GAWAT NAFAS PADA

BAYI DAN ANAK

dr. Liza Chairani,SpA,MKes
ANAK MERUPAKAN KELOMPOK YANG
UNIK PADA PELAYANAN GAWAT DARURAT

MEMERLUKAN PENDEKATAN DAN PENILAIAN

KHUSUS
PERMASALAHAN KHUSUS
PERALATAN KHUSUS
PERBEDAAN UKURAN
PERBEDAAN KARAKTERISTIK ANATOMIS DAN
FISIOLOGIS
 Kemampuan Anak melakukan
kompensasi terhadap injuri sangat
efektif, tetapi tidak cukup adekuat
dan berlangsung tidak lama
Kegawatan pada anak sering tidak
terdiagnosa
Pada fase dekompensasi anak sudah
jatuh dalam fase kritis
 Distress pernafasan
Kunjungan terbanyak di Unit Gawat
Darurat Anak. Hampir 10 20 %
Harus segera dikenali dan ditata-
laksana lebih agresif, karena cepat
sekali pasien jatuh dalam keadaan
dekompensasi

PENANGANAN HARUS
SEDINI MUNGKIN !!!
 Respiratory Distress

Respiratory Failure/Shock

Cardiopulmonary Failure

Cardiopulmonary Arrest
 Respiratory Emergencies
Respiratory arrest merupakan penyebab
cardiac arrest pada bayi dan anak.
Prognosis buruk

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 The Need for Oxygen

0 1 minute: cardiac irritability

0 4 minutes: brain damage not likely
4 6 minutes: brain damage possible
6 10 minutes: brain damage very likely
> 10 minutes: irreversible brain damage
 Factors that contribute to rapid
respiratory compromise in children

increased metabolic demands, increased

O2 consumption
decreased respiratory reserves,
inadequate compensatory mechanisms as
compared to adults.

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 Factors that contribute to rapid
respiratory compromise in children

Large head, small mandible,

small neck
smaller airways,
large tongue that fills a small
oropharynx

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 Factors that contribute to rapid
respiratory compromise in children
Neonates and infants are obligate nasal
breathers until the age of 2-6 months because
of the proximity of the epiglottis to the
nasopharynx.
Nose is responsible for 50% of total airway
resistance

Nasal congestion can lead to clinically

significant distress in this age group.10
 Factors that contribute to rapid
respiratory compromise in children
Infants and young children have a
cephalic larynx.
The larynx is opposite vertebrae C3-4 in
children versus C6-7 in adults.
The airways have less cartilage and
collapse easily

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 Factors that contribute to rapid
respiratory compromise in children
The epiglottis is larger and more
horizontal to the pharyngeal wall in
children than in adults.

The cephalic larynx and large epiglottis

can make laryngoscopy challenging.

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 Factors that contribute to rapid
respiratory compromise in children

The subglottic area is cone shaped and

narrow
The narrowest area at the cricoid ring.

A small amount of subglottic edema can

lead to clinically significant narrowing,
increased airway resistance, and
increased work of breathing. 13
 Factors that contribute to rapid
respiratory compromise in children
Adenoidal and tonsillar lymphoid tissue is prominent
and can contribute to airway obstruction.
Uncorrected congenital anatomic abnormalities (eg,
cleft palate, Pierre Robin sequence) or acquired
abnormalities (eg, subglottic stenosis,
laryngomalacia/tracheomalacia) may cause
inspiratory obstruction

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 Factors that contribute to rapid
respiratory compromise in children

Infants and young children have fewer alveoli

than do adults.
The alveolus is small.

Therefore, infants and young children

have a relatively small area for gas
exchange
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 Intrathoracic airway differences

Collateral ventilation is not fully developed;

therefore, atelectasis is more common in
children than in adults.

Smaller intrathoracic airways are more easily

obstructed than larger ones
Infants and young children have relatively
little cartilaginous support of the airways
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 Respiratory pump differences

The respiratory center is immature in infants

and young children
leads to irregular respirations and an
increased risk of apnea.
The ribs are horizontally oriented. During
inspiration, a decreased volume is displaced,
the capacity to increase tidal volume is
limited compared with that in older
individuals.
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 Respiratory pump differences

The small surface area for the interaction

between the diaphragm and thorax limits
displacing volume in the vertical direction.
The musculature is not fully developed. The
slow-twitch fatigue-resistant muscle fibers in
the infant are underdeveloped.

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 Respiratory pump differences

The soft compliant chest wall provides little

opposition to the deflating tendency of the
lungs.

This leads to a lower functional residual

capacity in pediatric patients than in
adults, a volume that approaches the
pediatric alveolus critical closing volume.

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 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 F I O2

Ventilation
without
perfusion Hypoventilation
(deadspace
ventilation)

Diffusion
abnormality
Normal

Perfusion
without
ventilation
(shunting)
 Causes of acute respiratory
compromise in children
Respiratory tract
Cardiovascular
Nervous system
Gastointestinal
Metabolic and endocrine diseases
Hematology
Poisoning
INFECTION, etc 25
 Causes of acute respiratory
compromise in children
Respiratory tract

26
 Causes of acute respiratory
compromise in children

Respiratory tract

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 Causes of acute respiratory
compromise in children
Cardiovascular

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 Causes of acute respiratory
compromise in children
Nervous system

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 Causes of acute respiratory
compromise in children
Gastrointestinal system

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 Causes of acute respiratory
compromise in children
Metabolic and endocrine diseases

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Causes of upper and lower airway
problems in children

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 Severity Level of
Respiratory problem

Respiratory distress,
Respiratory failure, and
Respiratory arrest.

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 Respiratory distress is a state where a child is
able to maintain adequate oxygenation of the
blood, but only by increasing his or her work
of breathing.

Respiratory failure occurs when a child cannot

compensate for inadequate oxygenation and
the circulatory and respiratory systems begin
to collapse.
 Respiratory arrest
are unresponsive and limp, with cyanosis
around the lips.
Respiratory rate and work of breathing may
be very slow or absent, or you may note
agonal respiration
infrequent, gasping breaths with no chest
rise
a pattern that is seen in dying
 Respiratory arrest is the most common
cause of cardiac arrest in children
outcomes are poor for patients who
develop cardiopulmonary arrest as the
result of respiratory deterioration

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 Clinical evaluation of Respiratory
Emergency

How do you initially assess a patient in

respiratory distress?

should be rapid and quickly determine

if patient needs emergent interventions and rule
out life threatening conditions

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 S E G I T I G A P E N I L A I A N P E D I AT R I K
( PEDIATRIC ASSESSMENT TRIANGLE = PAT)

T = Tonus Suara nafas abnormal

I = Interactiveness Posisi abnormal
C = Consolability Retraksi
L = Look/Gaze Napas cuping hidung
S = Speech/Cry

SIRKULASI KULIT
Pucat Mottled Sianosis

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 After completing the Triangle, begin a
more complete

pediatric primary survey.

DISABILITY

CIRCULATION

BREATHING

AIRWAY
Tachypnea: World Health Organization

Reproduced with permission from: World Health Organization. The management of acute respiratory infections in children. In: Practical guidelines for
outpatient care. World Health Organization, Geneva, 1995. Copyright 1995 World Health Organization.
GENERAL ASSESSMENT OF PEDIATRIC
RESPIRATORY EMERGENCIES

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42
AIRWAY ASSESSMENT AND MANAGEMENT

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 Airway Obstruction
Croup
A viral infection of the airway below the level of
the vocal cords
Epiglottitis
Infection of the soft tissue in the area above the
vocal cords
Foreign body airway obstructions
 Croup
is a common viral infection that usually affects
children 2 to 4 years old.
affects the larynx and trachea, although this illness
may also extend to the bronchi.
85% of children to have mild croup,
less than 1% with severe croup.

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 Croup
Typical signs include a low-grade fever of 38C to
39C,
a seal-bark cough, and stridor, particularly if the child
is agitated.
onset is gradual.
Breathing problems worsen at night, and may appear
severe and extremely upsetting to caregivers.

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 Severity level of croup
Mild severity - Occasional barking cough, no audible stridor at rest,
and either no or mild suprasternal and/or intercostal retractions
Moderate severity - Frequent barking cough, easily audible stridor at
rest, and suprasternal and sternal wall retractions at rest, with no or
minimal agitation
Severe severity - Frequent barking cough, prominent inspiratory
(and occasionally expiratory) stridor, marked sternal wall retractions,
significant agitation and distress
Impending respiratory failure - Barking cough (often not prominent),
audible stridor at rest, sternal wall retractions may not be marked,
lethargy or decreased consciousness, and often dusky appearance
without supplemental oxygen support

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 Severe Croup Management
ABC
Nebulized Racemic Epinephrine (2.25%)
observe for at least 3 hours post last treatment because of concerns for a
rebound phenomenon of bronchospasm ,
Dose: 0.05 ml/kg (maximum 0.5 ml in children)
Child under 6 months: 0.25 ml
Child: 0.5 ml
Adolescent: 0.75 ml

L Epinephrine 1:1000
Dose: 0.5 ml/kg (maximum 5 ml)
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 Severe Croup Management

CORTICOSTEROIDS
decreasing edema in the laryngeal
mucosa,
usually effective within six hours of
treatment.
decreases the need for additional medical
care, hospital stays, and intubation rates
and duration.
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 Epiglottitis
A bacterial infection that usually affects
children 4 to 6 years old
usually presents with a higher fever ranging
from 39C to 40C.
Difficulty swallowing may cause the child to
drool.
Stridor will be present even if the child is
resting.

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 Epiglottitis
Rapid onset, severe distress in hours
Intense sore throat, difficulty swallowing
Sits up, leans forward, extends neck slightly
often assume a tripod position to maximize
breathing comfort.
One-third present unconscious, in shock
 Epiglottitis
AVOID LARYNGOSPASM
PATENT AIRWAY
DO NOT VISUALIZE
POSITION OF COMFORT (TRIPOD)
HUMIDIFIED O2: Blow By
Have Needle Cric & Intubation equipment
ready
Minimize movement and stimulation
 Bacterial tracheitis

This bacterial infection causes the trachea to

swell,
resulting in partial airway obstruction. High
fever,
low-pitched stridor (a snoring sound)
a productive cough are usually present

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Foreign Body Airway Obstruction

FBAO
 FBAO: High Risk Groups

> 90% of deaths: children < 5 years old

65% of deaths: infants
 FBAO: Signs/Symptoms
Suspect in any previously well, afebrile child
with sudden onset of:
Respiratory distress
Choking
Coughing
Stridor
Wheezing
Decreased or absent breath sounds
Retractions
Difficulty speaking
 Signs of Complete
Airway Obstruction
Ineffective cough (no sound)
Inability to cry
Increasing respiratory difficulty, with stridor
Cyanosis
Loss of consciousness

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 FBAO: Management
Minimize intervention if child conscious,
maintaining own airway
100% oxygen as tolerated
No blind sweeps of oral cavity
Wheezing
Object in small airway
Avoid trying to dislodge in field
 FBAO: Management
Inadequate ventilation
Infant: 5 back blows/5 chest thrusts
Child: Abdominal thrusts
 SECONDARY ASSESSMENT
Focused history

SAMPLE
Signs/symptoms
Allergies, especially to medications
Medications the child is currently taking
Past medical problems
Last food or liquid the child has taken and time
consumed
Events leading to the illness or injury
 EACH MINUTE
IS CRITICAL TO ACHIEVING
BOTH SURVIVAL AND
A FAVORABLE
NEUROLOGIC OUTCOME.

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 Pediatric-CPR

Manifestasi klinis
Oksigen/Glukosa

Peningkatan
penggunaan Kulit SSP Kardiovaskuler Organ Abdomen Ginjal
Substrat

Dingin Irritable Takikardi Dysmotility Urine

Pucat output

Mottled Gelisah Resistensi Ileus Oliguria

kapiler

Pulses Respon Gagal jantung Third spacing Anuria

(voice, pain) fluids

CRT Kejang Bradikardi Bowel

slough

Koma Asystole

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 Identify respiratory effort:

Increased:
tachypnea and dyspnea
Suggest a heterogeneous group of mechanical
problems within the lung or chest wall

Decreased:
bradypnea, apnea, Cheyne Stokes
suggest fatigue, neuromuscular disease,
medications, etc.
SELAMAT BELAJAR