Apnea Dehydration Shock Respiratory failure
Transport Management
Asthma/Reactive Airway Disease Allergen response: Mast cell trigger Histamine release Bronchial mucosal edema Bronchospasm Mucus plugging
Asthma Causes Increased pollution Poor access to medical care Under-diagnosis Under-treatment
Asthma Risk Factors History of previous PICU admissions History of intubation Children of young mothers Children using >2 cannisters/month of rescue inhalers
Asthma Blood Gas Interpretation Respiratory alkalosis Increased ph, decreased PaCO2 Hypoxemia and hyperventilation without carbon dioxide retention Metabolic acidosis Decreased ph, normal CO2, decreased HCO3 Increased work of breathing, oxygen consumption, cardiac output Respiratory acidosis Decreased ph, increased CO2 Respiratory failure
Transport Management Bronchodilators Albuterol Levalbuterol Steroids Magnesium Sulfate Fluids Special intubation needs
Croup Common viral illness Characterized by barking cough and stridor Mild, moderate, severe Transport considerations Medication Intubation
Empyema
Empyema
Transport Management
Respiratory Distress Respiratory Distress: Increased work of breathing Increased respiratory rate
Respiratory Failure Inadequate blood oxygenation to meet metabolic needs of body tissues Most common cause of cardiac arrest in children Failure to improve or deterioration after treatment of respiratory distress
Signs Of Respiratory Failure Sleepy, combative, or agitated Decreased muscle tone Decreased level of consciousness Decreased response to pain Inadequate respiratory rate, effort, or chest excursion Nasal flaring Use of accessory muscles Tachypnea with periods of bradypnea or apnea Cyanosis
Intubation Considerations Competency Proficiency Attempts < 30 seconds Pre-oxygenate PEEP
Proper Positioning
Intubation Considerations RSI Recommended for every emergency intubation involving a child with intact upper airway reflexes Pediatric Emergency Medicine Committee of the American College of Emergency Physicians Simultaneous administration of a neuromuscular blockade agent and a sedative Medication choice
Laryngoscope Blades Straight Better in young children with floppy epiglottis Curved Better in older children with stiffer epiglottis
Endotracheal Tube Size Cuffed vs. uncuffed Air leak Placement confirmation Securing the ET tube
Mechanical Ventilation Modes of ventilation Pressure control Volume/flow control PRVC
Pressure Control Ventilation Volume and flow are dependent on pressure (PIP) Monitor chest rise Goal tidal volume 6-8 ml/kg Decreased compliance leads to decreased tidal volume for set pressure PIP constant Tidal Volume varies
Volume Control Ventilation Pressure is dependent on volume administered Decreased compliance results in higher pressures needed to deliver set volume Volume is constant PIP varies Air leaks around uncuffed ET tube Ventilator circuits In line treatments
PRVC Pressure Regulated Volume Control Allows control of tidal volume and peak inspiratory pressure
PEEP Prevents alveolar collapse Maintains alveolar stability Optimal PEEP keeps the alveoli open while not causing overdistention Use it!
Setting The Ventilator Mode Pressure or volume Rate PEEP Inspiratory time 0.5-1 in infants, children Can be set as a time should produce an I:E ratio of approx. 1:2 in most cases Oxygen Pressure support level above PEEP
Increasing Oxygenation Increase oxygen Increase PIP Can increase alveolar ventilation Monitor tidal volume Increase PEEP Increase I time
Anticipating High Risk Lung Acute respiratory failure ARDS Pneumonia Bronchiolitis Increasing PIP/PEEP Worsening oxygen requirement
Transport Considerations Mode of transport Air vs. ground Stressors of transport Altitude physiology Vibration Sound Weather Patient safety
PICU Management Of High Risk Lung High Frequency Oscillating Ventilator Nitric Oxide
2011-09-19 Transporting Children With Serious Respiratory Illness: A Presentation For Non-Specialty Teams Laurie Gehrke, R.N., BSN, CPEN, CEN, CMTE Pediatric Transport Team Blank Children s Hospital Des Moines, Iowa Blank Children s Hospital Des Moines, Iowa 1
2011-09-19 Pediatric Transport Team Objectives Review stages of growth and development in children Identify airway and respiratory differences encountered in the care of children Identify major causes of pediatric respiratory emergencies Understand intubation considerations and ventilator management for the child with a serious respiratory illness Incorporate understanding of pediatric respiratory illness into transport of the critically ill child Growth and Development Infants Toddlers Preschoolers School Age Adolescents 2
2011-09-19 Infants Birth to 1 year Triple birth weight Poor temperature control Obligate nose breathers, abdominal breathers Dependent on caregivers Infants Infants Approach slowly, gently, and calmly Provide comfort Vary assessment with activity level IV lines and thumbs Assess pain 3
2011-09-19 Toddlers 1-2 years of age By 18 months can run, grasp, feed self, play with toys, communicate Concrete thinkers Receptive vs. expressive language Delight in ability to control self and others Wide based gait Exaggerated lumbar curve Potbellied Weight 10-12 kg Continued use of abdominal muscles for breathing Can still develop cold stress Toddlers 3-5 years of age Magical and illogical thinkers Imaginary playmate Fear body mutilation, especially loss of genitalia, loss of control, death, darkness, and being left alone Preschoolers 4
2011-09-19 School Age Child 6-11 years of age Focus changes from family to friends Need to build independence and autonomy Fear loss of control or change in appearance Adolescents 11-18 years of age Fear looking stupid to friends Fear pain Acutely aware of body image-fear being different Time of experimentation and risk taking Rapid physical growth, puberty-trying to develop adult personality 5
2011-09-19 Differences Airway Obligate nose breathers Tonsils and adenoids large Large tongue Tracheal rings soft Trachea small and short Larynx more anterior and superior Epiglottis large, long, floppy, and U- shaped Airway 6
2011-09-19 Immature intercostal muscles Pliable chest wall Fewer and smaller alveoli High oxygen requirements Small functional residual capacity Smaller oxygen reserve Respiratory Common Pediatric Respiratory Emergencies Bronchiolitis RSV Asthma Croup Empyema Respiratory Failure Bronchiolitis An acute viral infection of the respiratory tract that affects the small airways of the infant Accounts for significant morbidity and mortality especially in those with underlying cardiac or pulmonary disease 7
2011-09-19 Respiratory Syncitial Virus First isolated in 1960 s Most common pathogen of bronchiolitis and pneumonia in children under age 2 Social and economic impact Loss of work/wages Pulmonary sequela Death of child RSV Single most important pathogen in infancy and early childhood Most common cause of lower respiratory infection world wide Strikes 70-80% of all children in their first year of life Peak incidence 2-6 months of age Virtually all children infected by age 2 RSV Epidemiology More common in non-breastfed infants Placental antibodies partially effective for up to 6 weeks in full term infants More common in infants who live in crowded conditions or attend day care More common in infants of mothers who smoke Reinfection is common as RSV antibodies do not provide long term immunity 8
2011-09-19 RSV Transmission Highly contagious Transmitted through direct contact with respiratory secretions Indirect inoculation through contact with contaminated surfaces Lives on countertops for up to 30 hours Lives on hands and clothes for 1 hour Pathophysiology of RSV Syncytium formation Invades ciliated cells Dramatic airway swelling Thick mucus formation Air trapping Bronchospasm Complications of RSV Apnea Dehydration Shock Respiratory failure 9
2011-09-19 Transport Management Asthma/Reactive Airway Disease Allergen response: Mast cell trigger Histamine release Bronchial mucosal edema Bronchospasm Mucus plugging Asthma Causes Increased pollution Poor access to medical care Under-diagnosis Under-treatment 10
2011-09-19 Asthma Risk Factors History of previous PICU admissions History of intubation Children of young mothers Children using >2 cannisters/month of rescue inhalers Asthma Blood Gas Interpretation Respiratory alkalosis Increased ph, decreased PaCO2 Hypoxemia and hyperventilation without carbon dioxide retention Metabolic acidosis Decreased ph, normal CO2, decreased HCO3 Increased work of breathing, oxygen consumption, cardiac output Respiratory acidosis Decreased ph, increased CO2 Respiratory failure Transport Management Bronchodilators Albuterol Levalbuterol Steroids Magnesium Sulfate Fluids Special intubation needs 11
2011-09-19 Croup Common viral illness Characterized by barking cough and stridor Mild, moderate, severe Transport considerations Medication Intubation Empyema Empyema 12
2011-09-19 Transport Management Respiratory Distress Respiratory Distress: Increased work of breathing Increased respiratory rate Respiratory Failure Inadequate blood oxygenation to meet metabolic needs of body tissues Most common cause of cardiac arrest in children Failure to improve or deterioration after treatment of respiratory distress 13
2011-09-19 Signs Of Respiratory Failure Sleepy, combative, or agitated Decreased muscle tone Decreased level of consciousness Decreased response to pain Inadequate respiratory rate, effort, or chest excursion Nasal flaring Use of accessory muscles Tachypnea with periods of bradypnea or apnea Cyanosis 14
2011-09-19 Intubation Considerations Competency Proficiency Attempts < 30 seconds Pre-oxygenate PEEP Proper Positioning 15
2011-09-19 Intubation Considerations RSI Recommended for every emergency intubation involving a child with intact upper airway reflexes Pediatric Emergency Medicine Committee of the American College of Emergency Physicians Simultaneous administration of a neuromuscular blockade agent and a sedative Medication choice Laryngoscope Blades Straight Better in young children with floppy epiglottis Curved Better in older children with stiffer epiglottis Endotracheal Tube Size Cuffed vs. uncuffed Air leak Placement confirmation Securing the ET tube 16
2011-09-19 Mechanical Ventilation Modes of ventilation Pressure control Volume/flow control PRVC Pressure Control Ventilation Volume and flow are dependent on pressure (PIP) Monitor chest rise Goal tidal volume 6-8 ml/kg Decreased compliance leads to decreased tidal volume for set pressure PIP constant Tidal Volume varies Volume Control Ventilation Pressure is dependent on volume administered Decreased compliance results in higher pressures needed to deliver set volume Volume is constant PIP varies Air leaks around uncuffed ET tube Ventilator circuits In line treatments 17
2011-09-19 PRVC Pressure Regulated Volume Control Allows control of tidal volume and peak inspiratory pressure Prevents alveolar collapse Maintains alveolar stability Optimal PEEP keeps the alveoli open while not causing overdistention Use it! PEEP Setting The Ventilator Mode Pressure or volume Rate PEEP Inspiratory time 0.5-1 in infants, children Can be set as a time should produce an I:E ratio of approx. 1:2 in most cases Oxygen Pressure support level above PEEP 18
2011-09-19 Increasing Oxygenation Increase oxygen Increase PIP Can increase alveolar ventilation Monitor tidal volume Increase PEEP Increase I time Anticipating High Risk Lung Acute respiratory failure ARDS Pneumonia Bronchiolitis Increasing PIP/PEEP Worsening oxygen requirement Transport Considerations Mode of transport Air vs. ground Stressors of transport Altitude physiology Vibration Sound Weather Patient safety 19
2011-09-19 PICU Management Of High Risk Lung High Frequency Oscillating Ventilator Nitric Oxide 20