Respiratory Failure in the Complex Care Patient
by Dr. Robert Graham.
Today I'm going to talk to you about assessing
respiratory distress in the child
with complex special healthcare needs.
We're going to pause at a vignette
and then describe some things that you might want to consider
during your assessment.
Assessment.
So we're going to start.
You've been called by the nurse saying, "Your patient is
having a breathing problem.
Please come now."
You walk to the patient's room and you begin your assessment.
So first things, as you probably know,
you start with basic airway, breathing,
circulation-- applies to any child you're seeing.
But there are lots of things to consider
with the child with special healthcare needs.
And you also have to wonder, what
is it that you were called for?
Is the patient working hard to breathe
or are they not breathing enough?
Are they on a monitor?
You need to get your first Gestalt assessment.
What do they look like?
What do their mouth look like?
What's their chest look like?
Do they have an artificial airway?
And then you work yourself top down and think, how can we
assess their breathing?
As you're doing all that, perhaps you want to think--
ask the nurse, can we put them on a monitor if they're not?
If they're on a monitor, are their saturations
being monitored, is their heart rate monitored--
all of those things.
You want to get as global of assessment as you can.
You want to learn a little bit about the patient.
If this is someone that you've been managing,
you perhaps already know that.
But if this is someone you just received signout on
or you're cross-covering, then you
want to get as much contextual and historical data
as you possibly can.
Does the patient have an artificial airway,
a tracheostomy tube?
Does the patient use respiratory supports at baseline?
Oxygen, CPAP, biphasic positive airway pressure--
so non-invasive measures.
Do they need cough assist usually,
something to aid them move their own secretions when
they're well?
Do they need chest physiotherapy?
Do they have suctioning needs?
All of these sort of chronic questions
may have implications for what you're
being called for acutely.
And really you also need to know,
why are they in the hospital?
Any stressor for a child with special healthcare needs
may alter their respiratory drive
or their respiratory sufficiency,
both their strength, their efficiency,
and their endurance.
So the question is, are they here with post-surgical needs?
They're in pain?
Are they here with a viral respiratory illness?
Are they here with gastroenteritis, fever?
Anything can kind of push the limits
of their baseline respiratory capacity.
It's crucial to understand the underlying
conditions of the child with special healthcare needs.
This will provide you some insight
into their propensity for respiratory insufficiency.
So the top-down or other systematic assessment
may be really helpful.
Think about central or peripheral neuromuscular
insufficiency resulting in altered mechanics
where there's upper airway obstruction or restricted
thoracic cage from scoliosis, questionable diaphragmatic
function, impaired secretion clearance, or aspiration risk.
Do they have hypotonia?
Do they have spasticity?
Is it mixed or inconsistent?
Do they have primary lung disease,
either from cumulative insults with aspiration pneumonitis
or community-acquired illnesses?
Are they immunosuppressed and they're prone
to other respiratory illnesses?
You need to tailor your support measures accordingly.
Could they have epilepsy?
Are they seizing?
Are they postictal?
Are they hyperventilating because of that
or hypoventilating?
Have they received any anti-epileptics
to address seizures and, in fact,
actually they're sedated because of those anti-epileptics?
Do they have hydrocephalus, either related
to myelomeningocele, interventricular hemorrhage
as a premature infant, traumatic brain injury, or otherwise?
Could there be a shunt malfunction
that's resulting in an obtunded or depressed mental status
and depressed respiratory status?
Do they have autonomic dysregulation.
Hypothermia or lack of a stress response from acute illness
or otherwise, it's simply exposure itself
may result in hypoventilation.
Do they have a metabolic disorder?
Is there something wrong?
Are they hypoglycemic?
Are they acidotic?
Could all of these impact the level of consciousness,
either making them breathe very quickly
or making them hypoventilate?
Could they have congenital heart disease--
a whole other group of patients where,
in fact, actually maybe their saturations
should be lower than your normal full saturation goals.
Could they have cardiomyopathies that
might be associated with some of the muscular dystrophies,
or perhaps they have an unknown diagnosis where
you need to sort of think about all of these things.
Are they osteopenic-- so someone who's
not ambulatory and non-weight bearing
and that they're vulnerable to pathologic fractures.
So maybe they're in pain.
Maybe they're actually breathing too quickly,
they're tachypnic, or just in discomfort,
and that's what's driving their respiratory distress.
You need to think broadly with the child
with special healthcare needs.
They may not be able to communicate to you,
but understanding their underlying condition and what's
happened to them acutely may help direct your examination
and your support measures.
Has the child had any recent procedures--
again, giving you a clue about the underlying pathology
and potential complications that might be driving this
call from the nurse.
When you think, also, acutely, what just happened to them?
The nurse was obviously doing an assessment.
Had she given any treatments or were there any medications
recently that might alter the respiratory drive
or have other systemic effects?
You want to confirm the dosing.
Consider reversal agents.
If they received a benzodiazepine or an opiate,
that might be suppressing their level of respiratory drive.
Think key points as you're doing your ABC assessment
as that oxygen saturation is only one aspect
of your respiratory assessment.
And in fact, it may be misleading and not
reflect ventilation or CO2 exchange.
Use your heart rate as a monitor.
Use the level of consciousness as a good index.
Think about positioning.
How does that help or hurt someone's
respiratory mechanics?
Is this someone who's better sitting upright, side lying,
prone?
Does any procedure that they may have
had have implications for that?
Acutely, you might also want to consider
holding the enteral feeds.
So if they have an NG tube or they're
getting gastrostomy feeds or other post-pyloric
feeds, that you may actually want
to hold those feeds until you determine
what the trajectory is.
What you don't want to do is compound issues
by placing them at risk for vomiting and aspiration.
Non-invasive measures, as you think
about the types of respiratory support
that you can provide them, have risks and benefits.
And if not implemented properly and reassessed,
they may actually potentiate the problems.
If you place a bag and mask on someone's face,
you can actually, if not done properly,
Create some airway obstruction.
Giving too much pressure or recognizing that you're not
completely inflating the chest, you
may be actually contributing to impaired mechanics
and lead to gastric distension, which decreases FRC but also
increases your risk of aspiration,
and so you need to be cautious and thoughtful
about any interventions that you do.
Call for help.
Low threshold-- you're in the hospital.
The nurses called you for help.
Clearly, there's some sort of distress,
and you should rely on your senior residents.
You can call the intensive care unit fellow.
You could hit the code blue if you are truly, truly concerned.
Call for help-- low threshold.
But use the family as a potential barometer.
They're often very good in terms of calibrating you
and everyone around you as to what their child's baseline
need is.
They may say, oh, in fact, he's always breathing this quickly
or, oh, she typically does this after she's
gotten a medication if we just wait,
or they may say, in fact, actually, this isn't right.
So use the bedside provider to help calibrate yourself,
whether it's the nursing staff, the respiratory therapist,
the parents, or simply call for help if people are uncertain.
Further evaluation.
The next set of questions that might come up
as you're working through your ABCs--
you're providing oxygen, you're providing bag mask ventilation,
you're calling the ICU, or you're just
sort of triaging this with the family and the bedside team--
what do I need for further evaluation?
Do I need labs?
Do I need radiography?
And when should I get them?
The key is, what are they going to add
to your exam and your vital signs?
And do you need to actually escalate your care prior to
or independent of these studies?
It's helpful to think of chest X-ray would be your first pass
test if you're worried about respiratory distress.
What are you going to do with that data
from the chest X-ray that's going to change what you
need to do in the short term?
First, there's a timing question.
Someone will have to call for the radiography tech.
They need to come up to the floor.
They'll take the X-ray and then read it.
That may take 20, 30 minutes.
But obviously you're going to need to support
the child in the meantime.
So in general, we would probably say, support the child
and then think about what an X-ray would add.
The same actually applies for most blood tests.
If you think you've got someone who's acutely changing,
then you probably need to get them
to a different level of care before doing labs,
unless there's something on a point of care testing,
either a blood sugar test or perhaps a blood gas,
that you'd want to do immediately.
That said, most blood gases aren't
going to tell you a lot more-- other
than, perhaps, pH, your acid base balance--
than you're going to glean from your exam
and your basic vital signs.
Remember that someone who's hypercarbic
may actually have quite an elevated heart rate.
Someone who's hypothermic and hypoventilating
may actually have a relatively low heart rate.
Every circumstance is a little different.
But the key is to say, what are these tests going to add
to my immediate management?
And is there a problem if we delay?
Higher level care considerations.
Other questions for higher level consideration
is, would this patient be a difficult airway
if I had to intubate them?
Do they have problems with their mandible, their midface,
their neck movement or otherwise that
would make me believe that someone, whether it's yourself
or anesthesia or one of the ICU fellows or any other staff--
would they be able to put in an endotracheal tube if needed?
You can start with the medical record.
Look back.
Have they ever had anesthesia?
Have they had procedural sedation?
And that will give you a sense to say,
do we need to get someone additional resources--
ENT, ORL, anesthesia, the ICU--
to give them a clue in terms of, are there other contingencies
we need to have in place?
Talk to the family.
They should know-- as I said basic, exam, as well,
in terms of positioning.
Certain conditions also place patients
at risk of receiving specific medications.
Are there malignant hypothermia risks?
While rare, there are certain myopathies
that, again, knowing the underlying diagnosis
will be helpful.
And lastly, what are the goals of care?
You can start with the medical record.
Talk to the family.
Is this a child who actually--
albeit the majority of patients with special healthcare needs
are going to want routine care provision in the acute setting,
there are some where special circumstances and the family's
goals of care may limit what you would actually implement, even
in the acute situation.
So it's helpful to clarify that with the family.
Do they want this child to be intubated?
Would they want to go to an ICU?
And with that in mind, you would then
reassess what your goals and what can be implemented
and the resources you need to call upon.
Summary.
So as we think back, the child with special healthcare needs
is like any other child.
You're going to start with your ABCs.
Get them on a monitor.
Provide oxygen. Provide respiratory
supports as you might.
Reflect back and think, what's their underlying diagnosis
that may lead them to be in distress?
What are the acute things that are superimposed,
either procedures, superimposed illnesses, medications
or otherwise that might lead to respiratory distress,
either working too much or working too little?
And then titrate your response accordingly.
Thank you for watching.