ANATOMY AND PHYSIOLOGY

The most important feature of conducting safe pediatric sedation is the ability to
assess and manage the pediatric airway. The upper airway is composed of three
segments:

1. Supraglottic – the most poorly supported segment, consisting primarily of the

pharynx;
2. Glottic (larynx) –comprising the vocal cords, subglottic area, and cervical
trachea; and
3. Intrathoracic – consisting of the thoracic trachea and bronchi.

There are a number of developmental characteristics that distinguish the pediatric

airway from the adult airway:

 The pediatric airway is smaller in diameter and shorter in length than the adult’s.
 The young child's tongue is relatively larger in the oropharynx than the adult’s.
 The larynx in infants and young children is located more anteriorly compared with the adult’s.
 The epiglottis in infants and young children is relatively long, floppy, and narrow.
 In children younger than 10 years of age, the narrowest portion of the airway is below the glottis at the level of the cricoid cartilage.

Consequently, the small caliber of the pediatric upper airway, the relatively larger tongue, and the “floppy” and relatively long
epiglottis predispose young children to airway obstruction during sedation. In addition, the large occiput of the infant places the head
and neck in the flexed position when the patient is placed recumbent, further exacerbating airway obstruction.

During normal inspiration, negative intrapleural pressure generated in the thorax creates a pressure gradient from the mouth to the
airways, resulting in airflow into the lungs. Extrathoracic airway caliber decreases during inhalation, whereas intrathoracic airway
diameter tends to increase. Under normal conditions, changes in airway caliber during respiration are clinically insignificant.
However, significant narrowing of the upper airway increases airway resistance, and a higher pressure gradient across the airway is
required if minute ventilation is to be maintained. A greater pressure gradient generated across the airway accentuates the normal
inspiratory and expiratory effects on the airway. Consequently, the greater negative pressure generated in the pharynx during
inspiration tends to further collapse the upper airway.

Resistance across the airway under laminar flow conditions is directly related to the length of the tube and the viscosity of the gas
and indirectly related to the fourth power of the radius. Thus, airway resistance is primarily influenced by the diameter of the airway.
In addition, the relationship between the pressure gradient across the airway and the subsequent flow rate generated is influenced
greatly by the nature of the flow (laminar versus turbulent). Laminar flow is inaudible and streamlined, typically through straight,
unbranching tubes. The flow rate under laminar flow conditions is directly related to the pressure gradient (driving pressure).
Conversely, turbulent flow is audible and disorganized, through branched or irregular tubes. Turbulent flow (e.g., stridor) tends to
occur with high flow rates and often under conditions of airway narrowing and high resistance. A greater pressure gradient is required
to move air through a tube under turbulent flow conditions.
DISEASE ENTITY Symptoms
Common symptoms of pneumonia in children include:
• Stuffed up or runny nose, headaches
Pneumonia is a lung infection caused by bacteria, viruses, or
• Loud cough
fungi.
• Fever, which may be mild or high, with chills and sweating
This article covers community-acquired pneumonia (CAP) in
• Rapid breathing, with flared nostrils and straining of the
children. This type of pneumonia occurs in healthy children
muscles between the ribs
who have not recently been in the hospital or another health
• Wheezing
care facility.
• Sharp or stabbing chest pain that gets worse when
Pneumonia that affects people in health care facilities, such as
breathing deeply or coughing
hospitals, is often caused by germs that are harder to treat.
• Low energy and malaise (not feeling well)
Causes
• Vomiting or loss of appetite
Viruses are the most common cause of pneumonia in infants
Symptoms common in children with more severe infections
and children.
include:
Ways your child can get CAP include:
• Blue lips and finger nails due to too little oxygen in the blood
• Bacteria and viruses living in the nose, sinuses, or mouth
• Confusion or very hard to arouse
may spread to the lungs.
•
• Your child may breathe some of these germs directly into
Exams and Tests
the lungs.
The health care provider will listen to your child's chest with a
• Your child breathes in food, liquids, or vomit from the mouth
stethoscope. The provider will listen for crackles or abnormal
into her lungs.
breath sounds. Tapping on the chest wall (percussion) helps
Risk factors that increase a child's chance of getting CAP
the provider listen and feel for abnormal sounds.
include:
If pneumonia is suspected, the provider will likely order a chest
• Being younger than 6 months of age
x-ray.
• Being born prematurely
Other tests may include:
• Birth defects, such as cleft palate
• Arterial blood gases to see if enough oxygen is getting into
• Nervous system problems, such as seizures or cerebral
your child's blood from the lungs
palsy
• Blood culture and sputum culture to look for the germ that
• Heart or lung disease present at birth
may be causing the pneumonia
• Weak immune system (this can occur due to cancer
• CBC to check white blood cell count
treatment or disease such as HIV/AIDS)
• CT scan of the chest
• Recent surgery or trauma
• Bronchoscopy -- a flexible tube with a lighted camera on the
end passed down into the lungs (in rare cases)
• Removing fluid from the space between the outside lining of
the lungs and the chest wall (in rare cases)
Treatment
The provider must first decide whether your child needs to be
in the hospital.
If treated in the hospital, your child will receive:
• Fluids, electrolytes, and antibiotics through the veins or
mouth
• Oxygen therapy
• Breathing treatments to help open up the airways
Your child is more likely to be admitted to the hospital if he:
• Has another serious medical problem, including long-term
(chronic) health issues such as cystic fibrosis or
diabetes mellitus  who have severe pneumonia with complications may need
• Has severe symptoms
• Is unable to eat or drink
• Is less than 3 to 6 months old
• Has pneumonia due to a harmful germ
• Has taken antibiotics at home, but isn't getting better
If your child has CAP caused by bacteria, antibiotics will be
given. Antibiotics are not given for pneumonia caused by a
virus. This is because antibiotics do not kill viruses. Other
medicines, such as antivirals, may be given if your child has
the flu.
Many children can be treated at home. If so, your child may
need to take medicines such as antibiotics or antivirals.
When giving antibiotics to your child:
• Make sure your child does not miss any doses.
• Make sure your child takes all the medicine as directed. Do
not stop giving the medicine, even when your child
starts feeling better.
Do not give your child cough medicine or cold medicine unless
your doctor says it is OK. Coughing helps the body get rid of
mucus from the lungs.
Other home care measures include:
• To bring up mucus from the lungs, tap your child's chest
gently a few times a day. This can be done as your
child is lying down.
• Have your child take a couple of deep breaths 2 or 3 times
every hour. Deep breaths help open up your child's
lungs.
• Make sure your child drinks plenty of liquids. Ask your
provider how much your child should drink each day.
• Have your child get plenty of rest, including napping
throughout the day if needed.
Outlook (Prognosis)
Most children improve in 7 to 10 days with treatment. Children
treatment for 2 to 3 weeks. Children at risk for severe
pneumonia include:
• Children whose immune system does not work well
• Children with lung or heart disease
Possible Complications
In some cases, more serious problems may develop,
including:
• Life-threatening changes in the lungs that require a
breathing machine (ventilator)
• Fluid around the lung, which can become infected
• Lung abscesses
• Bacteria in blood (bacteremia)
The provider may order another x-ray. This is to make sure
that your child's lungs are clear. It may take many weeks for
the x-ray to clear up. Your child may feel better for a while
before the x-rays are clear.
When to Contact a Medical Professional
Call the provider if your child has the following symptoms:
• Bad cough
• Difficulty breathing (wheezing, grunting, rapid breathing)
• Vomiting • After coming in contact with people who are sick
• Loss of appetite Vaccines may help prevent some types of pneumonia. Be sure
• Fever and chills to get your child vaccinated with:
• Breathing (respiratory) symptoms that get worse • Pneumococcal vaccine
• Chest pain that gets worse when coughing or breathing in • Flu vaccine
• Signs of pneumonia and a weak immune system (such as • Pertussis vaccine and Hib vaccine
with HIV or chemotherapy) When infants are too young to be immunized, parents or
• Worsening symptoms after starting to get better caregivers can get themselves immunized against vaccine-
Prevention preventable pneumonia.
Teach older children to wash their hands often: Alternative Names
• Before eating food Bronchopneumonia - children; Community-acquired
• After blowing their nose pneumonia - children; CAP - children
• After going to the bathroom
• After playing with friends