PEDIATRIC PROCEDURES
Aerosol Delivery Devices
TYPE USE
Small Volume Nebulizer  Deliver intermittent aerosolized
Handheld, mini-neb, medications.
mainstream, side stream,  Short term use only
slipstream  2-5 ml of solutions
 Gas flow rate 6-8 l/min
 Average particle size 1-5 micrometer
diameter
Large Volume Nebulizer  For continuous oxygen or aerosol
therapy (heated or cool)
 Variable particle size
 1-2 ml/min output
 mouthpiece, aerosol mask, trach-
collar, T-piece, ventilator circuit
 Pneumatic or ultrasonic
 Air, oxygen-hypoxic patient
 Facemask, trach-collar, t-piece
 Condensation collects in tubing
 Correct solution level must be
maintained
 Nosocomial infection
 Used primarily for the patients with
tracheostomies
Aerosol Delivery Devices
TYPE USE
Ultrasonic Nebulizer  Use to mobilize thick secretions in the  Drug preparation required
lower airways  Heat generated by USN may affect
 90% of particles are 1-5 micrometer bronchodilators
diameter  May precipitate bronchospasm, over
 1-6 ml/min output mobilization of secretions, or
overhydration
 Provides 100% humidity

Metered Dose Inhaler  Intermittent delivery of aerosolized  1st method of choice

medications  Small, easily cleaned
 Particle size 3-6 micrometer  Technique dependent
 Inexpensive, convenient, portable,
and no drug prep required
 Inspiratory flow rates should be </=
to 30Lpm
Aerosol Delivery Devices
TYPE USE
Metered Dose Inhaler  Intermittent delivery of aerosolized
medications
 Particle size 3-6 micrometer
Dry Powder Inhaler  Intermittent delivery of medication
 Particle size 1-2 micrometer
 Used in-line with ventilators
 Self-administered
 Not appropriate for infant and
geriatric patients
 Hand-breath-coordination
coordination, synchronization with
inspiration, 4-10 sec. breath hold
 Spacer or holding chamber is
recommended
 Breath actuated and patient self-
administered
 Breath holding not required
 High humidity may affect some
drugs
 Not recommended for patients
<6yrs or with acute bronchospasm
 Not appropriate for infant and
geriatric patients
Airway Suctioning
Recommendations vary
PALS recommends a maximum of -80 to -120 mmHg
Other sources recommend -80 to -100 mmHg
Give oxygen: pre and post
Limit attempts to 10 seconds unless the airway is obstructed
Monitor HR, SpO2, RR, and appearance during the procedure
If bradycardia develops or appearance deteriorates, stop the
procedure. Consider use of High flow O2 or BVM
If intubated: do not advance beyond end of the ET tube
Hazards
• Hypoxia
• Bradycardia (vagal stimulation)
• Gagging and vomiting
• Trauma to soft tissue
POSTURAL DRAINAGE
Indications Benefit patients with thick secretions
Technique  1 or 2 hrs. before meals
 Bronchodilator therapy 15 minutes before the procedure
 Ensure patient loosens any tight or binding clothing
 Drainage should begin with superior segments and progress downward. Lung
segment to be drained should be placed such that main bronchus is pointing down,
(use of pillows/blankets may assist in positioning)
 Maintain position for 3 to 20 minutes, depending on the quantity and tenacity of
secretions and patient tolerance.
 Have patient cough q5 min during each position and after therapy (use FET)
Monitoring  Watch for signs of patient intolerance and monitor HR, BP, and SpO2 during
treatment.
 Signs of respiratory compromise:
 Decrease diaphragm excursion in head-down position
POSTURAL DRAINAGE
Clinical Note  Oxygen requirements may increase during CPT
 Head-Down Positioning is no longer recommended to be used with PD & P in
neo/ped by the CF Foundation and various guidelines in Australia, Canada, Europe.
POSTURAL DRAINAGE
POSTURAL DRAINAGE
POSTURAL DRAINAGE
POSTURAL DRAINAGE
POSTURAL DRAINAGE
POSTURAL DRAINAGE
POSTURAL DRAINAGE
POSTURAL DRAINAGE
POSTURAL DRAINAGE
PERCUSSION and VIBRATIONS
Indications Benefit patients with thick secretions
Technique  Applied to various lung segments either manually (with cupped hands) or
mechanically with a motorized percussor/vibrator type unit (electric or pneumatic)
 Chest percussion or clapping and vibrations are often used in conjunction with
postural drainage.
 Remove any jewelry that might interfere with percussion technique
 Vibration is applied to the chest area with hands tensing at 6-8 vibrations per second
for 4-6 exhalations.
 The procedure concludes with a deep cough and expulsion of secretions.
 Patients should be allowed to rest as each lung segment is drained and cleared.
INSUFFLATOR (Cof-flator or Cough Assist)

Descriptions Applies a positive pressure to the airway and then rapidly shifts to a
negative pressure producing a high expiratory flow rate from the lungs
stimulating a cough

Indications
reduced PEFR.

with intrinsic lung disorders.

Contraindications
pneumomediastinum
POSITIVE EXPIRATORY PRESSURE
Descriptions Active exhalation against a variable flow resistor reaching pressures of
10-20 cmH20

Indications
and airflow through airways that are partially obstructed by stenting
the airways and/or increasing intrathoracic pressure distal to
retained secretions, which:

obstructions, improving pulmonary mechanics, and facilitating

gas exchange

slow disease progression.

Contraindications
pneumomediastinum
ACAPELLA
Descriptions Disposable, single-patient use device that delivers positive expiratory
pressure with high frequency oscillations.

Directions
a pivoting cone. As air passes through the opening, the cone will
open and close the airflow path. This produces a vibratory pressure
wave-form- allowing secretions to be mobilized and expectorated.
FLUTTER DEVICE
Descriptions Produces oscillations in expiratory pressure and airflow. The resultant
vibration of the airways loosens mucus from the airway walls.
Contraindications

Directions
with elbows resting on a table with head tilted slightly back.

then exhales actively if possible while keeping cheeks as hard and

flat as possible.
VEST AIRWAY CLEARANCE SYSTEM
Descriptions

mobilize secretion.
Indications
potential benefits risks.

to effectively mobilize and expectorate secretions.

Contraindications
 INTRAPULMONARY PERCUSSIVE
VENTILATION
Descriptions
airways by a pneumatic device
Indications
expiratory flow rates
Contraindications
 Airway Clearance Selection
Presence of Atelectasis

Thick Secretions

Can patient deep breath and cough? Can patient deep breath and cough?

CPT
< 3kg > 3kg IS < 2 yr > 2 yr HFO
PEP ACB
CPT IPV ACB CPT Muscle AD
CPT Weakness? DIRECTED
COUGH

IPV CPT
CPUGH
ASSIST
HELIOX THERAPY
Function  Helium reduces the resistance of air/O2 flowing through narrowed airways.
 Treatment of airway obstruction enhance the delivery of oxygen and aerosol to
the distal areas of the lung
Indications  Acute exacerbations of asthma
 Post extubation stridor
 Status asthmaticus
 Tracheal stenosis/upper airway obstruction
Benefits  Improved homogeneity of gas distribution resulting in:

I:E ratios, and Shunting

Common  80:20 or 70:30
mixtures  If FiO2 > 0.6 is required, He/O2 will have little effect.

Administration  Spontaneous breathing: NRB

 Intubated: Ventilator
INHALED NITRIC OXIDE
The body produces nitric oxide (endogenous) regulates vascular
tone, relaxing vascular smooth muscle
Selective pulmonary vasodilatorsmooth muscle relaxation of the
vessels around the lungs.
Allows for more effective perfusion in well-ventilated lung regions
(improves V/Q)
Acute Hypoxemic Respiratory Failure
 INHALED NITRIC OXIDE
Initiate at 22 ppm

Check ABG in 30 minutes: Does PaO2 increased by 20%

(SpO2 by 5%)

Wean O2 until < 60% for atleast 4

hrs Discontinue iNO

Wean INO from 20 ppm to 10 ppm

Wean INO from 10 ppm to 5 ppm

Wean in increments of 1ppm until

at 1 ppm

Discontinue iNO