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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
