Pediatric respiratory failure Resuscitation in children

Krzysztof Czyżewski, MD, PhD

Department of Pediatric Hematology and Oncology

Blood gases: standard ranges

PARAMETER RANGE

pH 7,35-7,45

PaCO2 35-45 mmHg

PaO2 75-100 mmHg

HCO3 22-26 mmol/l

BE (base excess) -3 do +3 mmol/l

SaO2 94-100%

Definitions

Respiratory failure

a condition in which there is a disruption of vital system dysfunctions gas exchange in the lungs, regardless of the mechanism of their formationor:

a state in which the respiratory system can not provide correct blood gas pressure while breathing air

Definitions

Acute lung injury (ALI)

is a diffuse heterogeneous lung injury characterized by hypoxemia, non cardiogenic pulmonary edema, low lung compliance and widespread capillary leakage.

ALI is caused by any stimulus of local or systemic inflammation, principally sepsis.

Definitions

Acute respiratory distress syndrome (ARDS)

is a medical condition caused by pulmonary lung damaging agents (direct and indirect).

ARDS is characterized by a triad of symptoms:

-hypoxemy refractory to oxygen therapy,

-diffused atelectasis in chest X-ray,

-decreased susceptibility of the lung.

ALI i ARDS definitions according toAmerican-European Consensus Conference (1994)

-Acute onsetBilateral pulmonary infiltrates on chest radiography

-

Criteria Description

Onset Acute

Eligibility criteria

Direct – pneumonia (esp. aspiration)

Indirect - septic states, severe trauma, prolonged hypoxemia, extensive fracture, multiple transfusions of blood products (TRALI)

Oxygenation

ALI – Pa02/FiO2≤300 i PAOP<18 mmHg

ARDS – PaO2/FiO2≤200

Radiological criteriaBilateral pulmonary infiltrates on chest radiography

Exclusion criteriaPulmonary artery occlusion pressure > 18 mm Hg or clinical evidence of left arterial hypertension

ARDS Berlin definition (2012)

ARDS Berlin definition (2012)

ARDS X-ray

Time of reccurance

Acute - is growing

rapidly and is potentially reversible

Chronic - develops gradually over time and is not

fully reversible

Etiology

Plmonary

Extra-pulmonary

Clinically

Hyperdynamic - excessive work of breathing (tachypnea, the collapse of the sternum, intracostal borrowing,

borrowing attachments of the diaphragm, drone

Hypodynamic - breathing was shallow, bradypnoea, apnea

1. Defective respiratory drive in the CNS - eg. Encephalitis, trauma,

drugs (opioids, barbiturates)2. Spinal cord injuries - mechanical trauma, hematoma, tumor, drugs

3. Failure of the respiratory muscles

Blood gases

Partial - only hypoxemia

Total – hypoxemia

and hypercapnia

Respiratoy failure - division

Criteria for diagnosis acute respiratory failure

(minimum 2 clinical+ 2 laboratory criteria simultanously)

Clinical criteria1. Dyspnoea2. Tachypnoe3.Disturbances of consciousness4. The weakening of the normal murmur5. Commissioning of accessory muscles

Laboratory criteria1. PaO2<50 mmHg at FiO2=0,212.PaCO2 >50 mmHg3. pH<7,204. Accumulation of lactic acid in serum5. SaO2 < 80%

Respiratory rate and age(mean values)

Age[years]

Rate (breaths/min)

BREATHS RESCUE IN CHILDREN

<1 30-40

Start if <10/min

2-5 24-30

5-12 20-24

>12 12-20

The child's age and the cause of acute respiratory failure (ARF)

••neonatal respiratory distress syndrome••transient, rapid breathing newborns••meconium aspiration syndrom••persistent pulmonary hypertension of the newborn••pneumonia••apnea••sepsis••Congenital anomalies of the respiratory system (rear nostril atresia, laxity of

the larynx)

Neonatal period

••pneumonia••bronchiolitis

sepsis••neuromuscular disease••myelitis••tetanus••neuromuscular blockade and respiratory muscle failure: drug-induced,

post-traumatic••degenerative muscular atrophy••inflammation of the subglottic larynx••foreign body in the airway••trauma

Infancy

••acute respiratory distress syndrome••trauma••sepsis••asthma••epiglottitis••neuromuscular dseases••pulmonary edema••pulmonary embolism••foreign body

> 1 ys

Treatment of acute respiratory failure

• The main goal of ARF treatment is to increase alveolar ventilation, the use of assisted breathing, oxygen therapy and sedation child.

• Intubation is the most necessary and directly saves the lives of the majority of patients.

Reactive Oxygen (100% 02)•• By mask•• By nebulizer•• Nasal insufflation through cannulas

Maintain airway•• Manual clearing the upper respiratory tract (eg. chin lift)•• Suctioning secretions from the upper respiratory tract•• Stimulation of cough•• The use of oral-throat tube

Treatment of acute respiratory failure

Maintaining the patient in the sitting position-if possible

Pharmacological sedation -midazolam

Maintaining normal body temperature

Fill vascular

Assisted ventilation - mechanical ventilation

Treatment of acute respiratory failure

Indications for intubation and mechanical ventilation

•• Recurrent apnea with bradycardia•• Increasing or persistent breathing effort•• SaO2 decreasing despite increasing FiO2•• Stop breathing and circulation•• Irregularities Gasometric: increasing hypercapnia

with acidosis progressive hypoxemia•• Progressive cardiorespiratory failure, despite the lack

of indications from gasometry•• General anesthesia for various procedures

Treatment of acute respiratory failure

Upper airway obstruction

The causes of stridor:•• Viral croup - discussed further•• Epiglottitis•• Complications after intubation – post-intubation edema of the larynx,

vocal cord paralysis•• Pertussis•• Parapharyngeal absces•• Laryngeal papillomatosis•• Laryngomalacia•• Thermal and chemical burns to the respiratory tract•• Foreign body•• External compression - tumor

Sedation child – pharmacologial sedation•• Eg. Fractionated doses of midazolam 0.1 mg / kg / dose or 0.05-0.1 kg / day

Laying in the semi-sitting position•• Laying in the semi-sitting position

Reactive Oxygen cool, well-humidified oxygen

Inhalation•• 0.9% NaCl

Budesonide at a dose adjusted to the age0.1% epinephrine in a dose of 0.01 mg / kg (max. 0.05 mg / kg bw / inhalation)

Monitoring of the patient•• Respiratory rate, SaO2, HR, RR

Gasometry - Examination of the acid-base

General anesthesia and intubation•• In the absence of the effect of treatment, severity of dyspnea, tachycardia, hypercapnia with pH <7.25 and a

progressive decrease in SaO2

Upper airway obstruction - proceeding

Lower respiratory tract obstruction

Causes:

•• Asthma•• Bronchiolitis•• Bronchopulmonary dysplasia•• Aspiration of gastric contents, foreign body•• Chemical damage•• Cystic fibrosis

Lower respiratory tract obstruction

Clinical::

•• Wheezing - the larger the longer the obstruction expiratory phase

•• Wheezing from the small airways•• Chest X-ray- excessive hyperinflation

Aspiration of foreign material into the airways

The location of the foreign body:

•• Frequently the right bronchus•• Less frequently: left bronchus, larynx, throat•• Esophageal foreign body airway closure -

especially at the site of stenosis of the trachea at the bifurcation of the trachea or the aortic arch

Aspiration of foreign material into the airways

Clinical:•• Cough•• Cyanosis•• Shortness of breath with varying degrees of severity

apnea•• Taking out one side of the chest•• In auscultation: all types of changes•• X-ray•• Contrast foreign body - the location of the X-ray

> 24 hours. can show up atelectasis / emphysema, mediastinal displacement, heart to the opposite side or pneumonia

Aspiration of foreign material into the airways - treatment

Rate the severity of the patient's condition

Ineffective cough

Unconscious patient

Open the airway 5 rescue breaths

Start CPR

Conscious patient5 back blows

5 thrust (chest ony in infants) (alternative abdominal and

and chest in children> 1 year old)

Effective cough

Encourage coughingContinue until the assessment of

the deterioration of the patient and the occurrence of inefficient cough or until you remove the

foreign body

Aspiration of foreign material into the airways

Treatment:

•• Removal of foreign body - shallow inhalation anesthesia, preferably on the patient's own breathing

•• Bronchoscopy rigid bronchoscope

Croup

Definition:•• is a respiratory condition that is usually triggered by

an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" caugh, stridor, and hoarseness. It may produce mild, moderate, or severe symptoms, which often worsen at night. It is often treated with a single dose of oral steroids; occasionally inhaled epinephrine is used in more severe cases. Hospitalization is rarely required.

Croup

Clinical:•• Barking cough•• Hoarseness•• Inspiratory stridor appear suddenly, usually at night,

increasing during the child's crying and agitation•• Tachypnoe•• Navigating the wings of the nose•• Commissioning of accessory muscles (retraction hole yoke,

intracostal borrowing, borrowing attachments of the diaphragm)

•• Central cyanosis with significant shortness of breath•• Temp normally <38 ºC

Croup

Croup

The most commonly used system for classifying the severity of croup is the Westley score.

It is primarily used for research purposes rather than in clinical practice.[

It is the sum of points assigned for five factors: level of consciousness, cyanosis, stridor, air entry, and retractions.

The points given for each factor is listed in the table to the right, and the final score ranges from 0 to 17.

Croup

≤ 2 indicates mild croup. The characteristic barking cough and hoarseness may be present, but there is no stridor at rest.3–5 is classified as moderate croup. It presents with easily heard stridor, but with few other signs.[6]

6–11 is severe croup. It also presents with obvious stridor, but also features marked chest wall indrawing.[6]

≥ 12 indicates impending respiratory failure. The barking cough and stridor may no longer be prominent at this stage.[6]

85% of children presenting to the emergency department have mild disease; severe croup is rare (<1%).[

Croup

All guidelines available at https://cprguidelines.eu/

https://cprguidelines.eu/sites/573c777f5e61585a053d7ba5/content_entry573c77e35e61585a053d7baf/573c780c5e61585a083d7bc9/files/S0300-9572_15_0034

0-8_main.pdf

Resuscitaion – selected issues

Diagnosis of cardiac arrest – Healthcare providers cannot reliably determine the presence or absence of a pulse in less than10 s in infants or children.

Healthcare providers should look for signs of life and if they are confident in the technique they may add pulse palpation for diagnosing cardiac arrest and decide whether they should begin chest compressions ornot.

Resuscitation

The decision to begin CPR must be taken in less than 10 s.

According to the child’s age, puls can be asses on:-carotid (children), -brachial (infants) or -femoral pulse (children and infants).

Resuscitation

Resuscitation -Chest compressions

The CV ratio used for children should be based on whether one, or more than one rescuer is present.

Use a ratio of 15 chest compressions to 2 ventilations.

Rescuers who are unable or unwilling to provide mouth-to-mouth ventilation should be encouraged to perform at least compression-only CPR.

Compress the chest to at least one third of the anterior-posterior chest diameter in all children (i.e., approximately 4 cm in infants and approximately 5 cm in children).

Subsequent complete release is emphasised.

For both infants and children, the compression rate should be at least 100 but not greater than 120/min (in the rythm of Staying alive song)

Resuscitation -Chest compressions

The compression technique for infants includes:two-finger compression for single rescuers and the two-thumb encircling technique for two or more rescuers. For older children, a one- or two-hand technique can be used, according to rescuer preference.

Resuscitation -Chest compressions

Resuscitation-defibryllation

a single-shock strategy using a non-escalating dose of 4 J/kg (preferably biphasic, but monophasic is acceptable) is recommended for defibrillationin children.

ALS – advanced life support

• A – (AIRWAY)

• B – (BREATHING)

• C – (CIRCULATION)

ALS

General recommendation for cuffed and uncuffed tracheal tube sizes (internal diameter in mm).

e.g. 6 years: (6/4)+4=1,5+4=5,5 – uncuffed tube size for 6 years-old children

ALS

• Drug access

– intravenous (preffeed)

– Intraosseous (equal to intravenous)

– tracheal tube access is currently not recommended

ALS

You have to remember all drug doses used in ALS. There will be no time to look for them in a book.

Adrenalin

The recommended IV/IO dose of adrenaline in children for the first and for subsequent doses is 10 mcg/kg. The maximum single dose is 1mg. If needed, give further doses of adrenaline every 3–5 min.

Intratracheal adrenaline is no longer recommended, but if this route is ever used, the dose is 100 mcg/kg.

ALSNota bene:

Intraosseous or IV access should be definitely preferred to the tracheal route for giving drugs.

Drugs given via the trachea have highly variable absorption but, for guidance, the following dosages have been recommended:-Adrenaline 100 mcg/kg-Lidocaine 2–3 mg/kg-Atropine 30 mcg/kg

The optimal dose of naloxone is not known.

Dilute the drug in 5 ml of normal saline and follow administration with five ventilations.

Do not give non-lipid soluble medications (e.g., glucose, bicarbonate, calcium) via the tracheal tube because they will damage the airway mucosa.