Respiratory issues & desats

EmilyUSFRN, RN · Feb 13, 2008

I'll try to answer your questions, as I'm pretty new myself, 9 months in...

I've explained to parents many times that the pulse ox is just a machine and many things can cause it to go off, it helps me to evaluate the child, but it is not diagnostic. Usually it self corrects, and I've asked parents to let me know if it goes off persistently for longer than say 10 seconds. Otherwise they will stand over the crib freaking out and wondering why I'm not doing something every single time it beeps.

As far as normal desating, that is pretty much age related too. As far as I'm concerned, it is acceptable to say to a parent that when it beeps sporadically, thats usually ok and part of the child's breathing pattern, and if you were at home, he/she would still be breathing like that, just without accompanying beeps.

We keep bulb suction in the crib for our RSV kiddos and if they have secretions, we suction them prior to feeding. I've deep suctioned only a few times, as the bulb suction will usually work, and i'll keep the nasal cannula on them even though O2 is turned off, but can be turned on without wrestling.

If I'm unsure, I definitely utilize our RTs. They're amazing!

You'll learn a lot more about respiratory problems and management when you take PALS.

vamedic4, EMT-P · Feb 13, 2008

Hi ilovepeds....

First off, I'm not a nurse, rather a paramedic who works strictly peds.

Okay, so here are a few answers to your quiestions: yes, it is absolutely normal for the pulse ox to beep and not require intervention. Annoying things pulse oxes can be - the probe slips off the toe, the baby has cold extremities so that the probe doesn't pick up the sats as normal... these things happen.

On your initial alarm response - this is the time to reassure parents that everything that beeps is not a life threat, and reassure them that you will monitor the child closely.

If you have problems with a probe, move the probe from one extremity to another and see if you get better results. Cold extremities don't get good blood flow, so warm one up with a sock over the extremity. Remember that, with tiny babies, you can also wrap the pulse ox over the pedal pulse on top of the foot, not just around the big toe, even on the top of the hand in some cases.

No, it's not normal for babies to desat to the 80s (assuming they're "normal" and don't have any congenital cardiac issues). It can happen, but usually it's one of two things - either equipment failure, or something more serious is going on (apnea spell, patient deterioration, "ineffective airway clearance" to use a nursing term). Either way - it's something to keep an eye on and notify the doctor for.

If a child can't maintain their sats, listen to their lung sounds. Do they sound different than they did when you did your initial assessment? If yes, then notify someone...charge nurse, definitely RT, and possibly the doctor. Listen for breath sounds - are they clear? Do they sound wheezy or stridorous? Also beware of breath sounds that you DON'T hear. If you see the chest rising and falling but don't hear breath sounds...that's a clue to you that something's wrong. Assess this child thoroughly and notify others of your findings immediately.

If you can, try to suction if you notice a lot of discharge from the nose or mouth...upper airway secretions can be very obstructive to children who primarily breathe through their noses. Bulb syringes are sometimes all that are needed. Other times call for more invasive suctioning, so grab some saline and a 10 french suction catheter (or some other size depending on the size of your patient) and see if you can get up some of the crud that may be causing their issue.

Here at my facility, respiratory therapy has orders on many kids for q4h CPT and aerosol nebulizer treatments. Do such orders exist where you work?

Also, and I know this is common sense, but sit the child up..Elevate the head of the bed, put the patient in the best position to optimize breathing...45 degrees elevation or more. We use a wedge and harness to keep our little ones up.

If there comes a point in your caring for a patient that you don't feel comfortable, call someone to help you. Your RT may be your best bet, but any experienced nurse would be an excellent resource and a valuable asset.

The best thing I can tell you to know for the RT are simple - your assessment findings. Pulse ox down to 92 from 100, resp rate increased from 20 to 28, (increased work of breathing), wheezes bilaterally....whatever you find that you feel is pertinent.

Best of luck with your little patients.

vamedic4

Qwiigley, BSN, MSN, DNP, RN, CRNA · Feb 13, 2008

Good response from Vamedic.

Help the parents to feel more empowered. Give them the bulb syringe and teach them how to use it. Teach them why you position the baby, why you suction. Eventually the baby will go home and you can bet they will get sick again sometime. Give them the knowledge to help their baby.

This is not to say that you no longer come in when the baby de-sats, but when you do get called you will know it is important.

Parents see their baby suffering and feel very helpless.

My background is PICU. We had other means at our disposal. Nowadays, my patients all have ETT and I put them there! (CRNA)

kristenncrn · Feb 15, 2008

Totally agree with vamedic's advice! And also with Qwiigley about parents and Emily's thoughts....

Babies desat - the alarms will go off constantly - especially if it is a well baby with RSV (by well, I mean floor status, feeding, alert, active.) I *always* reassure the parents and explain why the alarms go off. And that all those reasons listed above will make the alarm falsely go off, so don't stress! Socks are great, but wiggling babies will get a sock off at least every 4 hours, right? Wiggling babies are (generally) doing okay... so just joke with Mom and Dad about that. Every child (normally) drops down when they are asleep. And people can tolerate sats in the 80s for a few - just make sure you believe that when you are telling the parents! We monitor sats to see a trend as much as for immediate intervention... so maybe explain it like that. If said baby desats to 88-89 while asleep normally, then recovers on their own within a few minutes - great. If baby needs o2 when their sleeping, that says something different and give us an idea of if what we are doing is helping. Or if baby never desats and now has gone from 98 to 88... well, you get my point. I've always found that parents are okay with just about anything as long as I could give them an explanation that they could understand.

That being said - suction is your friend! I prefer BBG to bulb suction, but a good deep suction once a shift is the norm for me when I have a babe with RSV. That stuff just keeps coming - and sometimes it's easier not to wait for RT, ya know? Again - if you don't stress, the room won't (ususally) either. So you suction, the baby screams, desats, even turns blue for a second. But a minute later, said baby can take a whole bottle and keeps their sats in the upper 90s, right? I usually suction all of my RSV babies IF they have the typical thick secretions and are on o2.

If the idea of deep suctioning throws you - then ask someone to show you their technique. If you don't work with people who are cool like that, then maybe see if you can get some trach patients. Seriously. You get comfortable with those suction catheters real quick when you got pseudomonas bubbling (sorry - gross, I know!)

Definitely show parents how to bulb suction right away - and get them some sterile saline bullets or Ocean spray if possible (which most RSV babies may not need, but...)

Oh, and personally, I page RT if I hear increased wheezing, if they are retracting, if there are any signs of distress (obviously), if any baby needs an increase in O2 that is significant (like more than 0.5) or if I'm unsure about anything respiratory wise. Typically, though, I try to intervene first.... but trust your assessments. My MO is unwrap, look, listen, move baby - sometimes just flipping a baby around will rouse them enough to sneeze or cough - hooray!, O2, suction, O2... then re-assess with the babe as upright as possible.

Welcome to Peds! RSV season is LOOOOOONNNNNGGG, isn't it? =)