PALS Course

Our online PALS certification course includes pediatric assessment and practice of medical emergency scenarios. It also includes identifying shock and cardiac arrest in pediatric patients. OSHA-certified trainers have designed this course curriculum. It is for all medical/healthcare professionals. Read More Earn CE credit hours. Print your wallet card instantly after passing. Read Less

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Chapters	CE Credits	Validity	Cost	Duration	ECC	Exam Attempts	Wallet Card
08	4.0 – 8.0	2 Years	$119.00	3-4 Hrs	Compliant	Unlimited	Download/Print/Mail

Chapters08
CE Credits4.0 – 8.0
Validity2 Years
Cost$119.00
Duration3-4 Hrs
ECCCompliant
Exam AttemptsUnlimited
Wallet CardDownload/Print/Mail

Chapter 3: Respiratory Distress And Failure

Respiratory distress can lead to respiratory failure in children that can be life threating and can quickly lead to death. Prompt recognition and management of respiratory distress and failure in infants and children is one of the key components of PALS. Respiratory distress is when the rate and effort of breathing is increased and there are changes seen in airway sounds, skin color and mental status. Respiratory distress can quickly lead to respiratory failure, where there is inadequate oxygenation, ventilation or both and can quickly lead to cardiac arrest.

Respiratory First Aid

Lung of a child in respiratory failure and needs respirator for assist ventilation

Respiratory First Aid

Lung of a child with Respiratory distress syndrome and left sided pneumothorax

Respiratory Distress And Failure Video:

Hypoxemia or inadequate oxygenation and hypercarbia or inadequate ventilation can lead to respiratory distress and failure. It is important to note that oxygen consumption in infants is 6 to 8 mL/kg per minute, while in an adult it is 4 mL/kg per minute. A pulse oximetry helps indicate if there is decreased oxyhemoglobin saturation in the blood. A SpO2 <94% = hypoxemia. Tissue hypoxia could also be a cause of hypoxemia. It is important to recognize the signs of hypoxia to help distinguish between tissue hypoxia and hypoxemia. The following are signs of tissue hypoxia:

Tachypnea
Pallor
Early tachycardia
Late bradypnea
Late bradycardia
Altered mental status
Late cyanosis
Agitation
Anxiousness
Nasal flaring
Fatigue

PALS by American HealthCare Academy Video:

Increased PaCO2 in the blood indicated inadequate alveolar ventilation or hypercarbia. Hypercarbia is more severe, but is harder to detect. The following are signs of hypercarbia:

Tachypnea
Altered mental status
Agitation
Anxiety
Nasal flaring

Identification and Management of Respiratory Distress and Failure

Conditions that cause respiratory distress and failure include:

Upper airway obstruction
Lower airway obstruction
Lung tissue disease
Disordered control of breathing

Upper Airway Obstruction
Anatomy	Obstruction in the nose, pharynx, or larynx
Causes	Foreign-body aspiration Swelling of tissue of upper airway Tumor or abscess Croup Epiglottitis Anaphylaxis Hypertrophic tonsils
Signs and Symptoms	Tachypnea Increase in respiration and effort Inadequate chest rise and air entry on auscultation Stridor Change in voice, crying or cough Cyanosis Drooling Increased respiratory rate
Management	Management of all upper airway obstruction includes: Remove object obstructing airway Suction mouth or nose Reduce airway swelling Consider advanced airway or surgery

Specific causes of upper airway obstruction include croup and anaphylaxis.

Croup

Croup is a condition where the upper airway is affected due to an acute viral infection. Symptoms include barking cough, stridor and hoarseness. Treatment of croup can vary due to the severity of the disease. Management of croup includes the following:

Single oral dose of dexamethasone
Cool mist
Administration of nebulized racemic epinephrine or L-epinephrine
Perform endotracheal intubation
Use of heliox (helium-oxygen mixture)

Anaphylaxis

Anaphylaxis is a type I hypersensitivity allergic reaction that can causes intense bronchoconstriction in which the patient may stop breathing. The following table shows the actions needed for the treatment of anaphylaxis.

Treatment

Give IM epinephrine through the autoinjector – depends on how severe the problem is

Think of using endotracheal intubation if there is bronchospasm/wheezing – give albuterol through inhaler or by nebulizer

For severe bronchospasm give nebulizer continuously

Prepare for ET intubation

If the child has hypotension:

Put the child in supine position
Give small boluses of epinephrine or infusion titrated amount
Give isotonic crystalloid

Give methylprednisolone or corticosteroids and diphenhydramine

Lower Airway Obstruction
Anatomy	Obstruction in lower trachea, bronchi or bronchioles
Causes	Asthma Bronchiolitis
Signs and Symptoms	Tachypnea Cough Wheezing Increased expiratory effort with longer expiratory phase Increased respiratory effort
Management	Management of all lower airway obstruction includes: Slow rate with bag-mask ventilation

Specific causes of lower airway obstruction include asthma and bronchiolitis.

Bronchiolitis

Bronchiolitis is inflammation of the bronchioles with coughing, shortness of breath and wheezing. Management of bronchiolitis includes the following:

Nasal or oral suctioning
Ancillary testing – chest x-ray, arterial blood gas analysis and viral studies

Asthma

Asthma is a chronic inflammatory disease of the airway with symptoms of coughing, shortness of breath, wheezing and tightness of the chest. The following table illustrates the management of asthma.

Lung Tissue Disease
Anatomy	Clinical conditions with the lungs
Causes	Pneumonia Pulmonary edema ARDS Trauma Allergic reaction Toxins Vasculitis
Signs and Symptoms	Tachypnea Tachycardia Crackles Increased respiratory effort Grunting Hypoxemia Decreased breath sounds
Management	Management of all tissue lung disease includes: Use positive expiratory pressure for hypoxemia Administer humidified high-flow nasal cannula Monitor tissue perfusion and cardiac output

Specific causes of lung tissue disease include pneumonia, chemical pneumonitis, aspiration pneumonitis, cardiogenic pulmonary edema and noncardiogenic pulmonary edema (ARDS).

Pneumonia

Pneumonia is inflammation of the alveoli of the lungs due to infection by bacteria, viruses, fungi and parasites. Pneumonia presents with fever, chest pain, cough, difficulty in breathing. The management of pneumonia includes:

Antimicrobial therapy
Albuterol by MDI or nebulizer
Use CPAP or BiPAP
Normalize temperature by treating fever
Conduct ancillary testing

Chemical Pneumonitis

Chemical pneumonitis is inflammation of the lungs caused by breathing in toxic substances. Toxic substances include dust, fumes, irritant gases, hydrocarbons. Management of chemical pneumonitis is done by:

Use of CPAP or BiPAP
Give nebulized bronchodilator
Consultation of a severity center

Aspiration Pneumonitis

Aspiration pneumonitis is inflammation of the lungs caused by content of the stomach such as stomach acid and enzymes. For treatment of aspiration pneumonitis consider the following options:

Use of CPAP or BiPAP
Administer antibiotics for fever and infiltrates

Cardiogenic Pulmonary Edema

Cardiogenic pulmonary edema occurs when there is an accumulation of fluid in the lung interstituim and alveoli because of elevated pulmonary capillary pressure. Most common cause of cardiogenic pulmonary edema is congestive heart failure and acute myocardial dysfunction. Management of cardiogenic pulmonary edema includes:

Ventilatory support
Medical therapy by reducing left atrial pressure, left ventricular afterload and give inotropic or inodilator therapy
Decrease temperature and breathing by reducing metabolic demand

Noncardiogenic Pulmonary Edema (ARDS)

Acute respiratory distress syndrome is inflammation of the lung parenchyma causing difficulty in breathing, hypoxemia and multiple organ failure. ARDS as defined by the American Heart Association is, acute onset, PaO2/FiO2 <300, bilateral infiltrates on chest x-ray, and no evidence for a cardiogenic cause of pulmonary edema. Management of ARDS includes:

Monitor the patient’s pulse oximetry, end tidal CO2, cardiac markers
Get labs like ABG, venous blood gas and CBC
Give continuous ventilation

Disordered Control of Breathing
Anatomy	Problems associated with the respiratory system
Causes	Seizures CNS infections Head injury Brain tumor Hydrocephalus Neuromascular disease
Signs and Symptoms	Irregular respiratory rate Variable respiratory effort Shallow breathing – causes hypoxemia and hypercarbia Central apnea
Management	Management of disordered control of breathing includes: Conduct the ABC assessment

Specific causes of disordered control of breathing include increased intracranial pressure (ICP), poisoning or drug overdose, and neuromuscular diseases.

Increased Intracranial Pressure

Increased intracranial pressure can be caused by:

Meningitis
Encephalitis
Intracranial abscess
Subarachnoid hemorrhage
Subdural or epidural hematoma
Traumatic brain injury
Hydrocephalus
Central nervous system tumor

Proper management of respiratory distress or failure due to increased ICP includes:

Jaw thrust maneuver
Open airway
Give 20 mL/kg IV isotonic crystalloid
Give hypertonic saline, osmotic agent
Avoid hypothermia and hypotension
Treat agitation

Poisoning and Drug Overdose

Poisoning and drug overdose is one of the most common and frequent causes of respiratory distress in infants and children. The following actions must be taken to treat this type of respiratory distress.

Contact the poison control center
Administer the antidote to the poison
Suction airway if patient vomits
Conduct the ancillary test

Neuromuscular Disease

Neuromuscular disease is broad term that is given to various diseases that impair muscle control and causes spasticity or paralysis. Children with neuromuscular diseases which affect respiration have the following symptoms:

Cough
Atelectasis
Restrictive lung disease
Pneumonia
Chronic respiration insufficiency
Respiratory failure

For management of neuromuscular disease in children complete the ABC assessment, which includes supporting the airway, breathing and circulation.