Acute Respiratory failure in children Rattapon Uppala, MD. Department of Pediatrics, Faculty of...

Acute Respiratory failure

in children

Rattapon Uppala, MD. Department of Pediatrics,

Faculty of Medicine, KKU

Classification

Type I : Hypoxemic respiratory failure

Type II : Hypercapnic respiratory failure

Type I Type II

Causes of respiratory failure

Criteria for Diagnosis

Clinical criteria

•↓ or absent respiratory breath sound

•Severe inspiratory retraction

•Cyanosis in 40% O2

•↓ Level of consciousness

•Poor skeletal muscle tone

Physiologic criteria •PaCO2 > 65 mm Hg

•PaO2 < 100 mm Hg in 50% O2

Acute respiratory failure = 3 Clinical + 1 Physiologic Raphaely R. 1981

Acute respiratory failure

Clinical manifestationsHypoxemia - tachycardia,

tachypnea, sweating, restlessness, hypotension

CO2 retention – headache, confusion, coma

Abnormal respiratory signs – stridor, adventitious sounds

Acute respiratory failure

Ventilatory failure: CO2 retention

- Disease of brain & spinal cord- Disease of peripheral nerve, muscle- Drug overdose- etc

Acute respiratory failure

Oxygenation failure: hypoxemia, low PaO2

- Upper airway obstructioncroup, laryngeal edema, etc

- Small airway diseases acute bronchiolitis, asthma, etc- Parenchymal diseases

ARDS – pneumonia, near-drowning, etc

Respiratory assessment

1. Spontaneous respiration Respiratory rate

Respiratory assessment

Respiratory rateAge 0-2 month: >60/minAge 2 mo – 1 year: >50/minAge 1-5 years: >40/min

Respiratory assessment

1. Spontaneous respiration Respiratory rate Chest movement Chest retraction Breath sounds Upper/lower airway obstruction:

stridor, wheezing

Respiratory assessment

1. Spontaneous respiration Respiratory rate Chest movement Chest retraction Breath sounds Upper/lower airway obstruction:

stridor, wheezing Cynaosis

Respiratory assessment

2. Assessment and plan for respiratory management

Inadequate ventilation or severe upper airway obstruction: intubation and MV

Adequate ventilation but inadequate gas exchange: oxygenation

Respiratory assessment

Gas exchange assessment– Arterial blood gases

Ventilation (PaCO2), oxygenation (PaO2), pH

– Pulse oximetryOxygenation (SpO2)

Respiratory management

Type I Type II

Respiratory distress

Upper airway obstruction:

stridor

lower airway diseases &

lung

Severe retraction

Endotracheal intubation

Not severe

Oxygenation

Improve Not improve

O2 via T-piece Mechanical ventilation

Find out and treat definite causes

Management RS diseases

Croup:

Definite: Dexamethasone 0.3-0.6 mg/kg single dose oral or IM

RS: assess severity – CROUP score Mild - O2 therapy

Moderate – epinephrine nebulization with O2 therapy

Severe – endotracheal intubation + O

2 therapy

Management RS diseases

Acute bronchiolitis:

Definite: No definite treatment

RS: O2 therapy

Optional - bronchodilator vs dexamethasone

Management RS diseases

Asthma:

Definite: bronchodilator – 2 agonist systemic corticosteroid – hydrocortisone/prednisolone

RS: not severe – O2 therapy

severe – mechanical ventilation

Management RS diseases

Pneumonia:

Definite: virus – no specific bacteria – antibiotics

RS: not very severe – O2 therapy

severe – mechanical ventilation

Management

Treat primary insult Adequate tissue oxygenation Oxygenation NIV Mechanical ventilation

Prevent complications

Management

Treat primary insult Adequate tissue oxygenation Oxygenation NIV Mechanical ventilation

Prevent complications

Inhalation therapyOxygen therapy

Normal airway

Warm gas to 34oC

Airgas + humidity

Diffusion

Gas transport to the periphery

Oxygen source

เครื่��องทำ��คว�มชื้��น1. Humidifier

• Pass over• Bubble • Heated

2. Nebulizer• Jet• Ultrasonic • Hand medical

Humidity

Aerosol

Humidity & Aerosol

Humidity (ไอน���)น้ำ���ที่��อยู่�ใน้ำสภ�วะของก๊��ซ (vapor)Aerosol (ฝอยละออง)น้ำ���หรื�อของเหลวที่��แขวน้ำลอยู่อยู่�ใน้ำอ�ก๊�ศ

หรื�อก๊��ซ (liquid particle)Aerosolization = nebulization

Humidifier

Unheated humidifier Bubble

Heated humidifier with mechanical ventilator

Bubble humidifier

ทำ�อน��ก๊��ซ

Heated humidifier

Nebulizer

Jet nebulizer Untrasonic nebulizer Medical nebulizer

Hand held Pressurized metered dose

inhaler(pMDI) Dry powder inhaler (DPI)

Jet nebulizer

ทำ�อน��ก๊��ซ Corrugated tube

High flow

Jet nebulizer

Ultrasonic nebulizer

Medical nebulizer

Oxygen therapy

1. Cannula

2. Simple mask

3. Mask with reservoir bag

4. Hood or box

5. T-piece

6. Mechanical ventilator

O2 Cannula

Bubble humidifier

O2 1 LPM ~ 4%

O2

Mask / with reservior

Bubble humidifie

rSimple mask 5-10 LMP ~ 35-50%Reservoir bag 6-10 LPM ~ 60-90%

Tracheotomy mask

Corrugated tube

O2 Box/Hood

O2 T-piece

Heatedhumidifie

r

Endotracheal intubation

Oxygen dissociation curveSaO2

PaO2

PaO2

SaO

2

60 9050 8040 70

Gas transport to the periphery

Complication of O2

therapy

Retinopathy of prematurity (ROP)

Bronchopulmonary dysplasis (BPD)

Absorptive atelectasis Apnea in COPD patient

Management

Treat primary insult Adequate tissu

e oxygenation Oxygenation NIV Mechanical ventilation

Prevent complications

NIV

High flow nasal cannula CPAP BiPAP

Mechanical ventilation

Low tidal volume Precaution if high FiO2 for more than

24 hour Lung recruitment strategy in ARDS High PEEP in ARDS Considered HFOV

ARDS

Berlin’s definitions

Acute onset within 7 days Bilateral opacities PF ratio less than 300

<300 = mild<200 = moderate<100 = severe

Exclude volume overload

Pathophysiology

Primary insult to lungs Direct injury : aspiration เชื้�น n

- ear drowning, gastric, hydroc arbon, etc

Indirect injury : sepsis, brain e dema, etc

Alveolar-capillary membrane injury

Primary insult

- Alveolar capillary membrane in jury

Inflammato rycytokines

Surfactantdef

Vascularpermeabili

ty

Obliterationo f microcircula

tionAtelectasis

Cell+proteinleak

Dead spaceventilation

Intrapulmonary shunt, pulmary hypertension

Diagnosis Bilateral pulmonary infiltration No cardiogenic pulmonary ede

ma Severe acute lung injury : shunt

- PaO 2 / FiO2

< 300

- PaO 2 / PAO 2 < 0.15

- R.I. (Respiratory Index)R.I. - = P(A a) O 2 / PaO 2> 5

Management

Treat primary insult Adequate tissue oxygenation

Oxygenation NIV Mechanical ventilation: high PEEP with recruitment protocol

Prevent complications

THANK YOU