Interesting Pediatric

Respiratory Cases:
An Interactive Discussion
Ira M. Cheifetz, MD, FCCM, FAARC
Professor of Pediatrics
Chief, Pediatric Critical Care
Medical Director, PICU
Duke Children ’s Hospital
Children’s
 Case 1: Pneumonia
♦ Previously healthy 4 yo (18 kg) girl presents
with a 5 day h/o URI symptoms, cough, & fever
♦ Admitted to the pediatric ward with RLL
pneumonia
♦ Over 48 hours, she develops worsening
tachypnea, progressive bilateral infiltrates, and
hypoxia
♦ HR 152, RR 42, SpO2 89% (2 lpm), T 39.5 °C
39.5°C
♦ Diffuse rales, mod subcostal retractions
 Your Assessment
♦ Moderate subcostal retractions, no
supraclavicular retractions, good air exchange
except at R base
♦ Significant crackles on right, minimal crackles
on left, no wheezing
♦ SpO2 85% on 2 lpm via nasal cannulae
♦ CV normal pulses and capillary refill
♦ Exam otherwise unremarkable
 Case Progression
♦ Patient is transported to the Pediatric ICU
♦ Worsening respiratory distress
♦ Increased work of breathing
♦ RR 50s, SpO2 92% on 5 lpm
 Question #1
What would be your management?
A. Observe closely
B. CPAP
C. Bilevel non-invasive ventilation (i.e., BiPAP)
D. Intubate
E. Hope that help arrives soon
 Non-invasive Ventilation
♦ Use of NIV for acute, hypoxic respiratory failure
remains controversial
♦ ↓ intubation rate, ICU LOS, & ICU mortality
–– Keenan, CCM, 2004 (meta-analysis)
(meta-analysis)
♦ ↓ nosocomial pneumonia risk
–– Hess, Respir Care, 2005 (meta -analysis)
(meta-analysis)
 Case Progression
♦ Patient is intubated the next morning for
progressive hypoxia.
♦ PC/PS: rate 24 PIP 30 PEEP 12 FiO2 0.60
♦ ABG pH 7.3 PaCO2 55 PaO2 65
♦ PaO2 / FiO2 108
♦ Oxygenation index = 15
–– OI = (MAP x FiO22) / PaO22
 Question #2
What delivered tidal volume would
you choose?
A. 4 ml/kg
B. 6 ml/kg
C. 8 m/kg
D. 10 ml/kg
 Low Tidal Volume Ventilation

Volume 342(18) 4 May 2000 pp 1301-1308

Ventilation with Lower Tidal Volumes as Compared with
Traditional Tidal Volumes for Acute Lung Injury and the
Acute Respiratory Distress Syndrome

♦ The appropriate Vt for pediatric acute lung

injury has never been formally studied.
♦ Thus, the best we can do is extrapolate
from data in the adult ARDS population.
13 ‘Experts’
– Yes: 5
– No: 8
 ARDS Worsens
♦ Patient is transitioned to HFOV.
– MAP 28, Amp 59, 33% insp time, FiO2 0.70
– pH 7.25, PaCO2 67, PaO2 65, SaO2 90%
♦ PaO2 / FiO2 93
♦ Oxygenation index = 30
 Question #3
What should be the maximum
acceptable PaCO2?
A. 55 torr
B. 75 torr
C. 95 torr
D. Any PaCO2 as long as the pH is
‘acceptable’
 ‘Permissive Hypercapnia’
♦ Available data support permissive hypercapnia to
minimize vent settings and secondary lung injury
♦ Goal: maintain acceptable pH regardless of PaCO2
♦ Contraindications
–– increased intracranial pressure
–– reactive pulmonary hypertension
♦ Acute lung injury model (Laffey, AJRCCM, 2000)
–– hypercapnic acidosis is protective
–– buffering attenuates its protective effects
 Question #4
What is the goal SaO2 for your
patient?
A. ≥ 95%
B. 90 – 94%
C. 85 – 89%
D. 80 – 84%
E. < 80%
 ‘Permissive Hypoxemia’
♦ Definitive data are lacking in the medical
literature!
♦ Goal maintain a ‘safe’ level of oxygenation
♦ Maintain adequate O2 delivery
– optimize cardiac output
– measure ABG / MVO2 / serum lactate
♦ Assess end-organ function
– mental status (difficult 2° sedation)
– renal function / urine output
– cardiac function
 Question #5
Do you routinely use recruitment
maneuvers (i.e., sustained inflation)
for pediatric ALI / ARDS?
A. Yes
B. No
 Recruitment Maneuvers
♦ Use of RMs remains controversial.
♦ Bring lung to TLC to maximize recruitment,
then move down the deflation limb of the
pressure -volume curve to an ‘‘appropriate’
pressure-volume appropriate’
PEEP to prevent de -recruitment
de-recruitment
♦ No adult outcome data
♦ No pediatric data
Should RMs be routinely performed for
adult ARDS pts?
12 ‘Experts’
• Yes 3
• No 9
• Abstain 1
DISCUSSION
 Case 2: Trauma
♦ 3 year old unrestrained passenger ejected
from car
♦ Intubated for loss of consciousness
♦ Transported to ED
– GCS 5 5,, poorly perfused
– bruising noted over left chest wall
– SpO2 83%; FiO2 1.0
♦ ABG pH 7.25 PaCO2 32 PaO2 43 BE --9 9
♦ Trauma eval and stabilization in
Emergency Department then to PICU
 Pulm Contusion
♦ Patient placed on ventilator in PRVC mode
– Vt 7 ml/kg rate 20 PIP 31 PEEP 8
FiO2 0.70
♦ ABG pH 7.34 PaCO2 41 PaO2 43
 Question #6
Would you administer exogenous
surfactant?
A. Within the first 48 hours
B. If no improvement after 48 hours
C. If no improvement after 7 days
D. Not for this patient
 Exogenous Surfactant
♦ Exogenous surfactant administration is the
only adjunct therapy that has been shown to
be beneficial for the pediatric ALI / ARDS pt.
– Willson, JAMA, 2005

♦ Surfactant was shown to be beneficial when

administered within 48 hours of onset of ALI.
 Question #7
Would you offer a trial of inhaled
nitric oxide?
A. Within the first 48 hours
B. If no improvement after 48 hours
C. If no improvement after 7 days
D. Not for this patient
 Question #8
When would you consider a trial
of prone positioning?
A. Within the first 48 hours
B. If no improvement after 48 hours
C. If no improvement after 7 days
D. Not for this patient
 Inhaled NO / Prone Position
♦ Multiple studies have demonstrated improved
oxygenation for adult and pediatric patients
with the administration of inhaled nitric oxide
and prone positioning for acute lung injury.
♦ But, no study has demonstrated improved
survival with either therapy for acute lung
injury.
Prone Positioning Inhaled Nitric Oxide
Curley, JAMA, 2005 Dobyns, Pediatr, 1999
Guerin, JAMA, 2004 Dellinger, Crit Care Med, 1998
Gattinoni, NEJM, 2001
 Question #9
At what settings would you initiate
HFOV?
A. OI 17, MAP 18, PIP 30, FiO2 50%
B. OI 22, MAP 22, PIP 32, FiO2 65%
C. OI 38, MAP 27, PIP 37, FiO2 80%
D. Would not use HFOV
Pediatric HFOV

Arnold, Crit Care Med, 1994.

DISCUSSION
 Case 3: Status Asthmaticus
♦ 12 year old female with known history of asthma
♦ PMHx: 2 prior PICU admits; never intubated
♦ On ED arrival
– obvious respiratory distress

– SpO2 84% (RA); BP 110/57; HR 142; RR 48

♦ Triage nurses rushes patient to a room and
STAT pages you
 Initial Management
♦ Your initial assessment
– SpO2 85% (RA); HR 151; RR 54

– distant wheezing

– poor air exchange

– moderate subcostal & intercostal retractions
♦ FiO2 via face mask started at 0.60
♦ Solumedrol (1 mg/kg) IV ordered
 Question #10
Which of the following would you
do next?
A. Obtain an ABG
B. Start continuous albuterol at 20 mg/hr
C. Start continuous albuterol at 40 mg/hr
D. Start non -invasive ventilation
non-invasive
E. Emergently intubate
 Status Asthmaticus
♦ Continuous albuterol started at 40 mg/hr
♦ Patient initially with improved air exchange on
auscultation
♦ Continues to have increased WOB but slightly
improved
♦ Intern sends med student to obtain ABG

obviously unsuccessful
–

♦ Patient now complains that she cannot

breathe
 Question #11
Would you offer a trial of heliox before
intubation?
A. Yes
B. No
 Gas Densities
Relative density of He-O22 and N22-O22
mixtures compared with 100% O22.

Oppenheim-Eden, Chest, 2001.

 Principles of Gas Flow
♦ Because of its lower density than N2 or O2,
heliox would be predicted to improve gas
flow through a narrowed orifice.
♦ Reynold’s number (Re = VDρ / μ)
– Re > 4000 = turbulent flow
– Re < 2100 = laminar flow
 Turbulent Gas Flow
♦ Occurs in constricted passages

♦ Flow rate = k ΔP
√ ρ
♦ ↓ gas density yields ↑ gas flow.

♦ Thus, heliox improves turbulent gas

flow.
 Asthma and Heliox
Kass, Chest, 1999.
♦ Both groups received
– methylprednisolone 125 mg IV
– inhaled albuterol 2.5 mg nebs x 2
♦ After 20 minutes of therapy
– Heliox group PEF ↑ 58.4%
– N2-O2 group PEF ↑ 10.1%
Asthma and Heliox

Kass, Chest, 1999.

 A-a Gradient
300

250
control
control
200
heliox
heliox
150 *
100
* p = 0.003
50

0
Baseline 2 hrs
Schaeffer, CCM, 1999.
 Asthma and Oxygenation
♦ FiO2 in the heliox treated group
decreased from 0.81±0.25 to
0.37±0.27 after 2 hours of therapy.
(p = 0.0008)
♦ This study rejects the idea that a
minimum of 40% helium must be
used to obtain a therapeutic effect.

Schaeffer, CCM, 1999.

 The ‘Spiral’ Effect
‘some’ improve gas
heliox exchange

increase decrease
heliox FiO2
concentration
 But….
♦ What if your patient does not improve with heliox
or if you do not have heliox at your institution?
♦ Then, probably intubate.
♦ Patient intubated with 6.5 cuffed ETT without
difficulty (not by the med student)
♦ Patient is being hand ventilated with FiO2 1.0.
♦ Patient is transferred to the PICU.
 Question #12
What ventilator mode would be
most appropriate?
A. Volume control with square waveform
B. Pressure control with variable flow
C. PRVC with variable flow
D. High frequency ventilation
 Pressure Scalar
Constant, Variable,
Square Wave Decelerating Wave
PIP

Pressure
(cm H2O)

Paw
 Question #13
Which of the following settings
would you use?
A. Vt 12 ml/kg, rate 12, PEEP 5
B. Vt 8 ml/kg, rate 18, PEEP 5
C. Vt 6 ml/kg, rate 24, PEEP 5
 Asthma and Mech Ventilation
♦ 6 ml/kg has been shown to be the ‘ideal’ tidal
volume only for adult ALI / ARDS.
♦ Use long expiratory time ventilation which often
requires a ‘‘larger’
larger’ tidal volume and low set
ventilatory rate.
♦ Goal should be to transition to Pressure Support
Ventilation with goal of extubation as soon as
possible.
DISCUSSION
 Case 4:
Patient-Ventilator Interactions
♦ 10 mo old infant; 28 weeks prematurity
♦ Intubated for viral pneumonia

♦ HR 172, RR 65, BP 82/45, afebrile

♦ SIMV / PS

rate 24, PIP 28, PEEP 7, FiO22 0.50

–

♦ ABG: pH 7.25 / PaCO2 64 / PaO2 68

♦ Infant is very agitated

♦ Nurse requests additional sedation/analgesia
 Question #14
Why is the patient agitated?
A. Inadequate sedation / analgesia
B. Trigger insensitivity
C. Flow dys -synchrony
dys-synchrony
D. Inadequate PEEP
E. Inadequate tidal volume
 Question #15
Why is the patient agitated?
A. Inadequate sedation / analgesia
B. Trigger insensitivity
C. Flow dys -synchrony
dys-synchrony
D. Inadequate PEEP
E. Inadequate tidal volume
DISCUSSION