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

2. Classification Type I : Hypoxemic respiratory failure
Type II : Hypercapnic respiratory failure

3. Type I
Type II

4. Causes of respiratory failure

5. Criteria for Diagnosis
Clinical criteria
Physiologic criteria
↓ or absent respiratory breath sound
Severe inspiratory retraction
Cyanosis in 40% O2
↓ Level of consciousness
Poor skeletal muscle tone
PaCO2 > 65 mm Hg
PaO2 < 100 mm Hg in 50% O2
Acute respiratory failure = 3 Clinical + 1 Physiologic
Raphaely R. 1981

6. Acute respiratory failure
Clinical manifestations
Hypoxemia - tachycardia, tachypnea, sweating, restlessness, hypotension
CO2 retention – headache, confusion, coma
Abnormal respiratory signs – stridor, adventitious sounds

7. Acute respiratory failure
Ventilatory failure: CO2 retention
- Disease of brain & spinal cord
- Disease of peripheral nerve, muscle
- Drug overdose
- etc

8. Acute respiratory failure
Oxygenation failure: hypoxemia, low PaO2
- Upper airway obstruction
croup, laryngeal edema, etc
- Small airway diseases
acute bronchiolitis, asthma, etc
- Parenchymal diseases
ARDS – pneumonia, near-drowning, etc

9. Respiratory assessment
Spontaneous respiration
Respiratory rate

10. Respiratory assessment
Respiratory rate
Age 0-2 month: >60/min
Age 2 mo – 1 year: >50/min
Age 1-5 years: >40/min

11. Respiratory assessment
Spontaneous respiration
Respiratory rate
Chest movement
Chest retraction
Breath sounds
Upper/lower airway obstruction: stridor, wheezing

13. Respiratory assessment
Spontaneous respiration
Respiratory rate
Chest movement
Chest retraction
Breath sounds
Upper/lower airway obstruction: stridor, wheezing
Cynaosis

14. Respiratory assessment
Assessment and plan for respiratory management
Inadequate ventilation or severe upper airway obstruction: intubation and MV
Adequate ventilation but inadequate gas exchange: oxygenation

15. Respiratory assessment
Gas exchange assessment
Arterial blood gases
Ventilation (PaCO2), oxygenation (PaO2), pH
Pulse oximetry
Oxygenation (SpO2)

16. Respiratory management

17. Type I
Type II

18. Upper airway obstruction: stridor lower airway diseases & lung
Respiratory distress
Upper airway obstruction: stridor
lower airway diseases & lung
Severe retraction
Not severe
Endotracheal intubation
Oxygenation
Improve
Not improve
O2 via T-piece
Mechanical ventilation
Find out and treat definite causes

19. Management RS diseases
Croup:
Definite: Dexamethasone mg/kg single dose oral or IM
RS: assess severity – CROUP score
Mild - O2 therapy
Moderate – epinephrine nebulization with O2 therapy
Severe – endotracheal intubation +
O2 therapy

20. Management RS diseases
Acute bronchiolitis:
Definite: No definite treatment
RS: O2 therapy
Optional - bronchodilator vs dexamethasone

21. Management RS diseases
Asthma:
Definite: bronchodilator – 2 agonist systemic corticosteroid – hydrocortisone/prednisolone
RS: not severe – O2 therapy
severe – mechanical ventilation

22. Management RS diseases
Pneumonia:
Definite: virus – no specific bacteria – antibiotics
RS: not very severe – O2 therapy
severe – mechanical ventilation

23. Management Treat primary insult Adequate tissue oxygenation
NIV
Mechanical ventilation
Prevent complications

24. Management Treat primary insult Adequate tissue oxygenation
NIV
Mechanical ventilation
Prevent complications

25. Inhalation therapy Oxygen therapy

26. Normal airway
Warm gas to 34oC
Air
gas + humidity

27. Diffusion

28. Gas transport to the periphery

29. Oxygen source

30. เครื่องทำความชื้น Humidifier Nebulizer Pass over Bubble Heated Jet
Ultrasonic
Hand medical
Humidity
Aerosol

31. น้ำที่อยู่ในสภาวะของก๊าซ (vapor) Aerosol (ฝอยละออง)
Humidity & Aerosol
Humidity (ไอน้ำ)
น้ำที่อยู่ในสภาวะของก๊าซ (vapor)
Aerosol (ฝอยละออง)
น้ำหรือของเหลวที่แขวนลอยอยู่ในอากาศหรือก๊าซ (liquid particle)
Aerosolization = nebulization

32. Humidifier Unheated humidifier Heated humidifier Bubble
with mechanical ventilator

33. Bubble humidifier
ท่อนำก๊าซ

34. Heated humidifier

35. Nebulizer Jet nebulizer Untrasonic nebulizer Medical nebulizer
Hand held
Pressurized metered dose inhaler(pMDI)
Dry powder inhaler (DPI)

36. Jet nebulizer
ท่อนำก๊าซ
Corrugated tube
High flow

37. Jet nebulizer

38. Ultrasonic nebulizer

39. Medical nebulizer

40. Oxygen therapy Cannula Simple mask Mask with reservoir bag Hood or box
T-piece
Mechanical ventilator

41. O2 Cannula
Bubble humidifier
O2 1 LPM ~ 4%

42. O2 Mask / with reservior Bubble humidifier
Simple mask LMP ~ 35-50%
Reservoir bag 6-10 LPM ~ 60-90%

43. Tracheotomy mask
Corrugated tube

44. O2 Box/Hood

45. O2 T-piece

46. Endotracheal intubation
Heated humidifier

47. Oxygen dissociation curve
SaO2
PaO2 SaO2
PaO2

48. Gas transport to the periphery

49. Complication of O2 therapy
Retinopathy of prematurity (ROP)
Bronchopulmonary dysplasis (BPD)
Absorptive atelectasis
Apnea in COPD patient

50. Management Treat primary insult Adequate tissue oxygenation
NIV
Mechanical ventilation
Prevent complications

51. NIV
High flow nasal cannula
CPAP
BiPAP

52. 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

53. ARDS

54. Berlin’s definitions Acute onset within 7 days Bilateral opacities
PF ratio less than 300
<300 = mild
<200 = moderate
<100 = severe
Exclude volume overload

55. Primary insult to lungs
Pathophysiology
Primary insult to lungs
Direct injury : aspiration เช่น near-drowning, gastric, hydrocarbon, etc
Indirect injury : sepsis, brain edema, etc
Alveolar-capillary membrane injury

56. Alveolar-capillary membrane injury
Primary insult
Alveolar-capillary membrane injury
Inflammatory cytokines
Vascular permeability
Obliteration of microcirculation
Surfactant def
Dead space ventilation
Atelectasis
Cell+protein leak
Intrapulmonary shunt, pulmary hypertension

61. Diagnosis Bilateral pulmonary infiltration
No cardiogenic pulmonary edema
Severe acute lung injury : shunt
- PaO2 / FiO2 < 300
- PaO2 / PAO2 < 0.15
- R.I. (Respiratory Index)
R.I. = P(A-a) O2 / PaO2 > 5

62. Management Treat primary insult Adequate tissue oxygenation
NIV
Mechanical ventilation: high PEEP with recruitment protocol
Prevent complications

63. THANK YOU