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EDUCATIONAL AIMS
To review the physiology behind respiratory failure in children,
to provide guidance on how to assess the child with acute respiratory distress,
to emphasise that correct interpretation of clinical signs allows the physician to pinpoint the cause to a distinct part of the
respiratory system without the use of sophisticated medical examinations,
to emphasise the importance of recognising acute respiratory failure early in its course,
to provide some guidance on how to assess the urgency and correct timing of more invasive interventions in children with
impending respiratory failure,
to discuss some basic and general management issues of respiratory failure in children and
to emphasise that invasive airway management in critically ill children should be performed by an expert with experience in
paediatric critical airway management.
A R T I C L E I N F O S U M M A R Y
Keywords: Acute respiratory failure is the most common medical emergency in children. One aim of this review is to
Respiratory physiology
discuss the physiologic peculiarities that explain the increased vulnerability of infants and children to
Infants
any pathology affecting the respiratory tract. The other aim is to highlight the importance of history
Work of breathing
Cardio-respiratory arrest taking and correct physical examination for early recognition of an impending catastrophic progression
of respiratory failure. Under most circumstances, correct physical examination alone allows one to
pinpoint the cause to a particular part of the respiratory system and to make the appropriate decisions for
a proactive and life-saving management of the critically ill child.
ß 2013 Elsevier Ltd. All rights reserved.
1526-0542/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.prrv.2013.02.001
J. Hammer / Paediatric Respiratory Reviews 14 (2013) 64–69 65
Figure 3. The Hoover sign consists in the paradoxical inspiratory indrawing of the costal margin. The intercostal muscles and the diaphragm are antagonists at the costal
margin which moves very little during quiet breathing (left panel). Pulmonary hyperinflation results in a flattened diaphragm which exerts direct traction on the lateral rib
margin (right panel).
J. Hammer / Paediatric Respiratory Reviews 14 (2013) 64–69 67
Figure 4. Left panel: Decreased elastic recoil pressure render the bronchi of infants vulnerable to collapse. Right panel: Collateral pathways of ventilation do not appear until
3–5 years of age.
for airway collapse with increasing age. Collateral pathways of compression) may only be considered if there is a history or
ventilation (intra-alveolar pores of Kohn and bronchoalveolar possibility of recent choking and the child is still responsive, but
canals of Lambert) do not appear until 3–4 years of age, which unable to make a sound. Choking occurs in the field and children
excludes alveoli beyond obstructed airways to be ventilated by with large foreign bodies lodged in the larynx often arrive
these alternate routes and predisposes the infant to the develop- unconscious or even dead in the emergency room. In this rare
ment of atelectasis.9 Hypoxaemia and hypercapnia occur early and situation, bag-mask ventilation together with chest compression
can become profound quickly in infants (Figure 4). is recommended until direct laryngoscopy can be performed by a
person with sufficient expertise. Chin lift, an airway-opening
CLINICAL EVALUATION OF RESPIRATORY PERFORMANCE manoeuvre commonly taught because of its simplicity, should be
used with caution in patients with adeno-tonsillar hypertrophy
The presenting symptoms of respiratory failure are often not because it may convert partial into almost complete airway
specific to a particular respiratory illness, but correct interpreta- obstruction.12 Oral or nasopharyngeal airway devices such as a
tion of clinical signs should allow one to localise the cause to a Guedel tube may be useful under such circumstances and
particular part of the organ systems. Life-threatening upper- facilitate bag-mask ventilation.
airway obstruction, lower-airway disease, lung parenchymal If the child is breathing spontaneously, further steps are to assess
disease and non-pulmonary causes of respiratory failure such as respiratory rate, work of breathing, the efficiency of respiration and
cardiovascular disorders mostly manifest with clearly distinguish- the consequences of respiratory failure on other organ systems.
able symptoms. Therefore, a pathophysiology-based approach ‘Tachypnoea’ is commonly the first manifestation of respiratory
with correct interpretation of history and clinical signs is most distress. Noisy tachypnoea typically occurs in children with
helpful to assess the severity of respiratory failure. respiratory disease and is an indication of increased work of
The first task when evaluating a child with breathing difficulties breathing. The character of the noise allows the experienced
is to determine the urgency of more invasive interventions such as physician to attribute the problem to a defined part of the
intubation and non-invasive or invasive ventilatory support. This respiratory system. By contrast, quiet or effortless tachypnoea
decision is either reached within the first few minutes of mostly occurs in the context of non-pulmonary diseases and reflects
presentation or during close monitoring of disease progression severe metabolic acidosis such as in shock, diabetic ketoacidosis,
in the ICU. The most useful indicators are vital signs, work of inborn errors of metabolism, cardiac insufficiency and poisoning. In
breathing and level of consciousness. severe cardiogenic shock, increased work of breathing occurs due to
The first step is to evaluate whether the child is breathing the development of pulmonary oedema. A slow or irregular
spontaneously and able to maintain ‘patency of the upper respiratory rate (bradypnoea) is usually an ominous clinical sign
airways’. Partial or complete airway obstruction jeopardises and indicates impending cardio-respiratory arrest. One must be
sufficient oxygenation. In this situation, the most important and aware that a decrease in respiratory rate from a rapid to a more
efficient manoeuvre is to manually open up the upper airway and ‘normal’ (often shallow) rate may indicate deterioration and fatigue
to ensure its patency. Urgent interventions such as suctioning and rather than clinical improvement. This is usually accompanied by a
performing a jaw-thrust manoeuvre alone or together with bag- decreasing level of consciousness, which, however, can be masked
mask ventilation are needed if this is not the case.10 Airway by the use of sedation in the clinical setting.
foreign-body obstruction manoeuvres may also be considered. ‘Assessment of the work of breathing’ is most important to
Airway obstruction during mask ventilation can be avoided by evaluate the respiratory performance of the critically ill child.
paying close attention to the positioning of the head, by applying General signs of increased work of breathing, besides tachypnoea,
jaw thrust and most importantly by keeping the mouth of the are chest retractions, thoraco-abdominal asynchrony (which is
child open under the mask.11 Airway foreign-body obstruction more pronounced in upper-airway obstruction), nasal flaring and
manoeuvres (Heimlich manoeuvre, back blows and chest the use of accessory muscles (head bobbing). Head bobbing occurs
68 J. Hammer / Paediatric Respiratory Reviews 14 (2013) 64–69
manage the upper airway, which is the cornerstone of paediatric recently been proposed to be used in the situation of a difficult
resuscitations as respiratory failure is the major cause of cardio- intubation or the worst-case scenario: cannot ventilate and cannot
respiratory arrest in infants and children. This includes immediate intubate. These algorithms advocate the use of fibre-optic intubation
recognition of a potentially difficult airway problem, appropriate if mask ventilation is possible and the use of the laryngeal mask
medical-intervention strategies and experienced manual skills airway if mask ventilation is compromised.21,22
using appropriate equipment. Conventional treatment of acute respiratory failure includes
Because children require resuscitation less frequently than positive pressure ventilation with supplemental O2. The manage-
adults, paediatric residents usually have little training opportunities ment of mechanical ventilation should incorporate the underlying
to advance their airway expertise. It is not uncommon for paediatric pathophysiology and current concepts for prevention of ventilator-
residents to lack competency and knowledge of advanced life-saving induced lung injury. Non-invasive ventilation can be used in selected
skills such as strategies to improve bag-mask ventilation in difficult patients to decrease work of breathing or to assist weak respiratory
situations. It is essential to understand the anatomic and physiologic muscles in patients with preserved respiratory drive. If adequate
consequences of simple manoeuvres such as chin lift or jaw thrust oxygenation cannot be achieved with conventional mechanical
and to apply these and use other non-invasive airway devices ventilation, surfactant instillation, inhaled nitric oxide and high-
correctly to assure efficient mask ventilation. Excessive manual frequency oscillation may be considered. Extracorporeal membrane
ventilation must be avoided because of its detrimental haemody- oxygenation is the ultimate option and needed in the rare situation
namic consequences during low flow states such as cardiopulmon- where children with a reversible underlying illness fail conventional
ary resuscitation.16 It increases intrathoracic pressure and impedes ventilation strategies. Further details of ICU management of children
venous return, thereby reducing cardiac output, cerebral blood flow with respiratory failure are beyond the scope of this review.
and coronary perfusion. Excessive ventilation also causes air
trapping and barotrauma in patients with small-airway obstruction
and increases the risk of stomach inflation, regurgitation and References
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