Respiratory Support for Pneumonia

in
New Era

Indra Saputra
Divisi Emergensi Rawat Intensif Anak
Bagian Ilmu Kesehatan Anak
RSUP Dr. Moh. Hoesin / FK UNSRI
Palembang
2021
 Introduction
•  Pneumonia is the inflammation of the lung parenchyma
mostly caused by infectious agents ( bacteria, virus,
fungi, paracyte) in children
•  The inflammatory changes in the lungs impair effective
gas exchange leading to its various clinical manifestations
•  Childhood pneumonia is a leading cause of morbidity and
mortality then it is a major cause of hospital admission in
under-fives especially in developing countries
•  One major contributor of mortality in pneumonia is
hypoxaemia à respiratory distress à respiratory failure
 Introduction
•  Hypoxaemia, defined as low arterial blood oxygen saturation less
than 90% by pulse oximetry, correlates well with PaO2 < 60mmHg.
•  Results from impaired gas exchange due to the inflammation
causing alveolar congestion, increased dead space, marked
intrapulmonary shunting, and ventilation perfusion mismatch
•  Airflow obstruction from respiratory tract secretions, respiratory
muscle fatigue, reduced central respiratory centre response to
hypoxia and hypercarbia also contribute to the hypoxaemic state
•  Delivering oxygen to hypoxaemic children therefore improves the
outcome of childhood pneumonia
•  Respiratory failure is one of the most important causes of death in
patients with acute pneumococcal pneumonia
 Pathogenesis
Infectious Agents

O2

CO2

Hypoxemia
 Types of respiratory failure.

Respiratory Failure

Lung Failure Pumping Failure

Gas Exchange Failure Ventilation Failure

( Hypoxemia ) (Hypercarbia)

Central Mechanical
Fatigue
Depression Defect

Phuong Vo, and Virginia S. Kharasch Pediatrics in Review 2014;35:476-486

 Types of respiratory failure.
Type 2
Type 1
with alveolar
V/Q mismatch without
hypoventilation
alveolar hypoventilation

• Pneumonia • Respiratory impulse
• Acute pulmonary impairment
edema • Airway obstruction
• Thoracic trauma • Neuromuscular
• Mild ARDS (initial phase) weakness
• Hyaline membrane • Thoracic wall
disease abnormalities
• Bronchiolitis • Morbid obesity

Medina A, Pons M, Martinón-Torres F. Non-invasive ventilation in pediatrics. Madrid: Ergon; 2015.

Escalation therapeutic strategy
ICEMAN
METHODE
Medina A, Pons M, Martinón-Torres F. Non-invasive ventilation in pediatrics. Madrid: Ergon; 2015.

PHYSIOLOGICAL EFFECT OF HIGH FLOW NASAL CANULE (HFNC)
AND NON INVASIVE POSITIVE PRESSURE VENTITLATION
(NIPPV)

HFNC

Jean‑Damien Ricard et.all. Use of nasal high flow oxygen during acute respiratory failure. Intensive Care Med (2020) 46:2238–2247

NIPPV

MacIntyre. Physiologic Effects of Noninvasive Ventilation. Respir Care 2019;64(6):617–628

 Multimodal Devices
High Flow Oxygen NIV Modes in
Continous Positive Bi-level Positive
Therapy COnventional
Airway Pressure Airway Pressure
(High Flow Nasal Invasive
(CPAP) (BiPAP)
Canule) Ventilators

Anil Sachdev, Abdul Rauf. High-flow Nasal Cannula in Children: A Concise Review and Update.Critical Care Update 2019. https://
www.researchgate.net/publication/333448617

Medina A, Pons M, Martinón-Torres F. Non-invasive ventilation in pediatrics. Madrid: Ergon; 2015.

 Interfaces and Accessoris

Nasal Prong

Medina A, Pons M, Martinón-Torres F. Non-invasive ventilation in pediatrics. Madrid: Ergon; 2015.

 Highflow Nasal Canule

•  The high flow is believed to create a

small positive pressure (i.e. CPAP)
gradient that improves oxygenation
and decreases respiratory effort;
•  The humidity in the air has benefits
the body by improving ciliary
movement and removal of
secretions.
•  Airflow similar to the insufflation of
tracheal gas cleanses the anatomic
dead space, thereby improving
ventilation.

Medina A, dkk. Non-invasive ventilation in Pediatrics. Edisi ke-2. Barcelona:2009

Mikalsen IB, dkk. High flow nasal cannula in children: a literature review. Scan J Trauma Resusc Emerg Med. 2016
•  reduced mortality risk
•  higher ventilator-free days
•  reduced risk of intubation in
the subset of patients with
moderate or severe hypoxemia
(PaO2:FIO2 ≤ 200 mm Hg)
 Relationship between pharyngeal pressure and gas flow during
HFNC support

•  High flow rates create a positive airway pressure

•  Every 10 L/min increase MAP by ∼0.69 cmH2O in the mouth-
closed position and by 0.35 cmH2O in the mouth-open position

Milesi C. Intensive Care Med 2013

 Patient selection for HFNC Therapy

Moderate/severe bronchiolitis, pneumonia, postextubation state

( avoid unstabe hemodynamic, emergent intubation)

Initial Settings:
Gas temprature : 34 – 37 0C ; FiO2 : 0.4-0.6 ( adjust to achieve SpO2 92-95%)
Flow : start with I L/kg for first 10 kg and 0.5 L/kg afterwards

Monitor HR, RR, WOB, SpO2, Signs of impending RF at any stage

Consciousness severe respiratory acidosis
(PaCO2 > 60) FiO2 > 0.6

Not Improved RF
Improved RF

Increase Flow up to 2L/kgfor first 10 kg and 0.5 L/kg afterwards ; Max( Flow 50
L/min) ; Step up FiO2 at the last

Monitoring Improved Not Improved

Escalation
Respiratory Stable 24 – 48 h; HFNC success HFNC Failure Respiratory
Support
Wean FiO2 to 0.3-0.4 ; Flow 0.5 L/kg every 4-6 h Continue Monitoring
Flow 0.5 L/kg, SpO2 ≥
Weaning Failed Weaning Tolerated Well 92% with FiO2 0.4

HFNC discontinue Monitoring

Anil Sachdev, Abdul Rauf. High-flow Nasal Cannula in Children: A Concise Review and Update.Critical Care Update 2019. https://www.researchgate.net/publication/333448617
High Flow Nasal Canula

Ji-Won Kwon. High-flow nasal cannula oxygen therapy in children: a clinical review. CEP.Vol.63.No.1, 3-7, 2020. https://doi.org/10.3345/kjp.2019.00626


 CPAP BIPAP

•  Constant positive airway pressure •  Combination of IPAP and EPAP

throughout cycle •  Inspiratory PAP à pressure
•  Improves oxygenation support
•  Decrease work of breathing by •  IPAP: decrease work of breathing
alveolar recruitment and unloads & O2 demand, increases
inspiration muscles spontaneous tidal volume,
•  Decrease hypoxia by alveolar decreases spontaneous respiratory
recruitment and reduces rate
intrapulmonary shunt •  Expiratory PAP à CPAP
•  EPAP: provides PEEP, increase FRC,
reduces FiO2 required to optimize
SaO2

Sandrine Essouri, Christopher Carroll; for the Pediatric Acute Lung Injury Consensus Conference Group Noninvasive Support and Ventilation for Pediatric Acute Respiratory Distress Syndrome: Proceedings From the Pediatric
AcuteLung Injury Consensus Conference, Pediatr Crit Care Med 2015; 16:S102–S110

 NIPPV
ALGORITHM

Medina A, Pons M, Martinón-Torres F. Non-invasive ventilation in pediatrics. Madrid: Ergon; 2015.

 NIPPV
ALGORITHM

Medina A, Pons M, Martinón-Torres F. Non-invasive ventilation in pediatrics. Madrid: Ergon; 2015.

 Take Home Message
•  Non invasive ventilation can be used as initial
respiratory treatment in pneumonia with
respiratory distress/ failure
•  Properly choice of device and good
monitoring determine the successful of non
invasive ventilation usage in pneumonia


Thank You