Professional Documents
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Pediatrie
Pediatrie
Pediatrie
by
Esther Weathers
RRT, RCP
V7110 HC 02
This course is for reference and education only. Every effort is made to ensure that the
clinical principles, procedures and practices are based on current knowledge and state of
the art information from acknowledged authorities, text and journals. This information is
not intended as a substitution for diagnosis or treatment given in consultation with a
qualified health care professional.
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he pediatric patient is not just a little adult, when it comes to airway anatomy. In fact,
there are many significant differences often overlooked in general practice, especially for
those clinicians who have not specialized in pediatric critical care. In recognizing the
anatomical differences, the clinician is easily able to apply simple interventions that may
alleviate respiratory distress, or ensure a definitive airway can be secured in a timely manner.
Special considerations for patients with Downs Syndrome (DS) are also discussed, as there are
many respiratory factors associated with Trisomy 21 (Downs Syndrome).
ANATOMICAL DIFFERENCES
Thorax
he ribs of the infant and young child are more horizontally oriented, making anteriorposterior displacement of the chest less during inspiration. This is loss of the buckethandle effect.
Rib cartilage is more compliant in younger patients than older children and adults.
Manifestation: During episodes of respiratory distress the chest wall may actually
retract, decreasing the childs ability to maintain functional residual capacity or increase
their tidal volume.
Intercostal muscles are not fully developed until school age, acting primarily to stabilize the
chest wall. They do not have the leverage nor the strength necessary to lift the ribs.
As with the adult patient, the childs chief muscle of respiration is the diaphragm. However, the
muscles of the diaphragm are inset horizontally to the ribs, as opposed to obliquely.
Manifestation: Placing the infant/young child in a supine position may compromise
diaphragmatic function, in that contraction may draw the ribs inwards rather than expand
the chest out. This creates paradoxical chest movement.
Intervention: Elevating the head of the bed improves diaphragmatic function, and
may completely alleviate paradoxical work of breathing (WOB). This is an
important action to remember even in patients receiving mechanical ventilation, if
they have spontaneous efforts.
Head And Neck
Children tend to have a large occiput that can compromise the airway. Also, while laying
supine, which is considered the natural position, the neck is flexed causing an obstructive or
partially obstructed airway.
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Infant
Trachea
Adult
Trachea
16x
2 mm
R 2.4x
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Thyroid
Cartilage
Cricoid
Ring
Cricoid
Ring
Adult
Trachea
Infant
Trachea
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A normal respiratory rate is inversely proportional to patient age, namely, the younger a patient,
the higher the expected respiratory rate will be. As a clinician you will be less concerned about a
neonate breathing at a rate of 60 bpm, than a 10 year old.
Nasal Flaring
Nasal flaring is common across all age groups. Do not brush off moderate nasal flaring in an
infant as nothing when performing a respiratory assessment. Take note and use other clinical
indicators (to be discussed) to aid you in completing your assessment.
Tracheal Tug
While tracheal tug may be a late or unspecific sign of increased work of breathing in an adult
patient, it is very common in the pediatric patient, perhaps almost as prevalent as nasal flaring.
Often a slight gasp may be noted audibly on inspiration as well, which can seem to be associated
with head-bobbing. (It is the authors opinion that head bobbing is not a sign of work of
breathing, rather a physiological result of it).
Indrawing
Indrawing is grouped in one large heading when discussing pediatric respiratory distress. As
previously noted, infants and young children have under developed musculature and classic
retractions, such as intercostals, may be absent. This is not to say that indrawing will never exist
in the young patient, as it often does, rather to reinforce the anatomical differences may make it
appear less obvious or severe. In overweight infants and younger children, substernal and
intercostal indrawing may be all that is evident. Children who have been hospitalized for longer
periods of time, or appear as if they are failure to thrive have a thinner chest wall, and
retractions can be more evident. Keep in mind that patient position can affect work of breathing,
remember that simply elevating the head of the bed that improve diaphragmatic function and
improve signs of respiratory distress.
Grunting
Similar to pursed lip breathing, grunting is a way in which the neonate and young pediatric
attempts to maintain an open airway, essentially splinting the airways in an attempt to prevent
airway collapse and improve oxygenation and ventilation.
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hile it may not be routine to do central nervous system scoring on children for
respiratory admissions, or the Respiratory Care Practitioner may be unfamiliar with
what the grading means, the idea is simple. How alert is the child? When you walk
into the room, do they look up and greet you? Are they responsive to parents? Smiling,
grouchy, changes from the last time you saw them? Beware of the agitated child, who can not be
consoled, and/or with a high pitched cry. Though unspecific, it can be an indicator of poor
cerebral oxygenation. One simple system to use is AVPU: A awake; V verbal; P pain; U unresponsive. Keep in mind changes from baseline are very important to note, and for
physicians to be made aware of.
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risomy 21 is a fairly common syndrome, occurring in 1/733 live births.1 While we can
easily identify a patient with Downs Syndrome, we may not realize and/or account for all
of the contributing factors to the respiratory system.
hypotonia
11
relative glossoptosis
12
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In gait
hand preference
participation in activities
loss of continence
Root compression at C1 and C2 will produce pain to the upper C spine, neck and occipital area.
This pain can extend to the head eyes, ears and throat.
The patient may also have:
dizziness
vertigo
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tinnitis
syncope
Torticollis
The presence of torticollis in a person with Downs Syndrome indicates Atlanto-axial
instability until proven otherwise.
In many cases infections of the upper respiratory tract, middle ear or pharynx precede symptoms
of Atlanto-axial instability. Trauma rarely causes an initial appearance or progression of
symptoms.1
The inflammatory processes associated with upper respiratory tract infections and rheumatoid
arthritis can produce laxity of the transverse ligaments. The lymphatic drainage of this joint is
into the retropharyngeal glands, which also drains the nasopharynx and ends up in the deep
cervical glands. The disruption of the drainage may also have an effect on the ligaments laxity.
Due to the inherent abnormality, even minor trauma or acute nasalpharyngeal infections can
cause a subluxation.
There is wide spectrum of both congenital and acquired lesions that can produce Atlanto-axial
instability, and less frequently, occipital-atlanto instability. Signs of Atlanto-axial instability
precede almost all cases of atlanto-axial subluxation in Downs Syndrome. While the risk
remains relatively low (not all patients have the anomalies to the ligaments or bony structures)
the consequences are high enough to warrant full airway precautions. Remember that flexion
also poses a significant risk.
Intervention: When you are called upon to bag-valve-mask ventilate or assist in
intubating a patient with Downs Syndrome, consider the fact that they may have
Atlanto-axial instability or occiptal-atlanto instability, suggest the use of a jaw
thrust and C spine control and not a head tilt-chin-lift. If there is bradycardia
noted on any airway attempts with extension, immediately discontinue the
maneuver, assume a neutral airway position and try again as described above.
What is likely occurring is compression of the spinal cord and cervical arteries.
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nowing anatomical differences in the pediatric airway will make you more prepared as a
practitioner to provide appropriate care, and anticipate airway emergencies. By being
aware of the anatomy, you will not only recognize how it manifests in your clinical
practice, but be able to intervene in even simple ways to improve to respiratory function of your
youngest patients. A basic knowledge of the traits associated with Downs Syndrome will also
expand your services and, though low, given the risks with atlanto-axial or occipital-atlanto
instability, improve safety for this patient population.
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2. The natural position of the airway of a child when laying flat is neutral.
a. True
b. False
3. To ensure airway neutrality in any patient regardless of age, what two anatomical landmarks
much be aligned?
a.
b.
c.
d.
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asthma
pulmonary vascular disease
bronchomalacia
tracheomalacia
12. 50% of patients with Downs Syndrome have atlanto-axial instability (AAI).
a. True
b. False
13. Atlanto-axial instability can be asyptomatic.
a. True
b. False
14. Which of the following is not a sign of symptomatic Atlanto-axial instability (AAI)?
a.
b.
c.
d.
dizziness
loss of continence
drooling
torticollis
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NO (B)
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