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Respiratory Failure in Children. Maa’n Idrees,MD. Definition:. Respiratory failure exists when the patient has hypoxia while breathing 50% oxygen with or without hypercapnia. Hypoxic R.F(type 1): PaO2<60mmHg with FiO2>0.6(cyanotic heart disease excluded)

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Definition l.jpg
Definition:

Respiratory failure exists when the patient has hypoxia while breathing 50% oxygen with or without hypercapnia.


Slide3 l.jpg

Hypoxic R.F(type 1):

PaO2<60mmHg with FiO2>0.6(cyanotic heart disease excluded)

Hypercapnic or ventilatory failure R.F(type 2):

PaCO2>50mmHg


Clinical features l.jpg
Clinical features:

Pulmonary features:

Tachypnea

Chest retractions

Nasal flaring

Cyanosis

Diaphoresis

Grunting

Altered depth & pattern of respiration

Decreased air movement


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Cardiac features:

Tachycardia

Hypertension

Bradycardia

Hypotension

Cardiac arrest


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Neurologic features:

Headache

Restlessness

Irritability

Seizures

Coma



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Impending respiratory failure due to lung disease: difficulty is a rising resp. rate.

Tachypnea

Retractions

Nasal flaring

Grunting


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Impending respiratory failure due to resp. pump failure: difficulty is a rising resp. rate.

Decrease resp. rate

Shallowness of the breathing

No S & S of distress


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The severity is judged by the accompanying acedemia. difficulty is a rising resp. rate.


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Clinical respiratory physiology: difficulty is a rising resp. rate.

Perfusion distribution.

Alveolar physiology:LaPlaceLaw,surfactant.

Ventilation distribution.

Concept of shunting& dead space.

Hypoxemia&hypoxia.

Work of breathing.

Ventilatory reserve.


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Physiological classification of pulmonary diseases: difficulty is a rising resp. rate.

1)Dead space producing dis.:

A.Anatomic:rapid shallow breathing&+ve pressure breathing.

B.Alveolar:acute pulmonary embolus & uneven distribution.

C.Ventilation in excess of perfusion:alveolar septal defects,mechanical hyperventilation.


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2)Shunt producing dis.: difficulty is a rising resp. rate.

A.Anatomic:CHD,fistula,vascular tumor.

B.Capillary:atelectasis,fluid.

C.Perfusion in excess of ventilation:hypoventilation,uneven distribution of ventilation,diffusion defects.


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A. Assessment of ventilatory status : difficulty is a rising resp. rate.

i.PaCO2 < 30mmHg - vent. Insufficiency:

Acute : pH > 7.5

Chronic :pH 7.4 –7.5

Completely compensated metabolic acidosis

:pH 7.3 –7.4

Partially compensated met.acidosis

:pH< 7.3


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ii.PaCO2 30 –50 mmHg - normal : difficulty is a rising resp. rate.

Metabolic alkalosis : pH >7.5

Normal : pH 7.3 –7.5

Metabolic acidosis : pH <7.3


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iii.PaCO2 >50 mmHg - ventilatory failure : difficulty is a rising resp. rate.

Partly compensated metabolic alkalosis

: pH >7.5

Chronic ventilatory failure

: pH 7.3 –7.5

Acute ventilatory failure

: pH <7.3


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Ventilatory insufficiency: difficulty is a rising resp. rate. is the presence of alveolar hyperventilation.Hyperventilation leads to alkalemia (high pH) ; this in acute ventilatory insufficiency.

Chronic ventilatory insufficiency: is hyperventilation with normal pH. Acute respiratory failure: is high arterial CO2 with acidemia.Respiratory failure occur due to inability to increase alveolar ventilation

Chronic respiratory failure:When there is metabolic compensation.


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B.Assessment of hypoxemic status: difficulty is a rising resp. rate.

Mild hypoxemia < 80 mmHg

Moderate < 60 mmHg

Sever < 40 mmHg

O2 therapy

Uncorrected below room air minimal

Correcred below 100 mmHg

Excessively >100 mmHg;below predicted


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C.Assessment of tissue oxygenation difficulty is a rising resp. rate.

Cardiac output.

Peripheral circulation.

Blood O2 transport mechanism:

-PaO2

-Bd O2 content

-Hb O2 affinity


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ABGs mistakes: difficulty is a rising resp. rate.

1)Mixed with room air

2)CBGs

3)VBGs

4)Delay in running

5)Heparin addition

6)Plastic syringe

7)Machine error


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Rx: difficulty is a rising resp. rate.

Position

Supplemental O2 by mask

Aerosolized treatment

If failed go ahead & intubate


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Therapy Depends on: difficulty is a rising resp. rate.

-Degree of hypoxemia

-pH

-underlying pathophysiology

Treatment toward:

*correction of the underlying cause.

*respiratory failure recover


Oxygen therapy l.jpg
Oxygen therapy: difficulty is a rising resp. rate.

Why O2 therapy:

Rx hypoxia.

Decrease work of breathing.

Decrease myocardial work.

*Dangerous hypoxia should never be tolerated through a fear of O2 toxicity.

*Should be at the ,lowest conc. That provide an adequate PaO2.


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Methods of oxygen administration: difficulty is a rising resp. rate.

1)High flow oxygen systems:

Exact O2 conc. Delivered.

Given atmosphere is completely controlled.

Inspired O2 conc. does not vary.

2)Low flow oxygen systems:

Depends upon existence of reservoir of O2 & its dilution with room air.


O2 toxicity l.jpg
O2 toxicity: difficulty is a rising resp. rate.

Retrolental fibroplasia

R.O.P.

Convulsion

Hyaline mem. formation in the lungs.

Fibrosis & interstitial edema ( in lungs ).

Atelectasis

Alveolar cell Hyperplasia.


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! ! ! difficulty is a rising resp. rate.

In sever distress Rx before Dx .

But majoritycan tolerate performing ABGs & pulse oximetry .


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Mechanical ventilation for: difficulty is a rising resp. rate.

*Respiratory arrest.

*Repeated apnea.

*Sever shock.

*Acute neurological compromise.

*Therapeutic hyperventilation.

*Sever distress despite maximal therapy.

*High PaCO2.

*Prophylactic postop.

*Trauma.


Institution of invasive respiratory support l.jpg
Institution of invasive respiratory support: difficulty is a rising resp. rate.

??Tracheostomy.

Complications:

Early:

Death,surgical complications,misplacement.

Intermediate:

Cartilaginous erosion,fatal hemorrhage,stomal infection,pn.

Late:

Heal failure,ring stenosis or collapse,cosmetic.


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ETT: difficulty is a rising resp. rate.

Complications:

Immediate:

Tube in or other bronchus,in esophagus.

Early:

Migration,leak,obstruction.

Late:

Laryngeal injury,mucosal ulceration,tracheomalacia,

Tracheal narrowing & fibrosis.


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Mechanical ventilation dangers: difficulty is a rising resp. rate.

Airway complications.

CVS complications.

Respiratory complications.

Infections.

GIT complications.

Salt & water retention.


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Positive pressure ventilators: difficulty is a rising resp. rate.

Mask C-PAP vent.

Bag mask vent.

Mask BiPAP

Either ET tube or treacheostomy canula.


O2 applied to the bd gas exchange membrane due to l.jpg
O2 applied to the Bd gas exchange membrane due to: difficulty is a rising resp. rate.

The airway opening pressure > alveolar pressure,

so inflation occur in inspiration & the reverse (i.e.airway opening pressure < alveolar pressure)occur in expiration.


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Component of ventilator breath: difficulty is a rising resp. rate.

  • Inspiratory time ( I ).

  • Expiratory time ( E ).

  • Vent. Frequency.

  • Vt ( tidal volume ).

    Either sets the I or the I:E ratio .


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Pressure controlled vs. volume controlled vent. : difficulty is a rising resp. rate.

i.Pressure controlled vent. :

Delivered pressure built up to achieve PIP ,since then it maintained during the whole I.

-Sets PIP & PEEP.

-Vt determined by dynamics &not sated.


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ii.Volume controlled vent. : difficulty is a rising resp. rate.

Vt is sated & pressure reached its max. at Vt.

perfused alveoli ventilated & intrapulmonary shunting is prevented.

So PIP is determined by Vt & pulmonary mechanics ; & not sated .


S i m v l.jpg
S I M V : difficulty is a rising resp. rate.

-Either volume or pressure controlled.

-the determination of how long is too long is a function of vent. Frequency.

-Patient can inspire more often than the setting.

-Patient can’t control I time in assissted breaths.


Safety l.jpg
Safety : difficulty is a rising resp. rate.

Rule:

What is not controllable is monitored .

-Pop-off limits to the peak airway pressure .

-O2 analyzer for FiO2.


Lung diseases l.jpg
Lung diseases : difficulty is a rising resp. rate.

i)Decrease compliance : ARDS , Atelectasis, pneumonia , edema , intrapulmonary hemorrhage.

a-pressure controlled vent. :

increase MAP by increase PIP or PEEP.

Vt is low for a given PIP in normal lungs.


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b-volume controlled vent.: difficulty is a rising resp. rate.

PIP is higher than in normal lung.

ii)Increase airway resistance: Asthma , bronchiolitis , bronchopulmonary dysplasia, C.F.

Either lead to increase intrapulmonary shunting or increase dead space vent .

Dead space vent. Is due to traping phenomena.

Time constant is prolonged .

So prolongation of I : E ratio & decreasing the frequencu is ( or trapping will develop ).


Initial settings l.jpg
Initial settings : difficulty is a rising resp. rate.


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Initial settings : difficulty is a rising resp. rate.

i.Supporting normal lungs :

The vent.frequency is lower than normal frequency,but the Vt is larger than normal .

- (normal Vt :5 –7 mL/kg)

-So Vt setting at 10 –15 mL/kg to prevent atelectasis.

- Setting at 8 –10 mL is more suitable for prolonged vent.or diseased lung .

*This is for volume controlled vent.


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In pressure controlled : difficulty is a rising resp. rate.

Initial PIP :20 –25 cm H2O .

ii.Supporting diseases of decreased lung compliance:

Pressure controlled :

MAP need to be increased . Also PEEP needed to be titrated upward to achieve adequate oxygenation at FiO2 less than 0.6.

Initial PIP more than 30 cm H2O .

Pay attention to Vt.


Slide44 l.jpg

*In volume controlled pay attention to pressure alarms. difficulty is a rising resp. rate.

start with 100% O2 & then decrease to avoid O2 toxicity.

note : vent. Frequency can be set at higher rates than normal because T costant is decreased .

I time : 0.8 –1 sec.


Slide45 l.jpg

iii.Diseases of increase airway resistance: difficulty is a rising resp. rate.

Due to high T constant low vent. Frequency is needed(12 – 16 /min ).

Decrease PEEP To minimize trapping phenomena .


Complications l.jpg
Complications: difficulty is a rising resp. rate.

a.Barotraumas.

b.O2 toxicity.

c.Volutrauma: manifested as pul.air leak (pneumothorax , pneumomediastinium , interstitial emphysema &bronchopleural fistula ).

mechanism of volutrauma :

- Over distension leads to increase Vt .

-If PEEP sated at low levels there will be cyclic collapse and re-expansion.


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-Volutrauma affects the healthier alveoli in diseases of decreased compliance .

  • In increase airway resistance diseases:

    over filling of healthy alveoli & over distension of (trapping ) in diseased alveoli .

    d.Decrease cardiac input .

    e.Decrease left ventricular SV & after load of Rt or Lt ventricle.

    (so patient may need fluid & inotrops .

    f.ET obstruction ( life threatening ).

    g.Subglottic stenosis.

    h.Nosocomial infection (leading cause of deathin resp. failure patients ).


Newborn vulnerability to resp failure l.jpg
Newborn vulnerability to resp. failure : decreased compliance .

-Immaturity .

-High chest wall compliance.

-Malnutrition.

-Hypo perfusion.

-Electrolyte disturbances .

-Hypophosphatemia .


Nitric oxide l.jpg
Nitric oxide decreased compliance .


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ECMO decreased compliance .


Etiology l.jpg
Etiology: decreased compliance .


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Monitoring of respiratory failure: decreased compliance .

  • Clinically.

  • Pulse oximetry.

    Acid-base balance disturbance.

  • Bd gas analysis:

    Alteration in oxygenation.

    1.analyzer malfunctioning

    2.incorrect sampling (WBC&air O2)

    3.inadequate anticoagulation

    (1000 i .u ./mL 0.1ml for 2 mL)

  • Capnography.


Misleadings l.jpg
Misleadings : decreased compliance .

-PaO2 if inspire high FiO2 .

-PaO2 decrease due to intracardiac shunt without accompanying decrease in lung function .

-PaO2 increase in compensation for chronic metabolic alkalosis .


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