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Show full transcript for Overview of Respiratory Emergencies video

Any abnormal respiratory rate or effort is a condition known as respiratory distress. In this lesson, we'll go over the importance of early recognition of respiratory emergencies, the proper head position for treatment, and some tips, techniques, and equipment used in respiratory emergencies.

Respiratory emergencies can vary greatly, from something as benign as tachypnea that's self-limiting all the way to agonal gasps.

It's important to know the latest guidelines for PALS when treating for respiratory distress, and this includes conditions like hypoventilation (inadequate respiratory effort), bradypnea (slow respiratory rate), and irregular breathing issues.

It's vital that all PALS providers are well-prepared to identify respiratory conditions quickly and easily, whether you're dealing with something easily treatable – like suctioning an airway secretion or administering oxygen – to more serious conditions that are less obvious, harder to identify, and that can quickly deteriorate into respiratory failure.

The latter will require immediate and appropriate intervention most often using advanced airway techniques, including assisted bag mask ventilation.

Pro Tip #1: When it comes to infants and children, respiratory distress can quickly progress to respiratory failure and that system failure can eventually deteriorate into cardiac arrest. Neurologically intact survival to the hospital for infants and children is much more likely before cardiac arrest, than it is after.

Proper Positioning for Good Ventilation

One of the more common airway complications can be attributed to poor positioning of the pediatric patient, and thus poor airway access.

To combat any potential alignment issues, make sure the child is laying down and facing upward. The head and neck should be in a slightly sniffing position, which is more neutral than tilted, or ever so slightly tilted.

Be sure not to hyperextend the child's neck, as this can also impede the airway. Instead, flex the child's neck forward at the shoulders while extending the child's head. To achieve the slightly sniffing head position, consider how your head and neck react when you walk into a kitchen and smell a freshly baked apple pie.

Pro Tip #2: If the child is two years or older, use padding under the shoulder blades, if available, which should help maintain the proper positioning and make it easier to adequately oxygenate the patient. And if this doesn't help, assess for further airway obstructions.

Gastric Inflation

A frequent problem that can occur during bag mask ventilation is inflation or distension of the stomach. If this happens, it's much more probable that the patient will regurgitate gastric stomach contents, which can contribute to both acute and chronic respiratory issues.

Some common reasons for gastric inflation include:

  1. Partial airway obstruction when high airway pressure is required.
  2. When ventilating patients with poor lung compliance.
  3. While ventilating a patient with a bag valve mask, particularly if:
    a. The volume of oxygen delivered is too great
    b. The pressure created is too high
    c. The patient is unconscious or in full arrest and has poor gastroesophageal sphincter tone

Pro Tip #3: To prevent these situations from occurring, ventilate at a rate of 1 breath every 3-5 seconds and avoid creating too high of a peak pressure during ventilations. Deliver only enough pressure and air to see full chest rise and no more.

Warning: Delivering too much pressure and air could result in bypassing the esophageal sphincter, which means putting air into the stomach instead.

Cricoid Pressure

Though cricoid pressure is allowed for use in PALS, research suggests that the advantages are insufficient to make it a routine procedure. However, having said that, if you have an unresponsive victim and a second healthcare provider who can perform the cricoid pressure separate from other advanced life-saving duties, using it may be a good idea to prevent gastric inflation.

If there is evidence of gastric inflation, advanced healthcare providers are allowed to decompress the gastric pressure by inserting a naso or orogastric tube to help avoid gastric reflux.

Suctioning Devices

In PALS, both portable and mounted suction devices can be used.

Advantages of portable devices include transporting them to wherever needed. However, a common disadvantage is the poor or inadequate suctioning power, even at max capability.

A bulb or syringe style device is simple to use but has the same disadvantage, as it too offers little suction power. The benefit of these, however, is that they don't require a power source. However, they tend to only work on small patients and for very light secretions.

Pro Tip #4: A suction force of negative 80mm to negative 12mm of mercury is usually required to remove most airway secretions.

Wall mounted devices, while not portable, are usually more powerful and can offer much greater suctioning power. But the lack of portability limits the scenarios in which they can be used.

It's important to use an appropriate suction device whenever secretions, vomit, or blood is in the oropharynx, nasopharynx, or trachea. It's equally important to use one immediately after birth if there is evidence of a meconium stain.

Warning: Remember to suction the newborn's mouth first, as baby's are mouth breathers. Then suction the nasal passages after.

Common Complications with Suctioning

Some of the more common suctioning complications include:

  • Soft tissue injuries
  • Agitation
  • Gagging and vomiting
  • Vagal stimulation

It's important to understand and avoid these complications whenever possible, and to know the potential risks when suctioning a patient.

Types of Suction Devices

There are two common types of suction devices: rigid and soft.

Rigid suction catheters are most commonly used for suctioning the oropharynx when there are thick secretions like vomit and blood.

Soft, flexible suction catheters are most commonly used for aspiration of thin secretions from the oropharynx and nasopharynx or for suctioning an advanced airway like an endotracheal tube.

Pro Tip #5: A color coded link-based resuscitation tape is really helpful when trying to find the appropriate size of soft catheter to use for advanced airways. It's also important to limit suctioning to 10 seconds to help avoid the possibility of hypoxemia.

All healthcare professionals can greatly improve the outcomes of respiratory emergencies by quickly and properly identifying and treating respiratory distress and respiratory failure early and proactively. Doing so will limit the chances of that child's condition deteriorating into cardiac arrest.