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Respiratory Therapy Overview
Taresa Crisler RRT-NPS, Clinical Preceptor/Educator
Seattle Children’s Hospital
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Disclosure Statement
• I do not have any conflict of interest, nor will I be discussing
any off-label product use.
• This class has no commercial support or
sponsorship, nor is it co-sponsored.
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Objectives
• Discuss clinical signs and symptoms of respiratory
distress and failure in pediatrics
• Review respiratory interventions: O2 delivery, Sx, and
resuscitation bags
• Review bronchodilator therapy and other aerosols: how
to open the lungs
• Discuss Airway Clearance modalities: how to keep lungs
clear
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Children have proportionally lower VD/VT
(greater deadspace), higher resistance,
obligate nasal breathers
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Why Do You Need to Know This?
• #1 reason children go into cardiac arrest is respiratory
failure
• 5-12% of children who have a cardiac arrest outside a
hospital live to go home
• 27% of children who have a cardiac arrest in the in-
hospital setting live to go home
• We are in the business of…
ARREST PREVENTION!!!
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General Respiratory Assessment: Where do
you start?
• Start from the doorway. • What do you see?
• Chest movement
• Facial expressions (Parents and/or child)
• Positioning
• Calmly watching TV
• What do you hear?
• Stridor
• Grunting
• Secretions
• Crying
• Singing
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Signs and Symptoms of Distress
Supraclavicular
Intercostal
Intercostal
Substernal
Subcostal
Suprasternal
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What about rate? What’s “normal” for …
Infant 25-40
Toddler 2o-35
School age 12-18
Teenagers 12-16
Preschooler 20-30
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What can we do to prevent this
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Oxygen Therapy: Low Flow Devices
Simple Mask
Standard Infant
Oxygen Cannula
Standard
Peds/Adult Oxygen
Cannula (1-4 L/min
or 24-44%)
Standard Infant
Oxygen mask (5-10
L/min or 35-55%)
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Venturi Mask (24-55%) Non-rebreather Mask (>90%) Aerosol Mask
(ineffective for
“hydrating airways or
removing secretions)
Oxygen Therapy: High Flow Devices
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Heated/Humidified High Flow Nasal Cannula
(HFNC)
Infant: Flow> 2 L/min
Large Pediatric: Flow> 6 L/min
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High Flow Nasal Cannula
• Provides heated humidified
gas to eliminate drying of
nasal mucosae and
secretions
• Generates CPAP in the lung
• Difficult to measure, variable
with leak
• “Flushing” effect of anatomic
dead space; similar to TTO
• May be better tolerated than
N-CPAP
• Easier interface
• Less nasal injury
Flow Rate> 2 L/min; monophasic flow
CO2
CO2
+ +
+
+
+ +
+ + +
+
+ + +
+ +
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So what is next?
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Noninvasive Ventilation
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Suctioning
What?!?
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Suctioning Practices
Nasopharyngeal
(NP) Sx
Bulb Sx
Vacuum Sx Pressures: 80-120 cm H2O
Olive Tip Sx
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Suctioning Practices
• Simplify to two suction categories
nasal and NP
• No longer use the term “deep
suctioning” or “deep NP”
• Nursing/RT is to insert the
catheter into the child’s nose at
the approximate depth of nose
to ear measurement and advance
until cough
• Using this technique, the tip of
the suction catheter should
remain in the posterior pharynx
• The goal is to mobilize secretions
and provide aid with airway
clearance
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Bag Valve Mask
Ventilation
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Bag Ventilation
Ambu Bags
Popoff
Valve
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Aerosolized Drug Delivery
Ambu Bags
Popoff
Valve
• Open the airways
• Facilitate secretion removal
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Ari Arzu and Ruben Restrepo, Resp Care, 2013
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How do we deliver these to infants and toddlers?
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Keep things interesting
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Erzinger S et al. JAM 2007 Suppl S78 – S84.
Facemask and Aerosol Delivery In Vivo
Drug deposition <0.35% when an infant is crying or screaming
Non tight fitting Mask
MDI/Spacer
Non tight fitting Mask
Jet Neb
Tight fitting Mask
pMDI/Spacer, screaming
Tight fitting Mask Jet
Neb, screaming
Tight fitting Mask Jet
Neb, breathing quietly
Tight fitting Mask pMDI/Spacer,
breathing quietly
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AeroChamber MAX™ VHC
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How to Administer MDIs with Spacer
1. If possible, sit pt upright.
2. Use MDI-VHC with mouthpiece or face mask
3. With facemask or mouthpiece in place, actuate MDI.
4. Allow the pt to breath 5 to 6 spontaneous breaths between actuations.
5. Slow, deep breathing, with inspiratory hold if possible. This greatly improves drug deposition.
6. Shake MDI canister between actuations
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Airway Clearance
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What are we working with
• Airway Clearance Techniques (ACTs) are used in variety of settings for a variety of clinical ailments: 1) evidence of retained pulmonary secretions
2) weak or ineffective cough
3) focal lung opacity on chest x-ray consistent with mucous plugging and/or atelectasis and
4) intrapulmonary shunt requiring oxygen
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Airway Clearance Techniques
• At our institution, these therapies include: acapella and aerobika
therapy, mechanical insufflation-exsufflation, positive expiratory
pressure (PEP), huffing techniques and incentive spirometry (IS)
• Chest physical therapy (CPT) with postural drainage is the most
commonly used technique for airway clearance
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More airway clearance devices
Acapella
Mechanical Insufflation/exsufflation Aka “Cough Assist”
Aerobika
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Even more ways to facilitate airway clearance
Incentive Spirometry
Ambulation
Breathing games: BUBBLES
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Interesting facts from research
• ACTs have only been shown to be effective in
children with CF, Bronchiectasis and
neuromuscular weakness
• Definitive data do not exist for common forms of
pediatric respiratory failure
• Pneumonia (may cause patients condition to worsen)
• Bronchiolitis, asthma, pleural effusion
• Prevention of atelectasis
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Walsh BK et al, Resp Care, 2011
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Risks Associated with ACT
• Gastroesophageal reflux (Button BM, Pediatr Res
1994)
• Decreased oxygenation and increased
oxygenation requirements (Hough JL, Cochrane,
2008)
• Rib fracture (Purchit DM, Am J Dis Child, 1975)
• Increased intracranial pressure and
intracranial bleeding (Harding JE, J Pediatr, 1998)
• Longer duration of fever (Britton S, BMJ, 1985)
• Increased vomiting and respiratory instability (Roque et al., Cochrane, 2012)
• Increased SOB, arrhythmia, bronchospasm,
thoracic hematoma (Andrews J, Resp Care, 2013)
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Questions ?
That’s it!!
Thank you so much for having me!