Introduction to Pediatric Respiratory Disorders (Nursing)

00:01 Hi, this is the lecture where we're going to review low flow versus high flow nasal cannula use in pediatric patients.

00:08 We're going to start by going over some terms and conditions.

00:11 And then we're going to compare why low flow and high flow nasal cannula's are used in pediatric patients for different reasons.

00:20 First, let's start with terms and concepts.

00:22 How is work of breathing assess to begin with? First, you look for any obvious signs of increased work of breathing.

00:30 You can sometimes see these from the door as you walk in a patient's room, or it may take getting up close.

00:36 And you should always uncover a child or an infant when you're assessing their work of breathing because you can always tell what kind of effort they're putting in to breathing if they have clothes on.

00:48 Their nose may show nasal flaring, they might have retractions or sucking in of the skin.

00:54 That could be anywhere from the supraclavicular area.

00:59 To the above the sternal area could be sucking in between the ribs that's called intercostal retractions, or substernal, Under the sternum.

01:08 You could see some sucking in there.

01:10 Some small children also do what we call it is belly breathing or abdominal breathing, when they're really trying to get more air and more oxygen.

01:19 Sometimes their heart rate may increase just because they're in some distress and their little hearts are very reactive to any kind of stress on the body.

01:28 And their skin color may change.

01:30 So cyanosis is the most common word used for the skin color change that indicates hypoxia, or low oxygen to the tissues.

01:40 But skin color changes can sometimes be a little more subtle than that.

01:44 It's important to know and to understand, and remember that if you're assessing a child that does not have light colored skin, you may need to really check their mucous membranes well to see those skin color changes because they can be hard to see on the rest of the skin.

01:59 Fraction of inspired oxygen.

02:01 This is just a fancy term that respiratory therapists use mainly.

02:06 And what it means is it's the amount of oxygen that's estimated to be in the air that you're breathing.

02:15 Ambient air is another term you'll see use mainly by respiratory therapists and some notes in the chart.

02:21 And basically it just means the air around you.

02:24 So this is the air in your environment.

02:26 Despite when some people might think the FIO2, or the fraction of inspired oxygen, and ambient air around us is typically about 21%.

02:36 It varies a little bit based on where you live and on the altitude.

02:42 All right, let's review the lungs a little bit.

02:44 And let's review the parts of the lungs that do the actual gas exchange.

02:50 Alveoli are like little balloon like sacs at the very ends of your lungs.

02:55 They're kind of like balloons and that they require air in them to expand.

02:59 So they actually require air to be pushed into 'em.

03:02 And what that means is that if air is not getting to them, because of an obstruction somewhere in the lungs, or in the bronchioles that lead to the alveoli, they may not be able to expand enough or frequently enough and so they may end up collapsing.

03:18 This is an important concept to understand.

03:20 So, collapsing alveoli do not function as well, and they may stop working altogether.

03:26 Alveoli are the actual parts of the lung that do the gas exchange.

03:30 And they do this by exchanging carbon dioxide and oxygen with the blood or the circulation that surround them.

03:39 Okay, one more term.

03:41 PEEP. Positive End Expiratory Pressure.

03:44 This is another Respiratory Therapy term, but it's one that would be very helpful to you, especially if you want to work in an intensive care setting.

03:51 What this is, is the amount of air or pressure that's left in the alveoli at the end of an exhalation and it keeps them from collapsing.

04:01 Similar to, think of alveoli being a little balloon or a bunch of little balloons.

04:06 If you want to let most of the air out of them, but didn't want them to collapse all together.

04:11 It would require leaving some air in and that's what the alveoli require as well.

04:19 All right, we're gonna review oxygenation, ventilation, and perfusion first before we start talking about the different reasons why we use nasal cannulas.

04:27 Ventilation is the process of inhaling and exhaling.

04:30 That should result in gas exchange as long as the air that you're breathing can make it to your alveoli.

04:37 Oxygenation is just the delivery of oxygen to the body.

04:42 Perfusion is the blood flow or the delivery of blood flow to the body.

04:46 Whether a patient requires a low flow nasal cannula, or a high flow nasal cannula is largely dependent on whether they have a ventilation problem or an oxygenation problem.

04:59 Or whether they have both.

05:02 all right let's review low flow nasal cannula use in children.

05:06 The low flow nasal cannula is the most commonly used oxygen delivery device in all patients, including children.

05:16 It's often the first thing that is tried if a patient has hypoxic or requires oxygen.

05:22 It delivers up to about four liters of oxygen a minute.

05:25 But children often do not require that much.

05:28 In fact, an infant this size might require just a fraction of oxygen.

05:32 And then if that didn't work well enough, it might be increased or titrated.

05:38 The low flow nasal cannula allows for breathing around it.

05:42 So basically, the person still gets air from both their nose and their mouth when they're wearing the cannula.

05:49 It can deliver about between 22% and 40% FIO2.

05:55 Remember that FIO2 is fraction of inspired oxygen.

05:59 So basically, the patient wearing this type of cannula can receive about 22% to 40% of oxygen through the air they're getting through it.

06:11 The rest of it is other air.

06:15 So one disadvantage to these types of cannulas is that they can be very drying to mucous membranes, especially the higher the flow rate, the more drying it is because it's just more air going in.

06:26 And that is especially bad when it's delivered at a higher rate than about two liters a minute that can be very, very drying and very annoying, really.

06:35 It's important to understand too, is that the air delivered by low flow nasal cannula, when you're delivering it, the flow rate is directly related to the percentage of FIO2.

06:47 So, even though you're getting additional air besides oxygen, if you want to increase the FIO2 you just increase the flow rate They're directly related to one another.

06:59 But if the child especially the young child or infant is mouth breathing, their FIO2 will be decreased because there'll be getting more air through their mouth that just dilutes the air they're getting through the nasal cannula.

07:12 And that can make it really difficult to manage the amount of oxygen a young child is getting, especially if they don't understand the need for it or don't really care to cooperate with it.

07:21 All right, let's review some reasons why high flow nasal cannula may be used in an infant or child.

07:27 High Flow nasal cannulas are less invasive than mechanical ventilation.

07:32 But they come with a lot of the same advantages, including the ability to deliver PEEP, so that the alveoli don't collapse and they keep working.

07:41 So basically, the high flow nasal cannula is really useful when there's a ventilatory problem.

07:47 When the air that we breathe in, is having trouble getting to the alveoli.

07:52 It decreases the work of breathing and improves gas exchange.

07:55 It's safe and relatively simple and effective.

07:58 However, they're usually managed by respiratory therapists.

08:01 In fact, some respiratory therapists will get pretty upset if you touch it.

08:05 It is actually, it looks simple on the outside, but it's pretty complex circuit of air and oxygen and a warmer and various tubing to make sure that delivers the right concentration of oxygen versus air at the right pressure to the infant or child.

08:22 The high flow nasal cannula can be used when a patient requires a higher FIO2 than the low flow cannula can deliver or when the patient requires PEEP to keep their alveoli open and to prevent their lungs from collapsing.

08:36 It has an adjustable flow rate based on the patient's respiratory effort.

08:41 It's also humidified and heated, which makes it more comfortable for the patient.

08:46 It helps the patient thin their secretions and it also helps in patient compliance with the device because they're just more comfortable, and a happier more comfortable patient is more likely to use the device properly.

09:00 Bronchiolitis is a common example of something that affects young infants and causes a lot of respiratory distress and some of them.

09:07 Especially if they're premature or have young, narrow, immature airways.

09:13 The bronchial and the alveoli on the left here show you what healthy bronchioles and alveoli should look like.

09:21 They're open, they're expanded, they can receive gas and do gas exchange.

09:26 And so basically they're able to ventilate the patient, which leads to perfusion of oxygen to the body.

09:32 The ones on the right are inflamed.

09:35 You can see the inflamed tissue in the bronchial.

09:38 And then the alveoli at the top there of the right hand one are over expanded, sometimes they can over inflate and have air trapped in them because they're not able to really push all the air out like they should.

09:50 Or they can collapse just from not having air in them from not having air delivered to them.

09:56 Either way, that means they're not going to work correctly to help do gas exchange.

10:00 And then eventually lead to perfusion of oxygen to the blood.

10:05 This is a basic setup for high flow nasal cannula.

10:08 This would be set up and managed by respiratory therapist.

10:11 But nurses assess patients who are receiving this treatment, which is usually done in ICU setting because of the need for close monitoring.

10:18 There's a flow meter on the wall that addresses the oxygen part of it.

10:23 And then there's an air oxygen blender that blends the oxygen with the air from the ambient environment at a certain percentage of FIO2 that the patient requires.

10:34 There's an active humidifier and heated inspiratory circuit that makes the air more comfortable before delivering it to the patient.

10:41 And then there's of course, the nasal cannula which looks a little bit different from a low flow nasal cannula, but it's similar.

10:48 The NCSBN Clinical Judgment Measurement Model is a framework being used to design test questions and case studies for NCLEX.

10:56 It's also being used in a lot of nursing schools for exams.

10:59 So, I'm going to help you connect some of the lecture material to the first two steps of this model.

11:05 Recognizing Cues and Analyzing Cues.

11:08 To recognize the analyze cues in a pediatric patient and respiratory distress, you have to first understand the signs and symptoms of respiratory distress in infants and children.

11:19 There might be increased work of breathing that's visible from across the room, or you may not notice it unless you uncover the child and assess them really up close.

11:27 So it's super important to always uncover a child that you are assessing.

11:31 Not just to look and see what you see, but to listen against their skin and really hear the breath sounds well.

11:38 You may see retractions or sucking in of skin above the clavicles, above the sternum, between the ribs, or under the sternum.

11:46 Those are all referred to as different types of retractions.

11:49 Also, you may see nasal flaring, or basically the nose, the nares of the nose, opening and closing as they try to struggle to get more air.

11:57 You might see color changes.

11:59 They may get cyanotic or pale.

12:02 You may not notice color changes unless you look at their mucous membranes because that's where sometimes it shows the most especially in darker skinned people.

12:11 You may also notice that their respiratory rate increases as they work harder to get air.

12:17 Their heart rate might increase.

12:18 And they might become hypoxic.

12:20 Hypoxic meaning they might have a low pulse ox reading.

12:24 Always reassess any abnormal vital signs you get including low pulse ox reading.

12:29 Make sure the assessment matches the finding, validate it by getting it somewhere else on the body if possible.

12:37 Then once you identify a pediatric patient that's in respiratory distress, typically, you call a provider if typical repositioning and simple measures don't work to help alleviate their distress.

12:51 And between the provider and you as a nurse, and perhaps respiratory therapists, there's usually a collaborative discussion about how to manage this? Often oxygen is applied at a low rate at first, using the least invasive device possible.

13:07 And that's usually the low flow nasal cannula.

13:09 For an infant they might only require a fraction of a liter of oxygen at first.

13:14 Typically, if that doesn't help, it'll be increased or titrate it up a little bit.

13:19 The child will be reassessed.

13:21 And occasionally, if they still are in distress, other options might be considered.

13:27 As we talked about earlier, some children especially young infants, with immature or very narrow airways might require a high flow nasal cannula if they have a ventilation problem due to conditions such as bronchiolitis.