Child-with-Respiratory-Failure.pdf

7/27/2019 Child-with-Respiratory-Failure.pdf

1/73

RESPIRATORY FAILURE INRESPIRATORY FAILURE INCHILDREN:CHILDREN:

Stabilization & ManagementStabilization & Management

J. Dani Bowman, MD, PhDJ. Dani Bowman, MD, PhD

Calle Gonzales, MD, MPHCalle Gonzales, MD, MPH

Mike Engel, MDMike Engel, MD

ANMC Pediatric Critical CareANMC Pediatric Critical Care


2/73

Learning objectivesLearning objectives

Define and diagnose respiratory failureDefine and diagnose respiratory failure

Describe traditional and novel treatmentDescribe traditional and novel treatmentmodalities including their benefits andmodalities including their benefits andrisksrisks

Understand how and when to use nonUnderstand how and when to use non--invasive ventilation for respiratory failure ininvasive ventilation for respiratory failure in

kidskids Brief tour of High Frequency OscillatoryBrief tour of High Frequency Oscillatory

Ventilation and ECMOVentilation and ECMO


3/73

What is respiratory failure?What is respiratory failure?


4/73

Pediatric Respiratory FailurePediatric Respiratory Failure

Definitions: descriptive statistics or clinicalDefinitions: descriptive statistics or clinical

or physiological?or physiological?

What are the etiologies?What are the etiologies?

What H& P findings are significant?What H& P findings are significant?

What are the therapeutic options?What are the therapeutic options?


5/73

Respiratory Failure or Distress isRespiratory Failure or Distress is

The primary diagnosis in almost 50% ofThe primary diagnosis in almost 50% of

admissions to pediatric intensive careadmissions to pediatric intensive care A common cause of cardiopulmonary arrest inA common cause of cardiopulmonary arrest in

childrenchildren

The most common diagnosis in pediatricThe most common diagnosis in pediatricmedical evacuationmedical evacuation

Somewhat seasonal, but occurs throughout theSomewhat seasonal, but occurs throughout the

yearyear Capable of striking fear in the hearts of nonCapable of striking fear in the hearts of non--

peds medical providerspeds medical providers


6/73

Definition of Respiratory FailureDefinition of Respiratory Failure

Physiologically based definitionPhysiologically based definition

zz PaO2 < 60 with FiO2 > 0.6PaO2 < 60 with FiO2 > 0.6

zz PaCO2 > 60PaCO2 > 60

zz PaO2/FiO2 ratioPaO2/FiO2 ratiozz AA--a gradienta gradient


7/73

Derangements in pulmonary gasDerangements in pulmonary gas

exchange in respiratory failureexchange in respiratory failure HypoventilationHypoventilation

Diffusion impairmentDiffusion impairment

Intrapulmonary shuntingIntrapulmonary shunting

VentilationVentilation--perfusion or V/Q mismatchperfusion or V/Q mismatch Further classify these by anatomic lesion,Further classify these by anatomic lesion,

abnormalities of lung & chest wallabnormalities of lung & chest wallmechanics, neuromuscular systems, andmechanics, neuromuscular systems, and

CNS control problems.CNS control problems.


8/73

Classify Causes ofClassify Causes ofRespResp Failure ByFailure By

AgeAge

Anatomic lesionsAnatomic lesions

Abnormalities of lung and chest wallAbnormalities of lung and chest wall

mechanicsmechanics Neuromuscular systemsNeuromuscular systems

Abnormalities of CNS controlAbnormalities of CNS control


9/73

Reasons to Manage an AirwayReasons to Manage an Airway


10/73

Indications for AirwayIndications for Airway

ManagementManagement

1. Hypoxemia 2. Hypercarbia

3. Neuromusculardisease

4. Impending airwayobstruction

5. Therapies for other

non-respiratory diseases


11/73

HypoxemiaHypoxemia

Disorders associated withDisorders associated with

ventilation/perfusion (V/Q) mismatchesventilation/perfusion (V/Q) mismatcheszz Ventilation and perfusion normally equal inVentilation and perfusion normally equal in

alveolialveoli

Areas well ventilated are well perfused; areasAreas well ventilated are well perfused; areas

poorly ventilated are poorly perfusedpoorly ventilated are poorly perfused

Abnormal compliance of lungAbnormal compliance of lung Major diseasesMajor diseases -- pneumonia, sepsis, heartpneumonia, sepsis, heart

failure, bronchiolitisfailure, bronchiolitis


12/73

HypercarbiaHypercarbia

Better to be defined by pH rather than pCO2Better to be defined by pH rather than pCO2

zz Metabolic alkalosis can raise pCO2 withoutMetabolic alkalosis can raise pCO2 withoutacidosisacidosis

Also associated with V/Q abnormalitiesAlso associated with V/Q abnormalities

Disorders of airway resistance rather thanDisorders of airway resistance rather than

compliancecompliance

Can occur with many respiratory diseases,Can occur with many respiratory diseases,usually as patients get tiredusually as patients get tired

Classic example is asthmaClassic example is asthma


13/73

NeuromuscularNeuromuscularDiseaseDisease

Two different categoriesTwo different categories

zz Progressive muscular weakness doesnProgressive muscular weakness doesnt allowt allowventilation or oxygenationventilation or oxygenation -- respiratory pumprespiratory pump

failurefailure

examplesexamples -- WerdnigWerdnig--Hoffman disease, MuscularHoffman disease, Muscular

dystrophy, spinal cord injurydystrophy, spinal cord injury

zz Absence of airway reflexesAbsence of airway reflexes

Loss of cranial nerve function puts person at riskLoss of cranial nerve function puts person at risk

for aspiration, airway obstructionfor aspiration, airway obstruction

examplesexamples -- brain tumors, neuropathies,TBIbrain tumors, neuropathies,TBI


14/73


15/73

The nose knowsThe nose knows

Nose is responsible for 50% of totalNose is responsible for 50% of total

airway resistance at all agesairway resistance at all ages Infant: blockage of nose = respiratoryInfant: blockage of nose = respiratory

distress or failuredistress or failure

SoSo Sometimes, oral and nasalSometimes, oral and nasalsuctioning is all that is needed!!suctioning is all that is needed!!


16/73


17/73


18/73


19/73


20/73

Respiratory Assessment IRespiratory Assessment I

Impending Respiratory FailureImpending Respiratory Failure

Severe work of breathingSevere work of breathing

Reduced air entryReduced air entry

Cyanosis despite OCyanosis despite O22

Irregular breathing / apneaIrregular breathing / apnea

Altered ConsciousnessAltered Consciousness DiaphoresisDiaphoresis


21/73

Respiratory Assessment IIRespiratory Assessment II Status Asthmaticus/Obstructive DiseaseStatus Asthmaticus/Obstructive Disease

Tachypnea

Nasal flaringPale

Expiratory

wheezing

Tachypnea

RR > 60

Retractions,grunting

Mottled

Bradypnea

See saw

respirationsGray,

cyanotic

No airmovement

No wheezing

Insp/Exp

wheezing


22/73

Respiratory Assessment IIIRespiratory Assessment III Upper Airway ObstructionUpper Airway Obstruction

Tachypnea

Pale

Stridor

Sonorous

respirationsi.e.. snoring

Inspiratoryretractions

Mottled

Bradypnea

See saw

respirations

Gray,

cyanotic

No airmovement

despite effort!

Tachypnea

Head bobbing


23/73


24/73


25/73

Noninvasive Ventilation (NIV)Noninvasive Ventilation (NIV)

Provision of ventilatory support withoutProvision of ventilatory support without

the need for an invasive artificialthe need for an invasive artificialairway.airway.

Using a mask or cannula, gas isUsing a mask or cannula, gas isconducted from a positive pressureconducted from a positive pressure

source into the nose or mouth.source into the nose or mouth.

The expiratory phase is passive.The expiratory phase is passive.


26/73

NIV: Avoiding Complications ofNIV: Avoiding Complications of

Endotracheal IntubationEndotracheal Intubation

Insertion of endotracheal tubeInsertion of endotracheal tube*aspiration of gastric contents*aspiration of gastric contents

*esophageal intubation*esophageal intubation

*patient discomfort*patient discomfort

*vocal cord injury*vocal cord injury

*subglottic injury*subglottic injury Risks with sedatives/paralyticsRisks with sedatives/paralytics


27/73


28/73

Complications of NIVComplications of NIV

PneumothoraxPneumothorax

HypotensionHypotension

AspirationAspiration

*pneumonia*pneumonia*airway edema*airway edema

Over or underOver or undersedationsedation

Nasal congestionNasal congestion

SinusitisSinusitis Nasal/oral drynessNasal/oral dryness

Gastric distentionGastric distention

Mask discomfortMask discomfort

Skin breakdownSkin breakdown


29/73


30/73

Using NIV: CPAPUsing NIV: CPAP

Continuous pressure support ventilationContinuous pressure support ventilation

throughout inspiration and expirationthroughout inspiration and expiration Optimal patient is neonate or young infantOptimal patient is neonate or young infant

Settings:Settings:*Pressure 4*Pressure 4--10cm H2O10cm H2O*FiO2 max depends on TV times RR*FiO2 max depends on TV times RR

Alarms: loss of pressureAlarms: loss of pressure


31/73


32/73


33/73

NIV: BiPAPNIV: BiPAP

BiBi--level portable pressure supportlevel portable pressure support

ventilation that cycles between higherventilation that cycles between higherinspiratory and lower expiratory pressuresinspiratory and lower expiratory pressures

Adjustable triggering mechanismsAdjustable triggering mechanismsAdjustable inspiratory timesAdjustable inspiratory times


34/73


35/73


36/73


37/73


38/73

Indications for NIV in intensive careIndications for NIV in intensive care

Primary support mode for moderate toPrimary support mode for moderate to

severe respiratory failuresevere respiratory failure Stabilization before endotrachealStabilization before endotracheal

intubationintubation Difficult intubationDifficult intubation

End of life statusEnd of life status


39/73


40/73

Contraindications to NIVContraindications to NIV

Uncooperative patientUncooperative patient

Absent airway reflexesAbsent airway reflexes Full stomach/gastric distention?Full stomach/gastric distention?

Glasgow coma scale


41/73


42/73

Heliox and GrahmHeliox and Grahms Laws Law

The flow of gas through an orifice isThe flow of gas through an orifice is

inversely proportional to the square root ofinversely proportional to the square root ofits density.its density.

Thus,Thus, helioxheliox is useful in overcomingis useful in overcoming

airway resistance and obstruction.airway resistance and obstruction. HelioxHeliox reduces turbulent flow and allowsreduces turbulent flow and allows

laminar flow at higher rates.laminar flow at higher rates. Concomitant decrease in the work ofConcomitant decrease in the work of

breathing.breathing.


43/73


44/73

Advantages of Heliox:Advantages of Heliox:

MAY avoid endotracheal intubation andMAY avoid endotracheal intubation and

mechanical ventilationmechanical ventilation Less use of sedatives/paralyticsLess use of sedatives/paralytics

Can be used with CPAP and BIPAPCan be used with CPAP and BIPAP Patient benefits from more frequent visitsPatient benefits from more frequent visits

with respiratory therapistswith respiratory therapists


45/73

Heliox: How low can you go?Heliox: How low can you go?

Ideally, patient should receive an 80:20Ideally, patient should receive an 80:20

ratio of helium to oxygenratio of helium to oxygen----maximizes themaximizes thelaminar flow and decreases turbulencelaminar flow and decreases turbulencePublished peds studies are few, but havePublished peds studies are few, but have

used 70:30 and 80/20.used 70:30 and 80/20. DANGER: oxygen monitoring equipmentDANGER: oxygen monitoring equipment

can give inaccurate readings, thuscan give inaccurate readings, thushypoxemia is a riskhypoxemia is a risk


46/73


47/73

Nitric OxideNitric Oxide

Pulmonary vasodilator useful in PPHN andPulmonary vasodilator useful in PPHN and

reactive pulmonary hypertensionreactive pulmonary hypertension Can be given via NIV or ETTCan be given via NIV or ETT

Well studied in pediatrics,Well studied in pediatrics,especially in neonatologyespecially in neonatology

May combine withMay combine with

CPAP/BIPAP asCPAP/BIPAP as

alternative to intubationalternative to intubation


48/73

Nitric Oxide: DownsideNitric Oxide: Downside

Free radicalFree radical -- forms methemoglobin whichforms methemoglobin which

must be monitoredmust be monitoredAs a free radical, may have additionalAs a free radical, may have additional

unknown risksunknown risks Requires a specialRequires a special scavengingscavenging

mechanismmechanism

Must be weaned slowlyMust be weaned slowly

Expensive?Expensive?


49/73


50/73

Decision to IntubateDecision to Intubate

Ask the 4 questions for intubationAsk the 4 questions for intubation

Complications of intubationComplications of intubation Know the signs of a difficult intubationKnow the signs of a difficult intubation

Know medical conditions that wouldKnow medical conditions that wouldindicate intubationindicate intubation

Understand the decision tree to intubateUnderstand the decision tree to intubate(see appendix)(see appendix)

Ai C t l/AiAi C t l/Ai


51/73

Airway Control/AirwayAirway Control/Airway

ProtectionProtection

4 questions4 questions1.1. Is there failure of airway protection?Is there failure of airway protection?

2.2. Is there failure to ventilate?Is there failure to ventilate?3.3. Is there a failure to oxygenate?Is there a failure to oxygenate?

4.4. What is the anticipated clinical course?What is the anticipated clinical course?


52/73

INDICATIONS for INTUBATIONINDICATIONS for INTUBATION

Failed NonFailed Non--Invasive VentilationInvasive Ventilation

Lower airway and parenchymal disordersLower airway and parenchymal disordersresulting in hypoxemia and /or hypercarbiaresulting in hypoxemia and /or hypercarbia

Upper airway obstruction, actual or imminentUpper airway obstruction, actual or imminent

Hemodynamic instability or anticipated instabilityHemodynamic instability or anticipated instability

CNS dysfunction (loss of protective reflexes,CNS dysfunction (loss of protective reflexes,altered LOC, neuromuscular weakness)altered LOC, neuromuscular weakness)

Therapeutic hyperventilation (pulmonaryTherapeutic hyperventilation (pulmonaryhypertension, metabolic acidosis)hypertension, metabolic acidosis)

Management of pulmonary secretionsManagement of pulmonary secretions

Emergency drug administrationEmergency drug administration


53/73


54/73


55/73

HFOVHFOV

MAP provides a constant distending pressureMAP provides a constant distending pressureequivalent to CPAP. This inflates the lung to aequivalent to CPAP. This inflates the lung to aconstant and optimal lung volume maximizingconstant and optimal lung volume maximizingthe area for gas exchange and preventingthe area for gas exchange and preventingalveolar collapse in the expiratory phase.alveolar collapse in the expiratory phase.

Ventilation is dependent on amplitude and toVentilation is dependent on amplitude and to

lesser degree frequency. Thus when usinglesser degree frequency. Thus when usingHOFV CO2 elimination and oxygenation areHOFV CO2 elimination and oxygenation arerelatively independent.relatively independent.


56/73


57/73


58/73


59/73

PICUPICU--HFOV Initial ManagementHFOV Initial Management

Mean airway pressure (MAP) 2Mean airway pressure (MAP) 2--10 cms>MAP of10 cms>MAP of

CMVCMV Frequency (Hz) per body size, 2Frequency (Hz) per body size, 2--12 kg=10Hz,12 kg=10Hz,

1313--20=8Hz, 2120=8Hz, 21--34kg=7Hz, >35kg=6Hz OR per34kg=7Hz, >35kg=6Hz OR per

the disease processthe disease process Power set at 4.0 or to achieve a chestPower set at 4.0 or to achieve a chest wigglewiggle

(from shoulders to groin)(from shoulders to groin)

FiO2 at 1.0FiO2 at 1.0


60/73

Hazards of the OSCILLATOR:Hazards of the OSCILLATOR:

BarotraumaBarotrauma

Decreased venous return and cardiacDecreased venous return and cardiacoutputoutput

Hypotension, PPHNHypotension, PPHN Compromised secretion management,Compromised secretion management,

usually donusually dont suction ETT in pedst suction ETT in peds


61/73

Life Support: The Outer LimitsLife Support: The Outer Limits


62/73

Life Support: The Outer LimitsLife Support: The Outer Limits


63/73

Bypass the lungs: ECMOBypass the lungs: ECMO

Also known as extracorporeal life supportAlso known as extracorporeal life support

(ECLS)(ECLS)A modified form of cardiopulmonaryA modified form of cardiopulmonary

bypass to provide prolonged tissue oxygenbypass to provide prolonged tissue oxygen

delivery in patients with respiratory and/ordelivery in patients with respiratory and/or

cardiac failure.cardiac failure.

Overall survival is 60Overall survival is 60--70% in peds and70% in peds andneonatal patientsneonatal patients


64/73


65/73


66/73


67/73


68/73


69/73


70/73


71/73


72/73


73/73

Thanks for yourThanks for yourattention!!attention!!

Date post:	14-Apr-2018
Category:	Documents
Upload:	oxana-turcu
View:	214 times
Download:	0 times

Child-with-Respiratory-Failure.pdf

Documents