Paediatric Respiratory Care Flashcards
What are the anatomical and physiological respiratory changes in children and babies
- Up until the age of three the rib cage is soft & cartilaginous,
- Rib cage is placed horizontally in relation to the sternum (no bucket handle movement)
- Poorly developed intercostal muscles (↑ ventilatory requirements met by ↑ RR rather than ↑ depth )
- Angle of insertion of diaphragm is horizontal – so it is at a mechanical disadvantage & vulnerable to fatigue
- Up to 6 months preferential nasal breathing
- Airway diameters are small & therefore increase airway resistance & increase WOB. Also easier to occlude
- Less cartilaginous support of airways predisposes them to collapse
- Poorly developed cilia at birth increases the risk of sputum retention
- A new-born has on average 150 million alveoli, compared to 400 million in an adult, which are also much smaller in size – reduced area for gas exchange (in illness PaO2 will drop more quickly)
- Collateral ventilation does not exist at birth, but develops over the first 3 years of life
- Ventilation & perfusion – ventilation is preferentially distributed to the uppermost lung because of the soft ribcage, & perfusion remains best in the dependent regions
- FRC is sometimes below closing volumes due to compliant rib cage & immature respiratory control → increased risk of atelectasis
- Infants have a higher resting metabolic rate & thus higher oxygen requirements
- Children have less type I muscle twitch fibres therefore fatigue more quickly
How does communication differ in paediatrics
Think about how you will communicate with:
- The child
- The family/main caregiver
- The multidisciplinary team
Assessment and treatment requires an age appropriate approach
Children find questions easier to answer if they relate to their normal activities and functions of daily life, i.e. play
Can a baby drink their milk without getting breathless/splutter
Can a child keep up in sports/carry their bag to school
How does subjective Ax differ in paediatrics
PMH – birth history as development of respiratory system may be abnormal. Special needs?
SH – consent/family dynamics (SS, main carer, consent child protection), school/nursery?
FH – genetic illness, are there siblings?
Progression of illness – speed of deterioration and or recovery?
What is normal for the child? In terms of sleeping, crying, floppiness - ask parents
Additional information:
- Feeding – due to risk of coughing need to consider NG feed/vomiting/bolus & its affect on treatment; babies fed milk for at least 4 months
- Sleeping – babies /young children need to rest/sleep regularly
- IV’s/drugs – may affect your ability to move the child or be at risk if the child moves
How does Obj Ax differ in paediatrics
Be aware that babies find it difficult to control their temperature – shivering uses respiratory muscles & uses up oxygen. So care is needed when assessing – keep them covered.
Obs, Palp, Ausc, CXR
Specifically how does Obs differ
- Activity level: Lifeless/passive/sleepy (may be a good or a bad sign). Playing/crying:
- Irritable/agitated (may be a sign of hypoxia)
- Still & withdrawn could be severe respiratory distress
- Cyanosis/mottling
- Pallor/sweaty
- Monitors/apnoea alarms
IV’s
Specifically how does palps differ
- Tactile fremitus can be prominent
- May need to feel under baby grow/clothes to maintain warmth
Specifically how does Ausc differ
Ausc:
- Undress & be quick as loose heat rapidly
- Increased RR & reduced volumes make it more difficult to hear anything
- Combine with palpation
- Move child around as secretions can be quiet but very obvious once the child is moved
- Pleural rubs are rare but may be heard in more virulent pneumonia’s
Specifically how does CXR differ
- No control on inspiration
- Heart size is much bigger (>50% diameter of chest)
- Young children’s ribs look horizontal not bucket shaped
- Humeral head may be cartilage & the epiphyseal plate may be evident
- Thymus in children <2 years old may be visible. It is a kite shaped structure that can be mistaken for a right upper lobe collapse
How does normal values differ for paediatrics
HR, RR, PCO2 = high at birth and gradually lower
BP, SaO2, PO2 gradually increase
State Clinical Signs of Respiratory Distress
Recession – intercostal, subcostal, sternal Abnormal breath sounds Tracheal tug ↑ RR or ↓ RR/apnoea Expiratory grunting Stridor Nasal flaring Cyanosis Head extension
State Clinical Signs of Respiratory Distress relating to Cardiac symptoms
Tachycardia or bradycardia
Hypertension or hypotension
State other general signs of respiratory distress
Neck extension Altered conscious level Sweating Pallor Head bobbing Irritability/restlessness Reduced activity Reluctance to feed Headache Reduced cry Cool peripheries
State considerations for paediatric treatment
- Always uses a combination of techniques
- Involve /inform carers, you will achieve more
- Limit treatment times as children can tire quickly
- Make it fun, motivate the child, learn children’s songs & be aware of the latest children TV/games
- Always have oxygen ready due to rapid deterioration
State UK consensus guidelines for paediatric treatment
recommend the early establishment of a PT regime of advice, education for parents and physical activity, exercise & ACTs. As this can positively impact on lung function deterioration despite no obvious outward signs
The most common used ACTs for infants and children with long term respiratory disorders with chronic sputum production are:
1. Modified postural drainage + percussion 2. Infant PEP and Bubble PEP 3. Assisted Autogenic Drainage
State the paediatric treatment options
Manual techniques
Positioning/postural drainage
Breathing exercises (ACBT/AD)
Exercise/mobilisation
Adjuncts (PEP, Cornet/Flutter/Acapella, I.S, cough assist, IPPB) Suction
Manual Hyperinflation (MHI) in ventilated children
