paediatric ITU Flashcards
pads
consider attention span / co-operation
patient therapist interaction is difference vs adults
communication syle
consider family /carer
physiological difference
between adult and child
increased compliance in chest wall
decreased compliance in lungs
meaning decreased FRC and increased work of breathing
decreased % of T1 muscle fibres in diaphragm
diaphragm more prone to fatigue –> less able to withstand respiratory distress
increased metabolic rate ov O2 consumption
–> hypoxaemia develops more rapidly
preferential ventilation of upper lung when positioned in side lying
ensure SaO2 maintenance when repositioning
anatomical difference
decrease d of airways
increase ariway resistance
increase respiratory difficulties with any inflammation of airways
preferential nasal breathers
NG tubes
narrow d and increase WOB
ensure nasal passages are cleared of secretions
larger tonsils and tongue
increase airway obstruction
floppy cartilage
predisposes to airway collapse
more horizontal ribs and more cylindrical
lack of bucket handle and pump handle movement, unable to increase lung volumes
poorly developed intercostal muscles
nearly solely reliant on diaphragm for respiration
immature cilia
increased accumulation of secretions, mucus plugging
decreased alveolar surface area
decreased space for gas exchange
increased heart size in infants
less room for lung expansion
poor collateral ventilation in infancy
increased risk of atelectasis during RTI
collateral ventilation
Adults have a developed respiratory system therefore more collateral ventilation
Functional in paediatrics:
Pores of Kohn: 1-2 years (intra aveolar)
Canals of Lambert: 4-6 years (Bronchiol-aveolar)
Channels of Martin: Develop in pathology (Interbronchial)
ITU assessment
NB Respiratory +/- neurological if appropriate depending on PC Subjective Assessment Objective Assessment Problem List Treatment Plan Goals
subjective assessment in ITU
Presenting complaint
History of presenting complaint
Past medical history
Respiratory (normal chest status)
Orthopaedic (spinal deformities)
Neurological (reduced cough, risk of aspiration)
Bone health (osteopenia, osteoporosis)
Seek information from parents/carers if present
Information from staff nurse/ medical staff /ICIP including update on medical /nursing status
Tolerance of interventions / handling over last 12 – 24 hours
subjective assessment
birth history
Birth history
Particularly relevant for neonates and children with post natal problems
Method of delivery (immediate delivery, trauma)
Gestation and weight (lung development)
? SCBU (length of time, ventilation, oxygen requirements)
Chronic lung disease
subjective assessment developmental history family history medications other considerations
Developmental History Normal level of cognition and functioning Local service, specialised equipment used Family history Parents and siblings fit and well? Smokers, pets at home? Recent travel? Genetics Parental responsibility Child protections issues medications at home nebulisers patch - hyoscine order of medications Pain relief, sedation due? How does the child respond to handling? Apnoeas? Bradycardias? When was the last feed? Can the child cooperate? What is the parents’ understanding? Consent for respiratory treatment
objective assessment
observation Environment in ITU (Emergency bell, trolley, MIE set, suction) Your patient: Breathing pattern Colour (pink, pale, cyanosed) Level of alertness Are they puffy periorbitally, peripherally Position Lines: ETT, arterial line, catheter
ventilation
is the patient intubated and ventilated
nasally vs oral
what ventilation mode is the patient on
ventilation modes
vitals
Main modes in ICU: SIMV(PC)+PS PRVC CPAP+PS (weaning mode) HFOV NIV (CPAP+BiPAP)
Aim TV’s 6-8mls/kg
4-6mls/kg in adults
baseline vitals from subjective exam if known respiratory pathology neuro GCS temp HR RR BP SaO2 CRT PEWS
objective assessment
auscultation
palpation
expansion
auscultation air entry added sounds: creps wheeze stridor if extubated
palpation
any palpable remits
expansion
signs of respiratory distress
/WOB
tachypnoea nasal flare tracheal tug recession - intercostal, subcostal, substernal mild moderate severe grunting paradoxical breathing preparation and tense sternal retraction intercostal retractions
cough
if known respiratory condition may have an objective PCF measurement
if cough is strong or weak effective, dry or wet
chest x-ray considerations
position of ETT if intubated exposure and rotation of x-ray chest shape bones lung fields NG tube placement compare to previous if appropriate
blood
white cell count
Hb
platelets
CRP
ABGs
resp acid decrease pH increase pCO2 normal HCO3
resp alk. increase pH decrease pCO2 normal HCO3
metabolic acidosis
decrease pH normal PCO2
decrease HCO3
metabolic alk
increase pH
normal PCO2
increase HCO3
medications
sedations cardiac support antibiotics nebulised therapies anti convulsants diuretics
fluid output
24 hour, length of stay
microbiology
Nasopharyngeal aspirate (tests for viral conditions e.g bronchiolitis, influenza, coronovirus etc)
Sputum sample
Broncheoaveolar lavage
*Check previous sputum samples
other investigations
feeds
Other investigations:
CT thorax, DEXA, sleep studies
Feeds:
Oral, NG, NJ, PEG
Continuous vs bolus
Feeds must be stopped for >30mins prior to physiotherapy
indications for physio
chest xray changes
lobar collapse / atelectasis
retained pulmonary secretions
aspiration pneumonia
absent / ineffective cough
deteriorating ABGs
respiratory infection
background pathology
CF
NM
neurological disease
post op
prolonged immobility
aims of physio
Minimise the adverse effects of critical illness and intubation on the respiratory system
- Reduction of secretion retention
- Maintain alveolar expansion
- Improvement of V/Q matching
- Reduce airway resistance
- Optimise oxygenation
- Preservation of respiratory and peripheral muscle strength
Comellini et al 2019
physiology of secretion clearance
The mucociliary escalator consists of mucus producing goblet cells and the ciliated epithelium
Cilia beat in co-ordinated, efficient movements
mucus clearance in ITU
Patients admitted to ICU suffer from severe impairment of airway clearance capacity
Muscular weakness and sedation decrease ability to cough – retained secretions
If I+V mucociliary transport stops at the end of the ETT
Mucus movement in the airways occurs through 2 primary mechanisms:
Expulsive airflow (i.e coughing) however if ETT present holds glottis open
Two phase gas liquid interactions
expulsive flow
normal cough mechanism
deep inspiration of 80-90% of total lung capacity
glottic closure with a pause
effective contraction of expiratory muscles to generate rapid expiratory flows
two phase gas liquid interaction
The transfer of kinetic airflow energy onto liquid airway surface exerts a shear force moving sputum along the airway mucus layer in the direction of proximal airflow
Airflow remains laminar when flow rates are low
As flow velocity increases the mucus layer becomes unstable and forms ripples that move in the direction of the air flow
treatment techniques
reposition manual techniques MHI saline instillation suction cough assist early mobility
repositioning
Positioning to optimise ventilation or postural drainage
Children preferentially ventilate the uppermost lung
Head down tip avoided in babies as risk of GOR and aspiration
- Used alongside other techniques, can be of benefit to advise nursing staff positioning over 24 hour period
- Positioning specific programmes at bedside
manual techniques
Percussions:
Rhythmical cupped hand or palm cup over chest wall
Contraindications: Undrained pneumothorax Raised intracranial pressure Rib fractures Osteopenia/Osteoporosis Platelets of <40 Pulmonary haemorrhage
expiratory vibrations
compressive vibratory pressure on chest wall during expiration
CI: as per percussions
Manual hyperinflation
performing MHI
Prevent atelectasis and recruit areas of collapsed lung
Improve lung compliance and gas exchange
Increases movement of pulmonary secretions toward central airways
Prevent airway mucus plugging
Use manometer
2 breaths at PIP/PEEP on ventilator, 3rd breath 10% above PIP
Followed by end inspiratory hold with quick release to increase expiratory air flow
manual hyperinflation with expiratory vibrations
For effective treatment to mobilise secretions effectively:
- Expiratory flow during MHI must be greater then inspiratory flow
MHI with expiratory vibrations significantly increases expiratory flow to facilitate expulsive airflow and mobilisation of secretions
- More effective than just MHI alone
Expiratory vibrations should be applied at early expiration (during quick release phase) to achieve greatest expiratory flow, therefore mobilising the most secretions
MHI with expiratory vibrations:
80% increase in expiratory flow
MHI - CI / precautions
Contraindications/precautions for MHI: Cardiovascular instability Raised intracranial pressure Labile BP Undrained pneumothorax High ventilatory pressures Recent pneumonectomy Bullae Recent lung surgery Haemoptysis Clamped chest drain
suctioning
aims
CI/ PRECAUTIONS
To clear secretions thus maintaining a patent airway
To improve ventilation and oxygenation
To reduce the work of breathing
Contraindications/Precautions for suctioning:
- Unexplained haemoptysis
- Laryngospasm (stridor)
- Bronchospasm
- Basal skull fractures (no nasal suction)
- Recent oesophageal or tracheal surgeries
- Severe hypoxia
- Raised intracranial pressure
- Acute hypo or hypertension
oropharyngeal suctioning
nasopharyngeal suctioning
Oropharyngeal suctioning: Measure corner of mouth to ear lobe and add approx 2 cms
Nasopharyngeal suctioning: Measure tip of nose to ear lobe to thryoid cartilage
suction
tracheostomy patients
Ensure appropriate depth of suction
High risk of airway trauma and granulation tissue
suction
Beta-2 agonists (Salbutomol, atrovent) Effects: Bronchodilates airways Reduces inflammation Improve mucocillary clearance
Mucolytics (0.9%, 3%, 7% saline) Effects: - Rehydrate secretions - Increase airway surface liquid - Improve mucocilliary clearance - Stimulate cough Beta-2 agonist nebuliser
↓ (Wait 15 mins)
Mucolytic
↓
Chest physiotherapy
cough assist
cough assist precautions
Appliance of a positive pressure to the airway, followed by a rapid shift to negative pressures
Rapid shift increases expiratory flow aim ↑ peak cough flow
Cough assist in ICU:
Can reduce reintubation rates and ICU length of stay
Shorten treatment time in ICU without any difference in secretion clearance
As per positive pressure MHI
- Cardiovascular instability
- High intracranial pressure
- Undrained pneumothorax
- High ventilatory pressures
- Recent pneumonectomy
- Bullae
- Recent lung surgery
- Haemoptysis
- Clamped chest drain
early mobility in ITU
benefits
CI
PICU mortality rates have ↓, however the proportion of children surviving their critical illness with significant functional morbidity is rising
Prolonged immobility is an important predictor of poor functional outcome and the development of critical illness acquired morbidities
There is growing evidence that demonstrates the benefits of early implementation of rehabilitation and mobilisation
Reduces length of stay in ICU and overall length of stay Secretion mobilisation and clearance Increased TV, RR, MV Improves levels of consciousness Assists fluid distribution Improves venous return Reduces length ICU delerium Improves sleep
CV instability Spinal precautsios Unstable fractures Open abdomen Open chest ECMO <24 hrs admission to PICU
