respiratory problem

1. Breathing Difficulties
in
Children

2. Objectives
By the end of this session , learners will be able to:
• Describe reasons for increased susceptibility of children
to respiratory failure
• Describe the approach to a child with breathing
difficulties
• Outline causes and management of children with stridor
• Outline steps of management of a child with severe life
threatening bronchial asthma
• Diagnose and manage pediatric ARDS

4. Why children are more susceptible to
respiratory failure than adults?

5. Why children are more susceptible?
• Narrow and smaller airway:
- more easily obstructed by mucosal swelling and foreign
bodies
• Much more complaint thoracic cage:
- less support for the maintenance of lung volume
- marked chest wall recession
• Fewer alveoli in early childhood:
- susceptibility to ventilation-perfusion mismatch
• Tracheal cartilage is soft and easily collapsible in infancy
Contd…….

6. • Relatively inefficient respiratory muscle:
- early respiratory muscle fatigue
- rapid progress to respiratory failure and apnea
• Significant quantities of HbF till 4-6 months of life:
- left shift of oxygen dissociation curve
- poor release of oxygen at tissue level
• Susceptible to many infections to which adults have
acquired immunity
• Increased metabolic rate:
- increased O2 consumption

7. Causes of Breathing Difficulties
S.N Mechanism & Anatomical site Causes
1 Upper airway obstruction Croup/epiglottitis
Foreign body
Retropharyngeal abscess
2 Lower airway obstruction Tracheitis
Asthma/viral associated wheeze
Broncheolitis
3 Lung Pathology Pneumonia
Pulmonary edema/ARDS
4 Pathology around the lung Pneumothorax/Rib fracture
Empyema thoracis
5 Disorders of respiratory muscles Neuromuscular disorders
6 Pathology below the diaphragm Peritonitis
Abdominal distension
7 Pathology increasing respiratory drive Diabetic ketoacidosis
Shock
Poisoning
Anxiety/Hyperventilation
8 Pathology decreasing respiratory drive Coma , Convulsion
Raised Intracranial Pressure

8. Clinical Presentations
Respiratory Non-respiratory
Cough, Poor feeding
Grunting Abdominal pain
Noisy breathing Meningism
Breathlessness Hypotonia
Chest pain Change in color, Cyanosis
Decreased conscious level,
Convulsions

9. Respiratory failure
• Inability of physiological compensatory mechanisms to
ensure adequate oxygenation and carbon dioxide
clearance (ventilation).
• Results in arterial hypoxia with or without hypercapnia.
• Respiratory distress precedes respiratory failure
• Type 1 - Acute Hypoxemic respiratory failure-
Oxygenation failure
• Type 2 - Acute Hypercapnic respiratory failure –
Ventilation failure
• Mixed – having both hypoxia and hypercapnia

10. Respiratory Distress and Respiratory failure
Respiratory Distress Respiratory failure
Open and
maintainable
Airway Possibly obstructed
Tachypnea Respiratory rate Shallow
breathing/gasping
Increased effort Respiratory effort No or minimal effort
>92% on O2 therapy SPO2 <92% on O2 therapy
Tachycardia Heart rate Bradycardia
Agitated/Anxiety Responsiveness Fails to response
Pale Appearance/capillary
bed
Cyanosis

11. Acute Respiratory Distress Syndrome (ARDS)
ARDS is an acute non-cardiogenic pulmonary edema
with bilateral pulmonary infiltrates associated with
refractory hypoxia.

12. ARDS Pathophysiology

13. ARDS- Clinical features
• Increased WOB
• Anxiety, agitation
• Hypoxemia refractory to supplemental oxygen
• Hypercarbia and acidosis
• Chest X-ray shows bilateral infiltrates

14. ARDS-Early ARDS-Late

15. PALICC group criteria of PARDS

16. Management of ARDS
Goals:
• Treatment of the underlying disorder
• Provide adequate oxygenation and ventilation
• Treatment of the associated multiple organs
dysfunction
contd..

17. • Positive pressure ventilation is an important component
of management
• NIV:
- mild to moderate ARDS
- in the early phases
• Intubation and mechanical ventilation are likely to be
needed
• Mechanical Ventilation:
- Lung protective strategy: Low TV, High PEEP

18. • Multiple organ failure often follows
• Supportive treatments often includes:
Antibiotics
Inotropes
Nutrition, Analgesia, Sedation
Blood product transfusion
Targeted Hb: minimum 10gm/dl

19. Approach to ARDS
Child with respiratory distress
Maintain ABC
Clinical assessment, Pulse oximetry, CXR, ABG
Confirm ARDS Acute onset (< 7 days)
Severe hypoxemia PaO2/FiO2: <300
Bilateral Pulmonary infiltrate
No evidence of Left arterial hypertension
Identify underlying Risk factors Pneumonia, Sepsis, Drowning, Trauma, Burn,
Blood transfusion DIC, Pancreatitis
Management
Respiratory Supportive
High flow Oxygen Antibiotics for pneumonia and sepsis
Intravascular volume resuscitation
Evaluation for respiratory failure Inotropes, BT, Nutrition, Analgesia
Stable Sedation
Respiratory failure
Monitor and continue on going treatment
Ventilatory Support
Mechanical Ventilation (Lung protective strategy)
Non Invasive Ventilation Low VT, High PEEP
HFNC / CPAP/ BiPAP Failure of MV HFOV, ECMO

20. Any questions?

21. Summary
• What are the differences between respiratory
distress and failure?

22. Thank you