Tag Archive | "work of breathing"

The Five Ws of Intubation

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Ask yourself “w” questions (i.e., who, what, when, where and why) when starting an intubation. Photo iStockPhoto.com

We learned that airway comes first in the very first class all of us took in EMS. Up until the recent changes in the American Heart Association guidelines, we had the following mantra stuck in our heads: “Annie, Annie, are you OK?” We were to open the airway, then look, listen and feel. So when it comes to managing the airway in the field, this is the first priority and often the most overwhelming to EMS providers.

Airways can be simple or complex depending on the particular patient, the environment and the experience of the provider. The gold standard for a secure airway, however, the ultimate goal is oxygenation with successful first-time insertion of the endotracheal tube (ETT).We reserve the ETT for a particular patient population in the EMS community. Let’s call them the “who.”

Who & When
The “who or “when” would be those patients who are unable to protect their own airways, who are apneic or who require ventilator support—either manually or by ventilator.

In some cases, selecting this group is obvious. If they can’t breathe on their own, then someone or something needs to do it for them. In other patients, it’s a little harder to determine whether we need to intervene with the airway. This is where we providers need to read the signs or look at tea leaves for guidance. We find signs in our assessment with things like rate and quality of respiration, end-tidal CO2, skin color, work of breathing and pulse oximetry. And sometimes, you’ve gotta ask yourself, “What are the voices telling me?”

Sometimes we providers become a bit anxious, regardless of our level of certifications, licensure or experience, about placing an ETT and controlling a patient’s ability to breathe spontaneously. A good example of this is the provider that doesn’t have the correct medications or the experience to perform a rapid sequence intubation (RSI) on a patient, so they attempt to “snow” the patient with narcotics or try to muscle past the patient’s gag reflex. We’re all guilty of this in some form or fashion at some point in our careers. I sometimes hear providers (including physicians) say, “I did the best with what I had.” Is this really our best? Maybe looking at other options and supportive care that is more time consuming, less glorious and in the best interest of the patient would be the better choice.

“What” are we really attempting to do when we intubate using direct laryngoscopy? The simple explanation would be to place a tube into the patient’s trachea to allow for ventilation. This is easier said than done. It’s simple enough in concept but requires us to displace the anatomy that stands between the oral opening and the trachea. Part of this challenge is m the largest obstacle in the airway—the tongue. We need to move it out of the visual field to be able to see the laryngeal structures. Usually when you encounter that huge floppy tongue, there’s a big floppy epiglottis attached to the base of it. If you don’t see it right away, look in the pool of pizza, beans and beer oozing out of the airway, lying in the back of the posterior oral pharynx.

What's the structure at the base of the tongue that prevents aspiration?

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Complicating the patient’s own anatomy is the fact that we’re trying to place a large metal stick in this small space and make enough room to guide the ETT through it to the trachea without inadvertently placing it in the esophagus. If we understand the anatomical structures and how they move, we can use that to successfully manipulate the airway.

One of the most common mistakes I see is when providers attempt to pry with the laryngoyscope blade as opposed to lifting the structures. Remember that the structures we’re attempting to displace are still attached to the patient by a large hinge joint known as the jaw, or mandible. If we displace the jaw, the soft structures attached will follow. This holds true for correct manipulation as well as incorrect ones. If we pry back toward the patient’s head, then all the structures we’re attempting to move out of our way are simply coming up in our face. You may hear this referred to as rocking or prying. It’s often associated with contact with the teeth and pulling the oral opening closed.

The most common cause of that is holding high on the laryngoscope handle and using the 90-degree angle of the handle and blade as the fulcrum and rocking back. Remember basic physics from high school? “Every action has an equal and opposite reaction.” If you’re pulling back on the stick, the other end of the stick is going to react as well and pull the structures right into your view. If we lift the stick up and away, say toward the corner of the ceiling, the jaw will lift and the tongue and epiglottis will follow.

“Where” makes a difference—whether it’s on the cot, in the door, on the floor, in the dark on a train and in the rain. (This is starting to sound like a Dr. Seuss book, but it really is true.) We should make our first attempt our best attempt, so we should try to pick a place or modify the conditions to create our best attempt. If we can get the patient to the stretcher and an elevation and position that enhances our ability to obtain direct visualization of the airway, we’re setting ourselves up for success.

One bad habit I see providers have in the field is to slide the patient to the end of the cot and allow their head to hang back or attempting to intubate with the cervical collar in place. Again, think about the anatomy, have you ever tried to talk with a cervical collar on or hang your head over the back of the chair you’re sitting in? Did you notice that your chin was pointing one direction and your airway was going the other? Provide the patient has no cervical injury the ideal position would be to lift the patients head so to bring their ears even with their chest, you may hear this referred to as ear-to-sternal notch or a wedge technique.

Another great trick you might want to think about is a concept that Dr. Richard Levitan introduced in his book, “The Airway Cam Guide to Intubation and Practical Emergency Airway Management”, ELM or bimanual laryngoscopy, where the intubator actually will manipulate the trachea to bring the glottis opening into view. If the patient has a suspected cervical spine injury, hold inline stabilization while another provider secures the airway, allowing the jaw to be manipulated without restriction. We can’t always relocate the patient when we need to control the airway, so try to use gravity and the patient’s own anatomy to assist in locating and securing the airway.

Why & How
That would leave us with two final questions: why and how. The “why” is pretty simple, to oxygenate my patient. However, that is easier said than done because many of the airway adjuncts we use and the oxygen delivery system are subject to human error, failure or misuse result in injury to the patient, hyper- or hypo-oxygenation, so we must constantly reassess to ensure we are providing adequate oxygenation in a safe manner.

Finally comes the “how?” The simple answer is to do things with the easiest, safest and most efficient means possible. Every situation is different; some patients may require a simple oropharyngeal airway (OPA), a few breaths and transport. Another may need RSI, a definitive airway and the use of video laryngoscopy, which uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. A few may even need a surgical airway.

What benefit might video laryngoscope have that traditional direct laryngoscope does not?

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The patient, the situation, the patient’s illness or injury, the provider’s experience, and the resources available will determine the tools and means of airway control. Ultimately you have to have an airway plan tattooed on your brain so it’s right there every time you need to manage an airway. We’ll save that discussion for another day.

I hope the next time you pick up a laryngoscope or an endotracheal tube you ask yourself these simple questions: who, what, where, when, why and how. Hope to see you soon.

Stay safe,
Jim Radcliffe, BS, MBA, EMT-P

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Pediatric Respiratory Emergencies

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You arrive at a residence to find a 20-month-old male being held by his mother as she walks around nervously. She says something is wrong with her baby. You ask to see him and find that he is not very interactive with his environment and has a weak cry. He’s breathing at 64 times per minute, and you notice the bottom of his ribs are moving inward at the end of each inhalation, causing a seesaw motion between his chest and abdomen. He’s lifting his head as he breathes in, dropping it when he exhales. On closer inspection, you observe that he’s flaring his nostrils and he appears slightly pale.

Acrocyanosis: Cyanosis (bluish coloration) observed at the distal extremities (i.e., the hands and feet).
Alveoli: Pleural for alveolus, the primary respiratory unit of the lung; round sacs that serve as the main location of gas exchange, designed to increase overall surface area available for gas exchange.
Cricoid ring: The ring-shaped cartilage at the end of the larynx.
Glottic opening: The space, or opening, between the vocal cords.
Intercostal muscles: Muscles between successive ribs.
Pallor: Paleness, lack of color.
Phrenic nerve: The nerve that innervates the diaphragm.
Stridor: A high-pitched, harsh respiratory sound, resulting from laryngeal obstruction.

Respiratory dysfunction accounts for the majority of cardiopulmonary arrests in children, making prompt identification and treatment of respiratory distress the most important task of the health-care provider.(1,2) Unfortunately, the assessment of a child’s respiratory condition tends to be challenging for most health-care professionals—especially for prehospital providers whose education focuses on adults.

Newborns engage their environment via crying or active sucking, and older infants will follow a penlight or other object with their eyes (tracking). Photo JEMS

Depending on the population and geographic location of an EMS system, it’s generally accepted that 10% or less of total calls will be pediatric emergencies.(3,4) Also, children who require anything beyond basic care on the ambulance make up a small percentage of the prehospital pediatric patient load.(3,4) With such low frequency of use, what we learned as students often vanishes before the first critical pediatric call.

Knowledge—and periodic review—of the developing respiratory anatomy and physiology contributes to our understanding of the signs and symptoms exhibited by children in respiratory distress. By combining this understanding with a simple, effective assessment process, we can increase the likelihood of detecting respiratory dysfunction. The ideal assessment process should be applicable to children with injuries and illnesses of all types to prevent the necessity of memorizing multiple assessments.

•List anatomic differences between the respiratory systems of children and adults.
•Describe the standard approach to assessing the respiratory status of a pediatric patient.
•Explain the changes in the physiology of the pediatric respiratory system that lead to less efficient compensatory mechanisms for respiratory distress (compared with adults).

The developing respiratory system
All components of the respiratory system are present at birth. However, major structural and functional developments occur after birth and continue changing throughout childhood. Understanding these changes aids in our understanding of why children don’t respond to disease and injury in the same ways adults do. The respiratory system is divided into four components: the upper respiratory system, lower respiratory system, chest wall and diaphragm.

Upper respiratory system: The upper respiratory system comprises all structures and passages involved in the conduction of air from outside the body to the larynx. This system includes the nose, mouth and structures within the hypopharynx. Newborns and infants are often referred to as obligatory nose breathers due to the high resistance to air flow through the oral passage. Therefore, anything that increases resistance through the nose may result in respiratory distress, and a bilateral obstruction can be life-threatening.5 By five to six months of age, infants can take occasional effective oral breaths, and by eight months they’re capable of normal mouth breathing.(5,6)

The two major structures opposing efficient air passage through the mouth are the tongue and sucking pads. First, the tongue in infants and children up to two years old is large and rests entirely within the oral cavity.(6) It’s also lax, so it can easily fall back and obstruct the airway. Second, infants have sucking pads, composed of dense fatty tissue on the inside of each cheek, that improve suction when breastfeeding. The sucking pads slowly shrink as the child grows.

Major adjustments in the relative positions of upper respiratory structures begin to take place by the second year of life. The posterior third of the tongue descends into the neck and forms the upper anterior wall of the pharynx. The epiglottis descends from C1 as the neck elongates until it rests between C4 and C7 in adulthood.(6)

The lower airways extend from the larynx to the structures where gas exchange occurs. For the newborn, the trachea is short and funnel-shaped, with an average length of 4 cm and a diameter of 4 mm. The cricoid ring is narrower than the glottic opening. This means that an endotracheal (ET) tube that passes easily through the glottic opening may be tight at the level of the cricoid ring (see illustration).

Changes in head position result in ET tube movement due to the shortness of the trachea and the large tongue. Flexion of the neck moves the tip of the tube farther out of the trachea, and extension moves the tube farther into the trachea. Therefore, it’s necessary to stabilize the head of the intubated child with towel rolls and tape or a commercial device whenever possible.

Stabilize the head and the tube of an intubated child. Photo JEMS

Lower respiratory system: Most development of the respiratory unit where the blood-gas interface occurs takes place after birth. The respiratory unit of the lung consists of three orders of respiratory bronchioles, a generation of alveolar ducts and terminal clusters of alveolar sacs.(7,8) Alveoli are present at birth; however, they’re smaller and shallower than in older children and adults, resulting in less surface area for gas exchange.(8)

The number of alveoli increases dramatically in the first years of life, continuing to increase until approximately eight years of age. This increase is accomplished by the breakdown of the terminal bronchiole walls. Alveoli increase in size and depth until growth of the chest wall is complete. By eight years of age, a child has nearly 300 million alveoli.(9)

Neonates have thicker alveolar and capillary walls, increasing the diffusion distance for gas exchange.(9) Moreover, the premature neonate has a greater distance between the alveoli and capillaries, making diffusion more difficult than experienced by their full-term counterparts. This is counterproductive because the premature infant has greater oxygen requirements.

Chest wall: Of the chest wall and lungs, the lungs are the more compliant of the two structures in adults. The term compliance simply refers to an object’s ability to yield elastically in response to an applied force. Thus, when the chest wall moves outward as a result of diaphragmatic contraction, the lungs expand with it. Elastic recoil is required for passive expiration as the lung returns to a normal resting state. Lung elastic tissue and elastic recoil increase progressively until approximately 15 years of age.(8–10)

Children have a disadvantage in that their chest walls are very compliant due to cartilaginous and flexible ribs, and weak intercostal muscles.(9) By contrast, their lungs are less compliant than those of an adult; fortunately, lung compliance increases with age. In situations in which a disease process (such as asthma) or an injury decreases lung compliance, the chest wall becomes the most compliant structure.

Unlike the flexible, cartilaginous ribs of a child, the rib cage of the newborn is boxlike.9 The ribs come off the spine at closer to a 90° angle than at the approximate 45° angle of adult ribs.6 (See illustrations.) As a result, the ribs can’t be lifted to increase tidal volume, and the newborn is dependent on increasing respiratory rate rather than tidal volume to compensate for respiratory problems.

Diaphragm: The most important muscle of respiration is the diaphragm, a thin and dome-like sheet of muscle with two parts: an upper and a lower portion. The diaphragm is controlled by the phrenic nerve, which derives from C3, C4 and C5 nerve roots. In the adult, the upper portion is higher than the lower, and fibers of the upper and lower portions are also oriented differently than in children. The oblique insertion of the diaphragm and the orientation of its fibers cause the thoracic cavity to expand when the diaphragm contracts. During normal tidal breathing in the adult, the diaphragm will move only about 1 cm. However, during stressed or forced breathing, it may move as much as 10 cm.

In the infant, the diaphragm exists in a more horizontal orientation, and its dome shape appears less pronounced. This positioning is acceptable for normal breathing. However, during stressed breathing, the diaphragm contracts beyond the point where the dome is flattened. At this point, the contraction pulls the ribs inward rather than expanding them. This accounts for the seesaw motion observed during distressed breathing.

Although adult intercostal muscles are strong and effective accessory muscles of ventilation, the immature intercostal muscles of infants and young children serve only to stabilize the chest wall and cannot be effectively used to supplement ventilation.(9) Therefore, the younger the child, the more they rely on diaphragmatic and abdominal musculature for respiratory movement.

The diaphragm and intercostal muscles consist of two fiber types. Type I fibers are high-oxidative and are considered resistant to fatigue. Type II fibers, considered standard muscle fibers, are readily fatigued. The adult diaphragm is 50–55% type I fibers, whereas the term infant has 25% type I fibers and the premature infant has a mere 7–10%.(9,11) This means the muscles will likely fatigue more quickly. Coupled with the facts that infants and young children are rate dependent, have a higher oxygen utilization and the oxygen has a greater distance to cross the alveolar/ capillary membrane, decompensation occurs more rapidly once their respiratory muscles fatigue.(9)

Initial assessment
The assessment of a child follows a very simple process, with the approach adjusted according to the age and developmental characteristics of the child. The initial assessment, consisting of the internationally recognized pediatric assessment triangle (PAT) and the hands-on ABCDE (airway, breathing, circulation, disability, exposure) assessment, actually begins when you first see the child.(12) The PAT is a screening tool that takes 30–60 seconds to complete, beginning as the provider enters the room. Attempt to obtain as much information as possible before ever touching the child to allow them to build familiarity with you.

The status of the child’s ventilation, oxygenation, perfusion and brain function can be quickly determined by assessing the child’s appearance, work of breathing and circulation to the skin.12 The assessment requires nothing but the provider’s eyes, ears and professional acumen.

PAT leg 1: Appearance
The child’s appearance can be the most important consideration because it reflects the adequacy of ventilation, oxygenation and brain perfusion. The severity of the child’s condition and their subsequent response to treatment are often reflected in their appearance. Use the mnemonic TICLS to assess a child’s appearance (see Table 1).


Evaluate the child’s position and their interactiveness with the environment. All healthy children should engage their environment.(12) Newborns engage their environment via crying or active sucking, and older infants will follow a penlight or other object with their eyes (tracking). Toddlers engage by exploring and touching, while verbal children engage through talking.

PAT leg 2: Work of breathing
How a child attempts to compensate for abnormalities in oxygenation and ventilation provides the most rapidly identifiable indicators of the adequacy of these two processes. Auditory clues of inadequate ventilation include snoring, muffled or hoarse speech, stridor, grunting or wheezing. These sounds are audible without a stethoscope and provide information about the location of any airway obstruction and the amount of effort required to breathe.

Snoring, muffled or hoarse speech, and stridor are all indicative of upper airway obstruction. Snoring suggests an obstruction in either the oropharynx or hypopharynx. Muffled or hoarse speech indicates obstruction at or near the level of the vocal cords, and stridor suggests obstruction at the level of the larynx or in the trachea.

Pediatric patients in respiratory distress will frequently present to care providers in a “tripod” position, sitting straight up and sometimes leaning over a pillow to ease their difficulty breathing. They often gasp for air and exhibit extensive accessory muscle usage. Photo JEMS

Grunting occurs when air is being forced against a partially closed glottis, indicating severe distress. During times of distress, partial closure of the glottis becomes necessary to maintain pressure within the lungs, which keep the alveoli open. Grunting is best heard at the end of the expiratory phase and is often associated with pneumonia.

Wheezing is the result of air being forced through a partially obstructed lower airway. This obstruction is usually due to edema or bronchoconstriction. When it’s mild, it occurs at the end of the expiratory phase of breathing and can often be heard without a stethoscope. Wheezing diminishes as the child loses the ability to compensate and becomes incapable of generating enough force to produce the sound.

Abnormal positioning, retractions, nasal flaring and tachypnea are visual signs of increased work of breathing. Abnormal positioning includes a refusal to lie down and the assumption of the “tripod” or “sniffing” position as the child instinctively tries to line up the airways and use the accessory muscles of ventilation most effectively.

The identification of retractions is a more reliable indication of increased work of breathing in children than in adults. The weaker and less effective accessory muscles and the thin chest wall make it easier to see retractions in the supraclavicular, intercostal and substernal areas. However, they’re easily missed if the child is not exposed properly. Directly visualize the child’s chest by having either the caregiver or the child uncover their chest while still on the caregiver’s lap. Look at the suprasternal, substernal and intercostal areas for retractions and note their location and quality. Again, when a child is no longer able to compensate, begins to tire and approaches respiratory arrest, retractions may become less evident.

Another indication of increased work of breathing in infants is head bobbing. During inhalation, the infant extends the neck and during exhalation relaxes the neck, dropping the head. This is a visible form of accessory muscle use.

Nasal flaring is another visible sign of significantly increased work of breathing. The child instinctively tries to decrease resistance through the nasal passage by flaring the nostrils. This is also easily missed if not looked for specifically.

PAT 3: Circulation to the skin
The final component of the PAT is an evaluation of the child’s circulatory status. When determining the circulatory status of an adult, heart rate and blood pressure are the most valuable indicators; however, for kids, those vital signs can be deferred until the ABCDE phase of the initial assessment. In children, skin appearance is a reliable initial indication that something is wrong with their circulation.

The circulatory assessment establishes the adequacy of cardiac output and perfusion to vital organs. When perfusion to the skin or mucus membranes is poor, pallor is usually the first observable sign.(12) This is due to neuromuscular regulation of blood flow as the body attempts to maintain core perfusion. As the blood vessels to the skin constrict, mottling may also appear.

Cyanosis is a late sign of hypoxia in children.(12) Generally, the child will have shown pallor, mottling or other signs before becoming cyanotic. Also, it’s important to distinguish between acrocyanosis and true cyanosis. Acrocyanosis occurs in infants younger than two months old when they’re exposed to the cold.

When assessing the child’s skin signs, be sure the environment is warm. Infants and young children are very sensitive to cold, which is the most common reason for misinterpretation of skin signs.(12) When inspecting for signs of poor circulation to the skin, begin by looking at the chest, abdomen and extremities. Then look at the lips and the mucus membranes inside the mouth for signs of pallor or cyanosis.

ABCDE hands-on assessment
The second phase of the initial assessment of a child with respiratory distress is the hands-on ABCDEs. The assessment must be conducted in this order because it represents a prioritized sequence of events aimed at detecting life-threatening problems. Most assessment and management errors occur because the ABCDEs were not properly followed.(13)

Airway: The PAT will usually help the provider determine if the airway is open. If the airway is closed, attempt to open it manually and provide suction. If these maneuvers do not open the airway, consider obstruction, remembering that the tongue is a common culprit.

Breathing: When assessing breathing during the ABCDE phase of the initial assessment, start by counting the respiratory rate, then auscultate the chest for abnormal lung sounds, and obtain a pulse oximetry reading. The respiratory rate should be determined by counting a full 30 seconds and multiplying the resultant number by two. This is done to more accurately account for “periodic” breathing, which occurs normally in infants. Although tachypnea is usually the first sign of respiratory distress in young children, the rate must be interpreted carefully because a child’s respiratory rate is greatly influenced by other things, such as fever, pain or fear. Also, as a child fatigues, their rate may slow down and appear normal. For children younger than six years old, any rate greater than 60 or less than 20 per minute should be a red flag for the provider.(12)

Pulse oximetry is an excellent tool for helping determine the child’s respiratory status. However, it must be interpreted with knowledge of its limitations. For example, a cold environment may affect the device’s accuracy. Also, just because a child has a reading above 94% does not mean the child is not in respiratory distress. It may simply mean that they’re able to temporarily maintain saturation at that level due to physiological compensations. In the absence of such compensations, a reading above 94% suggests adequate oxygenation. A reading below 90% with 100% O2 via mask is an indication of the need to assist ventilations.(12)

A six-month-old models an adhesive foot probe often used to monitor oximetry in squirmy pediatrics. Photo JEMS

Circulation: The assessment of circulation in children during this phase of the initial assessment is similar to that for an adult, with some exceptions in how we interpret the signs. These steps include assessment of pulse, skin temperature, capillary refill and blood pressure. The best location to obtain the pulse in young children is at the brachial or femoral arteries. If you can’t obtain the pulse at one of these locations, obtain the apical pulse via auscultation over the apex of the heart with a stethoscope.

When the environment is sufficiently warm, the child’s skin temperature should be warm at the ankles and wrists. As perfusion is compromised, palpably cool skin may be felt farther up the limbs. This is known as the skin temperature margin, or core-peripheral temperature gap.

Next, obtain the child’s capillary refill time at the kneecap or forearm. Capillary refill should take less than three seconds. The value of capillary refill as an assessment tool has been disputed by some. It must be understood that a cool environment may result in longer capillary refill times.

When obtaining a child’s blood pressure, remember that normal blood pressure, like pulse rates, varies with age. It’s often difficult to obtain a blood pressure reading on young children, but it should be attempted on all patients. Use a blood pressure cuff with a width that is two-thirds the length of the upper arm or thigh to obtain an accurate reading. To determine the minimum systolic blood pressure, multiply the patient’s age (in years) by two, then add 70 (70 + [2 × age]).(12)

Disability: When assessing disability, you’re observing the neurological status of the child. This is accomplished in part by the appearance phase of the PAT. Use the AVPU scale (see Table 2) to assess level of consciousness. (Note: The Pediatric Glasgow Coma Scale [PGCS] has never been validated.)(12) Also, assess pupils and motor movement. Adults with fixed and dilated pupils usually have a high mortality rate, whereas children with isolated fixed and dilated pupils usually have a low mortality rate.(14,15) However, if motor flaccidity is observed in addition to fixed and dilated pupils, children usually have a high mortality rate.(15)

V–Responsive to verbal stimuli
P–Responsive to painful stimuli

Exposure: To complete the initial assessment, the child must be exposed sufficiently to allow the provider to see the skin over the chest, back, arms and legs. In a warm environment, have the caregiver or child expose one body area at a time. Note any abnormalities observed. It’s important to note that some medical texts identify the “E” component of the ABCDE process as indicating the need for assessment of potential exposure to the environment.

In a warm environment, sufficiently expose the patient to fully visualize them and complete your assessment of ventilation, oxygenation and perfusion. Photo JEMS

Secondary examination
When faced with a critically ill child, the prehospital provider may not have sufficient time to complete a thorough secondary examination, due to either resuscitation priorities or short transport times. Thus, it’s important to observe the environment where you contacted the child and to note the child’s interaction with the caregiver.

The secondary examination should be conducted in a toe-to-head sequence, rather than head-to-toe, because this is less frightening for the child.

Recognition of respiratory distress is the most important responsibility of health-care providers in preventing cardiac arrest in children. We must understand the anatomical differences between children and adults, because this helps us to better understand the child’s signs and symptoms. A standardized assessment can aid in early recognition of distress—and help avoid the need for memorization of several assessment techniques for a population infrequently encountered by EMS.

1. Perkin RM , Anas NG. “Acute Respiratory Failure.” In: Deickman RA, Grossman M editor. Pediatric Emergency Medicine: A Clinician’s Reference. Philadelphia: JB Lippincott Company; 1991.
2. American Heart Association, American Academy of Pediatrics: Pediatric Advanced Life Support (PALS) Provider Manual. American Heart Association, 2002. p. 23.
3. Joyce SM , Brown DE , Nelson EA . “Epidemiology of pediatric EMS practice: A multistate analysis.” Prehospital and Disaster Medicine. 1996;11(3):180–197.
4. Kallsen GW . Epidemiology of Pediatric Prehospital Emergencies. In: Dieckman RA editors. Pediatric Emergency Care Systems: Planning and Management. Baltimore: Williams & Wilkins; 1991;p. 153–158.
5. Polgar G , Weng TR . “The functional development of the respiratory system from the period of gestation to adulthood.” American Review of Respiratory Disease. 1979;120(3):625–695.
6. Van Stralen D, Perkin RM: “The pediatric airway, assessment and diagnosis.” Unpublished manuscript.
7. Emery JL . “The post-natal development of the human lung and its implications for lung pathology.” . Respiration. 1970;27(Suppl):41–50.
8. Charnock EL , Doershuk CF . “Developmental aspects of the human lung.” Pediatric Clinics of North America. 1973;20(2):275–292.
9. Blackburn S . “Alterations of the res-piratory system in the neonate: implications for clinical practice.” Journal of Perinatal and Neonatal Nursing. 1992;6(2):46–58.
10. Thurlbeck WN . “Postnatal growth and development of the lung.” American Review of Respiratory Disease . 1975;111(6):803–844.
11. Keens TG , Bryan AC , Levison H , et al. “Developmental pattern of muscle fiber types in human ventilatory muscles.” Journal of Applied Physiology. 1978;44(6):909–914.
12. American Academy of Pediatrics, American College of Emergency Physicians . In: APLS: The Pediatric Emergency Medicine Resource, Fourth Edition. Sudbury, Mass: Jones & Bartlett Publishers Inc; 2004;p. 21–49.
13. Bergman AB. In: 20 Common Problems in Pediatrics. McGraw Hill Professional; 2001;p. 128.
14. Lieberman JD , Pasquale MD , Garcia R , et al. “Use of admission Glasgow Coma Score, pupil size, and pupil reactivity to determine outcome for trauma patients.” Journal of Trauma . 2004;56(2):457.
15. Raimondi AJ , Hirschauer J . “Head injury in the infant and toddler. Coma scoring and outcome scale.” Child’s Brain. 1984;11(1):12–35.

James F. Goss, MHA, MICP, is program director and lead paramedic instructor for NCTI in Riverside, Calif. He’s also assistant professor of emergency medical care at Loma Linda University in Loma Linda, Calif., and a frequent contributor to JEMS. Contact him at jgoss@llu.edu.

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The Young Airway

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Case presentation
A 12-year-old male is accidentally shot in the face by a friend with a 410 shotgun at a distance of about 5 yards. His friend assists him in walking about a half mile out of the woods and summons 9-1-1. The location is rural, with a 20-minute response time and a 30-minute travel time to a hospital. Air transport is not possible due to fog and rain.

When you arrive on scene, the patient is alert, talking and anxious. He’s experiencing increasing difficulty swallowing. His initial vital signs include a pulse of 120, a blood pressure of 160/90, a respiratory rate of 24, and an oxygen saturation of 97% on room air. There’s no stridor, and his voice is normal. A non-rebreather mask is applied, and his oxygen saturation increases to 100%.

His face is peppered with buckshot entry wounds on the left side, and there’s a moderate degree of edema. The eyes are spared. There’s no neurological deficit. He can open his mouth, and there’s no swelling apparent inside the mouth or deviation of any anatomical structures.

Your neck exam reveals full and painless range of C-spine motion. There’s mild to moderate swelling of the left side of the neck. Examination of the chest reveals no obvious subcutaneous air, and the remainder of the physical examination is normal.

You start an 18-gauge IV with lactated Ringers in an antecubal area, and your crew packages the patient for transport to the hospital.

But what about his airway, which is likely to become obstructed? Should it be managed in the field? If his vitals deteriorate, how will you proceed?

Assessment of the pediatric respiratory system
Experience often lends providers a “sixth sense” about adult patient assessment. However, because pediatric care makes up just 10-20% of our prehospital patient population, many otherwise competent and experienced EMTs and paramedics often fear the assessment and care of critically ill or injured pediatric patients. (1) For this reason, we should rely on well-established and easily reproduced assessment tools for our pediatric cases.

The Pediatric Assessment Triangle (PAT) is a widely published and recognized tool to facilitate assessment of pediatric patients. The PAT relies on three key components — appearance, work of breathing and circulation — to quickly assess and triage patients into treatment categories of “sick” and “not sick.” (2)

Appearance:How does the patient look? Is there acknowledgement of your presence? This first assessment is the most important aspect of the PAT.

A general impression of appearance quickly reflects adequacy of ventilation, oxygenation, brain perfusion and central nervous system (CNS) function. (1) This initial assessment enables you to quickly prioritize your airway-management plan.

Loud, boisterous crying is the best sound any prehospital provider can ever hear going into an unknown pediatric emergency. Conversely, a flaccid, unresponsive child with a fixed gaze should be considered seriously ill, requiring immediate action to ensure adequate ventilation and oxygenation.

TICLS — which stands for tone, interactiveness, consolability, look/gaze, and speech/cry — is a useful mnemonic for assessing the pediatric patient for oxygenation failure and CNS dysfunction. This tool expands the first leg of the PAT and reminds you to examine all aspects of the patient’s appearance.

Utilizing the PAT appearance and TICLS assessment tools allows you to better detect subtle abnormalities than the more conventional AVPU (alert, voice, pain, unresponsive) scale.(1)

Work of breathing: Unlike the adult patient, a child’s work of breathing is often a better assessment of oxygenation and ventilation status than breath sounds and respiratory rate. Work of breathing reflects the patient’s attempt to overcome abnormalities in respiratory function and the patient’s ability to exchange gas.(2)

This doesn’t mean breath sounds should not be auscultated in the pediatric patient; however, an evaluation of the work of breathing in pediatric patients will alert providers of imminent respiratory arrest before auscultation will.

During this leg of your assessment, the first step can often be accomplished without using a stethoscope. Abnormal, audible airway sounds can quickly alert providers to upper airway status. Snoring, difficulty swallowing secretions and a muffled voice (aka, “hot-potato” voice, as though the patient is rolling hot potato with their tongue) or hoarse voice are subtle indicators of upper airway obstruction.

Stridor (a high-pitched, audible sound on inspiration) is a particularly sinister finding in pediatric patients with acute airway disorders and heralds total obstruction that’s often insurmountable by bag-mask ventilation. Croup, bacterial infections, foreign bodies, edema or bleeding can all result in upper-airway obstructions, which are clearly audible on work of breathing assessment.(2)

Grunting, like the pursed-lip expiration in adults with chronic obstructive pulmonary disease, provides a degree of positive pressure to be maintained throughout the expiratory phase and may be thought of as “auto-PEEP” (positive end-expiratory pressure). This maneuver enables you to stent open small airways and alveoli facilitating gas exchange.(2)

Pediatric patients who have an acute respiratory disorder and exhibit grunting are usually already moderately or severely hypoxic, reflecting poor gas exchange. Conditions most often associated with grunting in children include pneumonia and pulmonary edema.(1) Additional signs of increased work of breathing include displaying the sniffing position while breathing; the tripod position; retraction of the sternal notch, supraclavicular areas and intercostals spaces (a sign seen more in children than adults due to the pliability of their tissues); head bobbing; and nasal flaring.

The sniffing position is when the patient spontaneously flexes their neck slightly forward and extends their head up and back in order to open a partially obstructed upper airway. The tripod position is when the patient has an erect torso and their arms planted firmly on a horizontal surface to maximize the mechanical advantage of the accessory muscles of respiration in the neck and chest. Head bobbing is typically in response to the child’s use of accessory muscles and the attempt to produce maximal negative intrathoracic pressure for inspiration.

The Silverman-Anderson Index is an assessment scoring system that evaluates five parameters of work of breathing and assigns a numerical score for each parameter (see Table 1, below). Each category is scored as “0” for normal, “1” for moderate impairment or “2” for severe impairment. Parameters assessed are retractions of the upper chest, lower chest and xiphoid; nasal flaring; and expiratory grunt.(3) Normally functioning children should have a cumulative score of 0, whereas critically ill and severely depressed children will have scores closer to 10.

The last physical assessment tool used to evaluate work of breathing should be auscultation of the lower airways with a stethoscope. Because a child’s chest is so small, stethoscope placement differs slightly from auscultation of an adult’s chest. The transmission of sounds from areas distant from the stethoscope can be a problem when assessing breath sounds in small children. For this reason, place the stethoscope bell near the armpit to maximize transmitted breath sounds.(4)

Wheezing, the movement of air through partially blocked smaller airways, is the most common lower airway sound heard in children with respiratory compromise. Initially, wheezing is heard only on exhalation and upon auscultation with a stethoscope. But as the degree of obstruction increases, it may be heard in both inspiration and expiration, and may even be audible to the naked ear.

Once a patient becomes extremely fatigued, airflow velocity begins to fatigue and wheezing may attenuate and disappear, a pre-arrest finding. Therefore, it’s necessary to treat wheezing aggressively in the early stages before the increased work of breathing leads to fatigue and respiratory arrest.(1)

The goal is to determine the adequacy of cardiac output.(1) Key findings in the distressed child are related to signs of poor oxygenation, such as peripheral or central cyanosis. Bluish tinting to the skin and/or mucous membranes reflects significant hypoxemia. Corrective action regarding airway management and optimal oxygenation must be made a priority.

Beyond the PAT
EMS providers must also consider respiratory effort and rate when assessing the pediatric airway (see Table 2). Tachypnea is often the first manifestation of respiratory distress in children.(4) Irrespective of cause, rapidly breathing children will eventually tire and respiratory arrest will ensue.

Slow respiratory rates in acutely ill children, often associated with a disorder of mentation or decreased level of consciousness, is a particularly ominous sign.(4) Be alarmed if an acutely ill child has a slowing respiratory rate. Do not assume slowing rates equal improvement.

Lastly, diagnostic equipment can be very helpful in assessing the child’s respiratory system (including the upper airway). In children, pulse oximetry readings above 94% saturation are generally considered acceptable. A reading below 90% during administration of 100% oxygen is an indication for immediate intervention with assisted ventilations.

However, crews must be cautious not to discount or disregard symptoms or signs of respiratory distress in a child simply because the pulse oximetry reading is above 94%. This is because children in respiratory distress or failure can maintain acceptable oxygen saturation levels by increasing work of breathing and respiratory rate until the point of respiratory arrest, particularly if supplementary oxygen is being administered. Thus, pulse oximetry should always be used in conjunction with work of breathing assessment.

Anatomical & physiological factors
The fundamental priorities of prehospital pediatric airway management are: optimizing oxygenation, ventilation and airway protection. Decisions regarding airway management must be made rapidly, and the course of action selected should be designed to minimize error.

The anatomical development of the child in general, and the lungs in particular, along with associated changes in the maturing physiology, must be taken into consideration in pediatric airway management. Another factor frequently underemphasized is that, excluding congenital anomalies, children are remarkably consistent from one to another.

In pediatric patients from one to two years of age, the principal difference between the adult and pediatric airway is size.(5) For patients younger than one, the relative proportions of some structures vary from the adult proportions. In fact, most descriptions of the “pediatric” airway in the purest sense focus on this latter age group.

The age group from two to eight years represents a transition to the adult airway and, in fact, more closely resembles the adult airway than the infant’s. Besides size, the most obvious difference between the adult and pediatric airway is its position in the neck. The pediatric airway is described as “anterior,” when in reality it’s more superior, the glottic opening lying higher, at approximately the level of C-2 or C-3, as opposed to C-6 in the adult. This position places the glottic opening at the base of the proportionally larger and predominantly intra-oral tongue. Because the airway may become “hidden” up high behind the tongue on laryngoscopy, this position is often referred to as “anterior.”

All airways are anterior in the sense that they’re palpable externally, but the pediatric airway is also more superior. The relatively larger intra-oral tongue exacerbates this position.

The epiglottis is also proportionally larger in the child than the adult. The ligamentous connection between the base of the tongue and the epiglottis isn’t as strong as it is in the adult, making elevation of the proportionally larger epiglottis by manipulation of the vallecular space with a curved blade more difficult. For this reason, and because the large tongue is more difficult to remove from the field of vision with the curved blade, a straight blade is preferred for the first year or two of life when these changes are most pronounced. A straight blade can be inserted past the epiglottis to lift it up out of the field of vision.

The narrowest portion of the child’s airway is at the level of the cricoid ring, as compared with the adult, in which the narrowest portion is at the level of the vocal cords. The significance of this anatomical variation is that, in the adult patient, endotracheal tube size is less critical, because a low-pressure cuff can be inflated to ensure adequate fit.

In the child, the size is more critical because an uncuffed tube is used and therefore the largest possible tube is inserted to ensure the largest internal diameter possible. A smaller tube reduces ventilatory ability, and a tube that is too large can cause pressure ischemia and necrosis of the tracheal mucosa with resultant subglottic stenosis. At approximately eight years of age, this variation normalizes and cuffed tubes are appropriate.

Two anatomic variations preclude blind naso-tracheal intubation in the child younger than eight to 10 years of age. The first is the presence of adenoidal tissue, which is frequently hypertrophied. This tissue can easily be injured, resulting in copious bleeding. Second, the angle of approach that a nasally introduced endotracheal tube must take to find its way into the glottis is much more acute in a child than an adult, so the success rate of the procedure is unsatisfactory.

The optimal position for alignment of the tracheal, pharyngeal and oral axis for bag-valve mask ventilation (BVM) or intubation is the sniffing position. In the adult, optimal axis alignment is accomplished by flexion of the neck on the chest (usually accomplished by placing a towel or other support beneath the occiput) and hyperextension of the head at the atlanto-occipital joint.

In most children, it’s unnecessary to provide support to flex the neck because of their proportionally large occiput. Slight extension of the head at the atlanto-occipital joint (not hyperextension, which can actually cause obstruction) is all that’s necessary.

To achieve the sniffing position in small infants, it’s sometimes necessary to balance the disproportionate occipital size by placing a support under the shoulders. The older child and adolescent are positioned similar to the adult.

In all ages, once positioned, if an imaginary horizontal line can be drawn traversing the external auditory canal and passing anterior to the shoulders, correct positioning has been obtained (see Figure 1).

Proper BVM technique is particularly important in pediatric patients, whose crisis is often driven by a primary respiratory problem. They are more frequently hypoxemic than their adult counterparts and are subject to more rapid oxyhemoglobin desaturation, so BVM (Sellick’s is maintained during BVM to prevent one from inflating the stomach and enhancing the risk of regurgitation and aspiration) is frequently required during the pre-oxygenation and paralysis phases of rapid sequence intubation (RSI) to achieve and maintain adequate O2 saturation.

As in adults, oral and nasopharyngeal airways are important adjuncts to BVM.

Because of the miniscule size of the cricothyroid membrane in the child, surgical cricothyrotomy is contraindicated. Needle cricothyrotomy is the procedure of choice for small children.

A combination of physiological factors decrease the ability to pre-oxygenate the pediatric patient as efficiently as the adult patient. The first and most important isthat the pediatric patient metabolizes oxygen twice as quickly as the adult (6 mL/kg versus 3 mL/kg).

Because of the lack of elastic lung recoil of the pediatric patient’s chest, the child also possesses a proportionally smaller FRC — the lung volume measured when all forces in the chest are in equilibrium. This latter effect is especially exacerbated in the supine position.

Under similar pre-oxygenating conditions, the child sustains a significantly shorter period of oxygen saturation above 90% than the adult. The clinical implication is that a child may desaturate during the RSI procedure, and the provider must anticipate this and be prepared to initiate BVM ventilation with cricoid pressure.

Pediatric ventilation requires smaller tidal volumes, higher rates and size-specific equipment. The pediatric airway is particularly amenable to positive pressure ventilation, even in the presence of upper airway obstruction.

In pediatric airway management, identification and use of size-appropriate equipment is crucial. For this reason, standardized age and size-appropriate systems, such as the Broselow-Luten Color Coded systems, are recommended.

Advanced airway management
Because inadequate oxygenation and ventilation have been identified as primary contributors to preventable mortality, it would seem intuitive that successful endotracheal intubation (ETI) would mitigate these deaths. Thus, ETI has become the gold standard in prehospital airway management.

However, considerable controversy exists as to whether pediatric patients requiring ETI should have it performed in the field or deferred until hospital arrival. Studies have shown higher rates of complication and failure in children than in adults, and one prospective, pseudo-randomized trial showed no demonstrable advantage in survival outcome following ETI compared with a group managed via BVM.(6-10)

Despite controversy, the indications for ETI of adults and children in an emergency remain: failure to maintain adequate oxygenation, failure to maintain adequate ventilation (CO2 removal), failure to protect the airway, the need for neuromuscular blockade or the anticipated clinical course.(5) So even though there may not be a compelling reason to intubate the trachea at a given point in your care of a patient, prehospital providers must continually evaluate the risk of an insidiously progressive condition advancing to the point when intubation would become more hazardous or physically impossible.

The best example in prehospital care relates to the transport environment, such as in the opening case. GroundEMS providers should consider whether future patient positioning in a helicopter will severely limit access to the head and neck, and thus the airway.

Once the decision to intubate is made, you must decide how to proceed. First responders and basic rescuers are typically limited to basic upper-airway adjuncts and BVM ventilation. Intermediate rescuers may employ supraglottic devices, such as the Laryngeal Mask Airway (LMA), the Combitube and the King LT Airway, to facilitate bag ventilation and provide some element of airway protection. For these personnel, the decision is typically a simple one: Will the victim tolerate insertion of the device?

ALS providers capable of endotracheal intubation who do not use neuromuscular blocking agents have limited options available to them beyond BVM ventilation and direct laryngoscopy intubation.

Once the child is intubated, the endotracheal tube (ETT) must be secured at the mouth, and since head and neck movement translates into ETT movement, a cervical collar or other device should be employed.

In infants, small movements are capable of dislocating the ETT into the esophagus, emphasizing the importance of head and neck immobilization. Securing the ETT at the mouth is traditionally done by taping the tube to the cheek or by using commercial devices.

Drug dosage & selection
A significant problem in the management of pediatric emergencies is the timely and accurate delivery of medications. The use of color-coded resuscitation aids for drug dosing and estimating ETT size in children precludes many of these problems, including having to estimate weight and remember and calculate drug doses.

One particular drug worthy of special mention when used with children is succinylcholine. Because the drug is rapidly distributed into extracellular water, and children have a relatively larger volume of extracellular fluid than adults, the recommended dose of succinylcholine is higher in children.(5)

In 1993, the FDA, in conjunction with pharmaceutical companies, revised the package labeling of succinylcholine after reports arose of hyperkalemic cardiac arrests due to the drug’s administration to patients with previously undiagnosed neuromuscular disease. However, the initial advisory warnings continue to recommend succinylcholine for emergency or full-stomach intubation in children.

Case wrap-up
Because the 12-year-old patient’s respiratory status was kept stable, the patient’s airway did not require further field management.

On arrival at the emergency department (ED), the patient was unable to swallow secretions, had a muffled voice, was complaining of occasional air hunger and refused to lie flat. The attending emergency physician (a family practitioner) was unwilling to intubate the patient without anesthesia or surgery back-up available at the hospital. The weather had cleared, so air evacuation was requested.

When the air medical transport team arrived 20 minutes later, the patient’s condition was unchanged. The flight crew elected to progressively sedate the young patient and proceeded with a sedation-assisted direct-vision intubation prior to transport. He was sedated and paralyzed for the duration of the transport and arrived at the Level 1 trauma center in stable condition. He was weaned and extubated on the sixth hospital day, and the remainder of his recovery was uneventful.

Respiratory assessment and airway management in the pediatric patient present many challenges, including differences in equipment sizes and drug dosing, anatomical variation that continuously evolves as development proceeds from infancy to adolescence, and the stress of resuscitating a critically ill child.

During the emotional mix of a pediatric resuscitation, it’s easy to get sidetracked by co-existing confounding issues. Therefore, the importance of methodically working your way through airway evaluation and management cannot be overstressed. Assessment is the key to gathering critical evidence of a pediatric patient’s respiratory status or warning of impending respiratory arrest.

Michael F. Murphy, MD, FRCPC (EM), FRCPC (ANES), is certified as a specialist by the Royal College of Physicians and Surgeons of Canada in both emergency medicine and anesthesiology. He’s the professor and chair of anesthesia and professor of emergency medicine at Dalhousie University, and the clinical chief of anesthesia at the Capital District Health Authority in Halifax, Nova Scotia. He’s also a founding faculty member of “The Difficult Airway Course: Emergency” and “The Difficult Airway Course: EMS.” Contact him at murphymf1@gmail.com.

Michael Keller, BS
, NREMT-P, is a curriculum faculty member with Gaston College, Department for EMS Education in Dallas, N.C., a member of Lincoln County (N.C.) EMS and a national faculty member for “The Difficult Airway Course: EMS.”

Robert Luten, MD, is professor of pediatrics and emergency medicine at the University of Florida, Shands Jacksonville, and former president of the Society for Pediatric Emergency Medicine. He’s the author and principal instructor of the pediatric section of the National Emergency Airway Management course.

Colby J. Rowe, EMT-P, FP-C, CIC, is a paramedic supervisor, flight paramedic, and the continuing education and training coordinator at Stony Brook University Medical Center EMS on Long Island, N.Y. He’s also a national faculty member of “The Difficult Airway Course: EMS” and an adjunct faculty in the Emergency and Disaster Management concentration at Stony Brook University.

Mary Beth Skarote, NREMT-P, is an emergency response and recovery coordinator for Wake Forest University Baptist Medical Center, Winston-Salem, N.C.; a paramedic with Davidson County (N.C.) EMS; president for North Carolina Association of Paramedics; and one of the original faculty for “The Difficult Airway Course: EMS.”

1.AmericanAcademy of Pediatrics: Pediatric Education for Prehospital Professionals. Jones & Bartlett:Boston, Mass., 2000. pp. 2-35.

2. Caroline N: Emergency Care in the Streets. Jones & Bartlett:Boston,Mass., 2008. p. 41.

3. Institute for Continuing Education. www.ceu.org/cecourses/981117/ch11b.htm

4. Bledsoe B, Porter R, Cherry R: Paramedic Care: Principles & Practice. Pearson Prentice Hall:Upper Saddle River,N.J., 2006. p. 59.

5. Walls RM, Murphy MF, Luten RC (eds): Manual of Emergency Airway Management. Harvard Medical School: Boston, Mass., 2004. pp. 212Ï281.

6. Aijian P, Tsai A, Knopp R, et al: “Endotracheal intubation of pediatric patients by paramedics.” Annals of Emergency Medicine. 18(5):489-494, 1989.

7. Vilke GM, Steen PJ, Smith AM, et al: “Out-of-hospital pediatric intubation by paramedics: The San Diego experience.” Journal of Emergency Medicine. 22(1):71Ï74, 2002.

8. Brownstein D, Shugerman R, Cummings P, et al: “Prehospital endotracheal intubation of children by paramedics.” Annals of Emergency Medicine. 28(1):34Ï39, 1996.

9. Gausche M, Lewis RJ, Stratton SJ, et al: “Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial.” JAMA. 283(6):783-790, 2000.

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