\\\\\\\\\\\\\. mohammad rezaei fellowship of pediatric pulmonology
TRANSCRIPT
![Page 1: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/1.jpg)
/ \\\\\\\\\\\\\
![Page 2: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/2.jpg)
RESPIRATORY FAILURE
Mohammad Rezaei
Fellowship of Pediatric Pulmonology
![Page 3: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/3.jpg)
Respiratory distress
Respiratory distress is a clinical impression
![Page 4: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/4.jpg)
Respiratory failure
inability of the lungs to provide sufficient oxygen (hypoxic respiratory failure) or remove carbon dioxide (ventilatory failure) to meet metabolic demands.
![Page 5: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/5.jpg)
Respiratory failure
Pao2 < 60 torr with breathing of room air and
Paco2 > 50 torr resulting in acidosis,
the patient's general state, respiratory effort, and potential for impending exhaustion are more important indicators than blood gas values.
![Page 6: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/6.jpg)
Respiratory distress can occur in patients without respiratory disease,
and
respiratory failure can occur in patients without respiratory distress.
![Page 7: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/7.jpg)
Respiratory failure
Acute Chronic
![Page 8: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/8.jpg)
The physiologic basis of respiratory failure determines the clinical picture.
normal respiratory drive are breathless and anxious
decreased central drive are comfortable or even somnolent.
![Page 9: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/9.jpg)
The causes:
conditions that affect the respiratory pump
conditions that interfere with the normal function of the lung and airways
![Page 10: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/10.jpg)
Respiratory Pump Dysfunction
● Decreased Central Nervous System (CNS) Input — Head injury — Ingestion of CNS depressant — Adverse effect of procedural sedation — Intracranial bleeding — Apnea of prematurity
● Peripheral Nerve/Neuromuscular Junction — Spinal cord injury — Organophosphate/carbamate poisoning — Guillian-Barre´ syndrome — Myasthenia gravis — Infant botulism
● Muscle Weakness — Respiratory muscle fatigue due to increased work of breathing — Myopathies/Muscular dystrophies
![Page 11: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/11.jpg)
Airway/Lung Dysfunction
● Central Airway Obstruction — Croup — Foreign body — Anaphylaxis — Bacterial tracheitis — Epiglottitis — Retropharyngeal abscess — Bulbar muscle weakness/dysfunction
● Peripheral Airways/Parenchymal Lung Disease — Status asthmaticus — Bronchiolitis — Pneumonia — Acute respiratory distress syndrome — Pulmonary edema — Pulmonary contusion — Cystic fibrosis — Chronic lung disease (eg, bronchopulmonary dysplasia)
![Page 12: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/12.jpg)
Arterial gas composition
depends on :
the gas composition of the atmosphere the effectiveness of alveolar ventilation pulmonary capillary perfusion diffusion across the alveolar capillary
membrane
![Page 13: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/13.jpg)
Alveolar Gas Composition
PAO2 = PIO2 – (PCO2/R)
PIO2 = (BP – PH2O) . Fio2 PAO2 = [(BP – PH2O) . Fio2] – (PCO2/R)
![Page 14: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/14.jpg)
Hypoventilation VA = VT . RR
low respiratory rate and shallow breathing are both signs of hypoventilation.
![Page 15: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/15.jpg)
Dead Space Ventilation
Anatomical Physiological
VD/ VT = (PaCO2-PECO2)/ PaCO2 = 0.33
Increases in decreased pulmonary perfusion: PHTN, hypovolemia, decreased cardiac output
![Page 16: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/16.jpg)
Alveolar Ventilation
VA = (VT-VD). RR
![Page 17: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/17.jpg)
Hypoventilation
The Paco2 increases in proportion to a decrease in ventilation.
Pao2 falls approximately the same amount as the Paco2 increases.
![Page 18: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/18.jpg)
Hypoventilation
The relationship between oxygenation and hypoventilation is complicated by the shape of the Hb-dissociation curve
Because of the dissociation curve, a patient who exhibits alarming CO2 retention might have a near normal oxygen saturation.
![Page 19: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/19.jpg)
1. PO2 100 mm Hg= SpO2 of 97%
2. PO2 60mm Hg= SpO2 of90%
When Paco2 increases from 40 to 70 mm Hg, a dangerous level of hypoventilation, might have a Pao2 that has decreased from 100 to 60 mm Hg and, therefore, maintain an oxygen saturation of 90%.
![Page 20: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/20.jpg)
Thus: oximetry is not a sensitive indicator of the adequacy of ventilation.
This is particularly true when a patient is receiving oxygen.
![Page 21: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/21.jpg)
Lung/Airway Disease
Diseases of the lung or airways affect gas exchange most often by disrupting the normal matching of V/Q or by causing a shunt.
usually can maintain a normal Paco2 as lung disease worsens simply by breathing more.
hypoxemia is the hallmark of lung disease
![Page 22: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/22.jpg)
Ventilation-Perfusion Mismatch
![Page 23: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/23.jpg)
hypoxemia due to V/Q mismatch
& hypoxemia due to shunt
administering Oxygen
![Page 24: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/24.jpg)
Intrapulmonary Shunt
![Page 25: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/25.jpg)
Diffusion
diffusion defects manifest as hypoxemia rather than hypercarbia.
Examples :
interstitial pneumonia, ARDS, Scleroderma, Pulmonary lymphangiectasia,…
![Page 26: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/26.jpg)
Monitoring a Child in Respiratory Distress and
Respiratory Failure
![Page 27: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/27.jpg)
Clinical Examination
Clinical observation is the most important component of monitoring.
![Page 28: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/28.jpg)
ABG & Oximetry
ABG /CBG/ VBG
Oximetry- Oximetry provides an invaluable and usually accurate measurement of oxygenation.
- important to recognize its technical limitations
![Page 29: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/29.jpg)
Condition LimitationDark skin pigmentAnemia Causes inadequate signalBright external lightMotion
Decreased perfusion
Venous pulsations— Severe right heart failure— Tricuspid regurgitation— Tourniquet or blood pressure cuff above site
Results in low reading
Abnormal hemoglobin concentration— Methemoglobin
Unreliable reading (tends to read80% to 85% saturation regardless of actual saturation)
— SS hemoglobin Saturation accurate, but hemoglobin dissociation curve shifted to right
— Carboxyhemoglobin Spuriously high saturation readings
![Page 30: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/30.jpg)
Acute Respiratory Failure
![Page 31: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/31.jpg)
ARF most common cause of cardiac arrest in children.
When presented with a child who has: a decreased level of consciousness, slow/shallow breathing, or increased respiratory drive, the possibility of
ARF should be considered
![Page 32: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/32.jpg)
First: to assure adequate gas exchange and
circulation (the ABCs).
Oxygen Administration to maintain …. If Ventilation is or appears to be inadequate ….. Intubation ?
Need ICU
![Page 33: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/33.jpg)
Chronic Respiratory Failure
![Page 34: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/34.jpg)
CRF
is seen most commonly in children who have:
Respiratory muscle weakness (muscular dystrophy, anterior horn cell disease) or
severe chronic lung diseases (BPD, end-stage cystic fibrosis)
![Page 35: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/35.jpg)
usually has an insidious onset Most children do not have dyspnea. PH normal or near normal , unless…..
Recognizing need careful monitoring of children at risk for CRF
![Page 36: \\\\\\\\\\\\\. Mohammad Rezaei Fellowship of Pediatric Pulmonology](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649d9e5503460f94a8859c/html5/thumbnails/36.jpg)
Disordered sleep Daytime hypersomnolence Morning headaches Altered mental status Increased respiratory symptoms Cardiomegaly Decreased baseline oxygenation
CRF often presents first during sleep Develops an intercurrent illness , Fever