THE ANATOMY OF THE PEDIATRIC AIRWAY

by Esther Weathers RRT, RCP V7110 HC 02 RC Educational Consulting Services, Inc. P.O. Box 1930, Brockton, MA 02303-1930 (800) 441-LUNG / (877) 367-NURS www.rcecs.com

BEHAVIORAL OBJECTIVES UPON COMPLETION OF THE READING MATERIAL, THE PRACTITIONER WILL BE ABLE TO: 1. Identify the ways in which pediatric airway anatomy differs from that of an adult patient. 2. Indicate how pediatric airway anatomy differences may manifest in clinical practice. 3. Apply simple interventions to overcome the clinical problem that may manifest as a result of pediatric airway anatomy. 4. Identify ways in which respiratory distress may differ from an adult patient. 5. Give an example of both upper and lower airway disease in patients with Downs Syndrome. 6. Express a basic knowledge of craniovertebral instability, as it relates to patients with Down s Syndrome. 7. Identify what precaution may be taken to protect the patient while placing a definitive airway in the patient with Down s Syndrome. COPYRIGHT 2010 BY RC EDUCATIONAL CONSULTING SERVICES, INC. AUTHORED (2010) BY ESTHER WEATHERS, RRT, RCP ALL RIGHTS RESERVED This course is for reference and education only. Every effort is made to ensure that the clinical principles, procedures and practices are based on current knowledge and state of the art information from acknowledged authorities, text and journals. This information is not intended as a substitution for diagnosis or treatment given in consultation with a qualified health care professional. 1

TABLE OF CONTENTS INTRODUCTION... 4 ANATOMICAL DIFFERENCES... 4 THORAX... 4 HEAD AND NECK... 4 AIRWAY ANATOMY... 6 PEDIATRIC RESPIRATORY DISTRESS... 8 RESPIRATORY RATE (RR)... 8 NASAL FLARING... 9 TRACHEAL TUG... 9 INDRAWING... 9 GRUNTING...9 ACTIVE EXPIRATORY PHASE... 10 STRIDOR... 10 DECREASED EFFORT... 10 OTHER CLINICAL INDICATORS... 10 LEVEL OF CONSCIOUSNESS... 10 HEART RATE... 11 COLOR AND TEMPERATURE... 11 BLOOD PRESSURE... 11 SPECIAL CONSIDERATIONS IN CHILDREN WITH DOWN S SYNDROME... 11 UPPER AIRWAY DISEASE... 11 LOWER AIRWAY DISEASE... 12 2

CRANIOVERTEBRAL INSTABILITY... 13 ANATOMY... 13 NEUROLOGIC MANIFESTATIONS OF SYMPTOMATIC ATLANTO-AXIAL INSTABILITY (AAI)... 13 CONCLUSION... 15 SUGGESTED READING AND REFERENCES... 16 3

INTRODUCTION T he pediatric patient is not just a little adult, when it comes to airway anatomy. In fact, there are many significant differences often overlooked in general practice, especially for those clinicians who have not specialized in pediatric critical care. In recognizing the anatomical differences, the clinician is easily able to apply simple interventions that may alleviate respiratory distress, or ensure a definitive airway can be secured in a timely manner. Special considerations for patients with Down s Syndrome (DS) are also discussed, as there are many respiratory factors associated with Trisomy 21 (Down s Syndrome). ANATOMICAL DIFFERENCES Thorax T he ribs of the infant and young child are more horizontally oriented, making anteriorposterior displacement of the chest less during inspiration. This is loss of the buckethandle effect. Rib cartilage is more compliant in younger patients than older children and adults. Manifestation: During episodes of respiratory distress the chest wall may actually retract, decreasing the child s ability to maintain functional residual capacity or increase their tidal volume. Intercostal muscles are not fully developed until school age, acting primarily to stabilize the chest wall. They do not have the leverage nor the strength necessary to lift the ribs. As with the adult patient, the child s chief muscle of respiration is the diaphragm. However, the muscles of the diaphragm are inset horizontally to the ribs, as opposed to obliquely. Manifestation: Placing the infant/young child in a supine position may compromise diaphragmatic function, in that contraction may draw the ribs inwards rather than expand the chest out. This creates paradoxical chest movement. Head And Neck Intervention: Elevating the head of the bed improves diaphragmatic function, and may completely alleviate paradoxical work of breathing (WOB). This is an important action to remember even in patients receiving mechanical ventilation, if they have spontaneous efforts. Children tend to have a large occiput that can compromise the airway. Also, while laying supine, which is considered the natural position, the neck is flexed causing an obstructive or partially obstructed airway. 4

Manifestation: Patients in the flexed position will exhibit signs of airway obstruction, such as, snoring or an obstructive respiratory breathing pattern with possible mild stridor. Intervention: Placing a small roll behind the shoulders to maintain airway neutrality and airway patency in the neonatal and young pediatric patient is essential. In a neonatal or young pediatric patient, a small flannel sheet formed into a roll, or two face cloths folded together in quarters and placed directly and evenly (avoid patient rotation, as assessed by chin-sternal notch-navel in alignment when viewed from the head of the patient) behind the shoulders and upper thorax. This should be sufficient to elevate the thorax and move the occiput back. The goal is to have the airway in a neutral position, neither in flexion nor extension. The common sniffing position works well on adolescents, as in adults. A good way to check for this is to align the external auditory canal with the anterior shoulder for best alignment of the airway axes. (Airway axes: oral, pharyngeal and tracheal axes). Note: The old PALS manual (2002, see references end of course) has a wonderful illustration of the oral, pharyngeal and tracheal axes in the adolescent patient. If you are unfamiliar with the terms of airway axes and cannot picture them, try this. Slide the laryngoscope into the patient s mouth. This is the oral axis. Advance the laryngoscope blade to the base of the tongue, searching for the epiglottis. This is the pharyngeal axis. Lift up the epiglottis or insert your blade into the valeculla, viewing the glottic inlet, this is the tracheal axis. If the airway axes are in alignment, you will have a view of the vocal cords and glottic inlet. It will also allow the patient to breathe free of obstruction, and will best facilitate successful bagvalve-mask ventilation. Infants and young children also have a large tongue in comparison to their oropharyngeal space. Manifestation: Predisposition to soft tissue airway obstruction from the tongue is always a possibility. Also, be cognizant of the tongue/oropharyngeal space ratio in clinical scenarios of known airway edema, such as, recent dental work, tongue-lip adhesion surgery, etc. Infants and younger children are predominantly nose breathers. Manifestation: Pediatric patients who present with respiratory distress (RD) that have an upper respiratory tract infection may have an ineffective ventilatory pattern. Often it is just upper airway congestion/ stuffiness. Intervention: Simple nasal suction may alleviate this distress. 5

The small relative internal diameter of both the upper and lower airways predisposes the child to higher airway resistance. In a simplified illustration of Pouseille s law, if the radius decreases by half, the resistance increases by sixteen times. To negate the effects of this change, it is necessary to increase the pressure gradient or decrease the flow in the system. Manifestation: An infant or child with even mild airway obstruction or inflammation will present with moderate to severe respiratory distress. They are increasing the pressure in the system. Intervention: Depending on the clinical scenario and patient s physician, cool aerosols and/or corticosteroids, inhaled epinephrine and inhaled antibiotics may be useful in relieving airway infection, inflammation and edema of the trachea. Infant Trachea 2 mm R 16x Adult Trachea R 2.4x Figure 1. Schematic Illustration of Airway Resistance using Pouseilles Law. R = Resistance. This cross sectional view of the infant and adult tracheas provides an illustration of the increase in airway resistance that occurs when edema is present. Airway Anatomy Perhaps the best known anatomical difference in neonatal and pediatric patients is the cricoid cartilage. The narrowest portion of the pediatric airway is subglottic. The airway itself is funnel shaped, as compared to the cylinder shape seen in the adult patient, with the cricoid ring being the most narrow point, which is the rational use is to avoid pressure at the cricoid ring. Historically, this has been part of the basis for choosing uncuffed endotracheal tubes (ETT) for 6

neonatal and pediatric patients, though recent evidence strongly suggests with proper care in selection and sizing of a cuffed ETT, this is no longer a factor. (See RCECS course: Neonatal and Pediatric Cuffed Endotracheal Tubes: Safety and Use.) Manifestation: Any subglottic partial airway obstruction will be very poorly tolerated when compared to an older patient. Clinical examples are: post extubation subglottic edema, foreign body aspiration, mass lesions inside the trachea. Thyroid Cartilage Thyroid Cartilage Cricoid Ring Cricoid Ring Adult Trachea Infant Trachea Figure 2. Schematic Illustration of the Adult and Infant Tracheas. The adult airway is cylinder shaped. The pediatric airway is on the right, note the funnel shape with the narrowest portion being at the level of the cricoid ring. Uncuffed endotracheal tubes are thought to seal at this point. The infant and pediatric epiglottis is typically floppier and articulates at a more acute angle with the larynx. Manifestation: The epiglottis will be more difficult to displace with a laryngoscope. Intervention: Historically one of the reasons why a Miller or Wisconsin laryngoscope blade is chosen for intubation, as the entire epiglottis is lifted out of the field of view. The larynx is located more anterior and cephalad, with the glottis being located at the level of C3-4, compared with C5 in the adult patient. Manifestation: Often difficult to view the glottic inlet while performing laryngoscopy. 7

Intervention: Ensure proper alignment of the airway axes with patient positioning aids, alternately external laryngeal manipulation may be necessary to improve operator view of the vocal cords. (See RCECS Course Pediatric Airway Assessment for further information). Pediatric and neonatal vocal cords are more inclined, versus flat in the adult patient. Manifestation: Endotracheal tubes may be difficult to pass though the glottic opening, as it may get hung up on the cords. Intervention: A slight twist or rotation of the endotracheal tube by the intubator s assistant may facilitate passage of the endotracheal tube into the trachea. The infant trachea is more mobile and has a posterior descent into the thorax, whereas the adult trachea is more stationary and has a vertical descent. This may in part be due to immature cartilage of the young airway. PEDIATRIC RESPIRATORY DISTRESS A s previously discussed, pediatric and neonatal airways are, in a nutshell, smaller, floppier, more prone to obstruction and have less developed musculature. Due to some of these anatomical differences, they are often unable to manifest signs of increased work of breathing. They have more reasons to exhibit signs of respiratory distress, yet less power to manifest them. It makes it easier when the clinician is familiar with the pediatric anatomy, and manifestations of respiratory distress, so they can properly perform a respiratory assessment, and appropriately apply treatment in a timely fashion. Keep in mind, the younger a patient is, the less likely they will be to exhibit classic signs of respiratory distress. Respiratory Rate (RR) Just like heart rate is the single way in which young children are able to effectively improve their cardiac output, an increased respiratory rate may be the only sign of increased work of breathing. Tachypnea in any patient at a rate greater than 60 breaths per minute (bpm) is an ominous sign, even a neonate, as respiratory muscles fatigue. Bradypnea in any patient is a sign of central nervous system (CNS) impairment and bodes ill, as does any irregularity to the respiratory pattern or depth. However, it is important to note that patients who are tiring may vary their respiratory rate and tidal volume as a result of respiratory muscle fatigue, and not central nervous system depression. As a rule of thumb, a respiratory rate less than 8 bpm can be applied to all patients and constitutes respiratory failure. Certain situations excepted, assisted ventilations should be initiated if this is a clinical finding. Take note of the physiologic normals of respiratory rate for age, and apply them when performing a respiratory assessment at the bedside. Typically, these are: 8

Neonate 20-40 bpm Child 20-30 bpm Adolescent 12-20 bpm A normal respiratory rate is inversely proportional to patient age, namely, the younger a patient, the higher the expected respiratory rate will be. As a clinician you will be less concerned about a neonate breathing at a rate of 60 bpm, than a 10 year old. Nasal Flaring Nasal flaring is common across all age groups. Do not brush off moderate nasal flaring in an infant as nothing when performing a respiratory assessment. Take note and use other clinical indicators (to be discussed) to aid you in completing your assessment. Tracheal Tug While tracheal tug may be a late or unspecific sign of increased work of breathing in an adult patient, it is very common in the pediatric patient, perhaps almost as prevalent as nasal flaring. Often a slight gasp may be noted audibly on inspiration as well, which can seem to be associated with head-bobbing. (It is the author s opinion that head bobbing is not a sign of work of breathing, rather a physiological result of it). Indrawing Indrawing is grouped in one large heading when discussing pediatric respiratory distress. As previously noted, infants and young children have under developed musculature and classic retractions, such as intercostals, may be absent. This is not to say that indrawing will never exist in the young patient, as it often does, rather to reinforce the anatomical differences may make it appear less obvious or severe. In overweight infants and younger children, substernal and intercostal indrawing may be all that is evident. Children who have been hospitalized for longer periods of time, or appear as if they are failure to thrive have a thinner chest wall, and retractions can be more evident. Keep in mind that patient position can affect work of breathing, remember that simply elevating the head of the bed that improve diaphragmatic function and improve signs of respiratory distress. Grunting Similar to pursed lip breathing, grunting is a way in which the neonate and young pediatric attempts to maintain an open airway, essentially splinting the airways in an attempt to prevent airway collapse and improve oxygenation and ventilation. 9

Active Expiratory Phase As you are aware, expiration is a passive event, and should have no work associated with it. If you notice a patient actively trying to exhale, or audibly wheezing, it is generally evidence of air trapping. Due to the increased compliance of the chest wall (and loss of the bucket-handle effect) this can very easily occur, especially in situations of increased minute volume demands, or obstructive lung disease. Stridor As in all patients, stridor denotes an upper airway obstruction. On assessment, the clinician should note the quality of the stridor, is it high pitched and consistent on each breath, biphasic in nature? A very important piece of the assessment is the aucultory findings, ask yourself, does every breath move air? When and if the stridor disappears, does airflow remain? A history needs to be elicited from the caregiver. Does the patient have a fixed airway obstruction or increasing in size? Has it been treated with inhaled epinephrine or steroids to decrease the inflammation? Be very careful of agitating the patient with your assessment, and/or treatments, as their airway is already compromised. Allow them to remain in the position of greatest comfort, or with a parent or caregiver. This advice also stands for all patients with increased respiratory distress and O 2 requirements, as any stressors can tip the scales the wrong way. Decreased Effort As with bradypnea and irregularity to rate and depth, watch your patient very closely for changes to their work of breathing. Do not simply assume that there condition has improved, and that explains their decrease in work of breathing. A decrease in noted work of breathing may simply be fatigue. Use other clinical indicators and the assessments of other healthcare professionals and parents and caregivers to aid your decision making. OTHER CLINICAL INDICATORS Level of Consciousness W hile it may not be routine to do central nervous system scoring on children for respiratory admissions, or the Respiratory Care Practitioner may be unfamiliar with what the grading means, the idea is simple. How alert is the child? When you walk into the room, do they look up and greet you? Are they responsive to parents? Smiling, grouchy, changes from the last time you saw them? Beware of the agitated child, who can not be consoled, and/or with a high pitched cry. Though unspecific, it can be an indicator of poor cerebral oxygenation. One simple system to use is AVPU: A awake; V verbal; P pain; U - unresponsive. Keep in mind changes from baseline are very important to note, and for physicians to be made aware of. 10

Heart Rate A rapid heart rate can indicate the body is trying to provide more oxygen to the tissues. A slow heart rate, just like a slow respiratory rate is ominous sign. Cardiopulmonary arrest (CPA) in children is most commonly a result of respiratory failure, and outcome is dismal if respiratory failure progresses to the point of cardiopulmonary arrest. Color and Temperature The color of a patient is a simple assessment tool that can be readily used by the Respiratory Care Practitioner when approaching the patient while still at rest, prior to being disturbed for a treatment or physical assessment. Obvious peripheral or cicumoral cyanosis? Mottling of extremities? Pale, sweaty, flushed cheeks, changes from baseline, etc. On closer exam the Respiratory Care Practitioner can discern if the patient is diaphoretic, if the skin is hot to touch, if the extremities are cool. The so called blanket of perfusion comes into play here as well. Imagine the child covered in a blanket, now lift that blanket slowly off the child from the center of their body, stopping where the they warm up, or where the skin color changes..this is the blanket of perfusion. Blood Pressure Though not as widely available a tool to the Respiratory Care Practitioner, blood pressure can be useful in aiding assessment. Infants and young children are remarkably able to cope with respiratory failure and shock, with simple measures to increase oxygenation to the tissues such as increased minute ventilation and stroke volume by heart rate increase. A decrease in blood pressure in a pediatric patient is a very ominous sign of shock and must be acted upon quickly to prevent cardiopulmonary arrest. SPECIAL CONSIDERATIONS IN CHILDREN WITH DOWN S SYNDROME T risomy 21 is a fairly common syndrome, occurring in 1/733 live births. 1 While we can easily identify a patient with Down s Syndrome, we may not realize and/or account for all of the contributing factors to the respiratory system. Upper Airway Disease There are many factors which contribute to airway problems, many of which are under diagnosed in the Down s Syndrome patient. One study done in 1991 showed that 45% of patients with Down s Syndrome had Obstructive Sleep Apnea. 2 Most patients have relief of symptoms with a tonsil and adenoidectomy, or rarely a uvulopalatopharyngoplasty (UPP). Predisposing factors include: hypotonia midface hypoplasia (flattened mid face, narrowed nasalpharyngeal area) 11

obesity (not as common in the younger child, increases into adulthood) relative glossoptosis enlarged tonsils and adenoids increased secretions, chronic nasal congestion Lower Airway Disease Intervention: Treat problems as they arise, keeping in mind most of the factors noted above will not be an issue until the patient is being treated for an upper respiratory tract infection (URTI). Also, take note of the respiratory pattern of the child at night. Many of the patients with Down s Syndrome go undiagnosed with Obstructive Sleep Apnea (OSA) due to it being normal for them. If you note an obstructive pattern, drops in SpO 2, excessive snoring, or absence of airflow, ensure a note is made in the patient chart and the physician is made aware. It is possible a screening sleep study is needed. Obstructive Sleep Apnea, if left untreated, potentiates pulmonary hypertension (PH) and worsens heart failure. Congenital lower airway problems are more common in patients with Down s Syndrome, particularly if there are associated cardiac defects. Cardiac defects are present in about 50% of all patients with Down s Syndrome. 1 Some things to look out for in a neonate are compression of the airways due to vascular rings, slings or from the heart itself. Tracheo, laryngo, and bronchomalacia are often present. Pulmonary vascular disease is often present with Down s Syndrome. They have an increased risk for pulmonary hypertension (PH) and related Congenital Heart Disease. This can be explained by pulmonary hypoplasia and the presence of OSA. As the capillary bed parallels alveolar surface area, pulmonary vascular size is decreased linearly with the decreased number of alveoli present. And finally, gastroesophagealreflux (GER). Often this is overlooked, misdiagnosed as asthma. It is interesting to note that animal studies have shown that there is an increase in the work of breathing simply with the presence of acid in the esophagus and esophageal distention, regardless if there aspiration present. Intervention: Recall this information when treating a patient with Down s Syndrome, ensure O 2 levels are adequate, apply CPAP or noninvasive ventilation (NIV) therapies sooner than you would for other patients due to possible malacia, risk of pulmonary hypertension (PH), etc. 12

Craniovertebral Instability 10-30% of Down s Syndrome patients have been reported as having Atlanto-axial instability (AAI), with or without subluxation. Occipital-atlanto instability (OAI) is also an issue for some patients, though poorly understood. 3 These patients often have congenital anomalies of the odontoid or lax transverse ligaments, predisposing them to instability or subluxation at either point. Atlanto-axial instability is more prevalent than Occipital-atlanto instability in Down s Syndrome. Occipital-atlanto instability subluxation can occur with or without Atlanto-axial instability. Almost all patients with Atlanto-axial instability are asymptomatic, and can only be diagnosed with X-rays. Anatomy The occiput, atlas (C1) and axis (C2) are characterized by a high degree of mobility and little bony stability. The axis has a protrusion on it called the ondontoid. Strong ligaments facilitate movement and keep the structures in place. Most of the rotation of the head occurs at this junction. The atlanto-occipital joint allows both flexion and extension. With flexion, there is anterior translation of C1 on C2. Any changes to the odontoid or function of the ligaments can increase the displacement that is normal, and pressure from the vertebrae compresses the spinal cord. Neurologic Manifestations of Symptomatic Atlanto-axial instability (AAI) These are often the result of compression of the cervical nerve roots and/or spinal cord. These findings can be difficult to elicit in the Down s Syndrome patient, primarily motor system abnormalities. Non Specific Indicators - Changes from baseline: In gait hand preference participation in activities loss of continence Root compression at C1 and C2 will produce pain to the upper C spine, neck and occipital area. This pain can extend to the head eyes, ears and throat. The patient may also have: dizziness vertigo 13

tinnitis syncope one sided or bilateral tingling/numbness Torticollis The presence of torticollis in a person with Down s Syndrome indicates Atlanto-axial instability until proven otherwise. In many cases infections of the upper respiratory tract, middle ear or pharynx precede symptoms of Atlanto-axial instability. Trauma rarely causes an initial appearance or progression of symptoms. 1 The inflammatory processes associated with upper respiratory tract infections and rheumatoid arthritis can produce laxity of the transverse ligaments. The lymphatic drainage of this joint is into the retropharyngeal glands, which also drains the nasopharynx and ends up in the deep cervical glands. The disruption of the drainage may also have an effect on the ligaments laxity. Due to the inherent abnormality, even minor trauma or acute nasalpharyngeal infections can cause a subluxation. There is wide spectrum of both congenital and acquired lesions that can produce Atlanto-axial instability, and less frequently, occipital-atlanto instability. Signs of Atlanto-axial instability precede almost all cases of atlanto-axial subluxation in Down s Syndrome. While the risk remains relatively low (not all patients have the anomalies to the ligaments or bony structures) the consequences are high enough to warrant full airway precautions. Remember that flexion also poses a significant risk. Intervention: When you are called upon to bag-valve-mask ventilate or assist in intubating a patient with Down s Syndrome, consider the fact that they may have Atlanto-axial instability or occiptal-atlanto instability, suggest the use of a jaw thrust and C spine control and not a head tilt-chin-lift. If there is bradycardia noted on any airway attempts with extension, immediately discontinue the maneuver, assume a neutral airway position and try again as described above. What is likely occurring is compression of the spinal cord and cervical arteries. 14

CONCLUSION K nowing anatomical differences in the pediatric airway will make you more prepared as a practitioner to provide appropriate care, and anticipate airway emergencies. By being aware of the anatomy, you will not only recognize how it manifests in your clinical practice, but be able to intervene in even simple ways to improve to respiratory function of your youngest patients. A basic knowledge of the traits associated with Downs Syndrome will also expand your services and, though low, given the risks with atlanto-axial or occipital-atlanto instability, improve safety for this patient population. 15

SUGGESTED READING AND REFERENCES 1. www.ndss.org/index 2009 2. Marcus, CL et al. (1991) Obstructive Sleep Apnea in Children with Down Syndrome. Pediatrics. 88 (1): 132-139 3. Brockmeyer, D. (1999) Down syndrome and Craniovertebral instability: Topic review and treatment recommendations. Pediatric Neurosurgery. Aug; 31 (2): 71-7 4. Bertrand, P. (2003) Airway Anomalies in Children with Down Syndrome: Endoscopic Findings. Pediatric Pulmonology. Aug; 36(2):137-41 5. Hazinski, M.F., (Ed.) (2002) Textbook of Advanced Pediatric Life Support. American Heart Association. 6. Kacmarek, RM., et al (Ed.) (1990) The Essentials of Respiratory Care, 3 rd Edition. Mosby- Year Book, Inc. 16

POST TEST DIRECTIONS: Use the FasTrax answer sheet enclosed with your order to respond to all the test questions that follow. Leave the remaining answer circles on the FasTrax answer sheet blank. Be sure to fill in circles completely using blue or black ink. The FasTrax grading system will not read pencil. If you make an error, you may use correction fluid (such as White Out) to correct it. FasTrax answer sheets are preprinted with your name and address and the course title. If you are completing more than one course, be sure to record your answers on the correct corresponding answer sheet. RETURN TO: RCECS, P.O. Box 1930, Brockton, MA 02303-1930 or FAX TO: (508)-894-0172. 1. Name one way in which the anatomy of the thorax of a child differs from an adult. a. rib cartilage more compliant b. ribs horizontally oriented c. intercostals underdeveloped d. diaphragm muscles inset e. all of the above 2. The natural position of the airway of a child when laying flat is neutral. a. True b. False 3. To ensure airway neutrality in any patient regardless of age, what two anatomical landmarks much be aligned? a. sternal notch and navel b. chin and sternal notch c. external auditory canal and anterior shoulder d. external auditory canal and sternal notch 4. Infants and young children are predominately nose breathers. a. True b. False 5. The internal diameter of a young child is smaller than that of an adult, therefore airway resistance is lower. a. True b. False 17

6. The narrowest portion of an infant trachea is above the level of the glottis, at the cricoid cartilage. a. True b. False 7. The infant/pediatric epiglottis is more floppy and difficult to displace with a laryngoscope than an adult epiglottis. c. True a. False 8. It is 0700. You are called by the day shift RN to assess a 3 year old female patient who has been breathing at a respiratory rate of 60 all night and is distressed. When you arrive at the patient s room, what should your first action be? Choose the most correct answer. a. nothing, enter the room b. look at the patient for signs of respiratory distress, then enter c. look at the patient for signs of respiratory distress, check alert, voice, pain, unresponsive (AVPU), call the patient name if necessary, enter the room d. get report from the nurse first 9. The 3 year old female is lying flat in the bed, in obvious distress, with nasal flaring, and intercostal indrawing noted. She barely glanced up as you entered the room. The respiratory rate is 64, with some variation in rhythm, and there are coarse crackles scattered through out on auscultation. Her skin feels hot to the touch. She is wearing an oxygen mask and her saturations are 95%. The most appropriate action at this time is: a. turn up her O 2, get further report from other healthcare personnel and document your assessment in the patient record. b. elevate the head of the bed, get further report, and document your assessment in the patient record. c. take a room air saturation, get further report, and document your assessment in the patient record. d. press the emergency call button and start CPR 10. Obstructive sleep apnea is not present in patients with Downs syndrome. a. True b. False 18

11. Lower airway disease is common in children with Down Syndrome, especially if there is associated cardiac defects. Which of the following is not commonly associated with Down Syndrome? a. asthma b. pulmonary vascular disease c. bronchomalacia d. tracheomalacia 12. 50% of patients with Downs Syndrome have atlanto-axial instability (AAI). a. True b. False 13. Atlanto-axial instability can be asyptomatic. a. True b. False 14. Which of the following is not a sign of symptomatic Atlanto-axial instability (AAI)? a. dizziness b. loss of continence c. drooling d. torticollis 15. What precaution is recommended to be taken when bag-valve-mask ventilating or intubating a patient with Downs Syndrome? a. head tilt/chin lift b. premedication with lidocaine c. jaw thrust and control of cervical spines d. extreme sweep of tongue to the left 19

COURSE EVALUATION RC Educational Consulting Services, Inc. wishes to provide our customers with the highest quality continuing education materials possible. Your honest feedback will help us to continually improve our courses and meet state regulations. Responses to the following evaluation questions should be recorded in the far right hand column of the FasTrax answer sheet, in the section marked Evaluation. Mark A for Yes and B for No. Thank you YES (A) NO (B) 1. Were the objectives of the course met? 2. Was the material presented in a clear and understandable manner? 3. Was the material well-organized? 4. Was the content presented without bias of any commercial product or drug? 5. Was the material relevant to your job? 6. Did you learn something new? 7. Was the material interesting? 8. Were the illustrations, if any, helpful? 9. Would you recommend this course to a friend? 20

21