WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.149 fast. Welcome to the emergency room. Welcome 00:00:47.149 --> 00:00:51.250 back to the deep dive. We are jumping straight 00:00:51.250 --> 00:00:54.210 into the fire today. We're tackling a topic that 00:00:54.270 --> 00:00:57.070 Honestly, I think strikes more genuine fear into 00:00:57.070 --> 00:00:59.789 the hearts of nursing students. And let's be 00:00:59.789 --> 00:01:03.009 real, new grads and even seasoned nurses than 00:01:03.009 --> 00:01:05.370 almost anything else. Oh, for sure. We're looking 00:01:05.370 --> 00:01:08.109 at pediatric respiratory disorders. It's the 00:01:08.109 --> 00:01:11.549 absolute high stakes arena of pediatrics. It 00:01:11.549 --> 00:01:14.549 really is the great equalizer. You can have a 00:01:14.549 --> 00:01:17.489 nurse with 10 years of adult ICU experience. 00:01:17.569 --> 00:01:20.540 I mean, rock solid scene at all. But. you put 00:01:20.540 --> 00:01:22.599 a six month old in respiratory distress in front 00:01:22.599 --> 00:01:24.099 of them, the heart rate in the room just goes 00:01:24.099 --> 00:01:26.019 up, it changes everything. Because children are 00:01:26.019 --> 00:01:27.680 not just small adults, right? That's the cliche 00:01:27.680 --> 00:01:30.019 we hear on day one of nursing school. But it's 00:01:30.019 --> 00:01:32.560 just so fundamentally true. It is the truth of 00:01:32.560 --> 00:01:35.319 the field. And absolutely nowhere is that truth 00:01:35.319 --> 00:01:38.920 more critical, more life and death than in the 00:01:38.920 --> 00:01:42.200 airway. In pediatrics, the maxim is simple. Airway 00:01:42.200 --> 00:01:44.659 is king. If you lose the airway, you lose the 00:01:44.659 --> 00:01:47.420 child. And it happens fast. The margins for error 00:01:47.420 --> 00:01:50.859 are just razor thin. Well, to keep you from hyperventilating 00:01:50.859 --> 00:01:53.939 along with your future patients, we do have a 00:01:53.939 --> 00:01:57.859 very specific mission for this deep dive. We've 00:01:57.859 --> 00:01:59.819 combed through a massive stack of sources here. 00:02:00.140 --> 00:02:02.540 A huge stack. We're talking ATI pediatric nursing 00:02:02.540 --> 00:02:04.900 materials, the heavy -hitting Wolters Kluwer 00:02:04.900 --> 00:02:08.139 textbooks, lecture slides, clinical charts, the 00:02:08.139 --> 00:02:11.340 works. And our goal is to boil this ocean. We 00:02:11.340 --> 00:02:13.740 are going for the Pareto principle today, the 00:02:13.740 --> 00:02:16.900 80 -20 rule. Exactly. We want to find the 20 00:02:16.900 --> 00:02:19.319 % of the content. that is going to answer 80 00:02:19.319 --> 00:02:22.199 % of the exam questions you'll face, and vastly, 00:02:22.280 --> 00:02:25.259 more importantly, handle 80 % of the safety scenarios 00:02:25.259 --> 00:02:27.780 you will actually see at the bedside. Yeah, we're 00:02:27.780 --> 00:02:30.460 bypassing the fluff. We are not here to memorize 00:02:30.460 --> 00:02:32.860 obscure statistics that nobody actually uses. 00:02:32.939 --> 00:02:35.740 No. We're going to focus on safety, pathophysiology, 00:02:35.939 --> 00:02:38.659 and that critical thinking, that NCLEX -style 00:02:38.659 --> 00:02:41.099 judgment that separates a rookie from a really 00:02:41.099 --> 00:02:43.300 safe practitioner. So let's crack the code on 00:02:43.300 --> 00:02:45.360 this. We're dividing this deep dive into three 00:02:45.360 --> 00:02:47.960 distinct sections. Section A is the map. the 00:02:47.960 --> 00:02:50.080 big patterns that dictate everything in PEDS 00:02:50.080 --> 00:02:52.740 respiratory. Section B is the meat, the specific 00:02:52.740 --> 00:02:55.580 diseases, system by system, and then Section 00:02:55.580 --> 00:02:58.000 C is the cross -reference where we're gonna link 00:02:58.000 --> 00:03:00.240 it all together so you don't get tricked. Sounds 00:03:00.240 --> 00:03:02.800 like a solid plan. Let's get to work. Okay, Section 00:03:02.800 --> 00:03:06.719 A, the master 80 -20 map. Before we even talk 00:03:06.719 --> 00:03:09.900 about asthma or croup or anything specific, you've 00:03:09.900 --> 00:03:12.500 identified some patterns. in the source material. 00:03:12.599 --> 00:03:14.860 These are like the recurring themes that seem 00:03:14.860 --> 00:03:16.919 to dictate the rules of the game. They really 00:03:16.919 --> 00:03:18.560 are. They're the foundational principles. And 00:03:18.560 --> 00:03:21.000 the first one is catchy. You call it, anatomy 00:03:21.000 --> 00:03:23.620 is destiny. Or as I like to call it, the case 00:03:23.620 --> 00:03:26.139 of the four millimeter straw. Unpack that for 00:03:26.139 --> 00:03:28.580 me. This stat, I mean, it really blew my mind 00:03:28.580 --> 00:03:30.400 when I read the notes. So if you look at the 00:03:30.400 --> 00:03:33.039 source images, specifically from the ATI and 00:03:33.039 --> 00:03:35.659 Walter's Clure anatomy comparisons, there's this 00:03:35.659 --> 00:03:39.180 really stark visual. An adult trachea, the windpipe. 00:03:39.389 --> 00:03:42.330 is about 20 millimeters wide. Okay, that's a 00:03:42.330 --> 00:03:44.490 pretty generous size, almost like a garden hose. 00:03:44.669 --> 00:03:46.849 You can move a lot of air through that. It is 00:03:46.849 --> 00:03:49.870 a generous size, yeah. Now, look at an infant's 00:03:49.870 --> 00:03:52.270 trachea. It's approximately four millimeters 00:03:52.270 --> 00:03:56.370 wide. Four. That is roughly the width of a standard 00:03:56.370 --> 00:03:59.919 plastic drinking straw. That is tiny. that is 00:03:59.919 --> 00:04:02.960 terrifyingly small. It is. Now here's the math 00:04:02.960 --> 00:04:05.780 that appears in almost every major pediatric 00:04:05.780 --> 00:04:08.539 respiratory text, and it's a favorite concept 00:04:08.539 --> 00:04:10.500 for exam writers because it involves physics, 00:04:10.680 --> 00:04:14.259 right? If you have one millimeter of swelling 00:04:14.259 --> 00:04:17.339 edema in that 20 millimeter adult trachea. So 00:04:17.339 --> 00:04:19.560 20 millimeters goes down to 19. No big deal. 00:04:19.660 --> 00:04:23.459 Right. It's maybe a five to 20 % reduction in 00:04:23.459 --> 00:04:25.819 the cross -sectional area. You might clear your 00:04:25.819 --> 00:04:27.699 throat, feel a little scratchy, you carry on 00:04:27.699 --> 00:04:29.800 with your day. It's an annoyance. Right. But 00:04:29.800 --> 00:04:32.060 if you take that infant with the four millimeter 00:04:32.060 --> 00:04:35.100 straw and you add one millimeter of edema all 00:04:35.100 --> 00:04:36.819 the way around. You've practically closed it. 00:04:37.040 --> 00:04:39.600 You have reduced the airway diameter by 50%. 00:04:39.600 --> 00:04:42.860 Wow. One single millimeter equals a 50 % loss 00:04:42.860 --> 00:04:47.000 of airway. Yes. And here's the kicker. The resistance 00:04:47.000 --> 00:04:50.009 to airflow. So how hard that baby has to work 00:04:50.009 --> 00:04:53.290 to pull air in increases by a factor of 16. 16. 00:04:53.769 --> 00:04:57.329 16 times harder to breathe. 16 times the work. 00:04:57.930 --> 00:05:01.069 So a little bit of swelling in a baby is a catastrophic 00:05:01.069 --> 00:05:04.129 event compared to an adult. That is why we panic 00:05:04.129 --> 00:05:07.290 over a stuffy nose in an infant. And speaking 00:05:07.290 --> 00:05:10.089 of stuffy noses, the sources mention that infants 00:05:10.089 --> 00:05:13.269 are preferential nose breathers. What does that 00:05:13.269 --> 00:05:15.889 actually mean in practice? It means until about 00:05:16.519 --> 00:05:19.540 for maybe six weeks of age, they don't have the 00:05:19.540 --> 00:05:21.839 neurological reflex to automatically open their 00:05:21.839 --> 00:05:23.720 mouth and breathe if their nose is plugged. They 00:05:23.720 --> 00:05:25.560 don't know how. They're just hardwired to breathe 00:05:25.560 --> 00:05:27.639 through their nose. It's to facilitate breastfeeding, 00:05:27.800 --> 00:05:29.240 right? You latch on, you breathe through your 00:05:29.240 --> 00:05:32.620 nose. So if a newborn has a stuffy nose, whether 00:05:32.620 --> 00:05:36.060 it's from mucus or a condition like coanal atresia, 00:05:36.600 --> 00:05:39.160 they aren't just uncomfortable. They're in actual 00:05:39.160 --> 00:05:41.600 distress. They are in respiratory distress. They 00:05:41.600 --> 00:05:44.100 are, for all intents and purposes, suffocating. 00:05:44.269 --> 00:05:47.430 That is a massive exam tip right there. If the 00:05:47.430 --> 00:05:50.370 question says newborn with copious nasal secretions, 00:05:50.449 --> 00:05:52.689 it is not a hygiene issue. Not at all. That's 00:05:52.689 --> 00:05:55.629 an airway issue. Correct. Your nursing diagnosis 00:05:55.629 --> 00:05:58.370 isn't impaired comfort. It's ineffective airway 00:05:58.370 --> 00:06:00.189 clearance, and it's your number one priority. 00:06:00.589 --> 00:06:02.910 And there's one more anatomical nugget from the 00:06:02.910 --> 00:06:05.769 sources regarding the lungs themselves, the alveoli. 00:06:06.269 --> 00:06:08.949 Ah, yeah, the little air sacs where all the magic 00:06:08.949 --> 00:06:12.959 happens. The gas exchange. So adults have about 00:06:12.959 --> 00:06:15.860 300 million of them. A huge surface area, like 00:06:15.860 --> 00:06:17.939 a tennis court spread out inside your chest. 00:06:18.199 --> 00:06:20.459 And infants. They're born with only about 150 00:06:20.459 --> 00:06:23.319 million. Half. So half the engine room. Half 00:06:23.319 --> 00:06:26.360 the surface area means less room to trade oxygen 00:06:26.360 --> 00:06:29.259 for carbon dioxide. So when they get sick, when 00:06:29.259 --> 00:06:31.939 they have inflammation or fluid, they get hypoxic 00:06:31.939 --> 00:06:34.259 much, much faster. They just have less reserve. 00:06:34.319 --> 00:06:36.420 They run out of gas quicker. An adult can tread 00:06:36.420 --> 00:06:39.100 water for a while. An infant just sinks. OK, 00:06:39.240 --> 00:06:42.540 so pattern one is small airway, big danger. That 00:06:42.540 --> 00:06:45.160 is crystal clear. Let's move to pattern two, 00:06:45.339 --> 00:06:47.980 the assessment hierarchy. How do we spot trouble 00:06:47.980 --> 00:06:50.839 before the code bell rings? Because looking at 00:06:50.839 --> 00:06:53.040 the sources, there seems to be a major trap here 00:06:53.040 --> 00:06:55.660 that catches a lot of students. There is. And 00:06:55.660 --> 00:06:58.120 the sources all highlight a very specific progression 00:06:58.120 --> 00:07:01.019 of signs, and the trap is waiting for the wrong 00:07:01.019 --> 00:07:03.439 sign. It's the wrong sign. Cyanosis. Turning 00:07:03.439 --> 00:07:07.819 blue. Turning blue, yes. But blue means... Lack 00:07:07.819 --> 00:07:09.540 of oxygen. Shouldn't that be what we're looking 00:07:09.540 --> 00:07:11.939 for? If they're blue, you're late. I mean, you 00:07:11.939 --> 00:07:14.879 are profoundly late to the party. If they are 00:07:14.879 --> 00:07:18.540 blue, you are practically performing CPR. Cyanosis 00:07:18.540 --> 00:07:21.980 is a late ominous pre -terminal sign. If you 00:07:21.980 --> 00:07:24.439 wait for the baby to turn blue, you have failed 00:07:24.439 --> 00:07:26.980 the assessment. OK, so what is the first sign 00:07:26.980 --> 00:07:29.000 then? If I'm on top of my game, what am I actually 00:07:29.000 --> 00:07:31.720 seeing? The sources all emphasize that the very 00:07:31.720 --> 00:07:34.160 first sign of respiratory distress and hypoxia 00:07:34.160 --> 00:07:36.920 is behavioral. It's the brain screaming, hey, 00:07:36.939 --> 00:07:39.639 any more oxygen down here. Behavioral, like crying. 00:07:39.899 --> 00:07:43.649 Oh, not just crying, it's restlessness. irritability, 00:07:43.649 --> 00:07:46.129 agitation. Think about it. If I put a pillow 00:07:46.129 --> 00:07:47.810 over your face, what's the first thing you're 00:07:47.810 --> 00:07:49.370 going to do? I'm going to slash around. I'm going 00:07:49.370 --> 00:07:51.189 to get anxious. I'm going to fight. Exactly. 00:07:51.430 --> 00:07:53.389 The baby can't use words. They can't tell you, 00:07:53.430 --> 00:07:56.170 I can't breathe. So they get restless. They get 00:07:56.170 --> 00:07:58.629 agitated. They get tachycardia, a fast heart 00:07:58.629 --> 00:08:01.910 rate, and tachypnea, fast breathing. Their body 00:08:01.910 --> 00:08:06.170 is compensating. So exam tip. The child is described 00:08:06.170 --> 00:08:10.019 as fussy and cannot be consoled. breathing fast. 00:08:10.339 --> 00:08:13.120 That is hypoxia until proven otherwise. Bingo! 00:08:13.480 --> 00:08:15.379 Don't just assume they're hungry. Don't assume 00:08:15.379 --> 00:08:19.500 it's a wet diaper. Assume airway first. Always. 00:08:19.899 --> 00:08:22.800 Okay, so after that initial restlessness, what 00:08:22.800 --> 00:08:25.079 are we looking at? The sources have great diagrams 00:08:25.079 --> 00:08:28.420 on retractions. Right. Retractions are the muscles 00:08:28.420 --> 00:08:30.720 sucking in between the bones, because the body 00:08:30.720 --> 00:08:33.580 is working so hard to pull air through that tiny, 00:08:33.759 --> 00:08:35.539 swollen straw we talked about. And there is a 00:08:35.539 --> 00:08:37.620 hierarchy here, too, right? The location tells 00:08:37.620 --> 00:08:40.200 you how bad things are. Yes, absolutely. It's 00:08:40.200 --> 00:08:42.940 a progression. It usually starts low on the body. 00:08:42.960 --> 00:08:45.399 OK. You'll see subcostal. That's right below 00:08:45.399 --> 00:08:48.000 the ribs, or substernal, right below the sternum. 00:08:48.179 --> 00:08:50.700 As the distress gets worse, the recruitment of 00:08:50.700 --> 00:08:53.980 muscles moves up the body. Moves up. Yes. Next, 00:08:54.000 --> 00:08:56.059 you'll start to see intercostal retractions. 00:08:56.220 --> 00:08:58.039 That's when the muscles between the ribs get 00:08:58.039 --> 00:09:01.200 sucked in. Then when things are really bad, you'll 00:09:01.200 --> 00:09:03.960 see super sternal, that little notch above the 00:09:03.960 --> 00:09:06.340 sternum, and finally super clavicular, which 00:09:06.340 --> 00:09:08.919 is above the collarbone. So if I see a kid with 00:09:08.919 --> 00:09:11.080 muscles sucking in way up by their neck. That 00:09:11.080 --> 00:09:13.940 is severe obstruction. The higher the retraction, 00:09:14.200 --> 00:09:16.379 generally speaking, the worse the struggle. If 00:09:16.379 --> 00:09:19.220 you see super clavicular retractions, that child 00:09:19.220 --> 00:09:22.539 is using Every single accessory muscle they have, 00:09:22.639 --> 00:09:24.700 just to move a tiny bit of air, they are getting 00:09:24.700 --> 00:09:27.899 exhausted. And there's a specific terrifying 00:09:27.899 --> 00:09:30.220 concept mentioned in the asthma sources that 00:09:30.220 --> 00:09:33.200 fits here. It's called the silent chest. The 00:09:33.200 --> 00:09:37.480 silent danger. This is a classic NCLEX trap and 00:09:37.480 --> 00:09:40.019 honestly a real life horror story. Set the scene 00:09:40.019 --> 00:09:42.870 for me. OK, imagine you are listening to a child 00:09:42.870 --> 00:09:46.110 with a severe asthma attack. They are wheezing 00:09:46.110 --> 00:09:48.250 like a freight train. It's loud. It's scary. 00:09:48.330 --> 00:09:50.350 You can hear it from the doorway without a stethoscope. 00:09:50.649 --> 00:09:52.649 OK, I can picture that. You give a breathing 00:09:52.649 --> 00:09:54.149 treatment, or maybe you don't have time, and 00:09:54.149 --> 00:09:57.789 suddenly the wheezing stops. The room goes quiet. 00:09:57.950 --> 00:09:59.710 And the novice nurse thinks, oh, thank goodness 00:09:59.710 --> 00:10:02.090 they're better. The wheezing is gone. And the 00:10:02.090 --> 00:10:05.320 expert nurse calls the rapid response team. Because 00:10:05.320 --> 00:10:07.519 wheezing is the sound of air moving through a 00:10:07.519 --> 00:10:10.480 tight tube. If the wheezing stops, but that child 00:10:10.480 --> 00:10:12.279 still looks like they're struggling, they're 00:10:12.279 --> 00:10:14.419 retracting, they're sitting bolt upright, maybe 00:10:14.419 --> 00:10:16.740 turning pale, it means they aren't moving enough 00:10:16.740 --> 00:10:19.419 air to even make a noise anymore. That's total 00:10:19.419 --> 00:10:22.759 obstruction. That is impending respiratory arrest. 00:10:23.399 --> 00:10:27.059 Silence is not always golden. In pediatric respiratory 00:10:27.059 --> 00:10:29.860 distress, silence can be deadly. That's a chilling 00:10:29.860 --> 00:10:31.720 point. No lie. And it brings us perfectly to 00:10:31.720 --> 00:10:34.679 pattern three. The noise dictates the location. 00:10:35.000 --> 00:10:37.080 I love this because it really simplifies things. 00:10:37.279 --> 00:10:39.419 The sound tells you where the problem is. It's 00:10:39.419 --> 00:10:41.700 like a diagnostic map for your ears. There are 00:10:41.700 --> 00:10:44.059 three main sounds you absolutely need to master. 00:10:44.500 --> 00:10:47.620 Stridor. wheezing, and crackles. OK, bring them 00:10:47.620 --> 00:10:49.779 down for me. Let's start with stridor. Stridor 00:10:49.779 --> 00:10:52.899 is a high -pitched, inspiratory sound. It happens 00:10:52.899 --> 00:10:55.240 when they breathe in. It sounds like a seal barking 00:10:55.240 --> 00:10:57.500 or a high -pitched gasp. And where is that coming 00:10:57.500 --> 00:11:00.120 from? It comes from the upper airway, the neck 00:11:00.120 --> 00:11:02.779 area, the larynx or trachea. So think croup, 00:11:02.899 --> 00:11:05.379 think epiglottitis, or think a foreign body caught 00:11:05.379 --> 00:11:09.639 in the throat. OK, stridor equals upper. Neck 00:11:09.639 --> 00:11:12.779 issues. Got it. What about wheezing? Wheezing 00:11:12.779 --> 00:11:14.879 is usually expiratory when they breathe out, 00:11:14.899 --> 00:11:17.080 and it's a musical sound, a high -pitched whistle. 00:11:17.419 --> 00:11:20.019 It comes from lower airway constriction. The 00:11:20.019 --> 00:11:22.960 bronchi and the bronchioles are squeezed tight. 00:11:23.100 --> 00:11:25.720 So we should be thinking. Think asthma, think 00:11:25.720 --> 00:11:29.320 bronchiolitis or RSV. Wheezing equals lower, 00:11:30.059 --> 00:11:33.899 the squeeze. Okay, last one, crackles. Crackles, 00:11:33.919 --> 00:11:35.720 sometimes you'll see them called rails. That 00:11:35.720 --> 00:11:37.860 sounds like Velcro being pulled apart or like 00:11:37.860 --> 00:11:39.799 rubbing hair between your fingers right next 00:11:39.799 --> 00:11:42.279 to your ear. What does that mean? That is fluid 00:11:42.279 --> 00:11:44.860 in the alveoli, the very bottom of the lungs. 00:11:44.919 --> 00:11:46.720 So for crackles, you should immediately think 00:11:46.720 --> 00:11:49.340 pneumonia. Crackles equals fluid deep down. If 00:11:49.340 --> 00:11:51.840 you can just memorize that map stridor is up, 00:11:52.200 --> 00:11:54.440 wheezes down the squeeze, and crackles are fluid, 00:11:54.799 --> 00:11:57.159 you can answer half the scenario questions before 00:11:57.159 --> 00:11:58.940 you even read the vital signs. That is the 80 00:11:58.940 --> 00:12:01.480 -20 right there. Okay, we have our map. We know 00:12:01.480 --> 00:12:04.039 the anatomy is dangerous. We know to look for 00:12:04.039 --> 00:12:06.580 restlessness first, not blueness. And we know 00:12:06.580 --> 00:12:08.600 what the noises mean. Now we can apply it to 00:12:08.600 --> 00:12:11.730 the specific diseases. Let's do it. Let's move 00:12:11.730 --> 00:12:14.909 to section B, the system -by -system lecture. 00:12:15.370 --> 00:12:17.850 We're going to cross -reference the ATI and Voulter's 00:12:17.850 --> 00:12:20.470 Clure materials to give you the absolute need 00:12:20.470 --> 00:12:22.889 to know for each major condition. Let's start 00:12:22.889 --> 00:12:24.470 at the top of the airway and work our way down. 00:12:24.769 --> 00:12:27.470 Perfect. Up first, the sore throat spectrum, 00:12:27.870 --> 00:12:30.450 tonsillitis and pharyngitis. Right. So clinically, 00:12:30.649 --> 00:12:32.870 this is simply inflammation of the lymph tissue, 00:12:33.090 --> 00:12:35.049 the tonsils, or the pharynx, which is the back 00:12:35.049 --> 00:12:37.070 of the throat. Give me the one -liner on the 00:12:37.070 --> 00:12:39.899 patho. What's going on here? It can be viral, 00:12:39.980 --> 00:12:42.059 and most of the time it is, which is self -limiting. 00:12:42.139 --> 00:12:45.960 You just need supportive care. But the big bad 00:12:45.960 --> 00:12:48.620 wolf here, the one we really care about, is Gabby 00:12:48.620 --> 00:12:51.480 HS. Group A beta -hemolytic streptococcus. Or 00:12:51.480 --> 00:12:53.620 just strep throat to you and me. And the reason 00:12:53.620 --> 00:12:55.419 we care so much about strep isn't just because 00:12:55.419 --> 00:12:57.940 of the sore throat. The sources are very, very 00:12:57.940 --> 00:12:59.899 clear on this. Why do we care so much, then? 00:13:00.100 --> 00:13:02.360 If you don't treat Gabby HS with antibiotics, 00:13:02.500 --> 00:13:05.519 it can trigger a delayed post -infectious autoimmune 00:13:05.519 --> 00:13:08.080 response in the body. an autoimmune response 00:13:08.080 --> 00:13:12.539 from a sore throat. Yes. The body creates antibodies 00:13:12.539 --> 00:13:15.559 to fight the strep bacteria, but those antibodies 00:13:15.559 --> 00:13:18.620 can then mistakenly attack the body's own tissues. 00:13:19.159 --> 00:13:21.620 Specifically, they can lead to rheumatic fever, 00:13:21.919 --> 00:13:25.059 which attacks and scars the heart valves, or 00:13:25.059 --> 00:13:28.379 acute glomerulonephritis, which damages and can 00:13:28.379 --> 00:13:30.899 shut down the kidneys. So just to be clear, the 00:13:30.899 --> 00:13:33.179 antibiotics aren't just for the pain. They're 00:13:33.179 --> 00:13:35.120 to save the heart and the kidneys down the line. 00:13:35.230 --> 00:13:38.350 Precisely. That's the why behind the prescription. 00:13:38.590 --> 00:13:40.850 You aren't just treating the throat. You're preventing 00:13:40.850 --> 00:13:43.110 potentially permanent organ damage. It's a huge 00:13:43.110 --> 00:13:45.129 public health concept. That makes so much sense. 00:13:45.370 --> 00:13:47.429 Now, sometimes the tonsils are just chronically 00:13:47.429 --> 00:13:50.009 inflamed and they have to come out. Let's talk 00:13:50.009 --> 00:13:52.250 about the surgical fix, the tonsillectomy. This 00:13:52.250 --> 00:13:55.809 is huge on exams. There's a specific can't -miss 00:13:55.809 --> 00:13:58.690 complication. Bleeding. Post -op hemorrhage. 00:13:58.809 --> 00:14:01.149 The tonsils are extremely vascular. When you 00:14:01.149 --> 00:14:03.889 cut them out, you leave a raw open bed of tissue 00:14:03.889 --> 00:14:07.049 that has to scab over. And when is the risk for 00:14:07.049 --> 00:14:09.269 that bleeding the highest? There are two distinct 00:14:09.269 --> 00:14:11.129 windows you have to know. The first is obvious. 00:14:11.350 --> 00:14:13.769 It's the first 24 hours post -op immediate bleeding. 00:14:14.009 --> 00:14:16.289 That makes sense to everyone. But the second 00:14:16.289 --> 00:14:19.309 window is the trap. It's seven to ten days later. 00:14:19.769 --> 00:14:22.049 Wait, seven to ten days... After the surgery, 00:14:22.289 --> 00:14:25.210 why the delay? That's when the scabs, the escher, 00:14:25.350 --> 00:14:28.350 start to slog off and fall off. If the tissue 00:14:28.350 --> 00:14:30.669 underneath isn't fully healed, or if the kid 00:14:30.669 --> 00:14:33.210 eats something rough and scrapes it like a parkeia 00:14:33.210 --> 00:14:35.309 chip or a piece of toast, they can start bleeding 00:14:35.309 --> 00:14:38.009 again, sometimes heavily. So what does the nurse 00:14:38.009 --> 00:14:40.200 look for? Because a four -year -old isn't going 00:14:40.200 --> 00:14:42.399 to walk up to you and say, excuse me, I believe 00:14:42.399 --> 00:14:45.100 I am hemorrhaging from my tonsillar fossa. No, 00:14:45.120 --> 00:14:47.259 they're not. And what's worse is they just swallow 00:14:47.259 --> 00:14:50.440 the blood. Blood tastes metallic and salty, and 00:14:50.440 --> 00:14:52.139 it just trickles down the back of their throat. 00:14:52.200 --> 00:14:55.580 So the number one most frequent early sign of 00:14:55.580 --> 00:14:58.740 post -op bleeding is frequent swallowing. Frequent 00:14:58.740 --> 00:15:01.279 swallowing. If you see a child after a tonsillectomy 00:15:01.279 --> 00:15:04.179 who is constantly gulping, swallowing, clearing 00:15:04.179 --> 00:15:06.179 their throat, you need to get a pen light and 00:15:06.179 --> 00:15:07.820 look in the back of that throat. They are very 00:15:07.820 --> 00:15:09.960 likely swallowing blood. And eventually that 00:15:09.960 --> 00:15:12.179 blood is going to hit the stomach. And they will 00:15:12.179 --> 00:15:14.580 vomit. It might be coffee ground emesis if it's 00:15:14.580 --> 00:15:17.799 old blood or it could be Frank bright red blood. 00:15:18.200 --> 00:15:20.580 Which brings up a very practical exam tip in 00:15:20.580 --> 00:15:23.919 clinical rule. No red colored fluids post -op. 00:15:24.200 --> 00:15:26.980 No red popsicles, no cherry jello, no fruit punch. 00:15:27.340 --> 00:15:29.500 Absolutely not. Because if they vomit red fluid, 00:15:29.820 --> 00:15:32.000 you can't tell if it's Gatorade or blood. You 00:15:32.000 --> 00:15:35.419 want clear differentiation. It removes all ambiguity. 00:15:35.740 --> 00:15:37.899 That makes total sense. Now let's talk about 00:15:37.899 --> 00:15:40.019 the developmental angle here. You've got a toddler 00:15:40.019 --> 00:15:43.039 who just had major throat surgery. Their throat 00:15:43.039 --> 00:15:45.990 hurts like crazy. They don't want to drink. Dehydration 00:15:45.990 --> 00:15:48.649 is the other massive risk. So really, pain management 00:15:48.649 --> 00:15:51.070 is actually dehydration management. What do you 00:15:51.070 --> 00:15:53.570 mean by that? If you don't adequately control 00:15:53.570 --> 00:15:55.950 their pain, they will refuse to drink. A toddler 00:15:55.950 --> 00:15:58.929 in pain will not swallow. So staying on top of 00:15:58.929 --> 00:16:01.870 the pain with round the clock Tylenol, acetaminophen, 00:16:01.950 --> 00:16:04.090 or whatever is ordered is absolutely key. So 00:16:04.090 --> 00:16:06.710 they will take those fluids. A dehydrated toddler 00:16:06.710 --> 00:16:09.029 is a toddler who ends up right back in the hospital 00:16:09.029 --> 00:16:11.909 on an IV. OK, that's a great connection. Let's 00:16:11.909 --> 00:16:16.009 move down the airway. Next up, croup syndromes. 00:16:16.049 --> 00:16:19.409 Specifically, the classic one, acute laryngotracheal 00:16:19.409 --> 00:16:22.570 bronchitis, or LTB. This is the classic. You 00:16:22.570 --> 00:16:24.570 will hear this sound in the grocery store in 00:16:24.570 --> 00:16:26.509 November, and you'll know exactly what it is. 00:16:26.649 --> 00:16:29.730 The barking seal. Exactly. It's almost always 00:16:29.730 --> 00:16:33.649 viral. Perinfluenza is a common culprit. And 00:16:33.649 --> 00:16:35.809 as the name says, it affects the larynx, the 00:16:35.809 --> 00:16:38.340 trachea, and the bronchi. Because of that swelling, 00:16:38.480 --> 00:16:41.320 remember our four millimeter straw, the subglottic 00:16:41.320 --> 00:16:43.720 area gets very tight. And what's the typical 00:16:43.720 --> 00:16:47.039 presentation for croup? Usually a toddler, say 00:16:47.039 --> 00:16:48.940 three months to three years old, it's often a 00:16:48.940 --> 00:16:51.399 gradual onset and it's classically worse at night. 00:16:51.679 --> 00:16:53.159 They might have had a little cold during the 00:16:53.159 --> 00:16:55.080 day, they go to bed and they wake up at 2 a .m. 00:16:55.100 --> 00:16:58.000 with that characteristic barky seal -like cough 00:16:58.000 --> 00:17:01.159 and inspiratory stridor. That phrase, worse at 00:17:01.159 --> 00:17:03.299 night, is all over the source material. It is. 00:17:03.299 --> 00:17:06.039 It's a key feature. So for the need to know interventions, 00:17:06.220 --> 00:17:08.799 if it's mild and that means no stridor when they're 00:17:08.799 --> 00:17:11.339 resting, only when they get upset and cry, the 00:17:11.339 --> 00:17:14.220 first line treatment is Cool Mist. Why Cool Mist? 00:17:14.299 --> 00:17:17.420 What's the science there? It causes vasoconstriction. 00:17:17.839 --> 00:17:20.559 The cool, humidified air constricts the tiny 00:17:20.559 --> 00:17:22.900 blood vessels in the swollen tissue, which helps 00:17:22.900 --> 00:17:25.519 to reduce the edema just enough to open the airway 00:17:25.519 --> 00:17:28.079 a little. The old school trick is to take the 00:17:28.079 --> 00:17:30.359 kid outside into the cool night air or even just 00:17:30.359 --> 00:17:32.859 stand in front of an open freezer door. It often 00:17:32.859 --> 00:17:35.059 works surprisingly well. Okay, but what if it's 00:17:35.059 --> 00:17:37.700 severe? What if they have stridor while they're 00:17:37.700 --> 00:17:40.220 just sitting there quietly watching TV? Then 00:17:40.220 --> 00:17:42.640 we bring out the big guns. That's an indication 00:17:42.640 --> 00:17:45.819 for nebulized racemic epinephrine. Epinephrine. 00:17:46.180 --> 00:17:49.259 Like an EpiPen for allergies. Similar concept, 00:17:49.380 --> 00:17:51.839 but it's a specific formulation that's nebulized 00:17:51.839 --> 00:17:55.039 and inhaled directly onto the vocal cords. It 00:17:55.039 --> 00:17:57.980 is a powerful, rapid -acting vasoconstrictor. 00:17:58.079 --> 00:18:00.160 It shrinks that swelling almost immediately, 00:18:00.559 --> 00:18:03.279 but... And here's the major safety alert you 00:18:03.279 --> 00:18:05.839 have to know. It wears off very quickly. You're 00:18:05.839 --> 00:18:08.039 talking about the rebound effect. Exactly. The 00:18:08.039 --> 00:18:09.859 medication might wear off in about two hours, 00:18:09.980 --> 00:18:12.319 and the swelling can come right back, sometimes 00:18:12.319 --> 00:18:14.279 even worse than it was before. So you can't just 00:18:14.279 --> 00:18:16.740 treat and street them? Absolutely not. You cannot 00:18:16.740 --> 00:18:19.279 send a child home immediately after getting racemic 00:18:19.279 --> 00:18:22.079 epi. They have to be observed in the ER or admitted 00:18:22.079 --> 00:18:24.400 for at least two to four hours to ensure they 00:18:24.400 --> 00:18:26.579 don't rebound and lose their airway on the car 00:18:26.579 --> 00:18:29.579 ride home. That is a critical safety point. Don't 00:18:29.579 --> 00:18:32.119 discharge the croup kid immediately after the 00:18:32.119 --> 00:18:35.279 breathing treatment. Correct. We also give corticosteroids 00:18:35.279 --> 00:18:38.519 usually a single dose of dexamethasone, either 00:18:38.519 --> 00:18:41.599 oral or IM, to help with the inflammation long 00:18:41.599 --> 00:18:44.140 term over the next few days. Now, croup has a 00:18:44.140 --> 00:18:48.160 scary and thankfully much rarer cousin, the true 00:18:48.160 --> 00:18:51.180 emergency, epiglottitis. This is the nightmare 00:18:51.180 --> 00:18:54.119 scenario. Croup sounds worse than it looks. Epiglottitis 00:18:54.119 --> 00:18:55.940 looks worse than it sounds until it stops sounding 00:18:55.940 --> 00:18:57.789 like anything at all. Give me the one -liner 00:18:57.789 --> 00:19:00.250 on the path though. It's bacterial, almost always 00:19:00.250 --> 00:19:03.849 haemophilus influenza type B or Hib. The epiglottis, 00:19:03.930 --> 00:19:06.029 that little flap of cartilage that covers your 00:19:06.029 --> 00:19:08.730 windpipe when you swallow, gets infected and 00:19:08.730 --> 00:19:12.529 swells up like a giant inflamed cherry red cherry. 00:19:12.569 --> 00:19:14.410 And if it swells too much, it just acts like 00:19:14.410 --> 00:19:16.329 a cork in a bottle. It completely occludes the 00:19:16.329 --> 00:19:18.869 airway. Total obstruction. Game over. This is 00:19:18.869 --> 00:19:21.190 a can't miss, drop everything emergency. So how 00:19:21.190 --> 00:19:23.890 do we spot this? The sources consistently list 00:19:23.890 --> 00:19:28.539 the four Ds. Yes. Dysphonia, a muffled, quiet 00:19:28.539 --> 00:19:30.799 voice, often described as a hot potato voice, 00:19:30.900 --> 00:19:32.240 like they're trying to talk with a hot potato 00:19:32.240 --> 00:19:36.000 in their mouth. Dysphagia, they have severe pain 00:19:36.000 --> 00:19:38.200 on swallowing, so they can't swallow at all, 00:19:39.140 --> 00:19:41.160 which leads to the third D, drooling, because 00:19:41.160 --> 00:19:43.380 they can't swallow their own spit. It just runs 00:19:43.380 --> 00:19:46.759 out of their mouth. And the fourth D is distress. 00:19:48.099 --> 00:19:49.900 Respiratory distractor. At the posture, there's 00:19:49.900 --> 00:19:52.059 a classic look, right? The tripod position. You 00:19:52.059 --> 00:19:54.140 will never forget it if you see it. They are 00:19:54.140 --> 00:19:56.279 sitting bolt upright, hands on their knees or 00:19:56.279 --> 00:19:58.720 the bed, leaning forward and jetting their jaw 00:19:58.720 --> 00:20:00.940 out. They're physically trying to pull their 00:20:00.940 --> 00:20:03.319 airway open using gravity and muscle. They look 00:20:03.319 --> 00:20:06.240 terrified. Okay, here is arguably the most important 00:20:06.240 --> 00:20:09.299 single rule in this entire deep dive. If you 00:20:09.299 --> 00:20:12.119 suspect epiglottitis, there is one thing you 00:20:12.119 --> 00:20:15.809 must never... Never, under any circumstances, 00:20:16.009 --> 00:20:18.789 put a tongue blade, a throat swab, or any kind 00:20:18.789 --> 00:20:20.589 of instrument into that child's mouth. Do not 00:20:20.589 --> 00:20:22.569 try to visualize the throat. Do not ask them 00:20:22.569 --> 00:20:25.690 to say, ah. Why not? I mean, assessment is usually 00:20:25.690 --> 00:20:27.890 good, right? Getting a look is important. Not 00:20:27.890 --> 00:20:30.910 here. The stimulation of the gag reflex or even 00:20:30.910 --> 00:20:33.829 just touching that inflamed epiglottis can trigger 00:20:33.829 --> 00:20:37.049 a complete laryngospasm. The airway will slam 00:20:37.049 --> 00:20:40.210 shut. And because it's so swollen and didymidous, 00:20:40.509 --> 00:20:43.009 you cannot bag mask, ventilate them. You cannot 00:20:43.009 --> 00:20:46.089 easily intubate them. You have just lost the 00:20:46.089 --> 00:20:48.690 airway completely. So if the exam question asks, 00:20:49.210 --> 00:20:52.470 the nurse suspects epiglottitis, what is the 00:20:52.470 --> 00:20:54.769 priority action? The answer is almost always 00:20:54.769 --> 00:20:56.789 something like, do nothing to upset the child 00:20:56.789 --> 00:20:59.710 or keep the child calm and prepare for emergency 00:20:59.710 --> 00:21:02.509 airway management. You do not inspect the throat. 00:21:02.869 --> 00:21:04.690 You keep them with their parents. You let them 00:21:04.690 --> 00:21:07.029 stay in their position of comfort. You call for 00:21:07.029 --> 00:21:09.789 help, anesthesia and ENT and you get them to 00:21:09.789 --> 00:21:11.950 the operating room for a controlled intubation. 00:21:12.309 --> 00:21:14.410 And thankfully we see less of this now than we 00:21:14.410 --> 00:21:16.329 used to. Yes. This is one of the great victories 00:21:16.329 --> 00:21:18.630 of modern medicine. The Hive vaccine, which starts 00:21:18.630 --> 00:21:21.230 at two months, has made bacterial epiglottitis 00:21:21.230 --> 00:21:24.279 incredibly rare in vaccinated populations. But 00:21:24.279 --> 00:21:26.859 you still see it, so you have to know it. Developmentally, 00:21:27.000 --> 00:21:29.119 if you have a child in that tripod position, 00:21:29.460 --> 00:21:32.500 drooling, looking toxic. You do not leave their 00:21:32.500 --> 00:21:35.680 side. Your job is to be the calm in the storm. 00:21:36.180 --> 00:21:38.200 You keep the parents there to keep the child 00:21:38.200 --> 00:21:41.000 calm. Crying makes the swelling and the obstruction 00:21:41.000 --> 00:21:44.400 worse. Your entire job is to be the zen master 00:21:44.400 --> 00:21:47.500 until that airway is secure. Okay, wow. Moving 00:21:47.500 --> 00:21:50.819 down from the throat into the chest. Bronchiolitis. 00:21:52.090 --> 00:21:56.690 AKA RSV. Ah, respiratory syncytial virus. This 00:21:56.690 --> 00:21:59.329 is the scourge of every pediatric unit in the 00:21:59.329 --> 00:22:01.089 winter. So what's actually happening inside the 00:22:01.089 --> 00:22:03.529 lungs here? This is a lower airway problem. Right. 00:22:03.680 --> 00:22:06.019 This attacks the bronchioles, the tiniest little 00:22:06.019 --> 00:22:08.539 airways that lead to the alveoli. It causes inflammation, 00:22:08.799 --> 00:22:10.460 sure, but the main problem is that it causes 00:22:10.460 --> 00:22:13.500 the production of tons and tons of thick, sticky 00:22:13.500 --> 00:22:16.740 mucus. And it also causes sloughing of the dead 00:22:16.740 --> 00:22:19.440 epithelial cells from the airway lining. So the 00:22:19.440 --> 00:22:21.019 airways are getting clogged with all this debris. 00:22:21.240 --> 00:22:23.099 Exactly. It's like trying to breathe through 00:22:23.099 --> 00:22:25.420 a straw filled with rubber cement. And because 00:22:25.420 --> 00:22:27.519 babies have those tiny airways to begin with, 00:22:27.559 --> 00:22:30.200 they get air trapping. They can get air in past 00:22:30.200 --> 00:22:33.890 the mucus, but they can't get it back out. hyperinflated 00:22:33.890 --> 00:22:36.009 and they have to work incredibly hard to breathe. 00:22:36.210 --> 00:22:38.549 And who gets this the worst? It's most severe 00:22:38.549 --> 00:22:40.930 in infants under two years of age and especially 00:22:40.930 --> 00:22:43.329 in premature babies or those with underlying 00:22:43.329 --> 00:22:45.630 heart or lung disease. So what is the need -to 00:22:45.630 --> 00:22:48.410 -know assessment? What does an RSV baby look 00:22:48.410 --> 00:22:52.720 like? It's a wet messy disease. First, Reineria, 00:22:53.119 --> 00:22:55.579 a runny nose like you wouldn't believe, just 00:22:55.579 --> 00:22:58.259 copious, thick nasal secretions. Then you'll 00:22:58.259 --> 00:23:01.640 hear wheezing, a horrible hacking cough. And 00:23:01.640 --> 00:23:03.720 because they're working so hard, you'll see tachypnea 00:23:03.720 --> 00:23:06.400 and retractions. And the sources all mention 00:23:06.400 --> 00:23:09.359 a specific risk related to feeding. Yes, this 00:23:09.359 --> 00:23:12.099 is critical. Remember, infants are nose breathers, 00:23:12.299 --> 00:23:14.740 and they have to coordinate that complex suck 00:23:14.740 --> 00:23:16.880 -swallow -breath pattern. If they're touch -and 00:23:16.880 --> 00:23:19.460 -nake breathing 60, 70, even 80 times a minute, 00:23:19.500 --> 00:23:22.079 and their nose is completely full of snot, they 00:23:22.079 --> 00:23:24.200 cannot safely eat. They'll aspirate. They'll 00:23:24.200 --> 00:23:25.779 aspirate, or they'll just get too tired and give 00:23:25.779 --> 00:23:29.579 up. So dehydration is a major, major secondary 00:23:29.579 --> 00:23:31.660 issue. So what's the number one priority intervention 00:23:31.660 --> 00:23:34.730 then? Suction. The snot sucker. The nasopharyngeal 00:23:34.730 --> 00:23:37.190 suctioning. Before they eat, before they sleep, 00:23:37.609 --> 00:23:39.430 and anytime they look like they're in distress, 00:23:39.829 --> 00:23:41.809 you have to clear the path for air. It's often 00:23:41.809 --> 00:23:44.529 more effective than oxygen. What about medications? 00:23:44.589 --> 00:23:48.069 Do we give antibiotics? No. It's a virus. Antibiotics 00:23:48.069 --> 00:23:49.950 will do absolutely nothing. It's a common mistake, 00:23:49.950 --> 00:23:53.069 but it's incorrect. OK. What about bronchodilators, 00:23:53.470 --> 00:23:56.710 like albuterol? We use that for wheezing in asthma. 00:23:56.869 --> 00:23:59.470 This is controversial. The official sources and 00:23:59.470 --> 00:24:01.569 guidelines say it's not generally recommended, 00:24:01.730 --> 00:24:04.269 but you will sometimes see a trial dose given. 00:24:04.599 --> 00:24:06.599 The reason it's often ineffective is that the 00:24:06.599 --> 00:24:09.700 problem in RSV isn't primarily bronchoconstriction, 00:24:09.799 --> 00:24:12.900 a muscle spasm. The problem is obstruction from 00:24:12.900 --> 00:24:15.779 mucus and debris. So relaxing the muscle doesn't 00:24:15.779 --> 00:24:17.960 clear the mucus plug. So it's really just supportive 00:24:17.960 --> 00:24:20.680 care. Oxygen, suction, and hydration. That's 00:24:20.680 --> 00:24:24.000 the core of it. And isolation. RSV is incredibly 00:24:24.000 --> 00:24:26.680 contagious and spreads like wildfire on a pediatric 00:24:26.680 --> 00:24:29.839 floor. It requires contact and droplet precautions. 00:24:29.880 --> 00:24:33.039 That means gown, gloves, and a mask. And it's 00:24:33.039 --> 00:24:35.859 nice to know. There is a way to prevent this 00:24:35.859 --> 00:24:38.500 in high -risk kids, right? Yes. There's a medication 00:24:38.500 --> 00:24:41.480 called Pellivizumab, brand name Sinages, or the 00:24:41.480 --> 00:24:44.839 newer Nursivamab. These are monoclonal antibodies. 00:24:45.460 --> 00:24:48.279 They are given as monthly injections to preemies 00:24:48.279 --> 00:24:51.039 or babies with significant heart or lung disease 00:24:51.039 --> 00:24:54.019 during RSV season to give them passive immunity 00:24:54.019 --> 00:24:57.339 and prevent severe infection. It's not a vaccine 00:24:57.339 --> 00:24:59.680 in the traditional sense, but it's very effective. 00:24:59.920 --> 00:25:02.839 OK, let's move on to pneumonia. Right. The definition 00:25:02.839 --> 00:25:05.660 here is inflammation of the lung parenchyma. 00:25:05.740 --> 00:25:07.920 Basically, the alveoli, those little air sacs, 00:25:08.019 --> 00:25:10.519 fill up with fluid or pus. And this can be viral 00:25:10.519 --> 00:25:13.059 or bacterial? It can be either, and the presentation 00:25:13.059 --> 00:25:15.720 can vary. In younger kids, it's often viral and 00:25:15.720 --> 00:25:18.660 follows a cold. In older kids and teens, we start 00:25:18.660 --> 00:25:21.819 to see more bacterial causes, like mycoplasma, 00:25:21.920 --> 00:25:24.259 the walking pneumonia, or strep pneumo. What's 00:25:24.259 --> 00:25:26.200 the classic assessment for pneumonia? A high 00:25:26.200 --> 00:25:28.859 fever, a cough, which can be productive with 00:25:28.859 --> 00:25:32.140 colored or just dry and hacking, to chipnia is 00:25:32.140 --> 00:25:34.619 a big one. Sometimes chest pain, especially with 00:25:34.619 --> 00:25:37.559 breathing. And remember our sound map from before, 00:25:37.940 --> 00:25:41.000 crackles, or what we call dullness on percussion. 00:25:41.660 --> 00:25:44.079 Tapping on the chest over the affected area will 00:25:44.079 --> 00:25:45.940 sound dull because you're tapping over fluid, 00:25:46.200 --> 00:25:48.200 not air. And what are the key interventions? 00:25:48.579 --> 00:25:51.400 It depends on the severity. Oxygen for hypoxemia, 00:25:51.500 --> 00:25:55.220 for sure. Antibiotics, if it's bacterial. Antipyretics 00:25:55.220 --> 00:25:58.599 like Tylenol for the fever. And fluids, fluids, 00:25:58.740 --> 00:26:01.640 fluids to thin the secretions. And positioning 00:26:01.640 --> 00:26:04.759 is also important. The sources mention splinting. 00:26:05.099 --> 00:26:07.660 What is that? If a child has chest pain from 00:26:07.660 --> 00:26:10.059 the coughing or pleural irritation, having them 00:26:10.059 --> 00:26:12.380 hug a pillow or a stuffed animal tightly against 00:26:12.380 --> 00:26:14.359 their chest when they cough, that's splinting. 00:26:14.660 --> 00:26:17.279 It helps to brace the chest wall and manage the 00:26:17.279 --> 00:26:18.960 pain so they can take a deeper, more effective 00:26:18.960 --> 00:26:21.579 cough to clear secretions. OK, that's a great 00:26:21.579 --> 00:26:23.619 practical tip. Let's talk about a huge chronic 00:26:23.619 --> 00:26:26.730 one. Asthma. The most common chronic disease 00:26:26.730 --> 00:26:29.130 of childhood. You will see this everywhere. The 00:26:29.130 --> 00:26:31.730 sources define it as a chronic inflammatory disorder 00:26:31.730 --> 00:26:34.289 with reversible airway obstruction. And that 00:26:34.289 --> 00:26:37.230 word reversible is the absolute key. It sets 00:26:37.230 --> 00:26:40.190 it apart from things like CF or anatomical defects. 00:26:40.490 --> 00:26:42.890 It comes and goes. The airway can be completely 00:26:42.890 --> 00:26:45.470 normal between attacks, but it's always hyper 00:26:45.470 --> 00:26:48.089 responsive to triggers. And the patho involves 00:26:48.089 --> 00:26:51.369 three things. The asthma triad. Yes, you have 00:26:51.369 --> 00:26:54.220 to know these three. Inflammation. The airway 00:26:54.220 --> 00:26:56.359 lining is always chronically swollen and angry. 00:26:56.920 --> 00:27:00.220 You have mucus production thick, tenacious mucus. 00:27:00.680 --> 00:27:03.440 And you have bronchoconstriction. The smooth 00:27:03.440 --> 00:27:06.619 muscle wrapped around the airway spasms and squeezes 00:27:06.619 --> 00:27:09.259 them shut. So how do we treat this three -headed 00:27:09.259 --> 00:27:12.029 monster? The sources outline a tiered system 00:27:12.029 --> 00:27:15.089 of medications. This is the absolute bread and 00:27:15.089 --> 00:27:16.950 butter of asthma management. You have rescue 00:27:16.950 --> 00:27:18.789 meds and you have maintenance meds and you must 00:27:18.789 --> 00:27:20.750 know the difference. It's a huge safety issue. 00:27:20.890 --> 00:27:22.450 Let's start with the rescue meds. These are the 00:27:22.450 --> 00:27:25.549 short -acting beta agonists, the SAPAs. Albuterol 00:27:25.549 --> 00:27:28.210 is the prototype. This is your in case of fire 00:27:28.210 --> 00:27:30.710 break glass medication. It works within minutes 00:27:30.710 --> 00:27:33.369 to relax that squeezed smooth muscle and open 00:27:33.369 --> 00:27:35.190 the airway. What are the side effects parents 00:27:35.190 --> 00:27:37.740 should know about? It revs you up. It can cause 00:27:37.740 --> 00:27:41.339 tachycardia, jitters, a feeling of anxiety, even 00:27:41.339 --> 00:27:44.559 hyperactivity in some kids. Parents need to know 00:27:44.559 --> 00:27:47.420 this is a normal and expected side effect. Otherwise, 00:27:47.640 --> 00:27:49.720 they get scared and might not give a medication 00:27:49.720 --> 00:27:52.740 that their child desperately needs. OK. And the 00:27:52.740 --> 00:27:55.839 maintenance meds? The controllers? These are 00:27:55.839 --> 00:27:57.440 the meds that prevent the fire from starting 00:27:57.440 --> 00:27:59.759 in the first place. They treat the underlying 00:27:59.759 --> 00:28:03.390 inflammation. The cornerstone of this is inhaled 00:28:03.390 --> 00:28:06.549 corticosteroids, like fluticasone. Or you might 00:28:06.549 --> 00:28:09.430 see leukotriene modifiers, like Montelucast brand 00:28:09.430 --> 00:28:11.490 name Singulair. And what's the most important 00:28:11.490 --> 00:28:13.970 teaching point for those inhaled steroids? Rinse 00:28:13.970 --> 00:28:16.529 the mouth out with water after every single use. 00:28:16.930 --> 00:28:19.089 If the steroid medication sits on the tongue 00:28:19.089 --> 00:28:21.849 and oral mucosa, it can suppress the normal flora 00:28:21.849 --> 00:28:24.609 and lead to thrush a painful oral fungal yeast 00:28:24.609 --> 00:28:27.309 infection. So just to be crystal clear, do you 00:28:27.309 --> 00:28:29.589 ever use a control or medication for an acute 00:28:29.589 --> 00:28:32.119 attack? Never. Absolutely not. It's a common 00:28:32.119 --> 00:28:33.839 and dangerous mistake. It won't work fast enough. 00:28:34.259 --> 00:28:36.839 If a kid is gasping for air, you give them albuterol, 00:28:36.920 --> 00:28:38.920 not fluticasone. Let's talk about the equipment. 00:28:39.759 --> 00:28:43.500 Spacers. The sources all have pictures of a metered 00:28:43.500 --> 00:28:47.039 dose inhaler, an MDI, with a spacer chamber attached. 00:28:47.420 --> 00:28:50.519 Why is that so important? A spacer is non -negotiable 00:28:50.519 --> 00:28:52.799 for kids. Honestly, it should be for most adults, 00:28:53.079 --> 00:28:55.960 too. Without it, the medicine, which comes out 00:28:55.960 --> 00:28:58.279 of the MDI at about 60 miles per hour, just hits 00:28:58.279 --> 00:29:00.160 the back of the tongue and gets swallowed. So 00:29:00.160 --> 00:29:02.900 it doesn't even get to the lungs. Barely. With 00:29:02.900 --> 00:29:05.700 a spacer, it holds the aerosolized mist in the 00:29:05.700 --> 00:29:08.400 chamber, allowing the child to take a slow, deep 00:29:08.400 --> 00:29:10.940 breath and inhale it deep down into the small 00:29:10.940 --> 00:29:13.539 airways where it needs to go. It increases the 00:29:13.539 --> 00:29:16.519 drug delivery efficiency by a huge margin. In 00:29:16.519 --> 00:29:18.660 the peak flow meter. This is like a traffic light 00:29:18.660 --> 00:29:21.130 system for their breathing. It is. It's an objective 00:29:21.130 --> 00:29:23.529 measure of how open their airways are. Green 00:29:23.529 --> 00:29:26.710 zone is 80 to 100 percent of their personal best 00:29:26.710 --> 00:29:28.769 number. They're good to go. Okay. Yellow zone 00:29:28.769 --> 00:29:31.349 is 50 to 79 percent. This is a caution sign. 00:29:31.750 --> 00:29:34.190 The airway is tightening. The asthma action plan 00:29:34.190 --> 00:29:36.589 will say to use the rescue inhaler, albuterol. 00:29:36.650 --> 00:29:39.170 And red zone. That's below 50 percent of their 00:29:39.170 --> 00:29:42.609 personal best. This is a medical alert. Danger. 00:29:42.920 --> 00:29:45.920 The plan will say to use the rescue inhaler immediately 00:29:45.920 --> 00:29:48.099 and call the doctor or go straight to the emergency 00:29:48.099 --> 00:29:52.099 department. This sounds like a Harry Potter spell, 00:29:52.119 --> 00:29:54.960 but it's really bad. It means the asthma attack 00:29:54.960 --> 00:29:57.319 isn't breaking. It's refractory to treatment. 00:29:57.680 --> 00:30:00.380 They've had multiple doses of albuterol and they're 00:30:00.380 --> 00:30:03.799 still in severe distress. This is a medical emergency 00:30:03.799 --> 00:30:07.039 that requires IV magnesium sulfate to help relax 00:30:07.039 --> 00:30:10.380 that smooth muscle as well as continuous nebulizers 00:30:10.380 --> 00:30:13.539 and high dose systemic steroids. Developmentally. 00:30:13.789 --> 00:30:16.230 How does chronic asthma impact a kid's life? 00:30:16.490 --> 00:30:18.930 It has a huge impact. It's a leading cause of 00:30:18.930 --> 00:30:21.509 school absenteeism. It can lead to exclusion 00:30:21.509 --> 00:30:23.670 from sports if it's not well managed, though 00:30:23.670 --> 00:30:25.529 with a good plan they absolutely should play 00:30:25.529 --> 00:30:28.730 sports, just pre -medicate before exercise. And 00:30:28.730 --> 00:30:31.670 there's a concern about growth. Long -term, high 00:30:31.670 --> 00:30:34.369 -dose systemic steroid use can slow bone growth, 00:30:34.410 --> 00:30:36.430 so we have to monitor their height carefully. 00:30:36.650 --> 00:30:39.289 Okay, we have to shift gears to a genetic heavyweight. 00:30:39.940 --> 00:30:42.759 Cystic fibrosis or CF. This is a multi -system 00:30:42.759 --> 00:30:44.680 disorder. It's so much more than just the lungs. 00:30:45.099 --> 00:30:47.599 And it's autosomal recessive. Meaning both parents 00:30:47.599 --> 00:30:49.960 must be carriers of the faulty gene. And if they 00:30:49.960 --> 00:30:52.359 are, there's a 25 % chance with each and every 00:30:52.359 --> 00:30:55.160 pregnancy that the child will have CF. The patho 00:30:55.160 --> 00:30:57.720 is fascinating. It's a defect in a chloride channel. 00:30:57.940 --> 00:31:01.460 Right, the CFTR protein. In very simple terms, 00:31:01.619 --> 00:31:03.900 the cells can't move chloride, which is a component 00:31:03.900 --> 00:31:07.579 of salt, and by extension water, properly across 00:31:07.579 --> 00:31:11.059 the cell membrane. The result is that mucus secretions 00:31:11.059 --> 00:31:13.519 everywhere in the lungs, the pancreas, the gut, 00:31:13.700 --> 00:31:16.380 the reproductive tract, become incredibly thick, 00:31:16.839 --> 00:31:19.480 sticky, and dehydrated. It's like trying to move 00:31:19.480 --> 00:31:21.980 cement. How is it diagnosed? The gold standard 00:31:21.980 --> 00:31:25.079 is the sweat chloride test. Because the sweat 00:31:25.079 --> 00:31:27.539 glands can't reabsorb the chloride, their sweat 00:31:27.539 --> 00:31:30.160 is incredibly salty. Parents will often be the 00:31:30.160 --> 00:31:32.140 first to notice, saying, when I kiss my baby, 00:31:32.220 --> 00:31:39.660 he tastes like salt. Let's break down the management 00:31:39.660 --> 00:31:41.980 of this. It's intense. Let's start with the respiratory 00:31:41.980 --> 00:31:44.759 side. They need aggressive pulmonary toilet, 00:31:45.619 --> 00:31:48.960 a daily routine to clean out the lungs. The cornerstone 00:31:48.960 --> 00:31:52.380 of this is chest physiotherapy, or CPT. This 00:31:52.380 --> 00:31:54.579 can be done with cupped hands, percussing on 00:31:54.579 --> 00:31:57.519 the chest wall, or more commonly now with a high 00:31:57.519 --> 00:32:00.579 frequency chest wall oscillation vest. The shaker 00:32:00.579 --> 00:32:03.019 vest? The shaker vest. It vibrates at a high 00:32:03.019 --> 00:32:05.200 frequency to loosen that thick mucus from the 00:32:05.200 --> 00:32:06.859 airway walls. And how often do they have to do 00:32:06.859 --> 00:32:09.819 this? Every single day. Often twice a day for 00:32:09.819 --> 00:32:12.299 20 to 30 minutes each time. When they get sick, 00:32:12.460 --> 00:32:14.640 it can be up to four times a day. It's a huge 00:32:14.640 --> 00:32:17.299 burden of care. And the sequence of medications 00:32:17.299 --> 00:32:19.440 and treatments matters here, doesn't it? Critically. 00:32:19.609 --> 00:32:21.990 You give the bronchodilator, like albuterol, 00:32:22.230 --> 00:32:24.630 first to open up the airways as much as possible. 00:32:25.109 --> 00:32:27.589 Then you might give an inhaled mucolytic, like 00:32:27.589 --> 00:32:29.910 door nose alpha, which is an enzyme that acts 00:32:29.910 --> 00:32:32.029 like molecular scissors to chop up the thick 00:32:32.029 --> 00:32:34.809 mucus. Then you do the CPT to shake it all loose. 00:32:35.009 --> 00:32:37.470 And finally, you have them do huff coughing to 00:32:37.470 --> 00:32:41.390 get it up and out. Wow. Now, the GI side, this 00:32:41.390 --> 00:32:43.349 is where the exams love to test because it's 00:32:43.349 --> 00:32:46.220 so unique to CF. The same thick muphous that 00:32:46.220 --> 00:32:49.019 clogs the lungs also clogs the tiny ducts of 00:32:49.019 --> 00:32:51.880 the pancreas. So the digestive enzymes that the 00:32:51.880 --> 00:32:54.259 pancreas makes, the ones needed to break down 00:32:54.259 --> 00:32:56.920 fat, protein, and carbs, can't get to the food 00:32:56.920 --> 00:33:00.079 in the intestine. So the child eats, but they 00:33:00.079 --> 00:33:03.140 can't digest or absorb the nutrients, resulting 00:33:03.140 --> 00:33:06.859 in... Two things. First, statorrhea, which is 00:33:06.859 --> 00:33:09.859 fatty, frothy, foul -smelling, floating stools. 00:33:10.339 --> 00:33:13.539 And second, failure to thrive. They are literally 00:33:13.539 --> 00:33:16.980 starving despite having a ravenous appetite. 00:33:17.180 --> 00:33:19.240 So the key intervention is replacing those missing 00:33:19.240 --> 00:33:21.920 enzymes. Yes. They must take pancreatic enzymes 00:33:21.920 --> 00:33:25.180 in capsule form with every single meal and every 00:33:25.180 --> 00:33:27.420 single snack. Every single snack. They eat one 00:33:27.420 --> 00:33:29.650 cracker. If they eat one cracker, they take enzymes. 00:33:29.809 --> 00:33:31.410 If they have a glass of milk, they take enzymes. 00:33:31.529 --> 00:33:33.690 Otherwise, they don't absorb the nutrients. For 00:33:33.690 --> 00:33:35.549 babies and young children, you can open the capsule 00:33:35.549 --> 00:33:37.910 and sprinkle the little beads on a non -alkaline 00:33:37.910 --> 00:33:40.109 food like applesauce, but you must teach parents 00:33:40.109 --> 00:33:41.930 not to let them chew the beads because they are 00:33:41.930 --> 00:33:43.970 enteric -coated and can burn the mouth. On the 00:33:43.970 --> 00:33:46.609 diet itself, usually for chronic diseases, we 00:33:46.609 --> 00:33:50.069 think low fat, low salt. CF is the complete opposite. 00:33:50.490 --> 00:33:53.329 They need a high calorie, high protein, unrestricted 00:33:53.329 --> 00:33:56.599 fat diet, and they need extra salt. Because they 00:33:56.599 --> 00:33:58.640 lose so much salt in their sweat, they are at 00:33:58.640 --> 00:34:01.119 constant risk for hyponatremia, especially when 00:34:01.119 --> 00:34:03.279 it's hot or they have a fever. That is such a 00:34:03.279 --> 00:34:05.180 crucial counterintuitive fact that makes for 00:34:05.180 --> 00:34:07.500 a perfect exam question. It really does. Also, 00:34:07.599 --> 00:34:09.980 they need supplemental fat -soluble vitamins 00:34:09.980 --> 00:34:14.119 A, D, E, and K. Since they don't absorb fat well, 00:34:14.239 --> 00:34:16.519 they can't absorb these vitamins from food, so 00:34:16.519 --> 00:34:18.559 they need to take special water -soluble forms 00:34:18.559 --> 00:34:21.579 of them to prevent deficiencies. One last specific 00:34:21.579 --> 00:34:27.509 need to know on CF. sign in a newborn. Meconium 00:34:27.509 --> 00:34:30.449 ileus. This is when the baby doesn't pass that 00:34:30.449 --> 00:34:33.289 first sticky black stool, the meconium, within 00:34:33.289 --> 00:34:36.750 the first 24 to 48 hours. It's because the meconium 00:34:36.750 --> 00:34:39.110 is even thicker and stickier than usual and it 00:34:39.110 --> 00:34:41.949 gets stuck, causing an intestinal blockage. About 00:34:41.949 --> 00:34:44.489 10 to 20 percent of babies with CF will present 00:34:44.489 --> 00:34:46.570 with this at birth. That is heavy stuff. Let's 00:34:46.570 --> 00:34:48.670 do a quick hit on a couple of acute issues. First, 00:34:48.949 --> 00:34:51.050 foreign body aspiration. Toddlers put everything 00:34:51.050 --> 00:34:52.590 in their mouths. It's a developmental stage. 00:34:53.070 --> 00:34:55.190 If they inhale something small like a peanut, 00:34:55.469 --> 00:34:58.449 a piece of a hot dog or a toy part, where does 00:34:58.449 --> 00:35:00.710 it most likely go? It goes to the right bronchus. 00:35:00.889 --> 00:35:03.469 Correct. The anatomy dictates this. The right 00:35:03.469 --> 00:35:06.610 main stem bronchus is shorter, wider, and straighter 00:35:06.610 --> 00:35:09.250 than the left. So gravity and momentum favor 00:35:09.250 --> 00:35:12.070 the right side. So you'll often hear diminished 00:35:12.070 --> 00:35:14.670 breath sounds or localized wheeze on the right 00:35:14.670 --> 00:35:17.630 side specifically. And epistaxis, the simple 00:35:17.630 --> 00:35:20.670 nosebleed. A classic playground injury. And the 00:35:20.670 --> 00:35:23.369 old Old advice from our grandparents was, tilt 00:35:23.369 --> 00:35:25.829 your head back. Which is wrong. Very wrong. And 00:35:25.829 --> 00:35:28.130 potentially dangerous. That just makes all the 00:35:28.130 --> 00:35:29.630 blood run down the back of their throat, which 00:35:29.630 --> 00:35:32.409 can cause nausea, vomiting, and a risk for aspiration. 00:35:32.889 --> 00:35:35.210 The correct position is to have them sit up and 00:35:35.210 --> 00:35:38.150 lean forward. Lean forward. Yes. And pinch the 00:35:38.150 --> 00:35:40.710 soft, fleshy part of the nose. Not the bony bridge, 00:35:40.809 --> 00:35:43.849 but the soft cartilage below it. And hold continuous 00:35:43.849 --> 00:35:47.289 pressure for 10 solid minutes. No peeking. OK. 00:35:47.420 --> 00:35:49.679 We have covered the systems. This is great. Let's 00:35:49.679 --> 00:35:53.300 move to section C, crosslinking and comparisons. 00:35:54.219 --> 00:35:56.039 This is where we synthesize and make sure we 00:35:56.039 --> 00:35:58.780 don't get these conditions confused. Let's compare 00:35:58.780 --> 00:36:01.320 croup versus epiglottitis again just to hammer 00:36:01.320 --> 00:36:03.340 it home because they both present with stridor 00:36:03.340 --> 00:36:06.300 and confusing them is dangerous. Okay, lay it 00:36:06.300 --> 00:36:09.599 out for me. Croup. Croup? It has that loud barking 00:36:09.599 --> 00:36:12.000 cough. The patient sounds way worse than they 00:36:12.000 --> 00:36:14.840 actually look. The treatment is supportive with 00:36:14.840 --> 00:36:18.659 cool mist and, if needed, racemic epi and steroids. 00:36:18.780 --> 00:36:21.119 Yeah, epiglottitis. Epiglottitis. There is no 00:36:21.119 --> 00:36:23.340 cough. The room is quiet. The patient looks toxic. 00:36:23.460 --> 00:36:25.519 They're in the tripod position. They're grueling. 00:36:25.820 --> 00:36:27.940 The treatment is protecting the airway and IV 00:36:27.940 --> 00:36:31.360 antibiotics. Perfect. Next pair. Asthma versus 00:36:31.360 --> 00:36:34.539 bronchiolitis. Both have wheezing. They do. But 00:36:34.539 --> 00:36:37.159 asthma is usually related to an allergic or chronic 00:36:37.159 --> 00:36:39.980 trigger. The cough is often dry. And the treatment 00:36:39.980 --> 00:36:43.179 is with bronchodilators and steroids. It responds 00:36:43.179 --> 00:36:46.599 well to albuterol. And bronchiolitis. Bronchiolitis 00:36:46.599 --> 00:36:48.800 is viral and seasonal. You see it in the winter. 00:36:49.000 --> 00:36:51.739 It's a very wet disease with tons of secretions. 00:36:52.059 --> 00:36:54.940 And the treatment is primarily supportive. suction, 00:36:55.239 --> 00:36:57.719 and hydration. It often doesn't respond well 00:36:57.719 --> 00:36:59.980 to the albuterol. And finally, let's compare 00:36:59.980 --> 00:37:02.800 the logic of the tent versus the vest. Right. 00:37:03.039 --> 00:37:06.340 We use humidity, like a mist tent or a cool mist 00:37:06.340 --> 00:37:08.860 humidifier for upper airway swelling, like in 00:37:08.860 --> 00:37:12.599 croup. The goal is to soothe the inflamed mucosa. 00:37:12.739 --> 00:37:17.179 OK. We use percussion, the vest, or manual CPT 00:37:17.179 --> 00:37:20.199 for lower airway mucus plugging, like in CF or 00:37:20.199 --> 00:37:23.059 pneumonia. The goal is to physically shake the 00:37:23.059 --> 00:37:25.469 mucus loose. so it can be coughed out. You would 00:37:25.469 --> 00:37:28.030 generally not do CTT on a kid with Croof. It 00:37:28.030 --> 00:37:29.869 would just agitate them and make the stridor 00:37:29.869 --> 00:37:32.590 much worse. That is excellent clinical judgment 00:37:32.590 --> 00:37:35.610 right there. One last link. Development. We've 00:37:35.610 --> 00:37:36.949 touched on it throughout, but it's important 00:37:36.949 --> 00:37:39.429 to remember that any hospitalization for a serious 00:37:39.429 --> 00:37:41.869 respiratory illness can cause regression in kids. 00:37:42.150 --> 00:37:44.510 You mean the toddler who is perfectly potty trained 00:37:44.510 --> 00:37:46.880 suddenly starts wetting the bed again. Totally 00:37:46.880 --> 00:37:49.679 normal. It's a stress response. Don't shame them 00:37:49.679 --> 00:37:51.619 and support the parents in understanding that 00:37:51.619 --> 00:37:55.980 and for the teenager with CF or asthma The developmental 00:37:55.980 --> 00:37:58.739 task is all about identity and peer acceptance. 00:37:58.940 --> 00:38:01.639 It's all about compliance and body image They 00:38:01.639 --> 00:38:03.340 don't want to be different. They don't want to 00:38:03.340 --> 00:38:05.320 take pills or do an inhaler in front of their 00:38:05.320 --> 00:38:07.630 friends That's where the nurse has to become 00:38:07.630 --> 00:38:10.309 a negotiator and an educator, not just a task 00:38:10.309 --> 00:38:12.989 doer. Incredible. We have mapped the airway, 00:38:13.150 --> 00:38:15.429 we've dissected the diseases, and we've linked 00:38:15.429 --> 00:38:17.650 it all back to safety and development. We've 00:38:17.650 --> 00:38:19.650 covered the four millimeter straw, the frequent 00:38:19.650 --> 00:38:21.809 swallowing after tonsillectomy, the danger of 00:38:21.809 --> 00:38:23.989 the silent chest, and the importance of salty 00:38:23.989 --> 00:38:27.590 sweat. So as we wrap up this incredible deep 00:38:27.590 --> 00:38:30.250 dive, what is the one provocative thought you 00:38:30.250 --> 00:38:32.750 want to leave our listeners with to mull over? 00:38:32.909 --> 00:38:35.829 It's the concept of work of breathing versus 00:38:35.829 --> 00:38:39.369 oxygen saturation. New nurses and even experienced 00:38:39.369 --> 00:38:41.469 ones can get fixated on the monitor. They look 00:38:41.469 --> 00:38:44.389 up and say, oh, his O2 sat is 95%. He's fine. 00:38:44.489 --> 00:38:46.409 Right. The number looks good. But you have to 00:38:46.409 --> 00:38:48.889 look at the child. Is he retracting? Is he using 00:38:48.889 --> 00:38:51.510 his neck muscles? Is he grunting with every breath? 00:38:51.690 --> 00:38:54.530 Is his respiratory rate 60 times a minute? A 00:38:54.530 --> 00:38:56.929 child has a tremendous physiological reserve. 00:38:57.329 --> 00:39:00.309 They can maintain a normal O2 sat by, working 00:39:00.309 --> 00:39:03.300 incredibly, incredibly hard. right up until the 00:39:03.300 --> 00:39:05.440 moment they run out of energy. And then they 00:39:05.440 --> 00:39:08.239 crash. They don't drift down gently. They fall 00:39:08.239 --> 00:39:11.340 off a physiological cliff. They go from compensating 00:39:11.340 --> 00:39:13.840 to coding in a matter of minutes. So treat the 00:39:13.840 --> 00:39:16.579 patient, not the monitor. Exactly. If the work 00:39:16.579 --> 00:39:18.900 of breathing is high, that child is in danger. 00:39:19.000 --> 00:39:20.820 No matter what the number on the pulse oximeter 00:39:20.820 --> 00:39:23.460 says, your assessment of their work is a better 00:39:23.460 --> 00:39:25.500 predictor of their stability than that number 00:39:25.500 --> 00:39:27.820 is. That is a powerful and essential thought. 00:39:27.920 --> 00:39:30.599 Thank you for that deep dive. Listeners, go find 00:39:30.599 --> 00:39:32.719 that four millimeter straw and protect it. We'll 00:39:32.719 --> 00:39:34.579 see you on the next one. Stay safe out there.