• Respiratory failure occurs when oxygenation and ventilation are

insufficient to meet the metabolic demands of the body

• Traditionally defined as respiratory dysfunction resulting in Pa o2 < 60

torr with breathing of room air and Pa co2 >50 torr resulting in
acidosis
Differences in Airway
• Proportionally larger head & occiput (relative to body size), causing neck
flexion and potential airway obstruction when lying supine
• Relatively larger tongue, relative to the size of the oral cavity
• Decreased muscle tone -- passive obstruction of the airway by the tongue
• Shorter, narrower, horizontally positioned, softer, omega-shaped epiglottis
• Cephalad and anterior position of the larynx
• Shorter, smaller, narrower trachea
• Funnel-shaped versus cylindrical airway -- narrowest portion of the airway
is located at the level of the cricoid cartilage
• Prominent adenoidal and tonsillar lymphoid tissue -- airway obstruction
Differences in Respiratory Function
• Fewer alveoli compared to adults (approximately 20 million alveoli
after birth to 300 million alveoli by the age of 8 years)
• The size of each individual alveolus is smaller in children (150-180 μm
diameter versus 250-300 μm diameter)
• Together, these two anatomic differences markedly decrease the
surface area available for gas exchange.
Differences in Respiratory Function
• Airways - enlarge both in length and diameter with age - growth of
the distal airways lags behind that of the proximal airways during the
first 5 years of life - increased peripheral versus central airways
resistance
• R α 1/ r4Resistance is inversely proportional to the radius of the
airway to the fourth power - similar reduction in airway caliber results
in a greater decrease in the total crosssectional area as well as greater
increase in resistance in children vs adults
Differences in Respiratory Function
• The ribs are more horizontally aligned in infants & children compared to
adults - makes it difficult to generate a greater negative intrathoracic
pressure in the presence of poor lung compliance.
• The elastic recoil pressure of the alveoli is reduced in children, which
increases the risk of alveolar collapse in the presence of altered lung
compliance.
• Infant’s chest wall is soft and compliant, providing little opposition to the
natural recoil (deflating tendency) of the lungs - Low functional residual
capacity
• These developmental changes in chest wall and lung compliance require
the child to perform more work than an adult to generate the same tidal
volume.
• . Collateral pathways of ventilation (intra-alveolar pores of Kohn and
bronchoalveolar canals of Lambert) do not appear until 3–4 years of
age, which excludes alveoli beyond obstructed airways to be
ventilated by these alternate routes and predisposes the infant to the
development of atelectasis.9 Hypoxaemia and hypercapnia occur
early and can become profound quickly in infants
Differences in Respiratory Function

• Significant portion of the energy generated is wasted because of the

distortion of the highly compliant rib cage during negative pressure
generation from contraction of the diaphragm
• Infants become apneic in the face of increased work of breathing

• Collectively, all of these factors increase the risk of acute respiratory

failure in children
Causes of Acute Respiratory Failure

Neuromuscular
Lung parenchyma Airway dysfunction

• Pneumonia
• Croup • Myopathy

• Bronchiolitis
• Foreign body • Neuropathy ( GBS)

• Asthma
• Neuromuscular junction
• Subglottic stenosis disorders
• ARDS due to sepsis or
trauma
• CNS dysfunction (travel,
• Vascular ring infection, seizure)
• Aspiration

Pulmonary Oedema • Airway malacia • Diaphragmatic paralysis

• 1) NASAL FLARING:-V.imp sign of distress(esp. In infants). It indicates
discmfort, pain,fatigue,breathing difficulty. 2) DECREASED
RESPONSIVENESS:- S/o impending resp. Failure. 3) CHANGE IN RATE
& DEPTH OF RESPIRATION:-  ed lung complince -> rapid & shallow
Obstructive diseases -> slow & deep Non-respiratory causes ->
rapid & deep (metabolic acidosis, CNS stimulation)
• 4. CHEST WALL RETRACTION:- s/o increased inspiratory effort or
weak chest wall or both. 5. INSPIRATORY STRIDOR:- s/o airway
obstruction above thoracic inlet(e.g.laryngomalacia, choanal
atresia, laryngotracheobronchitis). 6. EXPIRATORY WHEEZE:- s/o
airway obstruction below thoracic inlet. 7. GRUNTING:- produced by
expiration against a partially closed glottis and is an attempt to
maintain PEEP for as long as possible. -occurs in diseases with
decreased FRC(such as in pulmonary edema, hyaline membrane
disease,and pneumonia) & also in bronchiolitis(to prevent airway
collapse).
• Respiratory failure is defined as inability of the lungs to provide
sufficient oxygen (HYPOXIC RESPIRATORY FAILURE) or remove
carbon dioxide (VENTILATORY FAILURE) to meet metabolic
demands.  Although respiratory failure is traditionally defined as
respiratory dysfunction resulting in Pao2 <60 torr with breathing of
room air and Paco2 >50 torr resulting in acidosis, the patient’s
general state, respiratory effort, and potential for impending
exhaustion are more important indicators than blood gas values.