Prone Positioning on PARDS, Prone, Positioning, pediatric, ARDS, medical rehabilitation

1. Prone Positioning pada Pediatric
Acute Respiratory Distress
Syndrome

2. Outline
I. Pendahuluan
II. Sistem Pernapasan pada Anak
III. Pediatric Acute Respiratory Distress Syndrome (PARDS)
IV. Prone Positioning pada PARDS
V. Kesimpulan

3. Outline
I. Pendahuluan
II. Sistem Pernapasan pada Anak
• Anatomi Perkembangan Sistem Pernapasan pada Anak
• Mekanika Perkembangan Sistem Pernapasan pada Anak
• Anatomi dan Fisiologi Perkembangan Sirkulasi Paru pada Anak
III. Pediatric Acute Respiratory Distress Syndrome (PARDS)
IV. Prone Positioning pada PARDS
V. Kesimpulan

4. Outline
I. Pendahuluan
II. Sistem Pernapasan pada Anak
III. Pediatric Acute Respiratory Distress Syndrome (PARDS)
• Definisi
• Epidemiologi
• Etiologi
• Patofisiologi
• Diagnosis
• Tatalaksana
• Pemberian ventilasi mekanik pada PARDS
• Prone positioning pada PARDS
IV. Prone Positioning pada PARDS
• Pengaruh positioning terhadap sistem pernapasan pada anak
• Prone positioning pada ARDS
V. Kesimpulan

5. Outline
I. Pendahuluan
II. Sistem Pernapasan pada Anak
III. Pediatric Acute Respiratory Distress Syndrome (PARDS)
IV. Prone Positioning pada PARDS
• Pengaruh positioning terhadap sistem pernapasan pada anak
• positioning
V. Kesimpulan

6. Anatomy of a Child’s Lung
• The anatomy of a child's lung is very similar to that of an adult. The lungs are a pair of air-
filled organs consisting of spongy tissue called lung parenchyma. Three lobes or sections
make up the right lung, and two lobes make up the left lung. The lungs are located on
either side of the thorax or chest and function to allow the body to receive oxygen and
get rid of carbon dioxide, a waste gas from metabolism. To understand the anatomy of
the pediatric lung and lung disease in children, it is important to take a look at the
entire respiratory system.
• The anatomy of the pediatric respiratory system can be divided into 2 major parts:
• Pediatric Airway Anatomy: Outside of the thorax (chest cavity) includes the supraglottic
(epiglottis), glottic (airway opening to the trachea), and infraglottic (trachea) regions. The
intrathoracic airway includes the trachea, two mainstem bronchi, bronchi
and bronchioles that conduct air to the alveoli.
• Pediatric Lung Anatomy: Lung anatomy includes the lung parenchyma are subdivided
into lobes and segments that are mainly involved in the gas exchange at the alveolar
level.

8. The Child Respiratory System
• Mouth and Nose
• Pharynx – cavity located behind the mouth
• Larynx – part of the windpipe that contains the vocal cords
• Trachea – also referred to as the windpipe, conducts into and out of the
lungs
• Lungs – a pair of spongy air filled organs.
• Bronchial tubes – passages that carry the air and divide and branch as the
travel through the lungs
• Bronchioles – tiny passages surrounded by bands of muscle that transport
air throughout the lungs. Bronchioles continue to divide into smaller and
smaller units until they reach microscopic air sacs called alveoli
• Lung Alveoli – clusters of balloon-like air sacs

9. • Lung Interstitium – Thin layer of cells between alveoli that contain blood vessels
and help support the alveoli
• Pulmonary Blood Vessels – tubes that carry blood to the lungs and throughout
the body
• Lung Pleura – thin tissue that covers the lungs
• Lung Pleural Space – area lined with a tissue called pleura and located between
the lungs and the chest wall
• Diaphragm – a muscle in the abdomen that assist with breathing
• Lung Mucus – sticky substance that lines the airways and traps dust and other
particles inhaled
• Lung Cilia – microscopic hair-like structures that extend from the surface of the
cells lining the airway. Covered in mucus, cilia trap particles and germs that are
breathed in.

10. Anatomy of a Child's Lung and the Breathing
(Inspiration and Expiration)
• Breathing is the process that moves air in (inspiration) and moves air out
(expiration) of the lungs through inhalation and exhalation. As the lungs
expand and contract, oxygen rich air is inhaled and carbon dioxide is
removed. Breathing begins at the mouth and nose where air is inhaled.
The air travels to the back of the throat, into the trachea and then divides
into the passages known as the bronchial tubes. The bronchial tubes
continue to divide as the go deeper into the lungs and the air is carried to
the alveoli. Oxygen passes through the walls of the alveoli and into the
blood vessels that surround these tiny sacs. Once oxygen enters the blood
vessels, it is carried out of the lungs and to the heart where it can be
pumped throughout the body to other organs and tissue. When the cells
use oxygen, they produce a waste product called carbon dioxide. The
carbon dioxide is carried by the blood vessels back to the lungs.
Through exhaling, the carbon dioxide is carried back out of the lungs
where it can exit through the mouth or nose.

12. Differences in Pediatric Pulmonary Anatomy
• While the basic anatomy of the pediatric lung and the adult lung are
the same, there are some important differences that should not be
overlooked. These differences can increase the occurrence and
severity of lung disease and respiratory issues in young children and
impact treatments and techniques that are most effective.

13. Differences in Pediatric Pulmonary Anatomy
• The ribs in infants and young children are oriented more horizontally than
in adults and older children lessening the movement of the chest.
• Rib cartilage is more springy in children making the chest wall less rigid.
This can allow the chest wall to retract during episodes of respiratory
distress and decrease tidal volume.
• The intercostal muscles that run between the ribs are not fully developed
until a child reaches school age. This can make it difficult to lift the rib cage
especially when lying flat on the back.
• The back of a child’s head is typically larger than in adults. This can cause
the neck to flex when a child is lying on his or her back and result in a
partially obstructed airway.

14. Differences in Pediatric Pulmonary Anatomy
• Infants and children tend to have a proportionally larger tongue in
relation to the space in the mouth.
• Younger children are typically nose breathers.
• The internal diameter of the airways in a child is smaller. Any
inflammation or obstruction may cause more severe distress.
• In general, pediatric airways are smaller, less rigid, and more prone to
obstruction.
• Children also have higher respiratory rates than adults making them
more susceptible to agents in the air.

15. • The anatomy of a child's lungs and other components of the
pulmonary (respiratory) system make treating pediatric lung disease a
very specialized practice. Children are unique and affective
treatments and approaches need to be as well.

16. https://www.google.co.id/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjft9PMnqPUAhWIK48KHYHhCl8QjhwIBQ&url=http%3A%2F%2Fbodell.mtchs.org%2FOnlineBio%2FBIOC
D%2Ftext%2Fchapter30%2Fconcept30.5.html&psig=AFQjCNFQn3MVtiAV7CpyPuIe80Bh81A5WA&ust=1496631674741154

17. Introduction
• Almost all of pediatric codes are due to respiratory origin
• 80% of pediatric cardiopulmonary arrest are primarily due
to respiratory distress
• Majority of cardiopulmonary arrest occur at <1 year old
• 1990 Closed Claim Project by ASA
• Respiratory events are the largest class of injury (34%)
• More common in children than adults
• 92% of claims occurred between 1975-1985 before continuous
pulsoximetry and capnography (Brain damage and death in 85% of
cases)
• With continuous O2 sat and ETCO2 monitoring after 1990s,
decrease in brain damage and death (56% 1970s to 31% 1990s)

18. Normal Pediatric Airway Anatomy
• Larynx composed of hyoid
bone and a series of
cartilages
• Single: thyroid, cricoid,
epiglottis
• Paired: arytenoids,
corniculates, and cuneiform

19. Pediatric Anatomy cont.
Laryngeal folds consist of:
• Paired aryepiglottic folds extend from epiglottis posteriorly to
superior surface of arytenoids
• Paired vestibular folds (false vocal cords) extend from thyroid
cartilage posteriorly to superior surface of arytenoids
• Paired vocal folds (true vocal cords) extend from posterior surface of
thyroid plate to anterior part of arytenoids
• Interarytenoid fold bridging the arytenoid cartilages
• Thyrohyoid fold extend from hyoid bone to thyroid cartilage
Sensory Innervation:
Recurrent Laryngeal Nerve-supraglottic larynx
Internal Branch of Superior Laryngeal Nerve-infraglottic larynx
Motor Innervation:
External branch of Superior Laryngeal Nerve-cricothyroid muscle
Recurrent Laryngeal Nerve-all other laryngeal muscles
Blood Supply
Laryngeal branches of the superior and inferior thyroid arteries

20. 5 Differences between Pediatric and Adult Airway
• More rostral larynx
• Relatively larger tongue
• Angled vocal cords
• Differently shaped epiglottis
• Funneled shaped larynx-narrowest part of pediatric airway is cricoid
cartilage

21. More rostral pediatric larynx
Laryngeal apparatus develops from brachial clefts and descends caudally
Infant’s larynx is higher in neck (C2-3) compared to adult’s (C4-5)

22. Relatively larger tongue
• Obstructs airway
• Obligate nasal breathers
• Difficult to visualize larynx
• Straight laryngoscope blade
completely elevates the epiglottis,
preferred for pediatric laryngoscopy
Angled vocal cords
• Infant’s vocal cords have more
angled attachment to trachea,
whereas adult vocal cords are more
perpendicular
• Difficulty in nasal intubations where
“blindly” placed ETT may easily
lodge in anterior commissure rather
than in trachea
Image from: http://www.utmb.edu/otoref/Grnds/Pedi-airway-2001-01/Pedi-
airway-2001-01-slides.pdf

23. Differently shaped epiglottis
• Adult epiglottis broader, axis parallel to trachea
• Infant epiglottis ohmega (Ώ) shaped and angled away from
axis of trachea
• More difficult to lift an infant’s epiglottis with laryngoscope
blade

24. Funneled shape larynx
• narrowest part of infant’s larynx
is the undeveloped cricoid
cartilage, whereas in the adult it
is the glottis opening (vocal cord)
• Tight fitting ETT may cause
edema and trouble upon
extubation
• Uncuffed ETT preferred for
patients < 8 years old
• Fully developed cricoid cartilage
occurs at 10-12 years of age
Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-
4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
INFANTADULT

25. Pediatric Respiratory Physiology
• Extrauterine life not possible until 24-25 weeks of gestation
• Two types of pulmonary epithelial cells: Type I and Type II pneumocytes
• Type I pneumocytes are flat and form tight junctions that
interconnect the interstitium
• Type II pneumocytes are more numerous, resistant to oxygen toxicity,
and are capable of cell division to produce Type I pneumocytes
• Pulmonary surfactant produced by Type II pneumocytes
at 24 wks GA
• Sufficient pulmonary surfactant present after 35 wks GA
• Premature infants prone to respiratory distress syndrome
(RDS) because of insufficient surfactant
• Betamethasone can be given to pregnant mothers at 24-35wks GA to
accelerate fetal surfactant production

26. Pediatric Respiratory Physiology cont.
• Work of breathing for each kilogram of body weight is similar in
infants and adult
• Oxygen consumption of infant (6 ml/kg/min) is twice that of an
adult (3 ml/kg/min)
• Greater oxygen consumption = increased respiratory rate
• Tidal volume is relatively fixed due to anatomic structure
• Minute alveolar ventilation is more dependent on increased
respiratory rate than on tidal volume
• Lack Type I muscle fibers, fatigue more easily
• FRC of an awake infant is similar to an adult when normalized to
body weight
• Ratio of alveolar minute ventilation to FRC is doubled, under
circumstances of hypoxia, apnea or under anesthesia, the
infant’s FRC is diminished and desaturation occurs more
precipitously

27. Physiology: Effect Of Edema
Poiseuille’s law
R = 8nl/ πr4
If radius is halved, resistance increases 16 x
Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

28. Normal Inspiration and Expiration
turbulence
Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

29. Obstructed Airways
turbulence &
wheezing
Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

30. Airway – passage through which air
passes during respiration
• pediatric airway ×mini adult airway
Nasal & oral
cavity
Pharynx &
larynx
Trachea & large
bronchi

31. • large occiput
• Obligate nasal breathers
• Large tongue
• Higher placed larynx
• Anteriorly angulated
vocal cords
Anatomical features of pediatric airway

32. • Work of breathing for each kg BW is same in infant&
adult
• O2 consumption 6l/kg/min in children and 3ml/kg/min in
adult
• Greater O2 consumption- inc RR
• Tidal volume is relatively fixed ( 6-7ml/kg/min)
• MAV is more dependent on RR then tidal volume
(130ml/kg/min)
• MAV/ FRC is double , so during hypoxia ,apnea &
anesthesia , desaturation occurs rapidly
• Poiseuille,s law

34. http://www.humpath.com/spip.php?article5706

35. http://www.organsofthebody.com/bronchi/