“Common Pediatric Respiratory Problems” by Monica Kleinman, MD for OPENPediatrics

[MUSIC PLAYING] The purpose of this video
to provide general information and education about the care of a critically ill child. It is in no way a substitute for the independent
decision-making and judgment by a qualified health care professional. The information contained in this video should
not be used to make a diagnosis or to overrule the advice of a qualified health care provider,
nor should it be used to provide advice for emergency medical treatment. Common Pediatric Respiratory Problems by Dr.
Monica Kleinman. Please note that in this video, we will be
following the guidelines used at Boston Children’s Hospital. Some of this information may need to be modified
based on the equipment, guidelines, and practices in place in your institution. Hello. My name is Monica Kleinman. I’m an attending physician in the Medical/Surgical
Intensive Care Unit at Children’s Hospital, Boston. And today, I’m going to be talking to you
about common respiratory problems that children can present with. Upper Airway Obstruction. Two of the most common respiratory problems
that children can present with are upper and lower airway obstruction. Now, there’s a whole set of conditions that
can result in upper airway obstruction, but what they all have in common is typically
some edema of the soft tissues of the upper airway, either in the subglottic region below
the vocal cords or in the soft tissues above that, such as that the epiglottis or hypopharynx. When you have obstruction in the upper airway,
you’ll demonstrate increased work of breathing because you’re trying to use your muscles
to draw in air against a higher resistance than normal, remembering that the pediatric
airway is already fairly small in caliber. With upper airway obstruction, you’ll typically
see suprasternal retractions or potentially sternal retractions, as well, in a young infant
with a compliant sternum. And there’s a characteristic noise that may
accompany this called stridor. [HIGH-PITCHED NOISE] And stridor is a high-pitched
noise that occurs on inspiration and is the noise essentially of the turbulent airflow
that the infant is generating by drawing air in through a narrowed area. If the infant has obstruction at a higher
level– for instance, swelling of the tongue or excessive secretions or poor muscle tone
resulting in hypopharyngeal obstruction– the sounds that may be produced are much coarser
sounds that are called stertor, for instance, which sounds more like a snoring or a rattling
type of respiration. [SNORING SOUND] This can be easily distinguished
from stridor if the baby responds to a jaw-thrust maneuver where when you relieve the upper
airway obstruction from soft tissue, the noise improves. Subglottic edema won’t have that same characteristic. It needs other forms of treatment, such as
inhaled therapy with racemic epinephrine. Upper airway obstruction is clearly one of
the most dramatic presentations that a child can appear with and can be very frightening
to the child, the family, and the provider. It is important to recognize a couple of types
of upper airway obstruction that require urgent and specific management, and one of those
is epiglottitis. Now, we already talked about subglottic edema. Subglottic edema is the characteristic finding
in croup, where one has inspiratory stridor and a barking type of cough associated with
upper respiratory infection symptoms and low-grade fever. Epiglottitis presents typically a more fulminant
way, where a child is well in the morning and by afternoon has a high fever, appears
toxic, and develops significant signs of upper airway obstruction that include perhaps some
noisiness on inspiration because of the soft tissue swelling of the epiglottis and the
surrounding tissues, but is also characterized by the child’s refusal to speak or swallow
because of the pain that they have in their throat. And those children will typically be drooling. If they are able to verbalize at all, they
have what’s described as a hot potato voice, where they’re talking as though their mouth
is containing something extremely hot that alters their speech pattern. And they may adopt a characteristic position
that’s designed to elongate and help open upper airway, which is called tripoding. And in tripoding, the child sits with the
arms forward, leaning forward with the neck extended, in an effort to further open the
airway. Epiglottitis can rapidly progress to complete
airway obstruction and cardiac arrest. And so it’s essential if you see this pattern
to, very early on, obtain expert airway help, typically from someone with training and experience
in anesthesia and possibly someone with the capability to do a surgical airway, like an
emergency tracheostomy in the event that the patient cannot be intubated. These children are also very anxious, and
stressing them further could precipitate worsening obstruction. And so in most cases, it’s best to avoid other
forms of stress, such as starting IVs or trying to position them in a way that you would like. Let them stay in the position they want to
be with family members while you gather your expert team.

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