Pediatric Fundamental Critical Care SupportCopyright © 2008 bythe Society of Crica Care Medicine, Copyright not aimed on material writen by an employe ofthe U.S. Government. ‘llrightsreserved, ‘No part of this book may be reproduced in any manner print or electron permission ofthe copyright holder ‘The les expressed herein ore thoreofthe authors and do not neesarily reflec the is of the Society of Critica Care Medicine Use oftade names or names of commerial source ifr information only and does not imply ‘ndorsementby the Soler of Critical Care Medicine. “This publication is intended to provide accurate information regarding the subject mater aaldresed herein However, ite published withthe understanding that the Society of rial Care Medicine not engaged in the rendering of medical, leg franca, accountng or thet anytime without ‘professional service. The information in tis publication is sobjet to change, otice and should not be relied upon a substute for profesional advice from an experienced, ‘competent practitioner in herelevant eld. Nether the Society of ital Cae Medicine, nor the authors ofthe publication, makes any guarantees or warranties concerning the information ‘contained herein. expert assistance isrquired please eck he services ofan experienced, ‘competent professional in the relevant id, Accurate indeaions, adverse reactions. and dosage schedules for drugs maybe provided in this ext, butitispossible that they may change, Readers are urged to review current package indications and usage gudeline provided by the ‘mamfatrets ofthe agents mentions, Soctery of teal Care Medicine Headquarters 00 fidway Drive Mount Prospect, 60056 USA Phone + (047}827- 6869 ax (817827-6886 oascem ore International Standard Hook Number: 97.-0:935145-50-1Pundamental Critical CareContbtors Bator: odcigo Noa, MD, Faar. FCM Associate Profesoc of Peis and Ciel Care Medline ‘Conte Medel Duero forthe Chidand Adolescent Center Associ Director of Pediat Cail Care Services Chiles Cancer Hospital a The Univesity a Texas MD. Andersen Cancer Canter Houston, Texas nancial isos: No faa dielocuree co-editor: Alan elds, MO, FCM, FAAP Professoro Petrie, Anesthesiology and Critical Care Medicine Director f ela Ctical ace Series ‘Childrens Cancer Hespcl a “The Universo Texas M.D, Anderson Can Houston Teas ancil Dios: No fnanci dtsurs Center Bruce Geel MD, FCCNY, BAP Profesor nial Pedi Directo, Divison of Podiatic Cal Cre Medicine ‘Weill Crna Medical College Now Yor Prebyterian Hosp New York New ok Financial Distosure: No fina dllsurs FernandoSten, MD. FAAP Associate Professor Medica Director af Progressive Care Deputy Dietorof Pediatric Iensve Cae ‘eras Childe Hospital Baylor Colege of Medicine Houston Teas Financial Dislosure: No finance dllsuresContributor: NaomiB. Bishop, MD Assistant Profesor of Petes ‘Weil Cored Medical Caege New Yrk Presbyterian Hospital New Yr New York ‘Hnancil Disclosure No ancl dslosures Gregory Bota. MD ‘Asoc Proferor of Anesthesiology sand Ctiteal Care Medical Directo, Medical Emergency Rapid Intervention Team ‘University of Texas M.D, Anderson Cancer Center Houston Tens ‘inant Disclosure: No ania disclosures ‘Susanna 8, Burkhead, MD Modi o-Diretor Podiatic intensive Care Unit ‘St.John Hospital and Metical Center Deol, Michigan Financia Disclosure: No iancal disclosures Joseph Caco, MD ‘Asocnte Profesor of ical Care Medicine and eas Univesity ofPitsburgh choo of Medicine Deparment of Critical Care Medicine (Cire Hospital of Pieburgh Piusburgh, Pennsylvania ‘lnancll Dlosue No earl dsclosures wand Conway. MS MD, FCM, Profesor of Clinical Peni Chairman othe Miton and Bernie Ste Deparment of Pets (Chie, Pediatric Critical Care ‘eth ral Medial Center "New ook, New York Fnancial Dilosue: No nancial disclosures Jose A Cortes, MD, FAAP Assistant Profesor (hires Cancer Hospital ‘The University of Texas [M.D.Anetson Cancer Center ouson, Texas Francia Dielesure: No nancial disclosures ‘Alan Davis MD, MPH, FOCM, EAAP Director, Pediat Cred Care ‘Associate Ciinical Profesor of Peiates, MON) Sant Bamabas Metal Genter vingston, New Jersey Financial Disclosure Nona stores Guilemo DeAngula. MD ‘tending Cancer Center of Miami Chiden’s Hospital Miami, Flosida Financial Disclosure No iancial disclosures aren Fast. MD Assistant Profesor Department of ediies Section for Children ik University of Arkansas or Medial Slences allege of Medicine ‘ekanaae Children Hori Ure Rock. Askansas Financial Disclosure No financial disclosures Kathyn A Felmet, MD Assistant Profesor of ees Care Meine ana Pediates University of Pitsbugh School of Medicine ‘Department of Cal Care Mediine (hile Hospital of Piteburgh Pusu, Pennsyvania ancl Disclosure No nancial dscosures Jonathan D. Feldman. MD Director, PediaticICU snd Inpatient Serves Medical Director, Pediaie Neonatal ‘TransportServies ‘ise Santa lara Medical Center Santa laa, Calfoaa nica Associate Professor (Afilaed), Department of Pediatrics Sanford Universit Schoo of Medicine Sanford, California Financia Disclose No financial disclosuresJoy. Hoel MD, FAAP Associate Professor of lineal Pediatrics ‘il Cornell Metical College ‘NewYodk Presbyterian Hospital NewYor, Newark ‘inancilDsclosure: No flnacial closures ‘Thomas ole. MD Lecture in Pediatrics, FOBM, Universidad Asta ead Pedic Intensive Cre Unit Hospital ‘Universit Atal ‘Buenos Ais, Argentina -RnanclalDitlsure: No financial dsclsures (Chav kayal, MD ‘Assistant Professor of Pdiatics Division of etieal Care Medicine ‘The Chikdreds Hospital at Montefiore Alber Ensen Collegeof Medicine Bron, New York ancl Dios No ancl dclocures (Carol. King ‘Aen eda Criteal Care Unit UTNE Cres Hospital alveston Texas ‘Financial Dslesures No financial diclosures ath Koi MD, MS ProfesorofPediatics Podiaie Cailogy ‘The Unversiy of North Ctein at Chapel Hit (Chapel Hl, Noe Croina ‘Financial Dslosur: Mo nancial closures Marta C Ruth, MD, FAAP ‘Associate Professor of Clinical edits Wall Comel Medial College ‘NewYork Presbyterian Hospital Newvodt, New York ‘Rancial Disclosure: No finanell deloures Mauren A Madea, MSN, PNP-AC,CCRN, PCCM Asdtant Professor of Pediatrics LUMDNI- Robert Wood Johnson Medial School PeitrcCiial Care Nurse Practitioner Bristol-Myers Squibb Childers Hospital ‘Nee Brunswick, New frsey ‘Financial Dislsure No nancial disclosures David Markenson, MD Disco, Center Tor Dimer Medicine Associate Professor Public Health "NewYork Medial Clog School of Publi Heath Chet Pediatric Emergney Medicine Associate Profesor Feats Maria Faer Childrens Hospi New Yr Medial Colege Vaal New York ‘hancalDiscloure No financial dslosure Ria Mauricio, MSN, RN, CRN, CPNE-AC Peatc Ciel Cae arse Praciconer Childers Cancer apical a “The Univers of Teas M.D. Anderson Cancer Center Houston Texas Financial Disclosure Ne inact ictosues Mai C Moris, MD, MPH Assistant Pofesa of Cnc Pediatsics Columbia Universiy ‘The lens Hospital of New York Presi NewYork. New York Financial Disclosure: No flnanetallicosures [Moan Mysore, MBS FAAP-FCCM nical Direct. PICU Childers Hospital Omaha, Nebraska Financial Disclosure: No inane icosures Reina Okhuysen Cavey, MD Asscite Professor of edits (Chidens Cancer Hosp at “The University of Teas MD Anderson Caner Center Houston, Texas nancial Disclosure: Ne laancialdisclonues Michele C. Papo, MD, MPH Media Directo PICU Medial City Childers Hospital Pedic Acute CareAsocates ‘of North Texas, PA Dalas Texas ‘nancial Disclsues: No ancl dizlounesJack, Percelay MD, MPH, FAAP ELMO. Pediatrics "NewYork, New ork ‘lnancial Disclosure Nofinancial disclosures Steven Pon, MD, FCCM, FAAP ‘Asociate Profesor of nial Planes ‘Associate Director Pitre Intensive Care Unit Weil Corel Medial Callege "NewYork Presbyterian Hospital [Now York, New ork ‘Financial Disclosure Nofinanelal dlcosues len Jane Pringle, FT University ofTexs MD Anderson Cancer Center Acute Care Training Center Hooston, Texas nancial Disclosure Parhak Prodhan, MD Assistant Profesor ef Peatrles ‘Sections of Pentre rica Care Medicine and Pediatrie Cardiology University of Arkansas for Medical Sciences College of Medicine Arkansas Childe Hospital Lite Rock, Aekasss ‘Financial Disclosure No financial dicosues Gerardo Quezada, MD Methodist Childe Hospital San Antoni, Teas Financial Diclonwe: Ramon River, MD Assistant Profesoref Anesthesiology ‘and Critical Cae Universi of Teas Medial Branch at Galveston Driscoll Childrens Hospital Corpus Christi, Texas Financial Disclosure No financial dslsures [AlerandreTelleches Rotts, MD, FAAP Associate Profesor of Anesthesiclogy University of Tas Medial Branch Department of Aneshesilogy and Ciel Care Driscoll Childrens Hospital (Compu Chit, Tass ‘nancial Disclosure No financial dislsues Michaet .Rytng. MD Assistant Profs Pediatrics Patient Care ‘Children’s CancerHosptal at “The Univesity ofTeas M.D. Andetson Cancer Center Houston, exe ‘Financial Disdosure:No nancial dsdosures ‘Chaos Selo, MD, MBA, ECCM, FAAR FARA Profeccor of antics & Anesthesiology Vice Chai Departnent of Pedatics Director, Ptr etcal Care Medicine Columbia University Collegeof Pysitans fe Surgeons New ork New ork ‘nancial Dislesure No financial disclosures Eduard juices, MD Associate Prtesr,Peiatis, FOBM, Universgad uta ‘Consultant edisrctnensivst, Hospi ‘Universi usta Medical Diector Hospital Universo Austral Buenos Ales. Argentina Financial Disosie No financial disclosures Steven M Sehwarw. MD Associate Profesor ofPdinses Head, Dsson of Cada Ciel Care Medicine ‘The Labat Family Heart Centre DeparimenteofCtieal Care Medicine and Paediatr, ‘The Hospital Sick Children Toronto, Canada Prnancial Digs: No financial dstosures Kar eran, MD, PAP Ascociate Profesor of Anesthesiology University offers Medical Branch at Galveston Driscoll Children’s Hospital (Corpus Cris Texas Financial Diclaswe: No financial dilosres Lind Soeing MD Associate Poles of Pedates Surgery ‘Chef Dvsian of edn Creal Care Medicine “The Warn Apert Medical School a Brown University Providence, Rhode land Financial Disclosure: No fnanclal disclosures‘Todd M, Seber, MD. FAAP ictal Usha, MD, PhD. FOC ‘nets see ne Aiencie gee ‘Seema Drastic hae vse hone Recuseerimauitncie Neouesnnumagcacl monet ny Parte fc es ‘aad feta cog hm xo smn so ohtencceshaes ‘tutu aes saan Chota Ttahentycncatmacagaia ene pastas Pel dc eo eee eee il Distore Nafeanciadioures ‘ele ese of Pies fe nn ie UMDNI-Robert Wood Johnson Medical School ‘Ann E-Thompson, MD, POCM Directo, Pediat Cra Care Professor Department of Critical are Medicine Bist Myers Squib Childrens Hospital Universin/ofPiusburgh SchocLof Medicine New unswck New lesey Directr, Pode OcM Financial Disclosure: No financial dsasures Childers Hospital of Pitsburg Pinsburgh,Pennsyeanin ‘Financial Disclosure No nancial dcioaues ‘Recognition s due othe Acute Care Taling Center atthe Univesity of Tenas MD Anderson Cancer Center Houston, ex, Medical City Childen’s Hospital in Dla Texas, and Presbyterian Hospital of ino ‘in Plano, Texas forthe coatinued support througout this projec.WB fentansniat critical cave su QtPretace Peoiatric FUNDAMENTAL Critica Care Support ‘The Sorey af Critical Care Medicine SCCM has continued to afer te Fundamental itil Cae ‘Suppor CCS) course to global audiences since the mid-190s. The goal ofthis curiculum sto lneroduce principles importantin the inital car of xc il or injured patents to physllans, rss, and other healthcare providers who are not sled critical ee but who must care or such patent in anticipation ofthe acval ofan intensit or pending tanaer ote palen toa ‘wore suitable fact. While FECS adresses both adult and peat populations, the major ocks has been onthe critically lvnjured adult Therefore, the need for spec eourse toaddioe the Pediatic population special neds hasbeen developed: P-FCCS, ‘This rat ion hasbeen developed as a est ofthe determination and dedication ofthe SCCM. al especialy Lynn Retford and Gervise Niels, MS, RN a diverse group of multprofessional ‘chapter contibutors: the invaluable guidance provided by Barbara McLean, MN, CORN, CONE FOC, andthe commitment ofthe co-ecitors Alan ies, MD, FCCM, and Brace Greewwald MD, CCM, andthe F-FCCS workgroup: Maureen Madden MSN, PNP-AC CN, FCCM: Kat eran, (MD; Elen Pringle, RT; Edward E. Conway. MD. MS ECCM Gregory Hota MD, FCM, ane, “Mohan R. Mysore, MB, FCCM, MB, freeing many ideas to improne the tee helped reach this ambitious gol. ‘The chaptersin the fst eition have been carefully writen, reviewed. and organlzed to reflect the mot curent guidelines and practices and ae exdence based where applicable Each captor and major section begins wth learning objectives and a case stu thal focuses atention on ‘ey linia findings and patient presentation. The majority of these chapters se une to the Pediatric population wile coverings broad range of pediatric lated topes naldessing the livers ofeathcare professionals who may take this course, we realize that some may fn the {eformation provided in this fist edition ery comprehensive. or those who may wants mone ‘api les extensive review information boxes inthe margins provide esenial prinaples and en ‘Theshapeand movement ofthe chet during respon wl let the observer to underlying rerprtory problems Asib-cage deformity euch specs excavetm, pct carnal, 0° ‘colons may saget the presene of steve ing deseo pulmonary hypoplasia ora toabnormal respiratory mechani Asymmetry ofchest einen unequal ai entry and serous undering pathology e Table 1-4, Auseultaton of — breathing sounds wil veal he adequacy and symmetry ofa entry andallwany other sounds, ich aswheezes, cracls and ibs, © become evident. auscultation maybe difcuk ores depencing len repre dives cn the chil level of cooperation, Bcsuzechidrenhave thinner chest wall than adults, breath sounds are easliyaudblebut less thai fmf. | ‘any localized, and ohertanmited sounds etennttere with = accurate auseuation When child isapated and crying adequate. ‘tsctation may not be possible PEI os isoeeiatariione feign agin nein | es gngrgtnanoaeoss ee Hore clrateeman euenentpang Gombopualan | Youblcosbereqaansl thera wih Grote iteae | Eire pighad ommatcoin epee bec ps Pe eorarerrepetiaretieey | eset hcenton set usr apetrraye {ru ftenngbin op perder ma ented ee eeeBecause chiren have lower hemoglobin concentration than adults the blood oxygen content ‘must alto very low eels before cyanosis is evident. The advent of pulse oximetry has enabled the noninvasive measurement of oxygen saturation oacurately determine the degree of ‘hypoxemia. Acommon etroris equating adequate gen saturations with adequate ventilation and respatory stability. Onygen saturation alone des not provide enough information about the ‘adequacy of venta, alveoar ventilation is primarily rexponsiblefor removal of cabon diode and istepresente by minute venation, which isthe prodic ofthe respiratory ate an tidal ‘volume Although alveolar ventlation isa determinant ofexygenation, a ptint may maintain adequate oygen saturation in the ace of inadequate ventiation especially if supplemental ‘nypen isprovded. Therefore clinical assessment including attention o chest movement, respiratory rat, and work of breathing is crucalto determine adequacy of ventilation, A useful adjunct ote clinical examination is noninvasive rneasurement of Pao, withthe ald atend idl ‘capnography and tanseutaneascatbon dioxide monitoring (. Airway Evaluation Batase stat ‘A.15-month-of boy was brought into the emergency department wth sudden-onst acute ‘espitatory distress after choking episode. The paint was noted tobe wheetingon auscultation -Achest radiograph reveals hyperinflation ofthe ight ung The patients taken tothe operating 00m for bronchoscopy Alatge peanut fragments emoved fom the right mainstem bronchs. Wye hispatont wheezing? What noninvasive monitoring might be wsefuin evaluating this patient? eimai mpm aeeosea fears orapaty nce Ts ewage pec vey Sbchmrntincnp cigar spanner conga ncaa, epieneeene / fms dunsny ccna) br rate de failure. Many times the same signs and symptoms could easilybe | mea ey . * ‘misinterpreted as indicators of reactive airway discase. The nasal ___ he nara pasiagescon be pathway isthe primary route for normal breathing (obligate nasal _ imparts intervention in Brehingnwonacandysngnatsuletey tance | eigen. {ith peil orempronid eshingecsipliety on a a | SooeabeWi Pediatric Fundamental Critical Care St 18 ‘The anatomy ofthe pediatric sway, especialy in infants and youngchilren, predisposes these patients to airway obstruction when they are postonedincoreyorare unable to maintain ‘equate hypopharymgel tone. Children fn this age group havealage occiput, aelavely age tongue a larger, Dopp epilois, and an anteriolyplaed laryme These factors, combined with decreased hypopharyneal tone lead tothe los of airway patency in obcunded patientsbecause ‘hoy are unable to keep these soft ssue structures apart. Jayoung children, common causes of airway obstruction are congenital, infectious (ral coup, ‘bacterial tracheiis, or ese commonly, epg), or related to the ngestion of foreign body. ‘Glnial examination ay help Kent the ste of obstruction, Asthma snot he sole reason Torwheezing and lowerarway obstruction. Alrway obsructon above the thoracic inlet tends ‘cans stridor Gnspiratry noise), whereas nathoracc obstruction tends to cause wheezing (expiratory nose. Fr children who present with stidor or wheezing unresponsive t appropriate ‘onchodator and steroi therapy, a dlagnosis of foreign body aspiration must be entertained U Respiratory Failure 7 ‘Children ia repletory detress progressing to respiratory file wl exhibit inereasod work of brthing mt they experience muscle fatigue or areno longer ableto compensate. Causes of respiratory fllure in children can usualy be grouped by age-In premature neonates respiratory failure rests from apneaof prematurity o inant espratory distress syndrome, in which stelectasis and impaled gas exchange occur as 2 esl of surfactant deficlency and inefective chest bellows. In term neonates, bacterial pneumonia, sepsis, meconium aspiration, and ‘congenital airway abnormalities are most common. in infants and toes, ower-respratory iseace fom preumonia, bronchiolitis, asthma, forign-body aspiration, and upperaineay ‘obstruction related tinfecton are common. The causes of respiratory fare in older chidren are similas to those foundin adults. "Noninvasive monitoring hss become indispensable inthe evaluation of patients in respiratory distress, With pulse oximetry and end-tidal capnography oxygenation and venation canbe objectively evaluated, Ancillary investigative tes, such as chest radiographs, arterial blood gas tests, and other studies summaiged in Table 1-5, ae useful in determining respiratory aur, elucidating ts edology. and monitoring therapy. These tools are not substutes for acinial exam, Untmetely the cinical aesesement and judgment ofthe healtheaepronder are the mos valuable tole for recognizing a patient i impending respiratory flue. Once shat possibly secogized, preparation and interventions can be made o secure gn airway. ensure adequate veiltion and facta transfer toa pediatric intensive care uit PICU)7 ok aso erase Ancillary Sues te Galatea State Atsessment of the Giialy I Child cao 0 408 eat ibm septa Alouette sate se eis H>1 sidan Sam yin selina en al beatin ‘sas imeen ain ae aime se oor Monteiro eet ‘Seema el oe Db i Det OngeEsP) gen oben a= Oe ‘ese es macs made eT vacant ese eile epee | ees er asin th a L aris ape ‘Gn ain ona den aces a syn tren te oes pronto mtn nrc ewe Femoral pts Puig lc ‘ae 19WH rediatie Fuadarcental critical Care Suppart WW, CARDIOVASCULAR SYSTEM A, Anatomic and Physialogic Considerations The circulating od volume is higher pe logram in ciren than in adults, but the absolute ‘olumeremaislower in children due o thelr small body ize. Consequently, cadre are ess tbl to tolerate small amounts of bleodloss, and blood replacement indicated when 5% t0 10% oftheir cicultng volume as been last Recause an infant ably Increase stoke volume islimited, any augmentation of cardia output depends onthe patients heart rate and diastole filing time Cardiac output per klogram of weight nthe newborn grater han 200 kg) {higher than tha fads, withthe eardac index a birth (4 Liminvm? gradual fling to adult normative values (25-3 L/min/m? i adolescence. Tis occurs because oxygen consumption bs dependent on cardiac output, and oxygen consumption per klogam of ody woightiswreatr in infants dann adults, Fama withthe normative ranges of heart rates important because thoee ange vary ith age, canbe seen in Table -6 Severe tachycardia wil decrease siastote filing ine resulting ina apd fl in stroke volume Bradyeard ell revit in decreased ‘cardiac output and therefore deceared oxygen delivery, and is most often an ominous sign of ‘Sienificant hypocemia or acidosis Other anthythmiss usually donot produce significant changes in earciae output unless sustained supraventricular tachyearda aces, Ventricular anrhyhmlas sre uncommon, but when present. hey may signify congenital bear disease, myocarditis ‘cardiomyopathy electrolyte abnormalities, or asphyxia, Toa tea bei he este sto -Myocardi maturton influences the heat’ response to volume challenges intended to increase preload. Ininfants younger than 8 weeks. cardiac output may not be increased by a uid bos, bur thereaterthe response i similar ta that of adult: The ental venous pressure however, does ‘ot necessarily reflec circulatory blood volume or ll ventricular eliclency. ef and right hear. function may be disparate and each sde may fall independently Therefore, pulmonary artery 1heters may ccraionally be requied to monitor lft and ght hear filing pressuresAssessment of the Critically UI bi Pulmonary vacua resstance falls quick aterbirth, reaching normal adult evel 8 weeks ote, However the pulmonary vasculature may emain very eactve to hyporia hypereapaa, lnypothermia, or acidosis thereby increasing afteriad to the right vntile yocardlal anatomy changes tterbith so that helarger righ ventricle decreases in mass and te eft ventricle ineretses in size and mass. The neonatal myocardium exhibits aiid response to catecholamines due timmatutty of sympathetic nervous system innervation aswel asa teduced ‘sumbor of receptors, both of which increases aver the frsteeerl weeks oie The physiologic effects ofexogsaous catecholamine adminisuaton, therefore, may be quit atiale, and eateal eatin to the individual cil’ responseis essential. 4. Physical Examination “The physical examination of the cardiovascular system should fous on assessing tissue persion sit lates to cculation and end-organ funtion. This includes evaluation of sin colo ‘emperacut, capillary rel, pulse character, heart ate and ehh, and bd presse, “| Cardiac ouput in children expecially infants, is dependent onthe Bo patient’ hearccate As with heat satesnd repro rte, blood | Pressure varies with age Systolic blood pressure inthe Sth percentile Teportasonel forthe patentsage ible at thelomer mia he seole ‘ange: ablood pressure below tat indicates hypotension | coli gsof ack IDE spoesiosnciten fom yam oldcanbe gy steminedsing eter o deol oman, 1 Systolic blood pressure (man Hg) <0 (Age in Years 2) 1 Mean arta pressure enm Hg) <0 «(ge in Years 2) PEGI isis ice nesses te Spt bet rae am @ » Mv bpionass2) I ” ‘The end-organ sstemsof special elevance st the brain andthe kidneys because the body ‘homeostatic mechani give priority o preservation of perfusion to these tse. Bain and bcney function ae assessed by evaluating the patents mental tatus and urine output Deterioration of end-organ function is precursor to cireulatory rest in ation tothe clinical exam, several ancilry studies, sted in able 1-8, should be used to fully evaluate and monito: the italy il eh. or ditional information, see Appendix 2janentl Citeal Care Sappert os 0 Evaluate Cardiovascular Syste yo aan ed ger ocey oon sel ope eae en | ates pe Seezatapeposndate vases pret tap er ‘ae in es Moms eines ‘Suporte coon seen angen en, | esr oss abe ak (yc Connie ec ae 2 La oe) ng | cnn ti ‘ia enon pee | Memon Sa amsonon ocr ec an decent ogh tom mt ets i etn eines py | festaesnaaltot gs omin CemamsreseeNeniony —Asminipetan gute ons cin ome eczema psn) a tah ono eae | ‘ones ines Fate teense ‘cont Owen | \ Oem Setroobs cenAscossment of the Ci cally Child BE (Stork = ‘Shock may be defined asa state of ceulatory dysfunction thet alto provide suficlent oxygen and uteens to meet the metabolic needs of val organ and peripheel sues Forename, ‘when a patent with hemorthage continues to lose blood, thebody compensates by ying maintainadequate perfusion pessureto essential organs The east ate incense na erp ‘oimaintain adequate cardia output as venous tun diminishes along wth a compensatory ‘crease in systemic vascular esistance. This els in preservation of «noel blood presse «luring the ery phase (compensted phase) of shock, wth hypotension occuring when the circulatory compensatory mechanisms are averwielmed by uncorected, ongoing blood os. When hypotension i present, te patent sn ate sage (decompensated) shock. which inaccompanied by weak thready pulses, markedly prolonged capilay tefl ie, mottled ‘exteites. and obtunded sensoiun Timely secoguition ofthe shockstate and aggrestve intervention ae exrenil to obiaining an ‘optimal outcome. As soon asthe diagnos ofshockis considered, mt ‘al exrdloputmonary monitoring. vascular acess and treatment | Fivsactton sth il | must be implemented | ay or nofemsof sec Rapidestutonofceulstnginiencarvolumeseiieait sod-ouan deage obese Heatly ene sag of a uid oman the pea patent homer ite vee — ‘tn cation Disease proces common chien eet eps and Pcs can aus lungpertaton and plone oft vee rages Ovo sould also be consent evaluation of hse paetsechld satan coc lea espond total fidadnitation alge txainatont eet ayo ‘lutea se Graces ma otra nce ose devlopngcongee tes 2 gulp may eau diconiniansowing oe apart we: Ponolcnopee Shoektetsed ntl 3 HDI ie isc - Sen et | Alton pena ie ot pe pe min | ett nang enters Coren ea i ai ett Dit Sack | Neon bi coy tas | ‘gy besa eile sepBiPetiauic Fe URE 50 sin | So ste | crooner | en sn ice det ech ne an tl imp | oot apenas | Neate — mental Critical Care Sup Sep heck es op! Si | rete | anti Sto | ican cena crab tc oe | oi amo doc urea | tin 1 -Hypovotemic Shock Biase Study -Apreviously healthy 4-month-old gil presents othe emergency department with a4 history ‘of vomiting, loose watery stools, and low-grade fever. She became lethafgie24 hours eater and has refused to rnk water or ta offered by her grandmother. Whats the etclogy of shockin this scenario = whats lethargy sign of what areothersigns of shock hat you might expect tof? “The most common cause of shock the pediatie patient is acute hypovolemia resulting fom Increase fluid and electrolyte losses (astrolntestinal disorder) er blood loss resulting fiom severe tats A detailed medical istry shouldbe obtained from the patients caregiver and! ‘refering instvution. history ofneeased Mid losses (vomiting and diathea, lethargy and ‘eresced urine opt ie foun in infants wth hypovolemle shock. Blood pressure is maintained Jonge in hypovoleric childrenthanin adults, and, as previously stated, blood pressure snot a ‘sor indicator ofthe status of perfusion. Capiary refill and temperature of extremities are much ieAserament ofthe Critcetly I Chité El ‘more eliable indicators of hypovolemia because they may become abnormal much ese than bloodpressure thechild wth shock. The primary treatment of hypowoemic shock is appropiate Inavascular Suid volume resuscitation (ee Chapter 7, 2.Cardiogenie Shock Biase Study ‘A3.month-old ge wih ahistory ofa ventricular septal defects sent hom the pedatcan fcr ‘othe radiology suite fo ches radiograph She presented witha I-weckhstry of progresie tachypnea,diaphoresis, weight loss, and decreased urine output Her mother ndieate that she had run out of medication, Examination reveals thatthe childs grunting. tachypee and 18000 cells mn. Absohte neutrophil cust 1,000 cll or sgaifca bands of 25% to 30% are also markets of severe bacterial nection in children, In such station, ‘full workup isecommended and should include bod elute, wine culture and lumbar unctue ifetiiealy indicated. Definitions for sepsis and organ dysfunction in pede patients (able 8-1) arediscassed a length in Chapter. ‘The features unique tothe cae of infants and children, as discussed in thischapte severely ec the main for erin the eatment of eicali il orijured pediatric paints. Therefore, specialty consultation should be requested ealKey Points PB svovesied neadings diate Fundamental Criteal Care Support Assessment of the Critically II Child 1 A question that shouldbe asked and answered in every healthcare provide’ mind i ‘Does this ebildlook sick Ifthe answer yes, tis key hat the his crcl i 1 Iskabity isan early sign of change the mental stats of young eile ‘8 Children should alvay be examine in the position thatthe spontaneously assume for ‘omfor, Forcing child into diferent poston may worsen respiratory distress and ven precipitate respiratory arrest. 1 Parl signs of respirator lees ebldren incl tchypne, grunting, nd nasal faring. 1 Enruringa patent airway isthe mos important inital step in teatinga chil with respiratory compromise. Chest movement doesnot ens paren airway. 1A chit’ perfusion stasis bes assessed inal by eapilary refill and temperature of ‘extremities ypotensioniss lat fndingin shock. Timely revogntion of the shock tate land aggressive intervention aeessenil to abtalning an optima outcome 1 toracranial hemoutoge inthe young infant can cause hesnodynamicallysgfcant blood ose 1 Infant and young children presenting wit selares should be evaluated for electrolyte imbalances and hypoglycemia. 1 Young infants face an increased rik of infection due o thelr immature immune systems. Empiric antes are considered emergency drug fo febrile infants younger than? months. | Carlo IA Fields, etal. Clinial practice parameter for hemodynamic support of pediatric and neonatal patents in septic shock. Crit Care Med 2002;0:1365-1378. 2. Epstein D, Wetzel RC, Cardiovascular physiology and shock In: Nichols DG, Ungereder RM, Spevak Ps et aed. Critical Hear Diseaze in Infants and Ohl. 2nd ed Philadelphia, PA: Mosby Elsevier; 2006:17-72, 3. Goldstein B GiroirB, Randolph A: and international Consensus Conference on Petite Sepsis, Definitions for sepsis snd organ dysfunction n pediatrics. Padiar Crit Cre Med 2005:62-8Assessment ofthe Ciisty A Child ‘Hacins MC Children are difeent In: HazinsiM, ed, Manual of Pela Critical Care. sted. St Louis, MO: CV Mosby 199811, 5. South Ls Heman L. Shock states. In: Fula Zimerman eds, Pediatric Critical (Care 3c ed, St Louis, MO: CV Mosby; 2006.394-10. 6: Thompson AE Pods sirway management. a Fukuman BE Zimmesman J, eds. Padiatr Cra Care, St Lous, MO: CW Mosby, 20064503, 7.Mood 6, Lmch RE Eletayte managementin pediatric critic ness. a ab ‘Be Zimmerman J eds Pediatric Critical Car, eed St Louis, MO: CV Mosby, 2005939.957 12i retianie Fasten__thapter 2 Airway MaNacemeNt A rriestives 1 Recognize signsand symptoms ofan unstable rway. Recognize sign and ymptoms of respiratory flue 1% Identify anatomicand physiologic variablesinvotved in the management the pediatric airway | Describe how to open and maintain an avay manually and wth se hep of sieway adjuncts {© Explain how tosupporca pation with bag-mask ventilation 1 Describe the preparation for and the sequence ofintubating peat patients, 1M Recognize the potential fr dificult intubation and diccut alternative methodsof ‘stablishingatabesirway. Bhiise Study ow are called tothe bedside ofa 7-month-od boy with respicatry syncytial virus bronchitis ‘who has developed worsening etractions and dessturations ovr the lst hour You male the decision to fatubate the patent, What signs and symptoms indletesrwayinstaiiy? What interventions may be atte ta malta te acway prior to deciding tointubaet What steps mustbe taken to ensue that intubation isa safe as possible?i rediotic Fe 22 ok Criteal Care Suppast LINTROOUCTION Respiratory disuess due to problems all levels ofthe respiratory tact, rom the nose othe ngs, {sa equent occurrence in cilden- Respiratory fares acommnion component cal ness In children. The majority of ariopulmonary aressin chden are heralded by espiratory flare. Alrwoy managements challenging dve to the anatomic differences ‘hat exit between children and adults a5 wells among clldren | The obit tora ary | ofediferent ages. Recogtion and interruption ofthe progression. | eonpromicandtoczaluh ftom respiratory compromise to resplatery fale damental | and manna ate ainay pediatric airway management. The ability to recognize airway | reat ‘compromise and to establish and maintain a patent airway —_ H1AMATOMIC ARO PHYSIOLOGIC CONSIDERATIONS — “The airway of child changes dramatically fom birth to adulthood. In order oases and manage slay emergencies it is necessary to understand certain anatomic and developmesl aspects, ‘of achilds airway Some key developmental diferencesamong infants, children, and adults are summarized blow: co Incdreo, the nose prosides nearly half ofthe total ee siney resistance. Theinfntsnoselsshor sof, and | learngthenaal ooops small with neatly creular mares. Infants under2 months | ysuctonngeon senfcnly Ofagzore obligate nasal eaters Although the mars | ingrown ints Adoubleinsize fom bir 196 months they canbe easily reiaay endian occluded by edema, secretions orexterl pressure ‘hearing he nasal passages by suctioning en ignicanty improve an infant respiratory condition, 1A chia tongues agen relation to the oral cavity. This elatve disproportion increased in developmental disorders such ax Pere Robin sequence and severe ‘micrognthism.A large tongue in aelativel smalloraleavity increases the dfclty of visualizing the ary during laryngoscopy Backward displacement ofthe tongue into ‘the posterior pharynxasa result of decreased muscle tone due to slep, depressed evel ‘of consciousness fom head injury, sedation, or aher nervous system dyshintion can result in upper airway obstsuction 18 The level of thelarynxin theneck changes rom C2in neonates to C3 to CAin children snd ends up at C5 0 C8in adults. The epglstisin infants at the level othe fist ‘ceria vertebra and overiaps the soft palate The high postion ofthe ayn, combined with large tongue and a small mandible, contibues oan infant's susceptibility to sinway obstruction.Airway Mesazement ~Due tothe high position ofthe larynx infants nd smal chile the angle ‘between the base of the tongue and the gloticopeningis more aut, which ‘creases the dificuly of visualizing the woes coed using laryngoscopy. ‘Theretoreastraight laryngoscope blade, such a Mille, may be superior for creating straight plane from ehe mouth othe gots 5 Aninfant’ pilot slong, ot, and omega 0) shape, whereas an ads epg shore mor rg and fate, Alongs and ster epg is more fie contol duinglarmgsecopy Using straight laryngoscope bade, whichis the eiglotisandexposes the ‘ocal cond, can overcame thie ificuly, Amelie fnnlstapd wh espn — g ‘orton angled posterior othe supraglotc portion . Consequety the nrrowestporonofthelarynrisinthe 4p aeyclayee fined subvotespace Anas linmcisbaeshaped wih Ge sa ‘henarrowest portion at the levl othe vocal eos, eaieerared {9 The intemal diameter of pediatric trachea is cara An dita approximately one-hit that ofan adult, esting Sere hp: th rarowet | lnhighesiriow resistance Resistance airflow sa | poranirh waco function of 1 were isthe aleway radius. A smal ~ decrscin alway dame (xd) de oedema a secretions causes far greater increase in resistance ina shld han an ad, |= Thelength ofa newborn’ trachea is approximately Scentnetrs end the aches of 2 18-month-old infantis approximately 7 centineters long. Given the short length of the aches, both right mainstem bronchus intubation and accidental extubation are 18 Theches wall ofintant relatively weak and unstable ~Theuse of abdominal muscles leads toa character see-saw. or abdominal breathing patern ~Interosal,subeostal and suprasternal etactons become prominent as erway obstruction or hung disease increases workof breathing. ~Ftigue of respiratory muscles may lead to decreased respiratory efor as respiratory allure progresses, 232-4 ee Fandementsl Critica Care Suppart IIL ASSESSING RESPIRATORY STATUS In chive, as in adults, assessment of airway ptency and spontaneous respiratory efforts rial ist stp. The cinician must recognize sign of distress as well as look stn, and fol for diminished or absent at movement. A. General frinciples of Airway Assessment ‘Obser the generl appearance ofthe child with careful attention to Muscle toneand spontaneous an reactve movement 1 Aleiness/interaton with environment oreaegver { inconsolable crying oragittion ' Ability to speskor ery (phonation and eying requie ar movement 1 Injury to theainway or other contions (eg. cervical pine fact or facial buns) that wilafect assessment and manipulation of he airway 1 Sign of congenital malformations of the face, mouth or tongue that might contbuteto respiratory problems 151s posible that vention may be adoqunte wih minimal thorace excursion bt that respiratory muscle acy and evn vigorous chest movement done ensure hat al solumefeadequate 1 Sigs of seway obsrvetion due to decreased level of consionsnest Asses the child espitatory at based onthe folowing ets: 18 Normal respiratory ate varies with age Table2-1) PED fs tsiov a tae spay ft rt pr ine)' Respiratory rates bes asiessed by observation: expose childs chestand watch the se and fal othe chest and abdomen, 1 A rospratory rate greater than 6 breaths per miqut is abnormal inacildof any age 1 An sbrormally ow rato may herald respiratory allt Consider work ofbreathing. locos subcostal andsiprsteal erations —— lf ine ih pogesie iy des Deeg — iwc enidnicninces cua ARNO history of distress may signal severe fatigue, minal cee ve | borin a childof ono. Moceuetingtuoy sotenamperninay ‘bance ewagcnp econ ersy ‘sings 1 Nasa faring an effort to increase airway ameter ands often seen with hypoxemia, 1 Gruntng is an expatory noise produced by an efoto prevent aay collapse by generating postive end-expiratory pressure (PEEP) ‘Auscultate over the mouth, nose, and necks wellas the centrl and priphealchest. Listen for ‘quali pitch, ight-to-1eft symmetry and magnitude of breath sounds, 1 Obstruction or nartowing ofthe extrathorsce airway (nose, posterior pharyn lary, ‘ne subglote space causes high-pitched inepratory noise (tide and erations 1 Obstuetin or narrowing ofthe itrathoraic airways esti signs an symptoms tat cccur predominantly during expiration, Wheerng(high-ptched expiratory sounds) ‘caused by expiratory obseetion. "Incomplete obstruction (during which aimed amount of arcan be inspired and ‘pit from che ung due to pharyngeal soft tssue collapse, a mas o foreign body inthe airway may be associated with snoring stridor, gurgling ot noisy breathing, | Complete airway obstruction (uring which noaican be inspite or expiced from the ‘ngs is ely when espiatory effort i vibe but breath sounds ae abet. "Cracks ate end-inspiatry noises usualy heard with parenchymal ung diseases such ‘s pneumonie and bronchiolitis andareloudestin the peripheral lung elds 1 Aymmetry ofbreath sounds isan important due. Breath sounds may be diminished ‘ec absent on one sid inthe presence of pneumotnrax or pleural effusion or when & ‘eachea tube i placed inthe opposite mala bronchus, 2526 re mental Critical Care Support raluatemmental status. 1% Agitation anditality may indicate hypoxemia. Lethargy inthe presence of acceptable oxygen saturadon may reflect avery elevated carbon diotde tension, 1 Assess presence and suength ofprotecivealrway eles gag —~ Gescoughand gap Usecautonbecnse ove aggresive Al ‘stimulation ofthe posterior pharyne whe assessing | those reflexes may precipitate emesis and aspiration of Aton ond ritably may ‘gastric contents, Moreover, stimulation ofthe posterior | indicate yporemia, ‘Pharynxmay convert partial upper airway obstruction due oillnessossuch as epigotis to complet airway obstruction, respiratory efforts ae sbsent and an immediate remedy i not svallable, proce to manval ‘suppor and asisted ventilation while preparing establish an artical airway, I. MONITORING RESPIRATORY FUNCTION A. Longitudinal Phasical As ‘Once a patient is found to bein respiratory dss, quent, epeated assessments are necessary ‘olook for improvements resting from intervention o for continuingelncal deterioration tat ‘necessitates further action. Constant vigilance isrequired once a patent isintubated and placed ‘ona mechanical ventilator. uscultation andebservaton are important tons for monitoring respiratory function, 8, Arterial Blood Gas ‘Arte blood gas measurement may be helpful when ether the eilogy othe degree of ‘espratoryinsuficeny is unknown, Careful consideration should be gen, however, tothe fat ‘hat arterial punctures painful procedure The agaton induced by terial puncture might ‘worsen the respiratory sues of some children. Asystematic approach to arterial blood gas interpretation consist of | Determining he degree of alveolar vetlaton based onthe Paco, | Assessing whether the pation’ pHcan be explained solely onthe basis of Paco, ois ‘metabolic component exists 1 Determining whether the ventilatory or metabolc even was primary or compensatoryAirway Wt 1 Assessing the eectivenes of correction of any hypoxemie sate ' Arterial bod gas dsordes ar classified into 4 min categories: hypoventilation, slveola hyperventilation, metabolic acidosis, and metabolic ltaloi 1. Hypovendation Hypoventiaton (respirator acidosis results in an elevation of Po, which, causes the HOO ‘oo, ratioto decease and esis in decrease in pl. Carbon donde retention canbe caused bbyhyporentiaton ora vention perfusion inequality tnreasing vention in mont eases wll correct espiatory acidosis. the paienis unstable, ans bag-mask eniltion sind unt the undeclying problem can be adresse, UE respiatry acidosis persists (s sen in chronic venitoy flue), the kidneys respons by conserving HOO,. Renal compensations typically not complet, and eo the pit approaches but des nc ily retuen 07.4, 2. Alveolar Hyperventilation Alveolar hyperventilation (espiratory alkalosis) results na deceased Poy which in tun elevates teand base excess emai nthe normal range because the ineyshave not had time co establsh adequate compensation. Pain and ansity may cause acute hypenentlaon and stlalossinchldren, Hypoxemis may leat increased minute ventilation and respiratory alll S. Metabolic Aldosis ‘Arimary decrease in bicarbonate in tun eads toa decreed pt. Bicarbonate can be lowered by Accumulation of aids in the blood, asin uncoetoled diabetes melts, and production of acc acid ine seting of tissue hyposa Respiratory compensation occurs by an increas in venation ‘thatlowersthe Po, ant in ten eises pl Respiratory insufciency in the presonce of metabolic acidosis conceming due wo the degree ‘acidosis that results when a patient is unable to inetease ventilation, 4. Metabolic Alkalosis ‘Am increase in HCO, rss the HOO, Poo, rato and thus the pl. Compensation occurs by hypoventilation and CO, retention, Metabolic alkalosis s semi the chld with plore stenosis ‘who loses large amounts of stomach acd due to vomiting. The ably ofthe child to compensate formetabalicaltaloss by hypoventilation i imied by hypoas, For additonal information, peas see Appendix 3. 27Wi Pediatric Fant aN Critical C, Pulse Oximetry Pulse cximetry provides continuous noninvasive measurement of arterial oyhemoglobin saturation (S00). Figure 2-1 shows the cxyhemogobin saturation curve, whichis graph of crjhemoglobin saturation versus partal pressure of oxygen (Pao). Under normal conditions hemoglobin s 90% saturated with oxygen at Pan of about 60 mim Hg (6.0KPa). Raising the Pan, above 6 mm Hg does notresultin an appreciable increase in hemoglobin saturation, However, {due othe sigmoidal shape ofthe oxyhemoglobin saturation curve, once the Pao, drops below 6) ‘am Hg, the saturation changes apaly with smal changesin Pan, ‘igure 2-1. Oryhemogbin Saturation Cure ‘Onygen Pact Press mm) reset ue ‘Theomfemoglobin sition cure eats the part pres ofmgen®D aperogakn tation, "Necrmnsnal stradonoftemogianin ose t=, omg (ot Ws 10, ves aoe pi ove ‘iy moter increase nonemoghbinsturtion. Ne owner ta arid decree oreo ‘Strain oars when iP, dps below mani BOP) Reproduced wihpermsion om Maye lic Tetnadonso pect date ome menngeg yar — catically patients inde the folaing —| sm Pate oximetry requis puss blood tow inine | Nome heen | presence of shock and poor perfusion, the accuracy and - 90% stwated with angen at | ‘signal strength become unreliable, a Pa02 of about 60 mm Hg (G.04P) Reig the ote incarbon mono pisonng mostpusecxmeters ge 60 mm Hg seat vilead fey igor oemogbin situation. | realnaneprelencese ‘Theinaccuracy occursbecausecarbaryhemogabin | seman state absorbsligh ata similar wavelength as oxyhemoglobin, “ee Blood gas measurement with co-animetr isthe a ‘only way to determine the true onyhemogobin and 7 carboxyhemogobin saturations 28Airway Moaaqesent 1 Pulse oximetry isnot accurate in methemoglobinemia. ' Oxygen saturation maybe underestimated Inpatients with sce cel disease and acute vasooceusive cris ' Incavenous dyes and certain colors of sal polis falsely ower pulse oximetry eeadings | The accuracy ofthe pulse oximeter should be questioned when. patients appearance and hear rate donot comtelste with the pulse oximeter reading 1 Iris always safer to question elevated saturaions and accept deceased saturations as accurate until proven otherwise. 1. Eubaled Carbon Giotite End:tdal CO, monitoring canbe used to estimate the atrial CO, tension Quanctative ‘continuous capnography canbe performed via nasal canna or with devices that attach othe tracheal ube. Qualitative (clorometric devices are availble that change colo when exhaled, 's presen. These are generally used for confirmation of tacheal tube pacement end ate discussed later in this chapter. tn the presence of ventilation perfusion mismatch airway obstruction, or tracheal ube leak end tidal CO, values may not accurately retlect tue atsial CO, levels, V.AIRWAY MANAGEMENT A. Uxyoen-Delivery Syatens - Oxygen shouldbe administeredimmediaely in vitualy every setting where resptatory fc {is suspected, Infants and chien consume 20 times more oxygen per blogram of ody weight than adults under basa conditions and even more when they ae illo stressed. Several eps ‘egatding administration of xygen to chldcen aes follows | When attempting oaiminster oxygen tan alr child tis important balance the ‘need o increase enygen delivery against the potential eet of promoting station, hs increasing oxygen consumption, ' Ifa childs intolerant of one metho of oxygen delivery (eg nasal canna), anothee ‘method should be wed (eg face ten tis ote hep to havea patent hold thee and assist wih placement of0, delivery devices 1 cauldren wit fen assume a position that maximizes sway patency and minimies ‘respiratory effort. They shouldbe allowed to remain in helt postion of comfort. 29mental Ciel Cate Seppent | Oxygen atminsration will havelinted effect nthe presence of airway obstruction. Ina somnolent or obtunded child the airway canbe obstructed due o nec exon, relzation ofthejaw, posterior displacement ofthe tongue agains the pharynx, and collapse ofthe hypopharynx. Before using airvay adunetsatempt to open the airway ‘using manual methods The airway shouldbe cleared of seuinrecpinus bapa et ae | In patients who are making respiratory efforts burt are | Ongen shouldbe } cmoupaniagee teeters | canning respiratory efforts can be assed witha bag-mask device. _ dca itu “These patients can then be trantioned tononinvasveor Invasive forms of entation ‘See Appendix fo addtional dscusion on sinay adjuncts. 1. Simple Oxygen Mask ‘Thesimple oxygen masks low-flow device that delves exygen ith aflow rate of 6 10ers er minute. The oxygen concentaton delivered to the patient can reach a maximum of 6 due ‘oentranment of rom alr through Ue edulation ports ofthe mask ts important to malaain an oxygen flow at ofat east 6 ters per minueto sustain an opi inspired onygen conceneation and prevent rebeathing of exhaled cazbon dioxide. 2.PartalRebreathng Mask | pardalrebreathng mask consists of simple face mask with reservoir bg, I provides oxygen ‘concentrations of50% o 60%. Duting inspiration the patient drews gas predominanly rom the fies oxygen inflow andthe reservoir bag, so entrainment of rom ar through the exhalation ports ‘sminimized. An oxygen flow rat of 1010 I2 ters per minute uevallyrequied, '.Non-rebreathing Mask ‘Anon rebreathing mak consists of ace mak and reservoirbag th valve incorporated into ‘ne orboth exhalation ports to prevent entrainment of ream air during inspietion. Another valve between the servi bag and the mack prevents low of exhaled gar into the reserve. An inepired concentration of85% canbe achieved withan oxygen low rate of10t015 ters perminite and tse ofa wll saled mask Face Tent |Aface tent isa high lw sft plastic bucket that children often tolerate etter than a face mas. "Even with high oxygen low rat, nspited enygen concentrations ovr 4% cannot be eiably provided. A fae tent permis acces tothe face without interipting onygen flo. 5.NaselCannula Anasal cannulas low-flow oxygen delivery system thats useful when low levels of supplemental ‘ongen are required. The net Fo, depends onthe child sespitatory effort, sie, and minute ‘vention inrcomparizon with the nasal cannula flow, 210