Recognition and Treatment

of Respiratory Distress
and Failure
Suryadi Susanto
Pediatric Department
Krida Wacana Christian University
Recognition and Treatment of
Respiratory Distress and
Failure
Goals
O Rapidly stabilize the child’s airway and breathing
O To identify the cause of the problem

Airway Obstruction
O Children <5 yr old : foreign-body aspiration and choking.
O Liquids, small objects and food
O A history consistent with foreign-body aspiration is
considered diagnostic.
O Sudden onset of choking, stridor, or wheezing 
foreignbody aspiration until proven otherwise.
 Airway Obstruction
Management of airway
obstruction:
O Head-tilt/chin-lift
maneuver
O Inspection for a foreign
body, and
O finger-sweep clearance or
suctioning
O Blind suctioning or finger
sweeps of the mouth are
not recommended.
O A nasopharyngeal airway
or oropharyngeal airway
 Airway Obstruction

O A conscious child suspected of having a partial

foreign-body obstruction should be permitted to
cough spontaneously until coughing is no longer
effective, respiratory distress and stridor increase, or
the child becomes unconscious.
 Airway Obstruction
If the child becomes
unconscious:
O Gently placed on the ground,
supine.
O Head-tilt chin-lift maneuver
O Mouth-to-mouth ventilation.
O If ventilation is unsuccessful,
the airway is repositioned,
and ventilation attempted
again. If there is still no chest
rise, attempts to remove a
foreign body are indicated.
 Airway Obstruction
In an infant <1 yr old
O A combination of 5 back
blows
and 5 chest thrusts
O After each cycle of back blows
and chest thrusts, the child’s
mouth should be visually
inspected
O If identified within finger’s
reach, it should be removed
with a gentle finger sweep.
O If no foreign body is visual,
ventilation is again
attempted.
 Airway Obstruction
In an infant <1 yr old
O If this is unsuccessful,
the head is repositioned,
and ventilation
attempted again.

O If there is no chest rise,

the series of back blows
and chest thrusts is
repeated.
 Airway Obstruction
A concious child > 1 yo
O A series of 5 abdominal
thrusts (Heimlich
maneuver)

O After the abdominal

thrusts, the airway is
examined for a foreign
body, which should be
removed if visualized.
 Airway Obstruction
A concious child > 1 yo

O Lying down if unconscious

O If no foreign body is seen, the
head is repositioned, and
ventilation attempted.
O If it is unsuccessful, the head
is repositioned and ventilation
is attempted again.
O If these efforts are
unsuccessful, the Heimlich
sequence is repeated.
 Airway Narrowing
Upper airways:
O Extrathoracic portion of the airway (oropharynx, larynx, and
trachea)
O Airway edema (croup or anaphylaxis).

Lower airways:
O Lower airway disease affects all intrathoracic airways notably
the bronchi and bronchioles.
O Bronchiolitis and acute asthma exacerbations  combination
with airway swelling, mucus production, and circumferential
smooth muscle constriction of smaller airways.

O Airway support for these processes is dictated by both the

underlying condition and the clinical severity of the problem.
 Classification of Airway
Obstruction
Mild upper airway obstruction:
O Minimally elevated work of breathing (tachypnea,
mild retractions).
O Stridor, if present at all, should be audible with only
coughing or activity.
 nebulized cool mist and supplemental oxygen
 Classification of Airway
Obstruction
Moderate obstruction:
O Higher work of breathing and more pronounced
stridor
 nebulized epinephrine and dexamethasone p.o or
IV

Severe upper airway obstruction:

O Marked retractions, prominent stridor, and decreased
air entry
O Hypoxic, dyspneic and agitated.
 impending respiratory failure vs improvement)
Cause Airways Obstruction
O When anaphylaxis is suspected as the cause for
upper airway edema,
 epinephrine IM or IV

O No matter the cause, any child in impending

respiratory failure
 prepared for endotracheal intubation and
respiratory support.
 Therapies
Lower airway obstruction
O Target: relieving obstruction and reducing work of
breathing.
O Inhaled bronchodilators (salbutamol, corticosteroids
oral or IV)

Significant obstruction  dyspneic, tachypnea,

retractions, and audible wheezing
O the addition of an anticholinergic agent (ipratropium
bromide) or
O a smooth muscle relaxant (magnesium sulfate)
O Supplemental oxygen and IV fluid hydration
 Therapies
Respiratory failure can be averted:
O Continuous positive airway pressure (CPAP)
O Bilevel positive airway pressure (BiPAP), or
O Heliox (combined helium-oxygen therapy)

Endotracheal intubation:
O Skilled providers
O Hospital setting (respiratory and circulatory
compromise)
Parenchymal Lung Disease
O Such as pneumonia, acute respiratory distress syndrome,
pneumonitis, bronchiolitis, bronchopulmonary dysplasia, cystic
fibrosis, and pulmonary edema.

O Effects on the small airways and alveoli

O Inflammation and exudation  consolidation of lung tissue
O Decreased gas exchange, and
O Increased work of breathing
O Specific treatment
O supportive care: supplemental oxygen, noninvasive respiratory
support (with CPAP or BiPAP), or invasive mechanical
ventilation.
Advanced Airway Management
Advanced Airway Management Techniques
1. Bag-Valve-Mask Positive Pressure Ventilation
O Can be as effective as endotracheal intubation and
safer
O The provider is competent to select the correct mask
size, open the child’s airway, form a tight seal
between the mask and the child’s face, deliver
effective ventilation, and assess the effectiveness of
the ventilation.

An appropriately sized mask:

O Fits over the child’s mouth and nose
O Adequate seal “C–E” grip on the mask
Appropiate mask?
CE Tehnique
Advanced Airway Management
O Find positions that best maintains airway patency
and allows maximal ventilation.
O In infants and young children: neutral “sniffing”
position without hyperextension of the head

O Poor chest rise and persistently low oxygen saturation

values indicate inadequate ventilation.

Recheck:
O The mask’s seal on the child’s face,
O Reposition the child’s head, and consider suctioning
Advanced Airway Management
2. Endotracheal intubation
Indication:
O Unable to maintain airway patency or protect the
airway against aspiration
O Failing to maintain adequate oxygenation
O Failing to control blood carbon dioxide levels and
maintain safe acid–base balance
O Sedation and/or paralysis is required for a procedure;
and
O Anticipate a deteriorating course
Advanced Airway Management
Absolute contraindications to tracheal intubation, but
experts generally
O Complete airway obstruction  “E’”cricothyroidotomy
O Provide appropriate cervical spine protection  neck
or spinal cord injury is suspected.
Advanced Airway Management
O The most important phase of the intubation
procedure is the preprocedure preparation, when the
provider ensures all the equipment and staff needed
for safe intubation are present and functioning.

An easy pneumonic for this is SOAP MM:

O Suction
O Oxygen
O Airway
O People
O Monitor
O Medications
Advanced Airway Management
Sized endotrache al tube (ET):
O Uncuffed ET size : age in years + 4
4

Preparations:
O Analgesia
O Premecations
O Rapid sequence intubation (RSI) .
Advanced Airway Management
The goals of RSI
O To induce anesthesia and paralysis
O To complete intubation quickly.

O This approach minimizes elevations of intracranial

pressure and blood pressure that may accompany
intubation in awake or lightly sedated patients.
O Because the stomach generally cannot be emptied
before RSI, the Sellick maneuver (downward pressure
on the cricoid cartilage to compress the esophagus
against the vertebral column) should be used to prevent
aspiration of gastric contents.
Advanced Airway Management
Once the patient is intubated:
O Proper ET placement
O Symmetric chest rise
O Analysis of exhaled carbon dioxide (CO2)
O Chest radiography
 Vascular Access
O Veins suitable for cannulation
are numerous  anatomic Upper extremities
variation

Upper extremities
O the median antecubital vein,
located in the antecubital
fossa,
O Many veins on the dorsum of
the hand
O The cephalic vein is usually
cannulated at the wrist, along
the forearm, or at the elbow.
O The median vein of the forearm
 Vascular Access
Lower extremity:
O Saphenous vein: anterior to the
medial malleolus
O The dorsum of the foot, large vein
in the midline, passing across the
ankle joint, but catheters are
difficult to maintain in this vein
because dorsiflexion tends to
dislodge them.
O A second large vein on the lateral
side of the foot, running in the
horizontal plane, usually 1-2 cm
dorsal to the lower margin of the
foot
 Vascular Access
Scalp veins:
O Superficial temporal
(anterior to the ear)
O Posterior auricular (just
behind the ear).

O Deeper and larger

central veins 
percutaneous
cannulation or surgical
exposure
 Vascular Access
Intraosseous Access
Indication:
O IV access proves difficult
or unattainable

Preparation:
O Large-bore needles (for
intramedullary venous
plexus access)
 Vascular Access
Intraosseous Access
Location:
O anterior proximal tibia

Administer:
O Any and all medications, blood
products, and fluids may be
administere
O All medications for emergency
resuscitation

Complications:
O osteomyelitis
O tibial fracture
 Vascular Access
Arterial AccessIndication:
O Frequent blood sampling
and/or
O Continuous blood pressure
monitoring

Location:
O The radial artery,
O The ulnar artery
O Lower extremity (neonates
and infants); dorsalis
pedis artery and the
posterior tibial artery
 Post Resuscitation Care
 Close observation in ICU

2 phases:
O Assess the ABC
O A systematic full organ system assessments (PE and
laboratory evaluation)

Optimal care includes:

O Ongoing support of cardiovascular and respiratory
system
O Identification and treatment of other organ system
dysfunction
O Supportive services
O Induced hypothermia
 Post Resuscitation Care
Avoid:
O Hyperthermia
O Hyper or hypoglycemia

Complications:
O Hypoxic-ischemic encephalopathy
O Intellectual impairment
O Spasticity