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CPC figures and statistics
Terms in this set (36)
Respiratory failure type 1:
oxygenation problem without hypercapnia. Below 8kPa. Difficulty getting 02 into the blood e.g. hypoxemia.
Respiratory failure type 2:
ventilation problem: decrease 02 and increased c02 (hypoxemia and hypercapnia). Struggle to get air in and out for adequate gas exchange.
Pro's of NIV's ?
Smaller, cheaper that those used for invasive ventilation in ITU, pt can be nursed on ward if nurses are trained, run off electricity, pts can take them home, use air as the ventilating gas - 02 needs to be entrained into the circuit if needed by the pt - e.g. during an acute exacerbation in hosp.
Theory of BiPAP
Application of positive pressure ventilation without intubation in pts with respiratory failures (usually type II)
IPAP = inspiratory positive airway pressure
EPAP = expiratory positive airway pressure
The use of inspiratory pressure gives the pt help with inspiration and thus a larger TV than they might achieve without it so: decreases the WOB and hence increases TV
The use of EPAP increases FRC
Starting values of BiPAP / CPAP
IPAP - 8-10cmh20
EPAP -4-5 cmh20
CPAP - 5-12 cmh20
Over 20 cmh20 IPAP non invasively is not commonly used although appropriate for some patients. May cause: Gastric insufflation / sinus pain
Brand names for BiPAP machines?
All do similar job
Maintains the same positive pressure throughout inspiration and expiration i.e. IPAP is equal to EPAP.
Used to correct type I RF seen in ;
e.g. post major surgery (cardiac, abdominal and thoracic with care)
Pulmonay odema -literally pushes fluid back into alveolar capillaries
Assists weaning from invasive ventilation
Used to treat sleep apnoea
Facts about lung volume and compliance
In 'normals' breathing at increased lung volume is harder BUT in a pt with reduced lung volume increasing the lung volume moves the lung volume to a volume where the WOB is reduced (the compliance is increased)
What to monitor when on NIV
ABGS / cap gases
Pt comfort / are they synchonising well with the machine
Indications for rx on a paed
Atelectasis / collapse
exacerbation of CF / bronchiectasis
Neuro conditions with resp. function
RR rate values for paeds
0 years = 40-60
1-3 years = 20-30
3-6 years = 20-30
over 6 years = 15-20
adult = 12 - 16
Heart rate and blood pressure for paeds
0 years = 140 average HR, minimum/maximum HR = 100-200, BP 60/40
6 months = 130 average HR, minimum / maximum HR = 90-170
1 year = 120 average HR, minimum / maximum HR = 80-150, BP 90/65
7 years = 100 average HR, minimum / maximum HR = 70-135, BP 105/65
14 years = 85 average HR, minimum / maximum HR = 55-120, BP 65/95
PH = 7.35 - 7.45
PA02 (KPAs) = 12-14 kPa
PAC02 = 4.6 - 6
HC03- = 22-26
BE = -4 - +4
1 month - 2 years
PH = 7.34-7.46
PA02 = 11.2-13.8
PAc02 = 3.95-5.9
HC03 = 20-28
BE = -4 to +2
What can reduced breath sounds indicate>
collapse, pneuomothorax or pleural effusion
What are some of the added sounds and what do they mean?
Crackles - sputum
Fine crackles - oedema or areas of atelectasis
Wheeze - bronchospasm or inhaled foreign body
Bronhcial breathing - consolidation of fibrosis
Posutural drainage positions for paeds
Upper lobes - use a sitting position, a baby can be sat on your lap
Lower lobes (lateral basal segment) - tilt of 20 degrees in side lying
LOwer lobes (anterior basal segment) - head down tilt of 20 degrees in supine. A baby may be positioned on your lap with a pillow
Lower lobes (posterior basal segment) - head down tilt of 20 degrees in prone. A baby may be positioned on your lap with a pillow
In the presence of gastro-oesophageal reflux the child must not be tipped
Manaul techniques for paeds
Perucssion - make sure you hold the childs head when using this technique in a child under 1 or a child with a neurological problem. Use a towel over the ski and a cupped hand. In a child under 4 months you may like to use a small face mask.
Vibrations - only use on expiration - therefore due to a childs high RR this is unlikely to be effective.
ACBT - can teach ACBT if the child is compliant and can understand
Acapella - handheld device that creates an oscillitating pressure on tidal expiration. It creates a back pressure which results in expansion of the small airways. The oscillation helps to move secretions from small airways to larger ones. It is recomended that 10-12 tidal breaths with the acapella is followed by graded huffs in a cycle for a set period of time.
Incentive spirometry - incentive spirometers can be used to encourage the child to take a deeper breath. Use in conjuction with ACBT
Other ideas - your imagination is the only limitation!! balloons, straws, bubbles, blowing games etc. These all encourage the child to take deeper breaths.
How long should you suction on a neonate?
shouldnt go over 15 seconds
For an adult it is 30 seconds
What will increase with a decreased lung volume?
anatomical dead space, normal anatomical dead space is 150ml, so when there is decreased lung volume this value increases which decreases sats further.
Why is it important to take into consideration that babies tend to be more nose breathers
Anything that occludes the nasal passages e.g. secretions, NG tubes, and suction catheters are likely to impede respiration.
What is different about a babies airway
They are smaller so need to consider implications. Adult trachea is 20mm, and the young baby is only 5mm. hence a ring of oedema 2mm thick has much more effect on the child than the adult.
Causes of oedema = infection, intubation, suction
All lead to increase WOB/SOB, equivalent to trying to drink through a narrow straw
What is different about a babies bronchial wall structure?
More mucous glands (birth - 17 per mm2 - adult 1 per mm2) , cilia are immature (prediposition to mucus plugging), debate whether fewer smooth muscle cells hence debate as to effectiveness of bronchidilators, smaller airways e.g. bronchioles contribute to more of overall airway often upto 50% which is why bronchiolitis has more disastrous effect on young babies than adults, fewer alveoli and their structure is immature.
Is collateral ventilation present is a neonate?
(accessory communicating channels between adjacent terminal bronchioles and alveoli)
Not absent, but they are underused. This leads to an increased risk of terminal airway collapse.
What is different about rib position in a baby?
Due to horizontal position of the ribs there is no bucket handle action during respiration up to about 2 years of age. This means that the infant is nearly totally reliant on the diaphragm for respiration.
What is different about the diaphragm in a baby?
it is relatively flat and works at a mechanical disadvantage. Can only increase their minute volume by increasing their RR (MV = TVxRR) as they struggle to increase their TV very much.
Infant diapghragm has fewer fatigue resistant fibers than the adult (30% in paeds compared to 50-60% in adults).
these factors mean that;
- reduced respiratory reserve
- higher RR at rest
- Increase in RR is first sign of resp. distress
Any abdominal distension will compromise the infant.
Higher basic metabolic rates in babies
Leads to higher 02 requiremnet thus to a more rapid development of hypoxia in times of stress. The 02 consumption in the newborn is pro rata, twice that of an adult.
What is different in the compliance of the chest wall in a baby
Greater in the child and almost approaches that of the lung so this causes a low FRC and the closing volume is within the TV. Both these factors result;
- in an increase of the work of breathing
- slightly lower pa02 - 9-11 kpa in the first year of life
- marked recession of the rib cage is resp. distress
- predisposition to atelectasis
ventilation / perfusion matching in babies
reverse of an adult, V/Q ratio is best achieved in the NON dependent lung whether the child is self or artificially ventilated. The reasons for this are
- the absence of the loading effect of the abdomincal effect on the already flat diaphragm
the negative intra-pleural pressure in the dependent lung is virtually abolished in side lying and thus the dependent lung does not ventilate much with shallow respirations
What is the consequence of babies having inhibition of their intercostal and other smooth muscle during REM sleep
Leads to an increase in the compliance of the chest wall, causing paradoxical movement of the chest wall thus further reducing FRC and potentially causing apnoeas during REM sleep
cardiac muscle in infants
Greater % of connective tissue compared to muscle than the adult so a babys main mechanism for increasing its cardiac output is by increasing its heart rate because it cannot increase its stroke volume by much. The cardiac muscle is also more susceptible to acidosis, hypoglycaemi, decreased calcium, and anaemia than the adult muscle.
Babies are very sensitive to heat loss
Signs of resp. distress of the infant
Observe rate and depth of respiration and look for signs of resp. distress
Tahcypnoea - unforunteley is not just a sign of increasing resp. problems e.g also sign of increasing heart failure. A rise in body temp. also leads to an increase resp. rate due to the subsequent rise in metabolism and hence c02 production.
Tachycardia - which often turns to bradycardia as the infant myocardiums response to hypoxeamia is bradycardia rather than tachycardia
Nasal flare - as neonates and young babies predominantly nose breath the flaring of their nostrils is an effort to increase the diameter of their airway
Tracheal tug - the increased pull of the diaphragm is transmitted as a downwards tug on the trachae during inspiration.
Grunting - this is caused by the baby actively adducting its laryngeal muscles to increase its auto PEEP and hence FRC.
Recession / retraction / indrawing - all terms used to describe the effects of increasing use of the resp. muscles on the compliant chest wall of the neonate described using the terms - intercostal, subcoastal, substernal, suprasternal
See-sawing - the babys lower ribs are sucked in during inspiration (also termed paradoxical breathing) an extreme sign of diaphragmatic pull on a compliant rib cage and the stiff non - compliant underlying lungs failing to expand
Pallor / grey / cynosis - Cardiac child may be cynosed anyway, and babies tend to go cynosed quite slowly. Pale and mottledas their peripheral circulation shuts down.
Reduced activity / floppy / inability to feed cry = a sign that they are saving their energies for breathing and confusion in the older child is a sign of c02 retention
What is their to consider in regards to feeding in babies
Rx best to be done before a feed , if not make sure it is one hour after feed as can cause vomitting. Unless emergency rx
Temperature in babies
Neonates have difficulty maintaing the normal temp of 37 due to their large surface area : body mass ratio and to the fact that they are unable to shiver to generate heat and rely on the release of noradrenanalin which causes the breakdown of brown fat (non-shivering thermogenisis) but this is a very oxygen expensive exercise.
Environmental temp. - keep babies withi ntheir neutral thermal environmental througout all nursing, medical and physio procedures.
Chest x-rays in babies
2) heart can be up to half the throacic width
3) thymus can mimic a right upper lobe collapse
4) the carina is situated at - T3 in neonate, T4/5 in the child, T6 in the adult
Consolidation only means that the alveolar spaces are full of something they shouldnt be, could be infection, oedema, blood.
Ausculation in paeds
use right stethoscope
Because there is less lung tissue for the high frequency sounds to be filtered the breath sound tend to sound harsher (more brochial) in the baby and young child than in the adult. You can also find that normal breath sounds can be transmitted acorss areas of pathology quite easily.
1) the presence and quality of breath sounds, there usually has to be a large area of consolidation or collapse for there to be marekd reduced breath sounds or bronchial breathing
2) the presence of added sounds
Compare a lobe of the lung to the corresponding lung
Hard to determine whether the added sounds are pulmonary oedeme or secretions. As a general rule;
- generalised fine crackles are usually indicative of probably oedema
- localised fine crackles it is probably resolving pneuomonia or re-expanding lung tissue
- coarse crackles are either gross oedema or secretions
- loud transmitted sounds are either secretions sitting very centrally or water in the ventilator tubing
- wheeze, if localised is secretions - if very monophonic indicates an obstruction in a bronchus either a foregin body, tumour or a large plug of secretions
- generalised wheeze is usually bronchospasm
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