Oxygentation

Respiratory rate

Normal or Tachypnea / Bradypnea

Respiratory effort

Depth, rhythm, regularity, symmetry

Adventitious Breath Sounds

Crackles, Rhonchi, Wheezing, Stridor

Oxygenation

Pulse oximetry, skin color

Activity Level

Neurological status (evaluate patient’s baseline and make a comparison)

Signs of Distress

Nasal flaring, respiratory grunting, accessory muscle use (retractions), head bobbing, cough

Body positioning (orthopnea, tripoding)
Dysphagia (drooling)

Stridor

Location: Larynx, trachea
• Cause: Narrowing in upper airway due to
inflammation or obstruction

•Laryngotracheobronchitis (Croup)

Rhonchi

Location: Primarily over trachea and Bronchi
• Cause: Mucous in larger airways

Wheezing

Location: Can be heard in all lung fields
• Cause: Narrowing of the bronchus & bronchioles

• Asthma
• Respiratory Syncytial Virus (RSV) Bronchiolitis

Crackles (rales)

Location: Commonly heard in dependent lobes
• Cause: Fluid trapping in alveoli and / or parenchymna (third space)

• RSV Bronchiolitis

Pediatric respiratory system considerations

Children experience respiratory arrest more commonly than cardiac arrest
Respiratory diagnosis are the leading cause of hospitalizations for ages 0-10 years (leading cause of morbidity)
Airway Size:
- Anatomically shorter and more narrow airways are more likely to become narrowed or obstructed by secretions or inflammation
Factors influencing pediatric immune resistance:
- Environmental exposures (attending daycare or school)
- Underdeveloped immune function (Review Immunity Content!)
- Developmental ability to social distance and utilize proper infection control hygiene techniques (cover cough, sneeze, hand wash, etc.)
Pediatric symptoms associated with respiratory infections:
- Nasal Blockage, due to small nasal passages (especially infants)
- Vomiting, typically from swallowing of copious oropharyngeal mucous / secretions (especially in children who can not expectorate or blow their nose)
- Poor feeding, caused by poor oxygenation or fatigue in infants
- Anorexia, caused by diminished sense of taste and smell
- Abdominal pain, caused by persistent cough
- Sore throat, caused by “post nasal drip” (oropharyngeal secretions and resultant irritation & inflammation)

Nasal cannula

0.25-6 lpm
- Humidification must be added 4-6 lpm

Simple mask

6-10 lpm

Non rebreather mask

10-15 lpm

Ambu bag (bag valve mask)

12-15 lpm

Nebulizer with mask

6-8 lpm
- For inhaled, aerosolized medication administration

End-Tidal Carbon Dioxide (ETCO2)Monitoring

- “Capnometry” meausures exhaled CO2, more sensitive
to VENTILATION, not just oxygenation
- Normal range 30-43 mmHG

Pulse Oximetry (SaO2)

- Infant: Great Toe, palm of hand, or sole of foot: Infant
- Toddler- Adolescent: Thumb or Index finger on non
dominant hand (ask if the child sucks thumb)
- Reading can be biased (requires adequate distal
perfusion and normal RBC / Hemoglobin levels)
- Remove nail polish / artificial nail. Cover probe if
exposed to UV light.
- Normal range 92-100%
- Probe needs repositioned on new site every 24 hours

Oxygenation definition

The process of oxygen diffusing passively from the alveolus to the pulmonary capillary, where it binds to hemoglobin in red blood cells or dissolves into the plasma.

Factors that influence oxygenation

Decreased oxygen-carrying capacity
Hypovolemia
Decreased inspired oxygen concentration.
Increased metabolic rate

Ventilation (breathing) definition

The act, or process of inhaling and exhaling to
exchange oxygen in the atmosphere for carbon dioxide in the alveoli.

Factors that influence ventilation

Lung size & compliance
Surface tension at the alveolar surface
Quality of inhaled air
Neurological status
Illness / Disease states

Iron, lead, and hemoglobin

Adequate iron is needed for the production of
Hemoglobin
• Iron deficiency Anemia (IDA) is a variable
increasing the absorption of lead.
•Increased Lead absorption (Lead Poisoning)
leads to poor oxygen carrying capacity, and
subsequent poor oxygenation of all body
tissues.

Lead poisoning

A build up of lead in the body, usually over months or years
• Most common exposures: Inhalation and Ingestion
Children 0-6 years are highly susceptible due to increased growth patterns
- Rapid period of growth result in increased oxygen consumption and demand
- Higher production of red blood cells (Iron needs are greater)
There is no “safe” level of lead in the human body

Lead poisoning assessment

All body tissues can be affected by lead poisoning. Symptoms will be based on individual tissues
affected in the body. Lead poisoning can also be asymptomatic in some patients.
• Renal, Hematologic, & Neurologic System are most commonly affected in pediatric patients
Lead poisoning is most dangerous to BRAIN & CNS tissues
- can result in life long developmental delay
- if left untreated, patients can experience seizures, coma, and death

Acute signs of lead poisoning

N/V, anorexia, constipation, abdominal pain

Chronic signs of lead poisoning

Iron deficiency anemia, glycosuria, & proteinuria

Lead poisoning screening & diagnosis

Universal Screening (all children in U.S.)

Universal Screening (all children in U.S.)

- At age 1 and age 2 years who are on Medicaid or Medicaid eligible
- Any child between 3-6 years who has not been tested
- Capillary Blood (Finger / Heel stick): Performed as the primary diagnostic test, but if results are
greater than or equal to 5 mcg/dl, the child must have a repeat serum blood draw (venipuncture)

0-10 mcg/dl

- Identify patient and family teaching needs related to environmental lead exposure. (All patients)
- Discuss age appropriate diet (All patients)

10-15 mcg/dl

- Same as above, plus prepare to provide information about follow up testing
- Repeat testing is needed in 3 months

15-45 mcg/dl

- same as above, plus obtain information through environmental inspection (country social worker)
- Repeat testing is needed in 1 to 3 months

>45 mcg/dl

- same as above, plus prepare patient for Chelation Therapy
- Patient will need additional venous (serum) blood testing prior to beginning Chelation in 1 to 2 weeks.
- Repeat lead level test, Complete blood count; reticulocyte count; urinalysis; and testing of electrolytes, blood urea nitrogen,
creatinine, and liver function should be performed and any iron deficiency should be identified
- Abdominal xray (if lead particulates are noted, patient may be prepared for rectal enema)
- Identify needs related to monitoring for adequate hydration (maintenance fluid needs, normal urine output for age)

Sources of lead

Take-home exposures (based on occupation of parents/family members)
• Battery reclamation workers
• Ceramics workers
• Construction workers
• Furniture refinishers
• Radiator repair workers
•Folk remedies
•Imported jewelry
•Imported toys
•Paint chips from lead-based paint
•Pottery and ceramics
•Soil contaminated with lead
•Tea kettles
•Vinyl mini blinds
•Water contaminated by lead leaching from pipes, solder, valves, fixtures

Lead poisoning intervention education

Provide suggestions for reducing blood lead levels
- wash toys & pacifiers frequently
- wash & dry face and hands frequently, & before eating
- Diet rich in calcium & iron, eat regularly
- have soil & water tested
- change work clothing outside of home
- take off shoes in house
- Wet mop and wet dust…floors, windowsills, baseboards
once per week

Lead poisoning intervention Chelation therapy

Chelating medications are used to bind with heavy metals in the body and are excreted in the
urine.
• Chelating medications are non-specific, and may bind with other trace minerals, including
calcium (Side effect)
• Removes lead from blood and soft tissues
- does NOT reverse damage already created by high BLL
- multiple treatments may be necessary
•Succimer (Chemet)
•Dimercaprol (British anti-Lewistite “BAL”)
•Calcium Disodium Edetate (calcium disodium EDTA):

Chelation basics

Lead is excreted through the kidneys = MONITOR KIDNEY FUNCTION BEFORE, DURING, AND
AFTER THERAPY!!!!!!
**HYDRATE**HYDRATE**HYDRATE**HYDRATE**HYDRATE**
*Calculate maintenance fluid requirements for patient
- Educate parents (if at home) how to monitor fluid needs

Chelation medications: Asymptomatic or mild symptoms

Succimer (Chemet)
- 19 Day oral treatment
- capsule can be opened and sprinkled on food

Chelation medications: Moderate or severe symptoms

Calcium Disodium Edetate (calcium disodium EDTA):
- IV over several hours (preferred when possible)
- Deep IM (fluid restriction) = mix with procaine
- Use topical analgesics before injection
Dimercaprol (British anti-Lewistite “BAL”):
- contraindicated with peanut allergy of G6PD deficiency
- NEVER USE ALONE = ALWAYS WITH Ca Na2 EDTA!!!
- Only given Deep IM