Management respiratory distress

Alexandra Wilson MD

Pediatric Cardiopulmonary Arrests

10%

10%

80%

Respiratory distress

• tachypnea
• retractions (subcostal/intercostal)
• nasal flaring
• grunting
• accessory muscle use (head bobbing)
• agitation
• somnolence

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Impending Respiratory Failure

• Severe work of breathing
• Irregular breathing /periodic apnea
• Altered Consciousness

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Beware children with underlying neuromuscular weakness

Goals for today

• Understand use, limitations, complications of HFNC
• Understand use, limitations and complications of NIV
• Review use of airway adjuncts and proper BVM ventilation

HFNC

HFNC (High Flow Nasal Cannula) what does it do?

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• Provides warm humidified oxygen

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• Satisfies patient inspiratory flow demand

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• Wash out of anatomic dead space

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• Stenting upper airways

• PEEP ?

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HFNC (High Flow Nasal Cannula) what does it do?

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• Provides warm humidified oxygen

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• Satisfies patient inspiratory flow demand

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• Wash out of anatomic dead space

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• Stenting upper airways

• Provides some level of CPAP

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HFNC mechanism

CPAP?

When to use

Indications

• Cardiogenic pulmonary edema
• Hypercarbic respiratory failure
• Hypoxemic respiratory failure
• Peri-extubation
• Immunocompromised patients
• Asthma

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Contraindications

• Significant altered mental status/inability to protect airway
• Hemoptysis
• Facial injuries
• NP obstruction
• Airway foreign bodies
• Significant cardiovascular instability

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HFNC

• Where to set ???
• neonates 4-8 LPM
• Infants 6-15 LPM (max 20)
• Children 10-20 LPM (max 25)
• Adults 20-60 LPM

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Formulas

• 2 L/kg/min up to 10kg then 0.5L/kg/min (max 60L)

DCMC floor guidelines HFNC

Does it work?

46 pediatric patients treated with HFNC

8 to12 lpm in infants

20 to 30 lpm in children

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• Improved oxygenation
• Decreased WOB
• Improved comfort

Does it work

retrospective cohort review of 498 children < 2yr who received HFNC within 24hrs of admission failure= intubation

Complications: HFNC

• Gastric distension

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• Skin breakdown

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• Pneumothorax

Weaning HFNC

• Based on assessment, decrease flow and reassess (generally by 2L)
• Remember to differentiate between WOB and hypoxemia

oxygen delivery and flow

An adult with inspiratory flow requirement of 30L/min

on HF 30 L 100% how much 0₂ is being delivered ? 30 x 50 = 1500/3000 =100 %

Now same patient on 15L HF at 100%

15 x 100 = 1000 + 15L x 21% = 1500 + 315 = 1815/ 30 = 60.5%

oxygen delivery and flow

Your patient has a peak inspiratory flow of 10L/min how much oxygen is being delivered to their lungs if they are on 10L HFNC 100% versus 5L HFNC 100% ?

1. 100% versus 60%
2. 100% versus 100%
3. 100% versus 50%
4. Can not be determined

10L x 100% /10 = 100%

5L x 100% + 5L x 21% = 500 + 105 = 605 / 10L = 60.5

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Non-Invasive Ventilation

Two modes

• CPAP
• BIPAP

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Delivery Systems

• Nasal prongs
• Nasal mask
• Face mask

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Prongs/Mask

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• Prong fixation gives best seal
• Mask for infants who develop breakdown along septum or nostrils are too big or too small for the prongs*

* alternate in DCMC PICU to prevent pressure ulcers

Masks

Case 1

You are called by the nurse about the 6 mo old infant with viral bronchiolitis who you admitted earlier today and started on 6 L HFNC. His parents would like to feed the infant who is irritable and inconsolable. The RN reports the infants has a RR = 60 and moderate SC retractions

You decide to

A. initiate oral feeding

B. initiate NG feeding

C. initiate NJ feeding

D. Keep NPO on IVF

Setting up NIV on servo

• Choose between CPAP and BIPAP
• Select a method of delivery (Prongs/NM/Face mask)
• Determine settings

CPAP= PEEP

PC (PIP/PEEP/rate)

Bipap (CPAP/PS)

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Pressure where to set???

Case 2

You are asked to see a 4 yo in the IMC with status asthmaticus . Patient has severe retractions and RR= 50. Co2 on a VBG =35. You determine he needs respiratory support

Would you place him on

1. HFNC at 8 LPM
2. BIPAP at 12/6

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Knowledge check

HFNC provides a constant level of positive end expiratory pressure

1. True
2. False

Patients with Asthma are good candidates for NIV

1. True
2. False

Airway adjuncts

• Nasopharyngeal airway
• Oral airway

Adjuncts: Oral Airway

Correct size

Adjuncts: Oral Airway

Wrong size: Too Long

Adjuncts: Oral Airway

Wrong size: Too Short

Nasopharyngeal Airway

Contraindications

• Basilar skull fracture
• CSF leak
• Coagulopathy

Length: Nostril to earlobe

Endotracheal tube as nasal airway

A regular ETT can be cut and used as a nasal airway

Case 3

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The mother of a 4 yo asks what are the potential complications of HCFN. Which of the following is NOT a complication.

1. Pneumothorax
2. Pneumomediastinum
3. Apnea
4. Gastric distention

Airway Positioning

“Sniffing Position”

In the child older than 2 years

Towel is placed under the head

Airway positioning for children <2yrs

Bag-Mask Ventilation

When to consider PICU transfer

Before you need to do this !🡺

“Early” indications

• difficult airway
• underlying neuromuscular weakness
• prematurity
• immunodeficiency
• young age
• patient with baseline depressed mental status
• chronic pulmonary/CV disease

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Difficult Airways

• Micrognathia
• Macroglossia
• Cervical spine abnormalities
• Infiltration of soft tissues
• airway problems (VC anomalies, subglottic stenosis etc.)

When to consider PICU transfer

• Needing initiation of NIV or patient on home NIV with inter-current illness needing increased support
• Patient with worsening respiratory status

as evidenced by ……

increasing WOB

worsening hypoxemia

altered mental status

not responding to therapy

Summary

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• Don’t wait until your patient is in respiratory failure to start resp support
• Match the patient’s clinical status to the appropriate mode of support
• Don’t be stubborn… reevaluate your patient and be prepared to move on to next level of support/transfer care