RESPIRATORY DISTRESS IN INFANTS AND CHILDREN

Presenters Bethelhem Berhanu Betelhem Getahun.

Outline
Introduction Respiratory failure Upper respiratory tract causes Lower respiratory tract causes Principles of Management

Oxygenation Elimination of carbon dioxide

Some terms.
Ventilatory capacity is the maximal spontaneous ventilation that can be maintained without development of respiratory muscle fatigue.
Ventilatory capacity > Ventilatory demand

Ventilatory demand is the spontaneous minute ventilation that results in a stable Pa CO2.

Understanding Gas exchange

V/Q : the ratio of the amount of air reaching the alveoli to the amount of blood reaching the alveoli. 1 liter of blood - 200 mL of oxygen; 1 liter of dry air - 210 mL of oxygen.
Ideal value Dry air 1.05 Humidified air 1
Reality??? 0.8 Not all alveoli are well ventilated, or perfused.

 Atmospheric air PO2 of 159 mmHg Alveolar air - PO2 of 104 mmHg
Why the difference?
Humidification Constant absorption into pulmonary vessels.

PaO2 85-100 mmHg PaCO2 40mmHg = PAO2

Gas exchange .
PAO2 Calculated as
PA O2 = FI O2 (PB PH2 O) PA CO2/R Where
Fi O2- fractional concentration of oxygen in inspired air (21% if atm. Air) PB - barometric pressure (assumed to be 760mmHg) PH2 O - is water vapor pressure at 37C PA CO2 is alveolar PCO2 (assumed to be equal to Pa CO2)

Normal gradient of alveolar and arterial blood should be <10mmHg

Definitions
Respiratory Distress - refers to both difficulty in breathing, and to the psychological experience associated with such difficulty. Respiratory Failure Is when the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination.

Classifications
Gas involved Course and clinical manifestaions Origin

Hypoxemic
(Type I) Hypercapnic (Type II)

Acute

Lung

Chronic

Respiratory pump

Hypoxemic Resp. Failure

Pathophysiologic mechanisms (two)
V/Q mismatch Low V/Q
Decreased ventilation with normal perfusion
Airway or interstitial lung disease

Over-perfusion with normal ventilation

pulmonary embolism, pulmonary HTN.

Hypoxemic contd
Shunt - Blood pathway which does not allow contact between alveolar gas and red cells Etiologies of Shunt physiology
Diffuse alveolar filling Collapse / Consolidation Abnormal arteriovenous channels Intracardiac shunts
Poor or no response to oxygen Therapy

Hypercapnic Resp. Failure

an arterial partial pressure of carbon dioxide (PaCO2) greater than 50 mmHg. Less common Normal How to Differentiate??? PA-aO2 Its due to
Decreased minute ventilation CNS, NMJ, chest w Increase in dead space Obstructive diseases Increased CO2 production fever, sepsis, seizure

PA O2 = FI O2 (PB PH2 O) PA CO2/R

In summary.

Clinical features of respiratory Failure

Increased Respiratory Drive Increased rate/depth of breathing Anxiety Breathlessness/dyspnea Retractions Accessory muscle use: - Sternocleidomastoid - Intercostal - Alar nasae (nasal flaring) Decreased Respiratory Drive Decreased rate/depth of breathing Lethargy Confusion

Why are kids different?

Obligate nose-breathers Tongue relatively larger Prominent tonsilar and adenoidal lymphoid tissue. Narrow airway Little cartilagenous support.

Increased metabolic demands

Less number and elasticity of alveoli. Lower FRC. Diaphragm Muscle fibers more vulnerable to fatigue Chest wall Ribs more horizontal

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LUNG CENTRAL AIRWAY OBSTRUCTION Tracheomalacia Subglottic stenosis

Epiglottitis Croup
Vocal cord paralysis

RESPIRATORY PUMP CHEST WALL DEFORMITY Kyphoscoliosis Diaphragmatic hernia Flail chest Eventration of diaphragm Prune-belly syndrome Pulmonary hypoplasia BRAINSTEM Sleep apnea Central hypoventilation Poisoning Trauma Central nervous system infection SPINAL CORD Trauma Poliomyelitis Werdnig-Hoffmann disease NEUROMUSCULAR Postoperative phrenic nerve injury Birth trauma Infant botulism Guillain-Barr syndrome Muscular dystrophy

Foreign body aspiration

Vascular ring Adenotonsillar hypertrophy Near-strangulation PERIPHERAL AIRWAY OBSTRUCTION

Bronchiolitis Asthma
Aspiration Cystic fibrosis Bronchomalacia DIFFUSE ALVEOLAR DAMAGE (acute respiratory distress syndrome) Sepsis

Pneumonia
Pulmonary edema Near-drowning Pulmonary embolism Lung contusion Shock Systemic inflammatory response syndrome

Common causes of Resp. Failure in children

Upper respiratory tract Croup Epiglottitis Foreign body aspiration Lower Respiratory Tract Pneumonia Bronchial asthma Bronchiolitis

Croup
Viral croup, AKA laryngotracheobronchitis
M. pneumoniae isolated from pts with croup

the most common form of acute upper respiratory obstruction. Common b/n ages 5 months and 3 years
Peak age 2 years M>F

Parainfluenza virus 75%

Influenza A&B, RSV, measles

Clinical features
Barking cough Stridor Low grade fever Hoarseness of voice Signs of respiratory distress Tachypnea Coryza Inflamed Pharynx Cyanosis Worse at night Aggravated by crying Resolve within a week

Diagnosis
Is clinical X-ray is not a requirement
Consider X-ray in patients with atypical presentation or clinical course

On X-ray

Hypopharnyx Narrow air column Trachea

Steeple sign

Epiglottitis
Inflammation of the epiglottis and adjacent supraglottic structures. dramatic, potentially lethal condition Common b/n 6 months to 3 years of age. Danger of airway obstruction - medical emergency.

Clinical features
High fever Sore throat Dyspnea Swallowing difficulty Drooling Tripod Position Stidor late sign

Diagnosis
diagnosis requires visualization of a large, cherry red swollen epiglottis by laryngoscopy.

Lateral neck radiograph ( "thumb print" sign)

Foreign body Aspiration

Toddler through preschool age common children <3 years 73%

Commonly aspirated nuts (1/3), popcorn, small parts of toys. Feared complication complete airway obstruction.
Unable to speak or cough

 Three stages of symptoms (partial)

Initial event sudden, violent cough, choking, gagging. Asymptomatic interval - FB becomes lodged, reflexes fatigue and irritation symptoms subside.
Common reason for delayed diagnosis and overlooked FB.

Complications Obstruction, erosion or infection

Hypoxia, hemoptysis, Fever, atelectasis

Diagnosis
P/E Respiratory distress. Inspiratory stridor (central airway obstruction)
Wheezing small airway obstruction If beyond the carina, usually asymmetric noises

Hyperinflation & air-trapping of the affected lobe(s) is typical

Best seen with X-ray taken at expiration

Bronchoscopy Diagnostic and therapeutic

Thank you!