Consultation with the specialist: respiratory failure in children.

Abstract

1. John Pope, MD* 2. John McBride, MD* 1. *Department of Pediatrics, Divisions of Critical Care and Pulmonology, Robert T. Stone Respiratory Center, Children’s Hospital Medical Center of Akron, Northeast Ohio Universities College of Medicine, Akron, OH After completing this article, readers should be able to: 1. Explain when hypercarbia interferes with metabolism. 2. Discuss why oximetry is not a sensitive indicator of respiratory failure in patients who are receiving supplemental oxygen. 3. List the indicators of chronic respiratory failure. 4. Describe the usual findings on blood gas analysis in patients who have chronic respiratory failure. 5. Identify which patients should be monitored regularly for the development of respiratory failure. A 16-year-old boy who has Duchenne muscular dystrophy presents to the pediatric clinic with a 2-day history of nasal congestion, intermittent headache, cough, and low-grade fever. The patient’s mother reports that her son’s cough was worsening last night, his chest was very congested, and he was sleepy this morning and difficult to arouse. The patient was transported to the clinic by a local ambulance company, who administered 2 L of supplemental oxygen by nasal cannula for mild respiratory distress. On physical examination, the patient is sitting in his wheelchair and requires gentle stimulation to remain awake and engage in conversation. His responses to questions are appropriate but slow and not typical for him. The patient has mild tachycardia, nasal flaring, and paradoxic respirations. His cough is weak. On auscultation, there are bilateral rhonchorous breath sounds with diminished air entry in the lower lung fields. The oxyhemoglobin saturation by pulse oximetry is 91% on 2 L of oxygen per nasal cannula. An arterial blood gas shows a pH of 7.18, a Paco2 of 70 mm Hg, a Pao2 of 60 mm Hg, and an Hco3 of 34 mEq/L. The patient is transferred to the pediatric intensive care unit, where he is treated with noninvasive positive-pressure ventilation by face mask and assisted mucus clearance techniques. After 2 days, he is weaned to nocturnal noninvasive ventilation. He is discharged from the hospital …