Pediatric respiratory failure

rsmonroersmonroe
in Pediatrics

Hi Pediatric CDI people! I'm 2 days in to reviewing pediatric charts. Whew! I'm not sure what I've gotten into. I just spoke to a doctor about a 1yr old that he sent to hospital from his office with "respiratory distress with costal retractions". Baby was dx with pneumonia and asthma exacerbation, and respiratory distress. Babies O2 sat on arrival was 77% and was put on O2 4L/NC.

I asked the physician to be more specific with diagnosis and he said "hypoxia" "respiratory distress" I tried to introduce the criteria of respiratory distress + O2 sat of 77% would met for respiratory failure. He argued "not intubated" "not going to make it worse than it is" I sent some printed education to him ... but he got mad and frustrated. I ended up I think defending pretty good but.... with my limited experience I told him I would research further. Seems like this is a big problem! Is the criteria met for failure ... now I'm not sure. Any thoughts?


Comments

  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu

    Welcome to the world of Peds...you are in the right place for help! We've all been in your shoes before! I think it's more of a training issue with the Pedi's and they just feel like resp failure means intubation + vent. It's only been In the last few years that we got a couple new Attendings that felt comfortable writing the dx on a patient on HFNC and now the others followed suit and don't give us trouble anymore.

    We have patients on the floor that qualify for acute resp failure but the hospitalists don't feel comfortable with using the dx because they've kept them on the floor and they haven't been transferred to the PICU for a higher level of care.

    ACDIS is a wealth of knowledge and we have a pediatric sub group APDIS. Send me an email and I will get you in touch with one of the officers so that you can get on the emailings. I would also recommend trying to attend the conference this year if at all possible, we have an entire pedi track this year!

    I will try to find a few other resources for you and send them your way later.

    Thanks, Jeff

    jwmorris@health.southalabama.edu


  • cmclose@saintfrancis.comcmclose@saintfrancis.com

    Welcome!

    Pediatric Resp Failure is a tough dx to get here where I work but it is a work in progress and is better than it used to be. Lots of docs here think pt should be in PICU and also have a blood gas in order to help support the Ac Resp Failure dx. We all know that blood gases (esp ABGs) HURT like the dickens and usually we avoid adding additional stress on the patient when he/she is already in resp distress, right? So what other criteria do I use to base a query on? RA sats, amount of supplemental oxygen (% or LPM; delivery system: NC, HFNC, simple mask, bipap, NRB mask), signs of WOB (resp rate outside of normal for age range; retractions: level and type: severe intercostal; grunting, head bobbing, etc; can age appropriate pt talk or using only 1-3 words; LOC: are they lethargic, anxious, not usual self/irritable; activity/position: won't lie down flat, tripoding, etc.). Plus what is the treatment being used: i.e. albuterol CBN/ back to back nebs, IV Steroid, CPO monitoring (how are the sats trending?). Is there a serum CO2 available? How is pt responding to treatment? Quickly or are the docs having to write a lot of orders/change treatment regimen? Along with any comorbid conditions (ie asthma, pneumonia, SMA, etc.).  So basically I look at the whole picture and then provide as much "evidence" as I can on the query.

    I agree with Jeff! ACDIS is a great resource and APDIS is very helpful!

    Again, welcome aboard!

    Claudine

  • jackietouch@aol.comjackietouch@aol.com
    Very good advice here! We tend to look at all the above and also calculate SF ratio (O2 sat / percentage of oxygen being administered) because often kiddos are put on oxygen right away even before a VBG is obtained. SF ratio <267 (thereabouts) might be indicative of failure. We also look for treatment given >2 hours (ie oxygen administration, or , in the case of hypercapneic respiratory failure, HFNC with room air).
  • larchibaldlarchibald
    I stumbled into this thread and wanted to pass along a couple ACDIS resources. ACDIS has a pediatric respiratory failure white paper that was published in 2016: https://acdis.org/resources/pediatric-respiratory-failure-need-specific-definitions
    The book "Pediatric CDI: Building Blocks for Success" (which Jeff worked on) also has a long section on respiratory failure: http://hcmarketplace.com/pediatric-cdi-building-blocks-for-success
    I'm sure your peers will be just as helpful (if not more so) as these resources, but I thought I'd pass them along :)
    Welcome to the world of peds! Feel free to reach out to any of us at ACDIS if you ever need help finding something on the website. We're happy to help you out!



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