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Acute Respiratory failure
in children
Rattapon Uppala, MD. Department of Pediatrics,
Faculty of Medicine, KKU
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Classification
Type I : Hypoxemic respiratory failure
Type II : Hypercapnic respiratory failure
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Type I Type II
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Causes of respiratory failure
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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
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Acute respiratory failure
Clinical manifestationsHypoxemia - tachycardia,
tachypnea, sweating, restlessness, hypotension
CO2 retention – headache, confusion, coma
Abnormal respiratory signs – stridor, adventitious sounds
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Acute respiratory failure
Ventilatory failure: CO2 retention
- Disease of brain & spinal cord- Disease of peripheral nerve, muscle- Drug overdose- etc
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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
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Respiratory assessment
1. Spontaneous respiration Respiratory rate
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Respiratory assessment
Respiratory rateAge 0-2 month: >60/minAge 2 mo – 1 year: >50/minAge 1-5 years: >40/min
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Respiratory assessment
1. Spontaneous respiration Respiratory rate Chest movement Chest retraction Breath sounds Upper/lower airway obstruction:
stridor, wheezing
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Respiratory assessment
1. Spontaneous respiration Respiratory rate Chest movement Chest retraction Breath sounds Upper/lower airway obstruction:
stridor, wheezing Cynaosis
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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
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Respiratory assessment
Gas exchange assessment– Arterial blood gases
Ventilation (PaCO2), oxygenation (PaO2), pH
– Pulse oximetryOxygenation (SpO2)
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Respiratory management
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Type I Type II
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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
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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
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Management RS diseases
Acute bronchiolitis:
Definite: No definite treatment
RS: O2 therapy
Optional - bronchodilator vs dexamethasone
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Management RS diseases
Asthma:
Definite: bronchodilator – 2 agonist systemic corticosteroid – hydrocortisone/prednisolone
RS: not severe – O2 therapy
severe – mechanical ventilation
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Management RS diseases
Pneumonia:
Definite: virus – no specific bacteria – antibiotics
RS: not very severe – O2 therapy
severe – mechanical ventilation
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Management
Treat primary insult Adequate tissue oxygenation Oxygenation NIV Mechanical ventilation
Prevent complications
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Management
Treat primary insult Adequate tissue oxygenation Oxygenation NIV Mechanical ventilation
Prevent complications
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Inhalation therapyOxygen therapy
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Normal airway
Warm gas to 34oC
Airgas + humidity
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Diffusion
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Gas transport to the periphery
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Oxygen source
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เครื่��องทำ��คว�มชื้��น1. Humidifier
• Pass over• Bubble • Heated
2. Nebulizer• Jet• Ultrasonic • Hand medical
Humidity
Aerosol
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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
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Humidifier
Unheated humidifier Bubble
Heated humidifier with mechanical ventilator
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Bubble humidifier
ทำ�อน��ก๊��ซ
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Heated humidifier
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Nebulizer
Jet nebulizer Untrasonic nebulizer Medical nebulizer
Hand held Pressurized metered dose
inhaler(pMDI) Dry powder inhaler (DPI)
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Jet nebulizer
ทำ�อน��ก๊��ซ Corrugated tube
High flow
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Jet nebulizer
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Ultrasonic nebulizer
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Medical nebulizer
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Oxygen therapy
1. Cannula
2. Simple mask
3. Mask with reservoir bag
4. Hood or box
5. T-piece
6. Mechanical ventilator
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O2 Cannula
Bubble humidifier
O2 1 LPM ~ 4%
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O2
Mask / with reservior
Bubble humidifie
rSimple mask 5-10 LMP ~ 35-50%Reservoir bag 6-10 LPM ~ 60-90%
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Tracheotomy mask
Corrugated tube
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O2 Box/Hood
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O2 T-piece
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Heatedhumidifie
r
Endotracheal intubation
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Oxygen dissociation curveSaO2
PaO2
PaO2
SaO
2
60 9050 8040 70
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Gas transport to the periphery
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Complication of O2
therapy
Retinopathy of prematurity (ROP)
Bronchopulmonary dysplasis (BPD)
Absorptive atelectasis Apnea in COPD patient
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Management
Treat primary insult Adequate tissu
e oxygenation Oxygenation NIV Mechanical ventilation
Prevent complications
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NIV
High flow nasal cannula CPAP BiPAP
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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
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ARDS
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Berlin’s definitions
Acute onset within 7 days Bilateral opacities PF ratio less than 300
<300 = mild<200 = moderate<100 = severe
Exclude volume overload
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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
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Primary insult
- Alveolar capillary membrane in jury
Inflammato rycytokines
Surfactantdef
Vascularpermeabili
ty
Obliterationo f microcircula
tionAtelectasis
Cell+proteinleak
Dead spaceventilation
Intrapulmonary shunt, pulmary hypertension
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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
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Management
Treat primary insult Adequate tissue oxygenation
Oxygenation NIV Mechanical ventilation: high PEEP with recruitment protocol
Prevent complications
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THANK YOU