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Paediatric ICU: Acute Respiratory Distress

Paediatric ICU: Acute Respiratory Distress. Aylin Seven. Upper – croup/epiglottis Lower – bronchiolitis Lung – pneumonia/ARDS, pulmonary oedema. Neuromuscular Chest wall trauma Pleural effusion Pneumothorax. CAUSES OF RESPIRATORY FAILURE. Cardiac Metabolic Hypovolaemia Septic Shock.

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Paediatric ICU: Acute Respiratory Distress

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  1. Paediatric ICU: Acute Respiratory Distress Aylin Seven

  2. Upper – croup/epiglottis Lower – bronchiolitis Lung – pneumonia/ARDS, pulmonary oedema Neuromuscular Chest wall trauma Pleural effusion Pneumothorax CAUSES OF RESPIRATORY FAILURE Cardiac Metabolic Hypovolaemia Septic Shock Status Epilepticus Apnoea of prematurity Intoxication Trauma

  3. Why are kids so vulnerable? • Efficiency of muscles • Metabolism • Risk of apnoea • Endurance of muscles (less type 1) • Upper airway resistance • Lung volumes • Lower airway resistance

  4. Identifying the deteriorating patient • Respiratory rate • Work of breathing • Bradycardia = BAD

  5. PAT

  6. Normal Respiratory Rates • 1 month to 1 year  24-38 breaths/min • 1-3 y  22-30 breaths/min • 4-6y  20-24breaths/min • 7-9  18-22 breaths/min

  7. What to do next?!

  8. What are your options? BMV HFO NIV Intubation + Mechanical Ventilation

  9. Positioning etc… • Midline sniffing position • Prominent occiput in infants  towel roll under the shoulders • Suction (remember nasal suctioning!) • Nasal + oropharyngeal airways

  10. HFO • Indications: • Respiratory distress from bronchiolitis, pneumonia, heart failure • Post extubation • Weaning from mask CPAP/BiPAP • Neuromuscular disease • Apnoea of prematurity • High flow can be used if there is hypoxaemia (SpO2<90%) and signs of moderate to severe respiratory distress despite standard flow oxygen. • Contraindications: • Blocked nasal passages/choanalatresia • Trauma/surgery to nasopharanyx

  11. Mechanisms of Action • Delivered at near body temp, up to 100% relative humidity  delivering up to 8L/min in neonates without irritation • Washout of inspiratory dead space  improves alveolar ventilation • HFNC may stent the upper airway  reduce upper airway resistance • Positive distending pressure (but signifcant affected by flow rate, leakage, cannula size)

  12. NIV • Bubble CPAP • (Others: BiPAP/CPAP)

  13. Bubble CPAP • Indications: • Acute lower airway obstruction • Dynamic upper airway obstruction (laryngomalacia, tracheomalacia) • Parenchymal lung disease (e.g. pneumonia) • Ventilation weaning

  14. Bubble CPAP • Contraindications: • Severe cardiovascular instability • Poor respiratory drive (frequent apnoea/brady) • Congenital malformations of airway • NOTE: relative contraindication in >10-12kg

  15. Bubble CPAP • Mechanism: • Expiratory arm is under water  generates pressure and oscillations (almost similar to high frequency 15-30Hz) • Gentle bubbling = vigorous bubbling • No bubbling = loss of seal (often open mouth)

  16. Intubation • Some important differences in intubating kids: • Large tongue • High, anterior airway • Acute angle between tracheal opening and epiglottis • Narrowest diameter is cricoid ring (adults = vocal cords) • Laryngospasm (2 x more common in older children, and 3 x more common in younger children)  light sedation, secretions, extubation. Up to 96/1000 in URTI patients. • Cuffed vsuncuffed and oral vs nasal • ? Apnoeic oxygenation

  17. Mechanical Ventilation • Indications: • Apnea • Respiratory failure not responsive to O2, HFNC, CPAP, or BiPap • Neurologic compromise • Impaired cardiovascular function • Post-Operative states with impaired ventilatory function • Some considerations in paediatrics: • Inspiratory time is usually 0.35-0.45s for full term babies  progressively increases to 1.0-1.4s by 8y • No difference in outcomes (mortality and length of ventilation) based on variety of modes including HFOV

  18. Zebras and PICU • Vascular rings/slings from aberrant vessels (pulmonary artery sling – anomalous L pulmonary artery and ductus encircling trachea) • Congenital diaphragmatic hernia • Spinal muscular atrophy • Diaphragmatic palsy (post CTx surgery) • Tick bite paralysis (toxin binds covalently to AchR) • Tumours (neuroblastoma and lymphoma)

  19. Case 1 • 10 month old • Admitted to ward with bronchiolitis D3 • Increased WOB on the ward  transferred to PICU • Placed on WHO 2L/kg/min initially • Ongoing significant work of breathing • What next?

  20. Case 1 • Bubble CPAP  no significant improvement • For intubation  unsuccessful intubation attempts x 3 • Eventual intubation with sevoflurane induction

  21. References • HNE – ICU guidelines for care of paediatricairway, paediatric bubble CPAP • Paediatric Airway Management, Santillanes and Gausche-Hill (2008) • Ventilatory strategies in the neonatal and paediatrc intensive care units, Mesiano & Davis, Paediatric Respiratory Reviews (2008) • Oh’s Intensive Care Manual 2013 • The evidence for high flow nasal cannula devices in infants, Haq et al, Paediatric Respiratory Reviews (2014) • Acute respiratory failure in children, Hammer, Paediatric Respiratory Reviews (2013)

  22. Questions?

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