Respiratory Management Resources © 2006 American Heart Association Contents Oxygen Delivery Systems..............................................................................3 High-Flow vs Low-Flow Delivery Systems..................................................4 Low-Flow Systems .....................................................................................4 High-Flow Systems ....................................................................................5 Airway Adjuncts .............................................................................................9 Oropharyngeal Airway (OPA).....................................................................9 Nasopharyngeal Airway (NPA).................................................................10 Bag-Mask Ventilation...................................................................................13 Understand Bag-Mask Ventilation Equipment..........................................14 Select and Prepare the Equipment ..........................................................19 Position the Child .....................................................................................21 Perform Bag-Mask Ventilation..................................................................22 Monitor the Effectiveness of Ventilation ...................................................25 Minimize the Risk of Gastric Distention....................................................26 Endotracheal Intubation...............................................................................29 Assemble Equipment and Personnel .......................................................31 Prepare the Child for the Procedure.........................................................35 Perform ET Intubation Procedure.............................................................36 Confirm Proper ET Tube Placement ........................................................38 Search for and Treat Causes of Acute Deterioration................................43 Tension Pneumothorax................................................................................45 Laryngeal Mask Airway................................................................................47 Emergency Tracheostomy...........................................................................47 Appendix.............................................................................................................48 Respiratory Function Monitoring Devices ....................................................49 Pulse Oximetry.........................................................................................49 Exhaled CO2 Monitoring...........................................................................54 Suctioning....................................................................................................57 Endotracheal Intubation Technique .............................................................60 Using the Laryngoscope ..........................................................................60 Visualizing the Epiglottis ..........................................................................61 Detailed Intubation Procedure..................................................................63 Rapid Sequence Intubation......................................................................65 Initial Ventilator Settings...........................................................................66 Troubleshooting Problems During Ventilation of the Intubated Patient ....68 Noninvasive Positive Airway Pressure.........................................................71 CPAP .......................................................................................................71 BiPAP.......................................................................................................73 Positive End-Expiratory Pressure (PEEP) ...................................................73 References .........................................................................................................75 © 2006 American Heart Association 2 Oxygen Delivery Systems Introduction During critical illness and injury, oxygen uptake by the lungs and delivery to the tissues are typically compromised at the same time tissue demand for oxygen may be increased. Oxygen should be administered in high concentration to all seriously ill or injured children suffering from respiratory insufficiency, shock, or central nervous system depression. As soon as feasible, add humidification to oxygen delivery systems to prevent obstruction of the small airways by dried secretions. Administering When attempting to administer oxygen to an alert child, the Oxygen to a desire to improve oxygen delivery must be balanced against the Conscious adverse effect of increased agitation that may be produced by Child applying any oxygen delivery equipment (eg, mask or cannula) to the child. Anxiety can increase oxygen consumption and respiratory distress. For this reason allow the alert child in respiratory distress to remain with a parent or caregiver. If needed, have a nonthreatening person, such as a parent, introduce the oxygen delivery equipment. If a child is upset by one method of oxygen delivery (eg, a mask), attempt to deliver oxygen by an alternative technique (eg, blow-by stream of humidified oxygen directed toward the child’s mouth and nose). To further prevent agitation, allow an alert child in respiratory distress to remain in a position of comfort to facilitate optimal airway patency and to minimize respiratory effort. Administering If a child is somnolent or unconscious, the airway may become Oxygen to an obstructed by a combination of neck flexion, jaw relaxation, Unconscious displacement of the tongue against the posterior pharyngeal Child wall, and collapse of the hypopharynx.1,2 Use manual airway- opening techniques (eg, head tilt–chin lift or jaw thrust in trauma) to open the airway before inserting an oropharyngeal airway. In the child without suspected trauma who is breathing spontaneously, rolling him on his side with the neck extended will help maintain airway patency and prevent the tongue from falling back to obstruct the airway. © 2006 American Heart Association 3 A properly performed jaw thrust is the most effective means to open the pediatric airway.3 Providers, however, are often inexperienced with the technique because it cannot be performed on some CPR manikins. If necessary clear the oropharynx and nasopharynx of secretions, mucus, or blood with suctioning. Once the airway is open and clear, oxygen can be administered to an unconscious child by a variety of methods. High-Flow vs Low-Flow Delivery Systems Overview If spontaneous respiratory efforts are effective, oxygen may be administered by several delivery systems. The choice of system is determined by the child’s clinical status and the desired concentration of inspired oxygen. Oxygen delivery systems can be categorized as • low flow/variable concentration of oxygen (nasal cannula, simple oxygen mask) • high flow/high concentration of oxygen (nonrebreathing masks, oxygen hoods, Venturi masks, face tents, and oxygen tents) Low-Flow Systems Introduction In a low-flow system 100% oxygen mixes with entrained room air during inspiration because the oxygen flow is less than the patient’s inspiratory flow and the mask or cannula does not fit tightly on the face. The delivered oxygen concentration is determined by the patient’s inspiratory flow rate and the gas flow delivery rate, which results in a variable concentration of oxygen. Low-flow systems theoretically can provide an oxygen concentration of 23% to 80%, although they do so unreliably. In small infants even low-flow systems can result in a high inspired oxygen concentration. The nasal cannula and the simple oxygen mask are both low-flow systems. © 2006 American Heart Association 4 Nasal The nasal cannula is a low-flow oxygen delivery device suitable Cannula for infants and children who require only low levels of supplementary oxygen. The net inspired oxygen concentration depends on the child’s respiratory rate, respiratory effort, and size.4 The nasal cannula may deliver high oxygen concentrations to small infants. The inspired oxygen concentration cannot be reliably determined from the nasal oxygen flow rate because it is influenced by other factors, such as • nasal resistance • oropharyngeal resistance • inspiratory flow rate • tidal volume • nasopharyngeal and oropharyngeal volume A high oxygen flow rate (>4 L/min) through a nasal cannula irritates the nasopharynx and may not appreciably improve oxygenation. A nasal cannula often does not provide humidified oxygen and may not deliver sufficient oxygen if the nares are obstructed. Simple The simple oxygen mask is a low-flow device. The maximum Oxygen Mask inspired oxygen concentration is approximately 60% because entrainment of room air occurs between the mask and the face and through exhalation ports in the side of the mask during spontaneous inspiration. Oxygen concentration delivered to the patient is reduced if the patient’s spontaneous inspiratory flow requirement is high, the mask is loose, or the oxygen flow into the mask is low. A minimum oxygen flow rate of 6 L/min must be used to maintain an increased inspired oxygen concentration and prevent rebreathing of exhaled CO2. Several types of oxygen masks may be used to administer humidified oxygen in a wide range of concentrations. The soft vinyl pediatric mask is often poorly tolerated by infants and toddlers, but it