Clinical Practice Case 3

This child's condition is very worrisome because he has significant tachypnea and respiratory distress and he is not responding well to oxygen administration (his pulse oximetry is still in the mid-80s despite oxygen administration).

He needs rapid interventions to try to improve his oxygenation.

expiratory pressure (PEEP) to help recruit collapsed alveoli. This may be delivered noninvasively (eg, BiPAP) or through an endotracheal tube during mechanical ventilation.

Grunting is always a worrisome sign. In the setting of respiratory distress, it almost always means the child is trying to keep alveoli and small airways open by increasing end-expiratory pressure. When grunting and hypoxemia are seen together, there is a high likelihood that the child has respiratory failure and will need ventilatory support.

This child has respiratory distress that is most likely caused by lung tissue (parenchymal) lung injury. This categorization is based on the presence of grunting and hypoxemia that is poorly responsive to oxygen administration. The lack of oxygen responsiveness suggests that the alveoli are not participating in gas exchange because they are collapsed or full of fluid (such as edema fluid or blood). In this case, aspirated lamp oil can injure lung tissue, disrupt surfactant, and stimulate an acute inflammatory reaction (chemical pneumonitis), leading to hypoxemia, pulmonary edema, and decreased lung compliance. The degree of respiratory distress and lack of response to oxygen indicate that the child has respiratory failure.

It is difficult to estimate the degree of hypercarbia in this situation­some children may maintain adequate ventilation even when they have significant hypoxemia. An arterial blood gas is the only way to quantify the adequacy of ventilation. But your clinical exam is often sufficient to recognize when the child is not moving air adequately.

The lack of response to high-flow oxygen indicates that this child's oxygenation will improve only with the application of positive end-expiratory pressure (PEEP) to help recruit collapsed alveoli. This may be delivered noninvasively (eg, BiPAP) or through an endotracheal tube during mechanical ventilation.

Lung tissue disease is caused by a range of conditions producing alveolar collapse or obstruction. The alveoli are filled with inflammatory exudate in children with infectious pneumonia. They may also be filled with edema fluid and varying degrees of inflammatory cells in children with acute respiratory distress syndrome. Children with left heart failure may have alveoli filled with a transudate (low protein­-containing fluid) produced from high pulmonary capillary pressures. Other less common causes include aspiration, such as in this case, and acute alveolar hemorrhage.

In addition to the monitoring that is in place, you will need to gather the following:

• Oxygen supply, equipment for connections to airway adjunct device
• Exhaled CO₂ detector device
• Suction equipment (large bore suction catheter or tonsil-tipped suction as well as a catheter that can pass through the endotracheal tube)
• Bag-mask connected to a high-flow oxygen source
• Face mask (correct size)
• Endotracheal tubes, proper size (ie, the estimated size and the size 0.5 mm above and below that size)
• Endotracheal tube stylet
• Laryngoscope blade (correct size), curved or straight, with working bulb
• Laryngoscope handle with connector and battery backup light source (another laryngoscope handle and blade)
• Medications
• Commercial endotracheal tube holder type
• Towel or pad to place under the patient's head (to align the airway)
• NG tube (correct size)
• Oropharyngeal airway (correct size)
• A length-based resuscitation tape (Broselow Pediatric Emergency Tape) or other reference is helpful to estimate the correct equipment sizes for the child.

When selecting an endotracheal tube for this child, you should consider that he will need increased end-expiratory pressures (ie, positive end-expiratory pressure [PEEP]) and relatively high peak inspiratory pressures, so a cuffed tube would be appropriate if available. If a cuffed tube is used, remember that you must monitor the cuff pressure and maintain it <20 cm H₂0 to avoid airway injury.

To improve oxygenation prior to intubation, a flow-inflating bag with a tight mask seal may be useful since you can easily provide continuous positive airway pressure (CPAP) with this setup. Alternatively, a PEEP valve may be attached to a self-refilling bag. You should anticipate the need for PEEP following intubation.

You must assume that this child's stomach is full. Therefore he is at risk for regurgitation and aspiration of stomach contents. In addition, he may have some of the lamp oil still in his stomach, and you want to avoid a second lamp oil aspiration episode during intubation.

To minimize the risk to this child, the provider with the greatest experience in intubation should perform or closely supervise the intubation procedure. You should use a rapid sequence intubation (RSI) protocol. Once the sedative paralytic has taken effect (and the child loses cough and gag reflexes), a team member should maintain cricoid pressure during attempted intubation.

Successful resuscitation of this child requires good teamwork. It is important that all members of the team know their roles and that the team leader clearly communicate requests. It is a good idea to assign roles before intubation. Clear communication is important so that the team leader knows what medication has been given and when. It is also essential that you assess the patient's airway anatomy. You should know or have confidence that you can provide effective bag-mask ventilation if needed before giving a neuromuscular blocker as part of a rapid sequence intubation approach.

Following intubation you should obtain a chest x-ray to assess the endotracheal tube depth of insertion and to evaluate the extent of the child's lung disease and the degree of lung inflation.

An arterial blood gas is also indicated to objectively assess the adequacy of ventilation and to compare the child's arterial Paco, with his end-tidal CO₂ reading if capnography is being used. 

In this setting consider causes of sudden deterioration in an intubated child. These can be recalled by the DOPE mnemonic (see Endotracheal Intubation on the student CD). On examination, it is clear that the endotracheal tube was displaced from the trachea.

You remove the tube and team members provide 2-person bag-mask ventilation using a flow-inflating manual resuscitator with a pressure manometer. You then successfully reintubate the trachea and confirm correct placement with clinical examination and detection of exhaled CO₂. The child's oxygenation and ventilation improve immediately following reintubation.