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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
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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
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What is respiratory failure?What is respiratory failure?
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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?
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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
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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
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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.
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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
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Reasons to Manage an AirwayReasons to Manage an Airway
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Indications for AirwayIndications for Airway
ManagementManagement
1. Hypoxemia 2. Hypercarbia
3. Neuromusculardisease
4. Impending airwayobstruction
5. Therapies for other
non-respiratory diseases
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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
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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
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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
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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!!
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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Contraindications to NIVContraindications to NIV
Uncooperative patientUncooperative patient
Absent airway reflexesAbsent airway reflexes Full stomach/gastric distention?Full stomach/gastric distention?
Glasgow coma scale
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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.
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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
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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
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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
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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?
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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
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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?
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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
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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.
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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
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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
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Life Support: The Outer LimitsLife Support: The Outer Limits
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Life Support: The Outer LimitsLife Support: The Outer Limits
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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
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Thanks for yourThanks for yourattention!!attention!!
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