Respiratory Failure in the Pediatric Patient

Abstract

The unique aspects of respiratory structure and function of newborn infants and older children make them particularly vulnerable to respiratory failure. In general, both obstructive airway disease and restrictive parenchymal disease may cause type I or type II failure. Only type I failure (hypoxemia, without hypercapnia) occurs with those disorders that lead to ventilation-perfusion imbalance, diffusion impairment, or an increase in the alveolar-arterial oxygen tension difference without concomitant ventilatory inadequacy. On the other hand, depression of the respiratory center and restrictive lung disorders due to failure of respiratory neuromuscular function (but normal lungs) lead to alveolar hypoventilation and type II failure (hypoxemia plus hypercapnia). Both clinical and laboratory assessment are crucial in establishing the precise type of respiratory failure and in directing the correct approach to management. The goal of therapy in patients with otherwise healthy lungs is to restore normal gas exchange as rapidly as possible and then to treat the underlying specific clinical condition. In patients with underlying chronic lung disease and acute respiratory failure, the goal of therapy is to return gas exchange to its previous level of compensation. Immediate recognition of total respiratory failure—cardiopulmonary arrest—and its prompt management requires clinical judgment as well as a maintained skill at cardiopulmonary resuscitation. The pediatrician should know not only when to institute immediate therapeutic measures but also when to transfer patients to an intensive care unit. The principles of intensive respiratory care of patients with acute respiratory failure also apply to the management of patients with mild respiratory insufficiency and, therefore, are essential for the prevention of acute respiratory failure—truly within the province of the general pediatrician.