What to do if a child experiences respiratory distress and discomfort after using a port (peripherally inserted central catheter) for about 5 minutes?

Managing Respiratory Distress After Port Access in a Child

When a child experiences coughing and discomfort for about 5 minutes after port access, immediate assessment of airway patency is essential, followed by appropriate interventions to ensure adequate oxygenation and ventilation. 1

Initial Assessment

Immediate Actions

• Assess for signs of respiratory distress:
  • Stridor
  • Accessory muscle use
  • Tracheal tug
  • Sternal, sub-costal and intercostal recession
  • Agitation or obvious distress 1
• Provide high-flow oxygen to the face 1
• Position the child appropriately to optimize airway patency
• Monitor oxygen saturation continuously

Possible Causes

1. Catheter tip migration or malposition - The port catheter may have migrated or become malpositioned, causing irritation to the trachea or bronchi
2. Air embolism - Small air bubbles introduced during port access
3. Reaction to flushing solution - Especially if heparinized saline is used
4. Port reservoir or catheter damage

Management Algorithm

Step 1: Assess Severity

• Mild symptoms (cough only, no significant respiratory distress, normal oxygen saturation):

  • Stop infusion if ongoing
  • Position child upright
  • Provide supplemental oxygen
  • Monitor vital signs

• Moderate to severe symptoms (significant respiratory distress, decreased oxygen saturation):

  • Call for immediate assistance
  • Ensure equipment for advanced airway management is available
  • Consider supraglottic airway device if needed for oxygenation 1

Step 2: Interventions Based on Suspected Cause

• If catheter malposition suspected:

  • Stop any infusion immediately
  • Consider chest X-ray to verify catheter position
  • Prepare for possible port revision if symptoms persist or recur

• If air embolism suspected:

  • Position patient in left lateral decubitus position with head down
  • Administer 100% oxygen
  • Monitor for cardiovascular compromise

• If reaction to flushing solution:

  • Consider changing to preservative-free normal saline for future access

Step 3: Follow-up Care

• Once acute symptoms resolve:
  • Document the event thoroughly
  • Consider port function assessment
  • Evaluate need for port revision or replacement if problems persist

Special Considerations

Port-Related Complications in Children

• Smaller children may have higher risk of complications, though recent evidence suggests weight under 10kg is not significantly associated with higher complication rates 2
• Frequent access to ports (≥3 per day over a 10-day period) is associated with an 8-fold increased risk of infection 3
• Port placement appears to be safe for most infants with acceptable rates of complications 4

Prevention of Future Episodes

• Ensure proper positioning during port access
• Use appropriate needle size for the port
• Flush slowly with normal saline
• Consider pre-medication with bronchodilators if episodes recur

Pitfalls and Caveats

• Do not ignore even mild symptoms as they may indicate catheter migration or damage
• Avoid forceful flushing if resistance is encountered, as this may worsen catheter malposition or cause catheter rupture
• Do not delay intervention if symptoms worsen or persist beyond 5 minutes
• Never clamp a bubbling chest drain if one is present, as this could lead to tension pneumothorax 1

Port-related respiratory symptoms are generally transient but require careful assessment and monitoring to ensure they do not represent a more serious complication requiring immediate intervention.