Respiratory Distress/Critical
Airway
Deb Updegraff, RN, CCRN
Clinical Nurse Specialist
LPCH Pediatric Intensive Care Unit
Signs of Respiratory Distress
Tachypnea
 Tachycardia
 Grunting
 Stridor
 Head bobbing
 Flaring
 Inability to lie
down
 Agitation

Continued- Signs and Symptoms of
Respiratory Distress
•Retractions
• Use of Accessory
muscles
•Wheezing
•Sweating
•Prolonged expiration
•Pulsus paradoxus
•Apnea
•Cyanosis
Causes of Resp Distress

Infections
Pneumonias
Bronchiolitis
Empyemas
Causes Cont.

Excessive fluid in the lung
Pulmonary edema (CHF)

Excessive fluid or air in the pleural space
Pneumothorax, pleural effusions

Upper airway obstructions
swollen airway, large tonsils, malacias,

Lower airway obstructions
asthma
Interventions
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Comfort measures
Patient position
O2
Diuretics
Broncho-dialators
Nasal trumpet
Positive Pressure
Chest tube
Intubation
The Pediatric Airway
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Introduction
Anatomy / Physiology
Positioning
Adjuncts
Intubation
Anatomy : Tongue
•
•
•
Large
Loss of tone with sleep, sedation, CNS
dysfunction
Frequent cause of upper airway
obstruction
Anatomy : Larynx
• High position
• Infant : C 1
• 6 months: C 3
• Adult: C 5-6
• Anterior position
Children are different
Photos : Calvin Kuan
Anatomy : Epiglottis
Relatively large size in children
 Omega shaped
 Floppy – not much cartilage

Airway Positioning
“Sniffing Position”
In the child older than 2 years
Towel is placed under the head
Photos: Calvin Kuan
Photo: Calvin Kuan
Airway positioning for children
<2yrs
Photo: Calvin Kuan
Photo: Calvin Kuan
Airway adjuncts
Nasal airway
 Oral airway

Adjuncts: Oral Airway
Correct size
Photo: Calvin Kuan
Nasopharyngeal Airway
Length: Nostril to Tragus
Contraindications:
 Basilar skull
fracture
 CSF leak
 Coagulopathy
Photo: Calvin Kuan
Endotracheal tube as nasal
airway
A regular ETT
can be cut and
used as a
nasal airway
Photo: Calvin Kuan
Intubation: Indications
Failure to oxygenate
 Failure to remove CO2
 Increased WOB
 Neuromuscular weakness
 CNS failure
 Cardiovascular failure

Laryngoscope Blades
Macintosh
Miller
Photo: Calvin Kuan
Intubation Technique
Better in
younger children
with a floppy
epiglottis
Straight Laryngoscope Blade – used to
pick up the epiglottis
Photo: Calvin Kuan
Intubation Technique
Better in older
children who
have a stiff
epiglottis
Curved Laryngoscope Blade – placed in the
Slide: Calvin Kuan
vallecula
Anatomy : Larynx
Narrowest point = cricoid cartilage in the
child
Photo: Calvin Kuan
Intubation
Age
kg
ETT
Newborn
3 mos
1 yr
2 yrs
3.5
6.0
10
12
3.5
3.5
4.0
4.5
Length (lip)
9
10
11
12
Children > 2 years:
ETT size:
Age/4 + 4
ETT depth (lip):
Age/2 + 12
Slide: Calvin Kuan
Technique: Intubation
How far
does it go in
?
Photo: Calvin Kuan
An Airway is designated CRITICAL by any of
the following Criteria
•Airway status post reconstruction surgery
•Difficult airway in the OR per anesthesia
•Patients with syndromes recognized with difficult airways
Micrognathia- Pierre Robin, Treacher Collins
Cervical Spine abnormalitieS
•Goldenhars, Klipper-Fiell
•Macroglossia
•Beckwith-Wiedemann, Downs, Achondroplasia
•Soft tissue abnormalities
•Submandiibular masses, epiglottis, hemangiiomas
Treacher Collins
Treacher Collins
Before Mandibular Distraction
After Mandibular Distraction
Hemangioma
Pierre Robin
Goldenhar
Airway Reconstructive Surgery- Very Common
Critical Airway patient in the PICU
Subglottic stenosis is a narrowing of subglottic
airway housed In the cricoid cartilage. This is the
narrowest area in the pediatric airway.
Normal view of trachea
4 month old with acquired Grade III
Subglottic stenosis from intubation
Same view: Magnified
Following Cricoid Split Surgical Procedure
Preoperative Subglottic View of
2 year old with acquired verticle subglottic
stenosis
After anterior and posterior grafting and successful decannulation of
tracheostomy
Patient’s Weight:
ICU Check list for Critical Airway:
Patient’s name:
-Room ready with intubation box.
-Critical Airway sign posted at HOB.
-Continuous infusion meds ordered (i.e.
benzodiazepines
, Opioids, muscle relaxants, and others).
-Antibiotics and anti-reflux meds ordered.
Sign-out has occurred and is documented.
-ET tube is secured.
-Chest x-ray obtained which is used to
determine where the ET tube and CVL are
located.
Patient to have arm restraints ordered and placed.
Code Pack in the room.
Code sheet completed in the room.
My Doctor sheet completed and at the head of the bed.