Respiratory Failure in Children

Critical Concepts Course

Objectives...

Define respiratory failure Common causes of hypoxemia/hypercapnia Clinical signs/investigations

How is respiratory failure defined?

Historically PaO2 <60 mm Hg, PaCO2 mm Hg

!0

O"viously must ta#e into account patient$s anatomy %ie & cyanotic heart lesion' Can (evelop acutely or over (ays Ho) the patient loo#s is usually incorporate( into (iagnosis/management *ymptoms/*everity (epen(ent on acuity

Adults vs. Kids

+ultiple (ifferences from un(erlying air)ay anatomy to (isease process ,i(s usually affecte( "y congenital or infectious processes -(ults inflicte( "y respiratory (isease such as COPD, as )ell as infectious processes .evie) (ifferences in vital sign normals such as resp/ rate, H. etc0 for chil(ren of (ifferent ages

Clinical decision making

-cute vs/ Chronic

Helps in (eci(ing acuity of treatment Progression of illness also important & history

-ny un(erlying chronic (isease1

i/e/ -sthma, congenital heart (isease0

2xamine patient333
4or# of "reathing, 5evel of consciousness, 6itals 4hat tests might "e helpful

aboratory investigations

-rterial "loo( gas %if possi"le'

Gives info on oxygenation and ventilation status Difficult to get in some patients Obtaining and ABG should be part of resident skills

Other "loo( gas 7 ventilation info "ut not oxygenation

Venous good only if obtained from free flowing site no

tourni uet
capillary easiest to obtain

Other "loo( )or# "ase( on clinical scenario %ie 48C count, cultures if suspect infection'

!mportant points on blood gas interpretation

,no)

type of gas %-89 vs 689 vs C89'

Only interpret PaO2 on -89 PaCO2 slightly higher in 689 .emem"er meta"olic si(e !base deficit" #$%O&'()

O"y#emoglobin dissociation curve

Two key points on curve:

:/ PO2 :00 mm Hg; *pO2 of <=> 2/ PO2 ?0 mm Hg; *pO2 of =!> %mixe( venous "loo('

Note the steep part of the curve in this area Small changes in clinical status will produce large swing in SpO2

Key points about t#e o"y#emoglobin saturation curve

.emem"er ho) flat the slope is a"ove PO2;60 mm Hg -ny small (rop in PO2 "elo) this )ill cause precipitous fall in saturation

O"ygenation failure$

+ost common type of respiratory failure Occurs in )i(e variety of (isease processes +ain pathophysiologic (erangements@
*+ **+ ***+

V,- mismatch .hunt $ypoventilation

Hypoventilation

AiO2 of air is 2:> PaO2 of air is %/2: B %=60 mm Hg & ?= mm Hg %)ater vapor'' PO2 of alveolar gas is "alance of removal an( replenishment O2 consumption varies little Cherefore, alveolar PO2 is (etermine( mostly "y level of alveolar ventilation

Df ventilation falls, PO2 (rops an( PCO2 )ill rise %this is #ey, hypoventilation )ill always lea( to high PaCO2

%#unting

8loo( entering the arterial system )ithout entering ventilate( lung Dntra& vs/ extra&car(iac shunting -l)ays a small amount of shunt via "ronchial vessels, coronary veins +ost important feature is :00> O2 does not resolve hypoxemia PCO2 usually normal or lo) as minute ventilation usually increase( "y chemoreceptors

&entilation 'erfusion (ismatc#

6entilation

/ 8loo( flo) are mismatche( in (ifferent lung fiel(s +ost common cause of hypoxemia Esually exclu(e other causes "efore settling on 6/F mismatch

&entilation 'erfusion (ismatc#

Chin# of 6/F ratios varying from little to no ventilation %6/F;0' to little to no "loo( flo) %6/F;infinity' Chose lung units )ith lo) 6/F ratios cause hypoxemia Enits )ith high 6/F ratios (o not compensate for lo) O2 content of others (ue to shape of (issociation curve

5o) 6/F unit )ith lo) en(& capillary O2 content

High 6/F unit )ith high en(&capillary O2 content

NOTE@ *teep part of curve in range of lo) 6O2 units

PO2 ; =0 mm Hg

&) mismatc# continues...

+ismatch occurs in healthy lungs, (ifference is accounte( for "y regional "loo( flo)/ventilation 6entilation / Perfusion "oth increase slo)ly from top to "ottom of the lung 8loo( flo) increases more rapi(ly than ventilation 6F ratio su"seGuently (ifferent as you move from : lung segment to the other

5ungs )ith significant 6F mismatch cannot sustain the same levels of PaO2 /PaCO

*#at are t#e important clinical points?

Ds

there an oxygenation (efect1

Chec# -&a gra(ient

; PAO2 - PaO2(arterial)
PAO2 = FiO2 - (PaCO2 !"#$

(alveolar gas e%u&n$

Hormal value !&I0 mm Hg%age (epen(ent' Df elevate( then almost always 6/F mismatch

Clinical e"amples of &+) imbalance

-sthma Pulmonary e(ema -.D*

How do you follow response to t#erapy?

Options include@
PaO2/AiO2 ratio Oxygenation in(ex %OD'

; +ean air)ay pressure %+-P' B AiO2 B :00> PaO2

8oth vali(ate( "ut OD "etter )hen ventilate( )ith positive pressure

/elationship between V,mismatch and gas exchange

HOC2@ *teep rate of (ecline in PaO2 compare( to PaCO2

CO, and respiratory failure

6entilation ; the air moving in an( out of lungs +inute ventilation is amount moving in an( out per minute %62' -lveolar ventilation is the volume of air that ta#es part in gas exchange/ Dea( space ventilation (oes not ta#e part in ventilation PaCO2 is only measurement that reflects alveolar ventilation an( the relationship to CO2 pro(uction CO2 pro(uction is continuous, elimination is through lungs pre(ominantly

*#y we care about #ypo"emia+#ypercarbia?

Hypoxemia@
*ignificant hypoxemia can lea( to tissue hypoxia an(

anaero"ic meta"olism

Different organ systems have (ifferent threshol(s for

tolerating hypoxemia %CH* an( heart most vulnera"le' %DO2', other important factors inclu(e hemoglo"in level, car(iac output hypoxia

-rterial PO2 is only one component of oxygen (elivery

.ising serum lactate is an in(icator of significant tissue

Hypercarbia$

Controversial topic )ith emergence of permissive hypercapnia in treatment of -5D/-.D* Definite CH* effects such as narcosis, mental clou(ing at high levels -(verse effects of aci(osis pro(uce( "y hypercar"ia may "e overstate( Has (emonstrate( some protective effects against mechanical ventilation in(uce( lung (amage

Clinical -ecognition

Clinical Categori.ation

!nitial (anagement

!n conclusion
Chin#

in terms of oxygenation an( ventilation Chin# 4HJ %ie physiology' the patient is hypoxic/hypercar"ic0 .emem"er to follo) patients closely as they can (eteriorate Guic#ly

-eferences/ -ecommended -eading/ and Acknowledgements

Ep to Date@ 2mergent 2valuation of -cute .espiratory Distress in Chil(ren Helson$s Cext"oo# of Pe(iatrics *ome sli(es "ase( on )or# "y Dr/ Keff 8rusins#i for Pe(sCC+ -merican Heart -ssociation P-5* gui(elines