The Airway Malacias (Nursing)

00:01 Hi, welcome to the pediatric lecture on The Airway Malacias.

00:05 We're going to start by going over the common terms and definitions, review the pathophysiology, go over the common manifestations of these conditions, and then review the treatments for them.

00:16 Let's start with terms and definitions.

00:19 Let's start by reviewing the Respiratory Anatomy.

00:22 The human airway is kind of like an upside down tree.

00:25 It starts at the larynx, which leaves the trachea, which leads the main bronchus and the bronchi on either side.

00:31 That's what's pictured here, because it's all made of the same or similar material.

00:36 It's flexible cartilage that allows the airway to expand and contract.

00:41 The bronchioles are super tiny little bronchi, that are at the ends of the left and right bronchus.

00:48 And they're not pictured here because they're not made out of the same material.

00:52 The malacia's only affect the airways that are made out of this flexible cartilage this pictured here.

00:58 This is the structure of healthy airway tissue.

01:02 The normal airway tissue on the left is fully expanded.

01:05 It has cartilage and mucosal wall, which allows that flexibility.

01:09 It's normal for airway tissue to expand a little bit and contract a little bit with inhalation and exhalation.

01:19 The lumen of the airway is just the opening within the airway.

01:24 In malacia, no matter where they occur, basically, it means that the airway is narrowing more than it should.

01:31 and either inhalation or exhalation depending on where the malacia is.

01:37 In laryngeal malacia, the airway collapses too much during inhalation and causes a noisy sound that can sound like croup, or strider, and trachea or bronchomalacia the airway collapses more during exhalation.

01:52 Laryngomalacia is the most common cause of noisy breathing in infants.

01:56 It's always congenital or present at birth.

01:58 And again, it's the voice box area, so you may notice a hoarse voice or a hoarse cough.

02:06 Tracheomalacia is the most common congenital tracheal defect, but can also be acquired or developed as a result of injury or damage from an infection after birth.

02:17 And bronchomalacia is in malacia of the cartilage below the trachea.

02:21 It's usually congenital, but it could be also acquired.

02:27 Alright, let's go over the pathophysiology of the malacias.

02:31 Laryngomalacia, bronchomalacia are congenital.

02:34 Bronchomalacia can be acquired in some instances, from procedures or from serious infections that affect the airway.

02:41 Tracheomalacia is congenital or acquired.

02:45 Congenital malacias can result from airway wall weakness or low airway pressure during fetal development.

02:51 Malacias are more likely to be seen in premature infants that are born before the respiratory system is fully developed.

02:57 But they can also be seen in full term infants.

03:01 Acquired tracheomalacia is an example of a malacia that can occur as a complication of procedures that involve dilatation or widening of the esophagus and or trachea.

03:13 All right, let's review the manifestations of the malacias.

03:17 One of the first things you'll notice in an infant or child who has an airway malacia, is abnormal airway noise.

03:24 And this noise will get worse when the child is upset or active in some way.

03:29 This is again a similar concept to croup.

03:32 So I often compare it to croup.

03:35 The reason is because when they're active, or straining, or crying, coughing, all these things cause additional pressure in the chest, which can cause louder airway noise, such as Stridor or wheezing, depending on where there malacia is.

03:52 These noisy sounds, again, will worsen when they're upset or coughing or crying.

03:57 So, it's very important if you're taking care of a child with an airway malacia that you assess their breath sounds not only when they're at rest and calm, hopefully breathing fairly quietly, but also when they're exerting themselves in some way.

04:11 So when they're crying when they're feeding, or when they're playing.

04:15 Make sure you know what their baseline is, and how they typically sound when they're active.

04:22 While malacias are often suspected, or considered to be a diagnosis based on clinical signs and symptoms.

04:29 The diagnostic test that's the only definitive way to diagnose a malacia is a flexible bronchoscopy.

04:38 All right, now let's discuss treatment.

04:40 The good news is, malicia usually resolve on their own as the infant grows.

04:44 And their airways get wider and stronger.

04:47 But up until that point, they may require some support.

04:50 One simple thing that can help is humidified air.

04:53 Again, I compare it to croup.

04:55 Humidified air is one of the first treatments that you hear up for croup, and it's because it helps kind of keep those airways open, and helps thin secretions.

05:03 It's naturally good for airways.

05:05 Special positioning may be necessary to help infants with malacia's breathe while feeding especially.

05:11 This can help prevent reflux and aspiration of stomach acid.

05:14 They're more likely to have aspiration just because they have a malacia.

05:18 So their airway is not completely normal.

05:21 CPAP may be used to keep the airways open and prevent collapse in infants with more severe malacias.

05:29 And antibiotics for any bacterial infection that may affect the airways or lungs can also be important.

05:36 Because these kids don't have normal lungs.

05:38 So, additional inflammation, or injury, or infection, is going to probably cause problems more so than for a healthy child.

05:46 And finally, surgical correction as an option if a milacia is severe, or doesn't resolve on its own, especially with age.

05:55 The NCSBN Clinical Judgment Measurement Model is a framework being used for many NCLEX exam items and test questions.

06:02 We're now going to connect some of the content from this lecture to this model.

06:07 We're going to focus mainly on recognizing cues and analyzing cues, the first two steps of it.

06:14 If you're caring for an infant or a child with an airway malacia.

06:17 The key to recognizing cues respiratory distress is knowing what they look like in a child or an infant.

06:23 No matter what the cause of respiratory distress, the signs and symptoms are similar.

06:28 They may include retractions or pulling in of the skin.

06:32 That basically is a sign of increased work of breathing.

06:36 And this might be retractions above the clavicle, above the sternum, between the ribs or under the sternum.

06:44 It might include also nasal flaring or opening of the nares as they try to get more air.

06:49 Some infants and children might become cyanotic or bluish, especially in their mucosa.

06:55 So, be aware that if especially if you have a dark skin infant or child, you may not be able to see cyanosis unless you really check their mucosa well, or their nail beds is another place you can sometimes see it.

07:07 Some children with airway malacia will need oxygen.

07:11 They might get hypoxic.

07:13 And they might have a low pulse ox reading.

07:16 But that's not that normal, especially if they're at rest or calm and otherwise healthy.

07:21 But however, if they are eating, if they are active, or if they have an infection, especially an infection that involves the lungs or airways, they're more likely to get hypoxic and require some oxygen.

07:33 This is why many kids and infants with airway malacias are monitored continuously at the hospital, especially when they're feeding.

07:42 Because that is something known to cause some distress or hypoxia and these children especially if they're really young, and their airways are still very narrow.