Pyramid of Care: Pediatric Edition

Free Clinical Continuing Education for Respiratory Therapists Foundations and Nurses A Patient-focused Education Program for Healthcare Professionals See Page 12 Advisory Board Pyramid of Care: Pediatric Edition Richard Branson, MS, RRT, FAARC Professor of Surgery, Emeritus By Matthew S. Pavlichko, MS, RRT, RRT-NPS University of Cincinnati College of Medicine Cincinnati, OH As our healthcare landscape changes, reimbursement difficulties, cost Kathleen Deakins, MS, RRT, NPS Manager, Women’s Children’s Respiratory Care containment, readmission penalties, and the role and scope of the future University Hospital, Rainbow Babies & Children respiratory therapist is up for debate. Identifying and providing value to Cleveland, OH William Galvin, MSEd, RRT, CPFT, AE-C, FAARC the patient and the organization is imperative for any respiratory care de- Program Director, Respiratory Care Program Gwynedd Mercy College, Gwynedd Valley, PA. partment, large or small. Our value is never more evident than during Carl Haas, MS, RRT, FAARC a respiratory emergency, most importantly, of a pediatric patient. This Educational & Research Coordinator University Hospitals and Health Centers Ann Arbor, MI article will review the historical need for winter pediatric preparations in Richard Kallet, MSc, RRT, FAARC Director of Quality Assurance, respiratory care as well as the treatment theory called the “Respiratory Respiratory Care Services USCF General Hospital Pyramid of Care: Pediatric Edition.” San Francisco, CA Neil MacIntyre, MD, FAARC Medical Director of Respiratory Services Duke University Medical Center Durham, NC Panel Discussion: NIV and HFNC for Neonates Tim Op’t Holt, EdD, RRT, AE-C, FAARC Professor, Department of Respiratory Care and Pediatric Patients and Cardiopulmonary Sciences University of Southern Alabama Mobile, AL Moderator: Kathleen Deakins, RRT-NPS FAARC Helen Sorenson, MA, RRT, FAARC Assistant Professor, Dept. of Respiratory Care Panelists: Rob DiBlasi, RRT-NPS University of Texas Health Sciences Center San Antonio, TX Lee Williford, RRT-NPS, RCP W ebinars Keith Hirst, MS, RRT-ACCS, RRT-NPS, AE-C Clinical Foundations is dedicated to providing healthcare professionals Several methods are used in pediatric and infant populations to ensure with clinically relevant, evidence- adequate breathing and sufficient levels of blood oxygen. These meth- based topics. Clinical Foundations ods are placed along a continuum or pyramid of utility. Two of the most is pleased to announce a webinar series featuring leading healthcare popular methods are: High-Flow nasal cannula (HFNC) which adds heat professionals. To find out more and humidity to the air flow to create a level of comfort that other oxy- about the current webinar and to register, go to www.clinicalfounda- gen devices are lacking, and continuous positive pressure airway pres- tions.org. Each webinar is accred- sure (CPAP) devices, which is a noninvasive method of delivering air to ited for CRCEs and CEs. the lungs under mild pressure. In this panel discussion, three experts dis- cuss the pros and cons of HFNC as well as CPAP, and when and how they Faculty Disclosures: should be used. Matthew S. Pavlichko, MS, RRT-NPS, Kathleen Deakins, RRT-NPS, FAARC, Rob DiBlasi, RRT-NPS, FAARC, Keith Hirst, MS, RRT-ACCS, RRT-NPS, AE-C, Lee Williford, RRT-NPS, RCP each disclosed no conflicts of interest associated with this publication MC-005904 This program is sponsored by Teleflex Incorporated Clinical Foundations Care” translates well to the pediatric patient population.(Figure 1) Pyramid of Care: The pyramid’s shape is the most im- portant concept. The foundation of the pyramid serves the largest population and Pediatric Edition has the least complexity; i.e., patients on room air. As one moves up the pyramid, By Matthew S. Pavlichko, MS, RRT, RRT-NPS one shifts in treatments that are higher cost and complexity but are necessary for a smaller number of patients. When pa- s our healthcare landscape will describe the Respiratory Pyramid of tients’ conditions worsen, they advance changes, reimbursement diffi- Care within the scope of pediatrics. Its up the pyramid, but when they improve, culties, cost containment, read- purpose, is to provide comprehensive in- they are weaned down the pyramid. Each mission penalties, and the role sight into the respiratory treatment strat- treatment meets the patient’s needs, but Aand scope of the future respiratory thera- egy of the sick child and to better prepare each has nuances that can serve as a con- pist is up for debate. Identifying and pro- clinicians for the child who will inevitably duit or a barrier to care. Each is described viding value to the patient and the orga- arrive. in more in depth below. nization is imperative for any respiratory care department, large or small. Our value What is the Pyramid of Care? Treatments that Resolve Hypoxemia/ is never more evident than during a respi- The Council for Advances in Respi- Hypoxia ratory emergency, most importantly, of a ratory Therapy developed the theory of When the body’s partial pressure of pediatric patient. This article will review “Navigating the Respiratory Pyramid of arterial oxygen (PaO2) falls below normal the historical need for winter pediatric Care” in 2010. Led by David Vines, PhD, levels, hypoxemia is present. Hypoxemia preparations in respiratory care as well as RRT, FAARC, the council (comprised of can be caused by hypoventilation, shunt- the treatment theory called the “Respira- expert respiratory care thought leaders ing, diffusion defects, abnormal hemoglo- tory Pyramid of Care: Pediatric Edition.” from across the country) developed an bin, anemia, and/or poor perfusion. Signs The Emergency Medicine Network extensive, peer-reviewed educational cur- and symptoms include increased work of has recorded that there are 5,273 EDs in riculum to create a comprehensive under- breathing (WOB), tachypnea, shortness the US.1 However, of those 5,273 emer- standing of oxygen therapy and ventila- of breath, tachycardia, poor perfusion, gency departments, only 220 reside in a tory support.5 This curriculum describes and potential neurological deficit.5 Hy- children’s hospital (CHA).2 These statis- the treatment selection strategy for adult poxemia can occur during severe trauma, tics lead to the assumption that most pedi- patients with respiratory compromise, shock, cyanide and carbon monoxide poi- atric ED visits are performed outside the as well as how to navigate the severity of soning, cardiac arrest, and perioperative walls of a children’s hospital. Chamberlain their illness, from worsening progression emergencies. and colleagues described the scope of this to weaning. Although, initially created to In 2016, The World Health Organiza- phenomenon in 2013,3 when they report- care for the adult patient, the “Pyramid of tion (WHO) created the Oxygen Therapy ed that up to 90% of all pediatric emergency cases did not receive care at a pediatric Respiratory Pyramid of Care specialty hospital. In addition, according to the Agency for Healthcare Research and Quality (AHRQ),4 only 5% of pediatric ED visits result in admission to the same hospital. The AHRQ also reported that in 2015, the most common reason for Extreme A Measures djunc pediatric patients to visit the ED was for C respiratory disorders, especially during Invasive omplexity 4 Ventilation winter months. tive The ED is not the only location that Noninvasive ost Ventilation Therapies deals with respiratory emergencies. Many C inpatient pediatric units and neonatal in- Heated, Humidied Oxygen Therapy (HFNC) tensive care nurseries across the country reside outside the wall of a children’s hos- High Flow/High FIO2 Oxygen Therapy pital. This phenomenon places enormous pressure to deliver high quality care in a Low Flow/Low FIO2 OIxygen Therapy low-volume, high-risk patient population in settings where the least amount of ex- Room Air perience, knowledge, and resources are available. Is pediatric respiratory emergency truly “low-volume”? This module Figure 1. 2 www.clinicalfoundations.org Clinical Foundations for Children Guide, which describes, in detail, assessment and identification, treatment strategies, and monitoring of children on oxygen therapy.6 PaO2 can be considered as a diagnosis of hypoxemia, but the measure of PaO2 requires an invasive arterial blood gas (ABG) test. The WHO identified a target oxygen satura- tion (SpO2), which is a non-invasive measure of tissue oxygenation, to adequately reflect hypoxemia and the response to therapy that is appropriate for children. This target goal is defined as a SpO2 of 90-94%6 via pulse oximeter. Treatment should target that goal. High-flow Nasal Canuala Room Air Although not addressed by Vines and They come in many sizes, can be humidi- cludes the recommendation to resuscitate colleagues, room air is the best option for fied using a bubble humidifier, and now infants using < 100% FiO2 to meet tar- most pediatric patients, even those who- are made of very soft material to maxi- get saturations over time.9,10 Air-oxygen present with respiratory illness. Oxygen is mise comfort. Patients can talk and eat blenders, found routinely in the delivery a prescribed therapeutic intervention that while fitted with a nasal cannula. The ini- room, are becoming popular for deliver- has benefits but also side effects. If a pa- tial application may be difficult depending ing oxygen therapy to all children. The use tient is adequately oxygenating, oxygen is on the patient, but the standard nasal can- of blenders allows the clinician to deliver contraindicated. Hyperoxia leads to oxy- nula should be the first option for oxygen flow and FiO2 independent of one another. gen toxicity, alveolar damage, absorption therapy. FiO2 can be adjusted to meet SpO2 targets, atelectasis, etc.7 In addition, oxygen ther- and flow can be adjusted to meet work apy devices are difficult to manage with High-Flow – Fixed FiO2 Devices of breathing targets. What if an oxygen pediatric patients due to lack of patient When a higher level of FiO2 is re- delivery device could give precise/pre- understanding.

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