Case conference,

1. CASE CONFERENCEEXTERN AKECHANOK WATCHARAPUNJAMART

2. RESPIRATORY FAILURE
IN PEDIATRICSEXTERN AKECHANOK WATCHARAPUNJAMART

3. DEFINITION
“When oxygenation and ventilation are
insufficient to meet the metabolic
demands of the body”
Reference:
Traditionally defined as respiratory
dysfunction resulting in PaO2 <60 mmHg
(room air) PaCO2 > 50 mmHg (acidosis)

4. Why does
RESPIRATORY FAILURE
tend to occur more in
Children than Adult?

5. Pediatric Airway Anatomy
1. Obligate nose breather
2. Small airway
3.Disproportionally bigger tongues

6. Pediatric Airway Anatomy
4. Long, floppy epiglottis, Larynx is higher in neck

7. Pediatric Airway Anatomy
Tracheal Position

8. Pediatric Airway Anatomy
5. Cone shaped, Cricoid ring is the narrowest
point of the pediatric airway

9. Pediatric Airway Anatomy
6.Children have large tonsils and adenoids

10. Pediatric Airway Anatomy
7.The process of alveolization continues beyond the infant age
20-50 million alveoli at birth in a term infant
300 million by the age of 8 years

11. Pediatric Airway Anatomy
8.Collateral ventilation through the
pores of Kohn and Lambert’s canal
are not well developed in the early
years

12. Pediatric Airway Anatomy
9.

13. Pediatric Airway Anatomy
10.Ossification of the rib cage,
calcification of the costal
cartilage, and development of
muscular mass develops
progressively until adulthood

14. Pediatric Airway Anatomy
11.development of Respiratory center
Apnea
Irregular
Respiration

15. What Causes
Respiratory Failure?

16. Causes of
Respiratory Failure?
1. Upper & Lower airway
obstruction
2.Alveolar-Interstitial lung
disease
3. Ventilatory pump failure
Reference:

17. Reference:

19. Acute respiratory failure in childhoood
Preterm infant
Hyaline membrane disease
= infant RDS
Lung immaturity
Congenital pneumonia
acquired lung diseases:
nosocomial pneumonia
bronchiolitis
sepsis
Newborn (at term)
Congenital pneumonia
Meconium aspiration
Malformations:
Lung hypoplasia, CDH
acquired lung diseases:
nosocomial pneumonia
bronchiolitis
sepsis

20. Acute respiratory failure in childhoood
Infant (1- 12 months)
sepsis-syndrome
infectious pneumonia
(RSV-bronchiolitis)
non infectious pneumonia
- inhalational injury
circulatory arrest
Preschool age
sepsis-syndrome
infectious pneumonia
(RSV-bronchiolitis)
non infectious pneumonia
- foreign body aspiration
- inhalational injury
- drowning
trauma
circulatory arrest

21. How do we know
if the patient has
RESPIRATORY
FAILURE?

22. Signs & Symptoms of
Respiratory Failure
Reference : http://depts.washington.edu/uwgenped/outpatient-clinical-guidelines (26/11/2015)

24. “RCA” ( 2-R,2-C,1-A)

25. คำย่อ คำอธิบำย
R Respiratory Rate (หำยใจเร็วขึ้น)
R Retraction (Work of Breathing)
(ใช้แรงมำกขึ้นกำรหำยใจ หอบ หน้ำอกบุ๋ม)
C Color (Cyanosis) (มีอำกำรเขียว)
C Conscious Change (ระดับกำรรู้สติเปลี่ยนแปลง)
A Air Entry (เสียงลมเข้ำปอดลดลง)
Impending
respiratory failure
: Reference

26. How Is
Respiratory Failure
Diagnosed?

27. Blood Gas Abnormalities
in Respiratory Failure
oTraditionally defined as
respiratory dysfunction resulting
in PaO2 <60 mmHg (room air)
PaCO2 > 50 mmHg (acidosis)
and Arterial Oxygen saturation,
SaO2 < 90%
o The patient’s general state, respiratory effort,
and potential for impending exhaustion are
more important indicators than blood gas
values.

28. • PaO2 Low ,PaCO2 Normal
• PaO2 Low ,PaCO2 High
Blood Gas Abnormalities
in Respiratory Failure
“Non ventilatory or Normocapnic
or Type I Respiratory Failure”
“Ventilatory or Hypercapnic or
Type II Respiratory Failure”
: Reference

29. Pathophysiology
Most Common!!
Reference : Kevin E J Gunning, Pathophysiology of Respiratory
Failure and Indications for Respiratory Support ,page 6

30. Range of V/Q Relationships
Intrapulmonary Shunt

31. The effects of alveolar–capillary leak and
positive end-expiratory pressure (PEEP)
on pulmonary gas exchange.

32. Pathophysiology
Reference : Kevin E J Gunning, Pathophysiology of Respiratory
Failure and Indications for Respiratory Support ,page 6

33. How Is
Respiratory Failure
Management?

34. How Is
Respiratory Failure
Management?
Treat Underlying cause and
pathophysiology
Adequate Oxygenation
: Reference

35. Adequate Oxygenation
Oxygen delivery,DO2ขึ้นกับ
cardiac output (Q),
hemoglobin (Hb) ,
oxygen saturation ในเลือดแดง(SaO2)
และค่ำ PaO2

36. Oxygen Administration
• Least invasive and most easily tolerated therapy
for hypoxic respiratory failure
• Oxygen nasal cannula 2-4 L/min
• Simple face mask 5-10 L/min, FiO2 0.35-0.65
• Partial rebreathing mask
• Non-rebreathing mask

37. Chronic CO2 retension

38. Positive-Pressure
Respiratory support
• High-flow nasal cannula (4-16 L/min)
• Continuous positive airway
pressure (CPAP)
• Bilevel Positive Airway Pressure (BiPaP)

39. ข้อบ่งชี้ในกำรใช้ NIPPV ในทำงปฏิบัติ
• อัตรำกำรหำยใจเร็วหรือหำยใจเร็ว
เพิ่มขึ้น
• ใช้กล้ำมเนื้อ Accessory ในกำร
หำยใจ
• มีกำรหำยใจแบบ Paradox
• PaCO2 >45 mm Hg, pH <7.35
ข้อห้ำมในกำรใช้ NIPPV
1.สัญญำณชีพไม่คงที่
2.มีเสมหะปริมำณมำก
3.ไม่สำมำรถสังเกตอำกำรของ
Upper airway Obstruction ได้
อย่ำงใกล้ชิด
: Reference

40. ข้อบ่งชี้ในกำรใช้ IPPV ในเวชปฏิบัติ
1.ภำวะกำรหำยใจล้มเหลว (Impending Respiratory failure)
2.Circulatory Instability
3.Increase intracranial pressure,ICP
4.Pulmonary Hypertension
Reference

41. Other Management
• กำรให้เลือด
• กำรลดควำมต้องกำรของออกซิเจน เช่น ให้ยำลดไข้ เช็ดตัวลดไข้ ให้ยำ
นอนหลับ ยำคลำยกล้ำมเนื้อ เป็นต้น
• กำรเพิ่ม cardiac output โดยกำรให้สำรน้ำทำงหลอดเลือดดำ ให้ยำ
กระตุ้นกำรทำงำนของหัวใจ เป็นต้น
• กำรเปลี่ยนที่นอน
• กำรให้ยำขยำยหลอดลม หรือยำต้ำนจุลชีพเมื่อมีข้อบ่งชี้
: Reference