NOISY BREATHING

NOISY BREATHING

The exact nature and location of the stimulus to noisy breathing will determine the type of noise.

            Snoring and gurgling tend to arise in the nasopharynx

            stridor in the area of the glottis

            wheezing lower respiratory tract

Some Causes of “Noisy Breathing”

(Stridor, Wheezing, Snoring, Gurgling)

Infection

Upper respiratory infection

Peritonsillar abscess

Retropharyngeal abscess

Epiglottitis

Laryngitis

Tracheitis

Bronchitis

Bronchiolitis

Irritants and Allergens

Hyperactive airway

Asthma (reactive airway disease)

Rhinitis

Angioneurotic edema

Compression (from the Outside of the Airway)

Esophageal cysts or foreign body

A variety of tumors

Lymphadenopathy

Congenital Malformationand Abnormality

Vascular rings

Laryngeal webs

Laryngomalacia

Tracheomalacia

Hemangiomas within the upper airway

Stenoses within the upper airway

Cystic fibrosis

Acquired Abnormality (at Every Level of the Airway)

Nasal polyps

Hypertrophied adenoids and/or tonsils

Foreign body

Intraluminal tumors

Bronchiectasis

Neurogenic Disorder

Vocal cord paralysis

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ASSESSMENT OF BREATHING 

Once the airway is established, evaluate air exchange.

Examine for evidence of abnormal chest-wall dynamics, such as tension pneumothorax, or central problems such as apnea.

MANAGEMENT

Positive pressure ventilation (application of 100% oxygen is never contraindicated in resuscitation situations).

Bag-mask ventilation is used at a rate of 20 breaths/min (30 breaths/min in infants). Assess chest expansion and breath sounds. Decompress stomach with orogastric (OG) or nasogastric (NG) tube with prolonged bag mask ventilation (BMV).

 

 

ASSESSMENT OF CIRCULATION

Rate:

Assess for bradycardia, tachycardia, or absent heart rate.

bradycardia is <100 beats/min in a newborn and <60 beats/min in an infant or child; tachycardia of >240 beats/min suggests primary cardiac disease.

Assess pulse (central and peripheral) and capillary refill (assuming extremity is warm): <2 sec is normal, 2 to 5 sec is delayed, and >5 sec is markedly delayed, suggesting shock. Decreased or altered mental status may be a sign of inadequate perfusion.

Blood pressure (BP): Measuring blood pressure is one of the least sensitive measures of adequate circulation in children.

MANAGEMENT

Chest compressions

Fluid resuscitation

If peripheral intravenous (IV) access is not obtained in 90 sec or three attempts, and the patient is <8 years old, then place an intraosseous (IO) needle

If still unsuccessful, consider central venous access.

Initial fluid should be lactated Ringer’s (LR) or normal saline (NS).

Administer a bolus with 20 mL/kg over 5 to 15 minutes. Reassess. If there is no improvement, consider a repeat bolus with 20 mL/kg of the same fluid.

Reassess. If replacement requires more than 40 mL/kg, or if there is acute blood loss, consider 5% albumin, plasma, or packed red blood cells (RBCs) at 10 mL/kg.

If cardiogenic etiology is suspected, fluid resuscitation may worsen clinical status.

Pharmacotherapy: See inside front and back covers for guidelines for drugs to be considered in cardiac arrest.

Note: Consider early administration of antibiotics or corticosteroids if clinically indicated.

MANAGEMENT OF CIRCULATION

 Location *                                           Rate (per min) Compressions:   Ventilation

Infants                                       >100                                                    5:1

1 finger-breadth below intermammary line

Children (<8 yr)                                    100                                                      5:1

2 finger-breadths below intermammary line    

Older children                           100                                                      15:2

(>8 yr Lower half of sternum  

*Depth of compressions should be one third to one half anteroposterior (AP) diameter of the chest and should produce palpable pulses.