Ministry of health of Ukraine

FIRST AID respiratory failure

1. Background:

Intensive therapy in pediatrics firmly established, although the conditions of its performance for the last time something changed. At present, in the case of a child in critical condition at FAPi or in the central district hospital, often have difficulty giving her a qualified emergency due to lack of appropriately trained specialists, as well as necessary equipment. If the training of doctors issue of intensive care for children can be resolved soon, then create the necessary technical level in intensive care units of children's central district hospitals - the prospect of the future.

2. Specific objectives:

1. To analyze the clinical classification of respiratory failure.
2. Justify the principles of emergency care for respiratory failure.
3. Suggest complex respiratory therapy.
4. To demonstrate the principles of a free airway and improve the drainage of lung function.
5. Analyze the features of respiratory failure in children and its treatment.
6. Analyze the features of respiratory failure in infants and its treatment.

4.2 Theoretical questions to studies.

1. Define the term acute respiratory failure
2. Provide clinical classification of acute respiratory failure.
3. What are the principles of combating respiratory failure?
4. Which leads to the upper-constrictive obstructive form of acute respiratory failure?
5. Which leads to the lower-constrictive obstructive form of acute respiratory failure?
6. What is restrictive acute respiratory failure?
7. What Thoracoabdominal acute respiratory failure?
8. Give causes respiratory disease in infants.
9. What is asphyxia newborn?

CONTENTS TOPICS

Acute respiratory failure (AReF) - a pathological condition of the body in which the function of external respiration does not provide a sufficient supply of oxygen and carbon dioxide output adequate or normal blood gas composition supported the price of excessive energy costs.
Lack of gas exchange is almost always secondary to disorders nedyhalnyh lung function.
Respiratory lung function performed by three processes:
1) ventilation alveolar air;
2) perfusion of pulmonary capillaries;
3) diffusion of gases through the alveolar-capillary membrane.
The main factors that affect the blood gas composition:
I. Intrapulmonalni:
1) fraction of O2 in the inspired air;
2) alveolar ventilation;
3) diffusion;
4) shunt;
5) ventilation-perfusion inequality.
II. Extrapulmonic:
1) cardiac output;
2) O2 consumption;
3) hemoglobin concentration;
4) CBS;
5) body temperature
6) carbonation curve O2.
From the clinical severity position AReF primarily characterized by:
1) decreased arterial PO2 (raO2) below 50 mmHg breathing ambient air;
2) increasing pCO2 of arterial blood (pa CO2) above 50 mm Hg;
3) violation of the mechanics and rhythm of breathing;
4) a decrease in pH (<7.35).
These symptoms may occur AReF not always, but among them are the essential characteristics - hypoxemia.
Clinical classification of respiratory failure.
Time of occurrence: acute and chronic NAM.
According to severity:
1. Decompensated. Normal blood gas composition is ensured even in peace, despite the inclusion of compensatory mechanisms.
2. Compensated. Normal blood gas composition is provided in a calm, under load possible decompensation.
3. Hidden. Symptoms AReF no. Gas composition of blood within normal limits, but the functionality of the respiratory system reduced. Look for signs of NAM - exertion.
There are three types of intensive care AReF:
1) substitution or posyndromna;
2) supporting;
3) pathogenetic.
All these therapies NAM exercise simultaneously or sequentially.
Respiratory therapy - a complex of therapeutic measures aimed at improving the function of the respiratory system effects on ventilation apparatus (lungs, chest, breathing muscles), mainly physical methods.

Principles to combat respiratory failure:

1-first emergency, then diagnosis and planned treatment;
2 - removing the main physiological mechanism DL;
3 - comprehensiveness;
4 - overall therapeutic approach (draining of body massage, prevention of infection, hygiene);
5 - elimination of pathologies other systems;
6 active involvement of the patient for preventive treatment.
Complex respiratory therapy.
1. Nedyhalnyy complex: normalization of blood (Hb, Ht, rheological properties, folding, CBS, PEO), hemodynamics, immuno-reactive detoxification.
2. Normalization of patency of the upper airways (airway, konikotomiya, intubation, tracheotomy).
3. Normalization drainage sputum (pulmonary complex respiratory physiotherapy, bronchoalveolar lavage).
4. Specific modes of spontaneous respiration (PDKV, oscillator modulation breathing, prompting spirometry).
5. Ventilation and respiratory support.
6. Artificial oxygenation and elimination of CO2 (oxygen inhalation, intravenous oxygenation, the method of fixed lungs).
Providing free airway and improve the drainage of lung function is achieved through:
A) the measures contributing discharge of phlegm;
B) Take measures aimed at thinning mucus;
B) stimulation of cough;
D) use other methods to ensure a free airway:
- Aspiration of mucus from the oral part of the pharynx electric pumps, pear, kortsanhom a napkin;
- Rehabilitation of the tracheobronchial tree in case of oppression cough reflex;
- With obstruction of bronchioles, airway obturation thick viscous sputum used lavage tracheobronchial tree mikrotraheostomiyu, bronchoscopy, endotracheal intubation, tracheostomy.
Features respiratory failure in children.
In children to respiratory failure (NAM) often causes acute and chronic respiratory diseases, hereditary due to chronic lung disease (cystic fibrosis, Kartahenera syndrome), respiratory defects. In acute NAM in children can cause aspiration of foreign bodies, of central regulation of respiration in neyrotoksykozi, poisoning, cranial trauma, as well as damage the chest. In newborns DN develops in pneumopathy, such as hyaline membrane disease, neonatal (respiratory distress syndrome newborns), pneumonia, bronchiolitis, with intracranial birth trauma, intestinal paresis, diaphragmatic hernia, paresis of the diaphragm, congenital heart defects, malformations of the respiratory tract.
Children NAM growing faster than in adults with similar situations. This is due to the narrowness of the bronchi, with a tendency to a more pronounced swelling of the bronchial walls and exudation, which leads to the rapid emergence of obstructive syndrome with inflammatory and allergic diseases. In young children, especially infants, intoxication is arrhythmia breathing. The weakness of the respiratory muscles, diaphragm high standing, lack of development of elastic fibers in the lung tissue and the walls of the bronchi in infants and preschool age lead to relatively lower compared with older deep breath, inhaling and exhaling reserve. Therefore, increased ventilation is achieved not only by increasing the depth of breathing, as by increasing its frequency.
To assess the degree of severity of DN in pediatric patients as in adults, it is classified according to the degree of dyspnea.
I degree (mild) appears with a slight shortness of breath on exertion: when respiratory failure
II degree (moderate) - alone: ​​with respiratory failure
III degree (severe) - alone and with auxiliary muscles.
More isolated hypoxic whom - respiratory failure IV degree (severe).

First aid in acute respiratory failure

Emergency assistance is provided depending on the type of DL.
Getting to the treatment of acute respiratory failure, must first provide fundamental criteria that determine the appearance of acute respiratory failure and the dynamics of its development. It should identify the main symptoms that require priority correction. Hospitalization for any form of acute respiratory failure in children is required.
The general direction of therapy of any kind of acute respiratory failure is timely restoration and maintenance of adequate oxygenation of tissues. You must restore the airway, give the patient oxygen mixture (heating of, hydration, adequate concentration of oxygen). According to testimony he transferred to the ventilator.
Upper-constrictive obstructive type of acute respiratory failure in children occurs most frequently. He accompanies SARS, valid and false croup, foreign bodies of the pharynx, larynx and trachea, acute epihlotyt, zakovtuvalnyy and paratonzilyarnyy abscesses, trauma and tumors of larynx and trachea. The main pathogenetic component of acute respiratory failure of this type that determines the severity of the condition and the weather - excessive work of respiratory muscles, accompanied by energy depletion.
Treatment. Given the risk of decompensated acute respiratory failure of all children with stenosis required hospitalization in a specialized intensive care unit or intensive care unit.
On stage dogospitalnom stenosis I-II degree should remove foreign objects or excessive amount of secretion of roto-and nasopharynx. Performed by inhalation of oxygen and transported the child to the hospital. Drug therapy is not required. When stenosis III degree - must spend tracheal intubation thermoplastic pipe deliberately smaller diameter and immediately hospitalized child in hospital. Tracheostomy stenosis III - IV degree is used only as an emergency measure when it is impossible to provide adequate ventilation through the endotracheal tube.
Treatment in hospital mainly be directed to adequate sanitation tracheobronchial tree and prevention of secondary infection.
Nizhny obstructive - constrictive type of acute respiratory failure develops in asthmatic condition, asthmatic bronchitis, obstructive lung diseases.
When subcompensated and decompensated stages of treatment dogospitalnom stage involves the use of non-pharmacological means: inhalation of oxygen, hot foot and hand baths, mustard plaster on the chest (if the child tolerates this procedure). It is necessary to isolate the child from potentially possible allergens: house dust, pets, woolen garments.
If no effect is used sympathomimetic - ß-adrenostimulyatory (novodryn, isoproterenol, euspiran), ß2-agonists (Alupent, Salbutamol, brykanyl) as inhaled aerosols - 2 - 3 drops of these drugs were dissolved in 3 - 5 ml of water or isotonic sodium chloride.

When hormonozalezhnыy form of the disease and inefficiency aforementioned therapy prescribed hydrocortisone (5 mg / kg) or prednisone (1 mg / kg) intravenously.

With bronchodilators drug of choice is 2.4% solution эufillinu (aminophylline, diafillinu). Loading dose (20 - 24 mg / kg) administered intravenously over 20 min, then injected dose supports - 1 - 1.6 mg / kg for 1 hour. Salbutamol is inhaled.
Antihistamines (pipolfen, diphenhydramine, suprastin et al.) And adrenomymetychni means the type of adrenaline and ephedrine hydrochloride administered inappropriate.
Parenchymal acute respiratory failure may accompany heavy and toxic forms of pneumonia, aspiration syndrome, fat embolism pulmonary artery branches, "shock" lung, exacerbation of cystic fibrosis, respiratory distress syndrome in newborns and infants, BPD. Despite the various etiological factors of primary importance in the mechanisms of acute respiratory failure of this type have impaired transmembrane transport of gases.
Treatment depends on the severity of acute respiratory failure. When compensated form of pre-hospital care is limited timely hospitalization of the child in somatic hospital. When transporting the patient carry out activities aimed at supporting the airway (aspiration of nasopharyngeal mucus et al.).
Decompensated acute respiratory failure requires the active participation of staff at all stages of treatment. The patient was hospitalized in the intensive care unit. Prehospital necessary to ensure airway (tracheobronchial reorganization, the testimony - endotracheal intubation). If necessary, use of mechanical ventilation (manual or hardware method). Be sure to hold oxygen inhalation.
Under conditions of hypoxia and hypercapnia cardiac glycosides and sympatomymetychni amines are contraindicated.
Restrictive acute respiratory failure develops due to decreased respiratory surface of the lungs, while squeezing them, caused pneumothorax, hydrothorax, extensive atelectasis, bullous emphysema. In the mechanism of pathophysiological disorders other than gas exchange disorders associated with a decrease in the active surface of the lung ventilation is very important pathological shunting of venous blood through unventilated areas of the lung. Clinical manifestations correspond compensated or decompensated forms of acute respiratory failure with typical symptoms of gas exchange.
Treatment. The patient was hospitalized in profile office (with hydro-or pneumothorax - in surgery). Note that during mechanical ventilation high risk of pneumothorax stress, shearing will of mediastinal and cardiac arrest because of mechanical ventilation in these patients is a method of risk.
Ventilating acute respiratory failure of central type develops overdose of tranquilizers, antihistamines and narcotics, barbiturates, as well as neuroinfections - encephalitis and meningoencephalitis, convulsive syndrome, edema and dislocation structures of the brain, cranial travmi.U mechanisms of acute respiratory failure is vital violation central regulation of breathing.
Treatment as dogospitalnom stage and in the hospital is to maintain the airway in compensated form of acute respiratory failure. Ventilation is carried out at a form that dekomptycjde '. All of these events are held during the treatment of the underlying disease.
Thoracoabdominal acute respiratory failure develops in trauma chest, abdomen, after thoracic and abdominal surgery, when expressed flatulence (especially in infants), dynamic intestinal obstruction, peritonitis. In the mechanism of acute respiratory failure of this type of prime importance is limited excursions of the chest and diaphragm. The effectiveness of treatment of acute respiratory failure depends on the underlying disease causing respiratory failure.
Neuromuscular acute respiratory failure caused by pathology at mionevralnoyi synaptic transmission observed in infants, dermatomyositis, muscular dystrophy, congenital amiotoniyi, polio syndrome Landry and Hyyena-Barre overdose relaxants and residual kuraryzatsiyi. In the mechanism of acute respiratory failure leading role played by functional failure of the respiratory muscles, loss of ability to reproduce cough impulse disorders excretion and accumulation of tracheobronchial secretions, atelectasis development and infection.
Treatment for pre-hospital and clinical stages should be directed to support the airway. Given the real danger exception respiratory muscles should develop early intubation, if necessary, carry mechanical ventilation (supporting or automatically). Treatment in hospital is in the prevention and elimination of respiratory disorders. Treats the underlying disease, the intensity of which depends on the duration of symptoms ventilator.

Respiratory failure newborns.

Respiratory failure newborns - clinical syndrome of diseases, the pathogenesis of which the main role belongs violation of pulmonary gas exchange.
Causes of respiratory disease in infants:
I. Pathology vozduhonosnyh ways.
- Malformations of airway obstruction (atresia, hipopolaziya choanae, anterior cerebral hernia, macroglossia, mikrohnatiya, congenital stenosis of the larynx, trachea, bronchi, etc.)..
- Acquired disease (swelling of the nasal mucosa, respiratory infections, larinhospazm et al.).
II. Pathology of the alveoli or lung parenchyma in violation utilization of oxygen in the lungs.
- Respiratory distress syndrome (WBS I type).
- Transient tachypnea.
- Meconium aspiration syndrome.
- Respiratory distress syndrome of the adult type.
- Sources of air, free air in the chest.
- Pneumonia.
- Atelectasis.
- Hemorrhage into the lungs.
III. Pathology of pulmonary vessels.
- Congenital malformations of the cardiovascular system.
- Pulmonary hypertension (transient or persystyruye).
IV. Malformations of the lungs.
V. Attacks apnea.
VI. Chronic lung disease.
- Bronchopulmonary dysplasia.
- Chronic pulmonary insufficiency of prematurity.
- Syndrome Wilson Mikiti.
VII. Extrapulmonary causes of respiratory disorders.
- Congestive serdtseva failure of various origins.
- Damage to the brain and spinal cord.
- Metabolic disorders (acidosis, hypoglycemia, electrolyte metabolism disorders).
- Shock (after hemorrhage, septic).
- Myopathy.
- Withdrawal of drugs that affect the central nervous system of the child.
- Innate hipoventilyatsiynyy syndrome.
The most common cause of respiratory failure in preterm infants is respiratory distress syndrome - a disease associated with insufficient production or excessive inactivation of surfactant in the lungs.
Treatment:
1. Maintaining normal body temperature (> 36,5 ° C):
- A child placed in kuvez (t - 34-36 ° C).
- Avoid cooling when viewed child!
- Optimally - use servokontrol.
2.Pidtrymka airway:
- The position of head slightly thrown ("out for sneezing") in the upper part of the chest put a cushion thickness 3-4 cm)
- Every 2-3 hours to change the baby's position (turn slightly to one side, on your stomach, etc.).
- If indicated - sanitation trachea.
3. Enteral nutrition is generally begin at 2-3 days of life after stabilization (decrease dyspnea, lack of sleep long, persistent vidryzhok).
4. Oxygen various methods, depending on the severity of the SDR:
- Oxygen inhalation.
- The method of spontaneous breathing with continuous positive airway pressure (SDPPT).
5. Support for water and electrolyte balance, the need for fluid and electrolytes should be determined strictly individual.
Infusion rate newborn - 4-5 drops / min, no more than 5 ml / kg / h.
6. Newborns with srednotyazhkym and difficult WBS shown holding in hospital antibiotic therapy for one of two combinations of antibiotics:
- Semisynthetic penicillins (ampicillin 50-100 mg / kg / day) + aminoglycosides (gentamicin 5 mg / kg / day)
- Or 2nd generation cephalosporins (50 mg / kg / day) + aminoglycosides.
7. Posyndromna therapy - correction of hypovolemia, hypotension, swollen syndrome, maintenance of acid-base status.
8. Exogenous surfactant replacement therapy prophylactically in the first 15-30 minutes of life, the medical - at the age of 2-24 hours according to the instructions for each drug surfactant. The child requires intubation and mechanical ventilation nahodytsya on hardware.
9. Glucocorticoids routinely for respiratory distress syndrome are not appointed (shown only in clinical laboratornыh data for adrenal insufficiency).
Resuscitation and intensive care of newborns with asphyxia
Commonly accepted definition of asphyxia newborn until there. The most informative and objective definition of asphyxia newborn seems like syndrome, characterized by lack of efficiency of gas exchange in the lungs immediately after birth, inability to breathe in the presence of heart rate and (or) other signs zhivonarodzhenosti (spontaneous muscle movement, pulsation of the umbilical cord).
Severe asphyxia at birth - heart rate less than 100 bpm. / Min, which slows down or stable, breathing is absent or impeded, pale skin, muscles are atonic. Asphyxia with Apgar score 0-3 points a minute after birth. White asphyxia.
Average and moderate asphyxia at birth, normal breathing within the first minute after birth is not established, but heart rate is 100 bpm. / Min or more, little muscle tone, response to minor irritation. Apgar score 4.7 points a minute after birth. Blue asphyxia.
There are also acute asphyxia, which is a manifestation of intrapartum hypoxia and asphyxia that developed on the background of chronic prenatal antenatal hypoxia.
General principles of care:
In providing intensive care newborn should strictly adhere to the following sequence of actions:
-Forecasting need resuscitation and preparation for their implementation;
Assessment of the child immediately after birth;
Recovery-free airway;
-Restore adequate breathing;
-Restore adequate serdtsevoyi activities;
-Administration of medicines.

Materials for self-

Tests:
1. For respiratory failure II stage is characterized by:
A) appears with a slight shortness of breath on exertion
B) appears dyspnea at rest
B) appears dyspnea at rest and with auxiliary muscles

2. In the mechanism of acute respiratory failure of central type is vital:

A) of central regulation of respiration.
B) functional failure of the respiratory muscles, loss of ability to reproduce cough impulse disorders excretion and accumulation of tracheobronchial secretions, atelectasis development and infection.
B) abnormal venous shunting of blood through unventilated areas of the lung.

3. In restrictive mechanisms of acute respiratory failure is vital:

A) of central regulation of respiration.
B) functional failure of the respiratory muscles, loss of ability to reproduce cough impulse disorders excretion and accumulation of tracheobronchial secretions, atelectasis development and infection.
B) abnormal venous shunting of blood through unventilated areas of the lung.

Situational task.

Task 1. Mother nursing home brownies with walnuts child 2.5 years, suddenly child choked on `made manifest anxiety, cough, breathing became more frequent, noisy, with cyanosis appeared nasolabial triangle.
• Previous diagnosis.
• Type of respiratory failure.
• Treatment.
Answers:
1. Foreign body airway.
2. Upper obstructive type of acute respiratory failure.
3. Bronchoscopy, remove foreign objects or excessive amount of secretion of roto-and nasopharynx.

Task 2. Child 10 years old, fell ill two days ago. Inspect the district pediatrician diagnosed influenza. On the 3rd day the child's condition worsened, was hospitalized in intensive care unit with signs of respiratory failure 2-3 degrees. The X-ray eclipse both lungs.

1. Preliminary diagnosis.
2. Type of respiratory failure.
3. Treatment.
Answers:
1. Bilateral viral pneumonia.
2. Parenchymal acute respiratory failure.
3. Prehospital necessary to ensure airway (tracheobronchial reorganization, the testimony - endotracheal intubation). If necessary, use of mechanical ventilation (manual or hardware method). Be sure to hold oxygen inhalation.

Problem 3. Newborns during the inspection specified pulse less than 100 beats / min., Which tends to slow, difficult breathing, skin pale, atonic muscles. Asphyxia with Apgar score 0-3 points a minute after birth. White asphyxia.

1. The degree of asphyxia.
2. General principles of treatment.
Answers:
1. Severe.
2. Assessment of the child immediately after birth, the recovery of free airway, adequate breathing recovery, restoration of adequate cardiac activity, administration of medicines.

Problem 4. In the newborn, auscultation, left breathing is not made, hollow belly, after X-ray set diaphragm hernia.

1. Type of respiratory failure.
2. Treatment.
Answers:
1. Restrictive acute respiratory failure.
2. Surgical treatment of diaphragm hernia, then restored lung volume excursions.

Problem 5. Newborn 3 days of life, difficult breathing, breathing in participating auxiliary muscles, the child is pale, cyanosis nasolabial triangle. On palpation the abdomen is swollen, painless, after X-ray set Hirschsprung's disease, acute form.

1. Type of respiratory failure.
2. The degree of respiratory failure.
3. Treatment.
Answers:
1. Thoracoabdominal acute respiratory failure.
2. Severe degree of respiratory failure.
3. Surgical treatment of Hirschsprung disease, then restored lung volume excursions, decreases intraperitoneal pressure.