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    Respiratory Failure in Children PDF

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    Oxana Turcu
    This document discusses respiratory failure in children and the need for mechanical ventilation. It begins by defining respiratory failure and discussing its significance. It then covers the physiology of ventilation, perfusion, and diffusion in the lungs. Various causes of respiratory failure are outlined, including issues with the respiratory center, nerves, muscles, airways, and lung parenchyma. Type 1 respiratory failure is oxygenation failure, which can be caused by hypoventilation, shunting, ventilation-perfusion mismatching, or low inspired oxygen. Type 2 is ventilation failure leading to carbon dioxide retention. Initial settings for mechanical ventilation are discussed. The goal of treatment is to maintain gas exchange while minimizing lung injury through an individualized approach.

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    Respiratory Failure in Children PDF

    Uploaded by

    Oxana Turcu
    229 views47 pages
    This document discusses respiratory failure in children and the need for mechanical ventilation. It begins by defining respiratory failure and discussing its significance. It then covers the physiology of ventilation, perfusion, and diffusion in the lungs. Various causes of respiratory failure are outlined, including issues with the respiratory center, nerves, muscles, airways, and lung parenchyma. Type 1 respiratory failure is oxygenation failure, which can be caused by hypoventilation, shunting, ventilation-perfusion mismatching, or low inspired oxygen. Type 2 is ventilation failure leading to carbon dioxide retention. Initial settings for mechanical ventilation are discussed. The goal of treatment is to maintain gas exchange while minimizing lung injury through an individualized approach.

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    This document discusses respiratory failure in children and the need for mechanical ventilation. It begins by defining respiratory failure and discussing its significance. It then covers the physiology of ventilation, perfusion, and diffusion in the lungs. Various causes of respiratory failure are outlined, including issues with the respiratory center, nerves, muscles, airways, and lung parenchyma. Type 1 respiratory failure is oxygenation failure, which can be caused by hypoventilation, shunting, ventilation-perfusion mismatching, or low inspired oxygen. Type 2 is ventilation failure leading to carbon dioxide retention. Initial settings for mechanical ventilation are discussed. The goal of treatment is to maintain gas exchange while minimizing lung injury through an individualized approach.

    Copyright:

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    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    229 views47 pages

    Respiratory Failure in Children PDF

    Uploaded by

    Oxana Turcu
    This document discusses respiratory failure in children and the need for mechanical ventilation. It begins by defining respiratory failure and discussing its significance. It then covers the physiology of ventilation, perfusion, and diffusion in the lungs. Various causes of respiratory failure are outlined, including issues with the respiratory center, nerves, muscles, airways, and lung parenchyma. Type 1 respiratory failure is oxygenation failure, which can be caused by hypoventilation, shunting, ventilation-perfusion mismatching, or low inspired oxygen. Type 2 is ventilation failure leading to carbon dioxide retention. Initial settings for mechanical ventilation are discussed. The goal of treatment is to maintain gas exchange while minimizing lung injury through an individualized approach.

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    Respiratory Failure in Children

    Assessing the need for Mechanical Ventilation

    Dr. Mohamed Salim Kabbani


    Pediatric Critical Care consultant Director of Pediatric Cardiac ICU King AbduAziz Medical City National Guard Health Affairs

    Objectives...

    Define respiratory failure Overview of respiratory physiology Causes of hypoxemia/hypercapnia Clinical signs/investigations Ventilator management

    Respiratory Failure
    Defined as the impairment of the lungs ability to maintain adequate oxygen and carbon dioxide homeostasis.

    Significance
    Respiratory failure has significant morbidity and mortality. Optimal ventilatory management will reduce morbidity and mortality. Optimal ventilatory management should be individualized and be based upon the pathophysiology and certain basic concepts of mechanical ventilation

    Physiologic functions of the lung


    Ventilation
    The movement of air between the atmosphere and the respiratory portion of the lungs

    Perfusion
    The flow of blood through the lungs

    Diffusion
    The transfer of gases between the air-filled spaces in the lungs and the blood.

    Others

    Anatomy of the lungs


    Pulmonary system consists of 2 components:
    Airway: conductive system Terminal respiratory unit: alveolar capillary unit where gas exchange occur.

    Airway
    Conducting system

    Terminal respiratory unit


    Alveolar capillary unit

    Ventilation
    Depends on the conducting airways:
    Nasopharynx and oropharynx Larynx Tracheobronchial tree

    Open Alveoli Function:


    Moves air in and out of the lung, warms and humidifes. Airways do not participate in gas exchange.

    Physiology
    Ventilation
    Perfusion Ventilation to perfusion Diffusion

    Pathology
    Impaired ventilation
    Shunt V/Q mismatch Diffusion block

    Function of the respiratory system


    It is Conceptualized as pump consisting of:
    1) CNS, Spinal nerves, peripheral nerves, neuromuscular junction 2) Respiratory muscles, chest wall 3) Conducting airways 4) Alveolar unit where gas exchange and diffusion occur

    failure of respiratory pump leads to hypercapnia

    Alveolar disorders primarily cause hypoxia .


    11

    Causes of respiratory failure


    Respiratory Center in Brain Neuromuscular Connections Thoracic Bellows Airways (upper & lower) Lung parenchyma (alveoli) Brain

    Nerves

    It only requires one disrupted link to cause respiratory failure !


    Alveoli

    Bellows
    Airways

    Definition continued...
    Historical definition includes Type 1 vs. Type 2 respiratory failure Basically hypoxic vs. hypercarbic respiratory failure Best way to think about it is oxygenation vs. ventilation failure

    How is respiratory failure defined??


    Historically usually PaO2 <60 mm Hg, PaCO2 > 50 mm Hg. Obviously must take into account patients anatomy (i.e. ? cyanotic heart lesion). Can develop acutely or over days

    Symptoms/Severity dependent on acuity

    Assessing respiratory failure


    Clinical signs and symptoms

    How does the patient look?.


    Blood gas analysis O2 saturation Other parameters Interpretation should be taken in the context of :
    Age Presentation Acuity Etiology
    15

    Type 1 failure: Oxygenation failure



    1. 2.

    Most common type of respiratory failure Occurs in wide variety of disease processes Will deal with main pathophysiologic derangements:
    Hypoventilation (Alveolar hypoventilation ) Shunt: percentage of venous blood returning to systemic circulation bypassing the alveolar gas exchange unit V/Q mismatch: pulmonary edema, pneumonia...
    Low inspired FiO2 Smoke suffocation, high altitude. Impaired diffusion

    3.

    4. 5.

    1) Hypoventilation
    PO2 of alveolar gas is balance of removal and replenishment In general, O2 consumption varies little If the O2 replenishment is not adequate enough, the alveoli O2 will fall.

    Therefore, alveolar PO2 is determined

    mostly by level of alveolar ventilation

    Hypoventilation continue
    If ventilation falls, PAO2 drops and PACO2 will rise as well ( hypoventilation will always lead to high PaCO2. Example of alveolar hypoventilation: over-sedation which leads to hypoxia and hypercarbia

    Case Scenario
    A 2 month old boy underwent abdominal surgery. He came from OR extubated. 2 hours after surgery, he became agitated. He was given twice 0.5 mg/kg of morphine sulfate to alleviate pain. Subsequently, His breathing became shallow and slow (10/minute). ABG : pH 7.10, PaO2 52, PCO2 81, Sat 75% on RA. Is he in respiratory failure? What is the cause and management?
    19

    Hypoventilation continued
    Hypoxia due to hypoventilation is easily overcome by increasing FiO2 May take a while for PCO2 to equilibrate due to large amount of CO2 in body (HCO3-)

    Other causes of hypoxia

    The concept of shunt


    Blood entering the arterial system without entering ventilated lung Intra- vs. extra-cardiac shunting Always a small amount of shunt via bronchial vessels, coronary veins (< 5%) Most important feature is :

    Supplying: 100% O2 does not resolve hypoxemia


    PCO2 usually normal or low as minute ventilation usually increased by chemoreceptors

    Intra-pulmonary V.S intra-cardiac shunt Intra-cardiac V.S Intra-pulmonary shunt

    23

    A month old baby presented with deep cyanosis and saturation of 70%. O2 saturation did not improve with 02
    ABG: pH 7.30, PCO2 30, PaO2 40, HCO3 15, BE - 9

    24

    What type of shunt does this patient have?


    Example of Intra-cardiac shunt (TOF)

    25

    A full term baby developed tachypnea and desaturation after birth. He required intubation with increasing amount of FiO2 to keep saturation > 80%. ECHO showed normal heart but a ductus arteriosus with R to L shunt and mild TR were observed. Dx: persistent fetal circulation

    26

    A 4 years old child with ARDS, O2 Saturation of 60% while on 100 FIO2.

    Extra-Cardiac shunt {Intra-pulmonary shunt } as a result of severe lung disease {pneumonia, ARDS.}

    27

    Ventilation-Perfusion Inequality (mismatch V/Q)

    Ventilation / Blood flow are mismatched in different lung fields Most common cause

    of hypoxemia
    Usually exclude other causes before settling on V/Q mismatch

    Ventilation perfusion relationship

    Shunt

    Normal

    Dead Space

    30

    Ventilation / Perfusion mismatch


    It is most common cause of hypoxic failure

    V
    Q >>>

    Blood Pus Air Water Atalectasis

    Quantitate using A a Gradient

    31

    3 weeks old infant presented with fever, respiratory distress, Grunting and desaturation. Nasopharyngeal swab is + for RSV. CXR showed evidence of Lower Respiratory Tract Infection (LRTI) leading to V/Q mismatch Air Trapping RUL infiltrate Atelectasis Streaky Markings

    32

    How can we quantify the degree of V/Q mismatching objectively?

    33

    A a Gradient {Alveolar-arterial oxygen gradient} O2 Index {Oxygen index} PaO2 / FiO2 Ratio
    [(Pb-PH2O) x FIO2 - (PCO2/.8)] - PaO2

    normal value: < 10 ( related to age)

    Other useful equations


    PaO2/FiO2 Ratio ( normal > 400 )

    OI = (Paw x FIO2 x 100)/ PaO2


    Mean airway pressure (MAP) X FiO2 X 100% PaO2
    OI Normally < 5
    34

    Example of calculation
    Child with ARDS has PaO2 60, PCO2 40, FiO2: 0.6, MAP 20 A-a gradient:
    [(Pb-PH2O) x FIO2 - (PCO2/.8)] - PaO2

    [(760 40) 0.6 40 x 0.8 ] 60 [720 X 0.6 50] -60 432 110 = 322 ( NL 10 30) OI
    OI = (Paw x FIO2 x 100)/ PaO2

    =( 20 X 0.6 X 100) / 60 = 20 X 60 / 60 = 20 (NL < 5) PaO2 / FiO2 ratio = 60 / 0.6 = 100 (NL > 400 )
    35

    Clinical examples of V/Q imbalance


    Asthma Pulmonary edema ARDS

    Ventilation perfusion mismatch secondary to RDS

    37

    A 10 days old infant was referred to our ICU because of respiratory distress and heart murmur V/Q mismatch due to pulmonary edema

    38

    Other causes of hypoxia


    (uncommon in children) Low inspired FIO2
    Deficiency in FIO2 : high altitude Low oxygen inspired:
    Inhalation injury Smoke suffocation

    39

    Type II Respiratory Failure

    40

    Type 2 respiratory failure: Ventilation Failure

    The hall mark is CO2 retention There are 3 mechanisms for that:
    Hypoventilation Dead Space Ventilation Increased CO2 : {Fever, High Carbohydrate load..}

    41

    3 months old infant with progressive hypotonia ,Presented with respiratory failure due mainly hypoventilation
    ABG pH 7.1, PCO2 95, PaO2 60,HCO3 45
    42

    Increased Dead Space


    (factor that decreases cardiac output to the lungs)

    Hypovolemia Low cardiac output Pulmonary embolus High airway pressures Short-term compensation by increasing tidal volume and/or respiratory rate

    43

    Volume vs. Pressure Control Ventilation


    Volume Ventilation
    Volume delivery constant Inspiratory pressure varies Inspiratory flow constant

    Pressure Ventilation
    Volume delivery varies Inspiratory pressure constant Inspiratory flow varies

    When do you use pressure or volume control ventilation ?


    In general pressure control in babies and small infant < 6-8 kg In general volume control in children and adolescence > 8-10 kg

    Initial Settings
    Settings
    Rate: start with a rate that is somewhat normal; i.e., 15-20 for adolescent/child, 20-30 for infant/small child FiO2: 100% and wean down PEEP: 3-5 TV 8-10 ml/kg, or PIP 14- 20 Pressure support 5-10 Determine the mode: control every breath (A/C) or some (SIMV)

    45

    Summary
    The practice of the art of mechanical ventilation lies in the application of the underlying scientific and physiologic concepts to the specific clinical situation An individualized flexible approach aimed at maintaining adequate gas exchange with the minimum of lung injury, should optimize the possible outcome

    THANK YOU

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