Page 710 - ACCCN's Critical Care Nursing

Paediatric Considerations in Critical Care 687

the history of a sudden choking episode can clarify the determined by angiography. Treatment is surgical correc-
diagnosis. 19,80,82 tion of the vascular malformation. 84
MONITORING AND DIAGNOSTICS
CONGENITAL AIRWAY ABNORMALITIES
Congenital structural abnormalities of the airway are Initial monitoring and diagnostic studies for infants and
children with upper airway obstruction are ideally of a
present at birth; depending upon severity of obstruction, non-invasive nature, to avoid distress.
it may take hours to months to become apparent. These
include laryngomalacia, laryngeal web, tracheomalacia
and vascular rings. These infants and children will require
referral to a specialist paediatric centre for ongoing man-
agement and, if they develop respiratory infections, are Practice tip
likely to become compromised much more easily than
children with normal airways. Close direct observation from a short distance away is an ideal
nursing practice, accompanied by non-invasive monitoring.
Laryngomalacia is the most common cause of stridor Ideally, the critical care nurse will be positioned to hear the
in the newborn period. Stridor is produced by flaccid, child’s stridor. Blood sampling, cannulation and other invasive
soft laryngeal cartilage and aryepiglottic folds that procedures should be left until the airway has been secured,
collapse into the glottis on inspiration. An inspiratory the child has been anaesthetised, or airway obstruction is
83
stridor, usually high-pitched, will be present. It may be resolving.
intermittent, may decrease when the patient is placed
prone with the neck extended, may increase with
agitation, and is usually present from birth or the first
weeks of life. The infant’s cry is usually normal. Feeding Pulse oximetry is a non-invasive method of monitoring
problems may be associated with increased respiratory oxygenation. Arterial blood gases are performed only
distress. Laryngoscopy confirms the laryngomalacia when absolutely necessary, as this may increase the child’s
diagnosis. Treatment is supportive, with only a small distress and thus worsen the degree of obstruction. Con-
proportion of infants requiring airway reconstructive tinuous ECG monitoring is also indicated.
surgery unless respiratory distress interferes with feeding
and growth, in which case a tracheostomy may be Lateral airway X-rays are unlikely to be helpful in the
indicated. 84 setting of croup and epiglottitis and, when they are likely
to involve separating the child from a parent, are poten-
A laryngeal web is made of membrane that typically tially harmful and not recommended. When there is a
19
spreads between the vocal cords, with an inspiratory less dramatic presentation of the infant or child, or when
stridor present soon after birth. Diagnosis is confirmed the diagnosis is not clear, as in the case of an inhaled
by laryngoscopy. Treatment involves lysis in the case of foreign body, then a chest X-ray may be diagnostic.
thin membranous webs while a tracheostomy may be
required for a thicker fibrotic web. Laryngeal webs can MANAGING THE PAEDIATRIC AIRWAY
also develop after contracting illnesses such as diphtheria,
and are occasionally reported in otherwise normal adults, A child’s airway may be managed in a number of ways.
typically at intubation for an operative procedure. 85 Simple positioning may be all that is required to manage
an infant’s airway. Children will often assume an upright
Tracheomalacia and tracheobronchomalacia involve sitting position and may become more distressed if placed
malformed cartilage rings, with lack of rigidity and an into the supine position, thus when possible the best
oval shape to the lumen. Secondary tracheomalacia is position for an infant or child with upper airway obstruc-
associated with prolonged intubation and prematurity tion may be sitting on their parent’s lap. Because of the
and presents within the first year of life. Malacias are anatomy and physiology of the respiratory tract, avoid
17
characterised by wheezing and stridor on expiration, with extending the head of infants. Chin-lift and jaw-thrust are
collapse of the tracheal or bronchial lumen. Diagnosis is useful airway adjuncts in children to maintain an airway
confirmed by fluoroscopy and bronchoscopy, which and to facilitate use of a bag–valve–mask. It may be nec-
demonstrate tracheal collapse on expiration. As the infant essary to use an oropharyngeal airway or nasopharyngeal
grows, cartilaginous development improves the airway by airway, laryngeal masks and endotracheal intubation in
about two years of age, but a number of children will an unconscious or sedated infant. 19,80
require airway stenting or reconstructive surgery. 83
Vascular rings result from congenital malformations of Intubation
the intrathoracic great vessels, resulting in compression Intubation may be required to manage airway obstruc-
83
of the airways. Infants present with stridor at birth or tion. Uncuffed endotracheal tubes (ETT) have been
86
within the first few weeks of life. Other symptoms include favoured in paediatric practice over cuffed tubes. Inflating
wheezing, cough, cyanosis, recurrent bronchopulmonary the cuff of a regular ETT can cause damage in prepubes-
infections, and dysphagia. Diagnosis may be confirmed cent children, as the subglottic area is the narrowest
by CT scan, MRI scan or endoscopy, which reveals inden- portion of their airways. The recent availability of a
tations secondary to the extrinsic pressure of the vascu- paediatric-specific ETT with microcuff and markings to
84
lature. The anatomy of the vascular malformations is ensure correct placement below the glottis has facilitated