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.