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Respiratory failure

Respiratory (ventilation-pulmonary) insufficiency is characterized by such disorders in which pulmonary gas exchange is impaired or occurs at the cost of excessive energy costs.

Types of respiratory failure:

1) ventilation;

2) distribution-diffusion (shuntodiffusion, hypoxemic);

3) mechanical.


I degree. Dyspnea varies without the participation of auxiliary muscles in the act of breathing; at rest, as a rule, absent. Cyanosis is perioral, intermittent, aggravated by anxiety, disappearing by respiration with 40-50% oxygen; pallor of the face. Blood pressure is normal, rarely moderately elevated. The ratio of the pulse to the number of breaths is 3.5-2.5: 1; tachycardia. The behavior is restless or not disturbed.

II degree. Dyspnea at rest is constant, with the participation of auxiliary muscles in the act of breathing, retraction of compliant places of the chest; may be with a predominance of inhalation or exhalation, that is, wheezing, groaning exhalation. Cyanosis of the perioral face, hands is constant, does not disappear when breathing with 40-50% oxygen, but disappears in the oxygen tent; generalized pallor of the skin, sweating, pallor of the nail bed. Blood pressure is elevated. The ratio of the pulse to the number of breaths is 2-1.5: 1, tachycardia. Behavior: lethargy, doubtfulness, adynamia, followed by short-term periods of excitement; decreased muscle tone.

III degree. Dyspnea expressed (respiratory rate - more than 150% of the norm); shallow breathing, periodic bradypnea, respiratory desynchronization, paradoxical breathing. Reduction or absence of respiratory sounds on inspiration. Generalized cyanosis; there is cyanosis of the mucous membranes, lips, does not pass when breathing with 100% oxygen; generalized marbling or pallor of the skin with blue; sticky sweat. Blood pressure is lowered. The ratio of the pulse to the number of breaths varies. Behavior: lethargy, doubtfulness, consciousness and reaction to pain suppressed; muscle hypotension, coma; cramps.

Causes of acute respiratory failure in children.

1. Respiratory - acute bronchiolitis, pneumonia, acute laryngotracheitis, false croup, bronchial asthma, congenital malformations of the lungs.

2. Cardiovascular - congenital heart disease, heart failure, pulmonary edema, peripheral discirculatory disorders.

3. Neuromuscular - encephalitis, intracranial hypertension, depressive states, poliomyelitis, tetanus, status epilepticus.

4. Injuries, burns, poisoning, surgical interventions on the brain, chest organs, poisoning with sleeping pills, drugs, sedatives.

5. Renal failure.

Differential diagnosis. Acute bronchiolitis in children

1st year of life is carried out with bronchial asthma, obliterating bronchiolitis, congenital malformations of the vascular system and heart, congenital lobar emphysema, bronchopulmonary dysplasia, cystic fibrosis, foreign body, acute pneumonia.

Acute bronchiolitis in older children is carried out with allergic alveolitis, aspiration of foreign bodies, with bronchial asthma, gastroesophageal reflux and with aspiration of food into the respiratory tract, parasitic pneumonia. Obstructive syndrome is manifested by increased breathing up to 70 in 1 minute and above; anxiety of the child, changing poses in search of the most convenient; noticeable exhalation of intercostal muscle tension; the appearance of a difficult breath with the retraction of compliant places of the chest; central cyanosis (one of the signs is tongue cyanosis); decrease in PO2; increased PCO2.

Treatment. Treatment of obstructive syndrome: a constant supply of oxygen through a nasal catheter or nasal cannula is necessary, the introduction of b-agonists in an aerosol (2 doses without a spacer, and preferably 4-5 doses through a spacer with a capacity of 0.7-1 l), parenterally or orally: salbutamol ( ventolin), terbutaline (brikanil), fenoterol (berotek), berodual (fenoterol + ipratropium bromide), orciprenaline (alupent, astmopent). Together with the b-agonist, one of the corticosteroid preparations, prednisone (6 mg / kg - at the rate of 10-12 mg / kg / day), is administered intramuscularly. In the absence of the effect of the administration of b-agonists, aminophylline is used together with iv drip corticosteroids (after a loading dose of 4-6 mg / kg, continuous infusion at a dose of 1 mg / kg / hour). Intravenous fluid infusion is carried out only if there are signs of dehydration. The effectiveness of therapeutic measures is judged by a decrease in respiratory rate (by 15 or more per 1 minute), a decrease in intercostal retraction and the intensity of expiratory noise.

Indications for mechanical ventilation in obstructive syndrome:

1) attenuation of respiratory sounds on inspiration;

2) preservation of cyanosis during breathing with 40% oxygen;

3) reduction of pain response;

4) the fall of RaO2 below 60 mm RT. st .;

5) an increase in PaCO2 above 55 mm Hg. Art.

Etiotropic therapy begins with the appointment of antiviral agents.

1. Chemotherapy - remantadine (inhibits the specific reproduction of the virus at an early stage after penetration into the cell and before the start of RNA transcription) from the 1st year of life, course 4-5 days - arbidol (the mechanism is the same + interferon inducer), from 6-year-old age - 0.1, over 12 years old - 0.2, course - 3-5 days - amiksin is used in children older than 7 years. When an adenoviral infection is applied locally (intranasally, on the conjunctiva), ointments are used: oxolin ointment 1-2%, Florenal 0.5%, Bonaphton 0.05%.

2. Interferons - native leukocyte interferon (1000 units / ml) 4-6 times a day in the nose - recombinant a-interferon (rheoferon, fluferon) more active (10,000 units / ml) intranasally, viferon in the form of rectal suppositories.

3. Interferon Inductors:

1) cycloferon (methylglucamine acridone acetate), neovir (kridanimod) - low molecular weight substances that contribute to the synthesis of endogenous a-, b-, and y-interferons;

2) amixin (tilorone) - ribomunil (in the acute stage of a respiratory disease, it is used according to the scheme (1 sachet of 0.75 mg or 3 tablets of 0.25 mg in the morning on an empty stomach for 4 days). Antipyretic drugs in pediatric practice

use - amidipyrine, antipyrine, phenacetin, acetylsalicylic acid (aspirin). At present, only paracetamol, ibuprofen are used as antipyretic drugs in children, and when it is necessary to quickly reduce the temperature of the lytic mixture, 0.5-1.0 ml of i / v 2.5% solutions of chlorpromazine and promethazine (pipolfen are used) ) or, less desirable, analgin (50% solution, 0.1-0.2 ml / 10 kg of body weight. Symptomatic therapy: antitussive drugs are indicated only in cases where the disease is accompanied by an unproductive, painful, painful cough) leading to impaired sleep, appetite and general exhaustion of the child. They are used in children of any age with laryngitis, acute bronchitis and other diseases accompanied by a painful, dry, obsessive cough. Non-narcotic antitussive drugs are preferable. acute bronchitis is better to use mucoregulators - derivatives of carbocestein or mucolytic drugs with an expectorant effect. Mucolytic drugs can not be used with antitussive drugs. Expectorant preparations are indicated if the cough is accompanied by the presence of thick, viscous sputum, but its separation is difficult. Antitussive drugs of central action.

1) narcotic: codeine (0.5 mg / kg 4-6 times a day);

2) non-narcotic: synecode (butamirate), glauvent (glaucine hydrochloride), dry cough fervex (also contains paracetamol and vitamin C).

Non-narcotic antitussive drugs of peripheral action: libexin (prenoxdiazine hydrochloride), levopront (levodropropisin).

Combination antitussive drugs: tussinplus, stoptussin, broncholitin (glaucine, ephedrine, citric acid, basil oil).

Mucolytic agents.

1. Actually mucolytic drugs:

1) proteolytic enzyme;

2) dornase (pulmozyme);

3) acetylcysteine ​​(ACC, mucobene);

4) carbocysteine ​​(broncatar, mucodine, mucopront, fluvik).

2. Mucolytic drugs with expectorant effect:

1) bromhexine (bisolvone, broxin, solvin, phlegamine, fulpen);

2) ambroxol (ambrobene, ambrohexal, ambrolan, lazolvan, ambrosan).

3. Expectorant medicines:

1) broncholithin (glaucin, ephedrine, citric acid, basil oil);

2) glycerols (licorice);

3) Dr. IOM (licorice, basil, elecampane, aloe);

4) coldrex (terpinghydrate, paracetamol, vitamin C).
Bronchodilators are used for obstructive

forms of bronchitis. Preference is given to sympathomimetics of β-agonists in the form of an aerosol. B2 adrenergic agonists:

1) salbutamol (ventolin);

2) fenoterol (berotek);

3) salmeterol (long-acting);

4) formoterol (the action begins quickly and lasts a long time).

The program “ARI in children: treatment and prevention” (2002) says that the use of EUFILLINE is less desirable because of possible side effects. Anti-inflammatory drugs. Inhaled glucocorticosteroids:

1) beclomethasone (aldecin, becotide, etc.);

2) budesonide (budesonide mite and forte, pulmicort);

3) flunisolid (ingacort);

4) fluticasone (flixotide).

Non-steroidal anti-inflammatory drugs Erespal (fenspiride) - counteracts bronchoconstriction and has an anti-inflammatory effect in the bronchi.

Indications: treatment of functional symptoms (cough and sputum) accompanying bronchopulmonary diseases. Antihistamines are prescribed when ARI is accompanied by the appearance or intensification of allergic manifestations (histamine H1 receptor blockers).

First-generation drugs: diazolin, diphenhydramine, pipolfen, suprastin, tavegil, fenistil.

Preparations of the second generation: Zyrtec, Claritin, Semprex, Telfast, Erius.


1. Ribomunyl - a ribosomal immunomodulator, which includes ribosomes of the main pathogens of ENT and respiratory infections, which have a vaccinating effect, and membrane proteoglycans, which stimulate the nonspecific resistance of the body.

2. Bronchomunal, IRS-19 - bacterial lysates, which include bacteria of the main pneumotropic pathogens and which mainly have an immunomodulating effect.

3. Lycopid - membrane fractions of the main bacteria that cause respiratory infections, stimulate the nonspecific resistance of the body, but do not contribute to the development of specific immunity against pathogens.

Indications for the appointment of ribomunyl.

1. Inclusion in rehabilitation complexes:

1) recurrent diseases of the ENT organs;

2) recurrent respiratory diseases;

3) often sick children.

2. Inclusion in the complex of etiopathogenetic therapy:

1) acute otitis media;

2) acute sinusitis;

3) acute pharyngitis;

4) acute tonsillitis;

5) acute laryngotracheitis;

6) acute tracheobronchitis;

7) acute bronchitis;

8) pneumonia.

Immunoglobulins for iv administration, registered and approved for use in the Russian Federation.

1. Human immunoglobulins normal (standard) for iv administration:

1) normal human immunoglobulin for iv administration (Imbio, Russia);

2) immunoglobulin (Biochemie GmbH, Austria);

3) intraglobin (Biotest Pharma GmbH, Germany);

4) Octagam (Oktapharma AG, Switzerland);

5) sandoglobulin (Novartis Pharma services, Switzerland);

6) endobulin (Immuno AG, Austria);

7) biaven B.I. (Pharma Biajini S. p. A, Italy);

8) Whig-liquid (Bio Products Laboratory, UK);

9) Wigam-C (Bio Products Laboratory, UK).

2. Immunoglobulins for iv administration enriched with antibodies of the IgM class are pentaglobin (Biotest Pharma GmbH, Germany).

Non-drug therapies.

1. LFK.

2. Electrical procedures (UHF, microwave, diathermy) are indicated for sinusitis, lymphadenitis; with diseases of the chest organs, their effectiveness has not been proven, including electrophoresis of drugs.

3. Thermal and irritating procedures. Dry heat with sinusitis, lymphadenitis, wet compress with otitis media (subjective relief). Fat rubbing is not effective and should not be used. Mustard plasters, cans, burning plasters and rubbing are painful, fraught with burns and allergic reactions.

Conditions that are not indications for the use of antibiotics for acute respiratory viral infections.

1. General disorders: body temperature less than 38 ° C or more than 38 ° C for less than 3 days, febrile seizures, loss of appetite, headache, myalgia, herpetic eruptions.

2. Syndromes: rhinitis, nasopharyngitis, tonsillitis, laryngitis, bronchitis, tracheitis, conjunctivitis.

3. Respiratory syndromes: cough, hyperemia of the pharynx, hoarseness, scattered rales, airway obstruction, difficulty breathing.

Signs of a probable bacterial infection: body temperature above 38 C from 3 days or more, asymmetry of wheezing during auscultation, chest pulling, severe toxicosis, leukocytosis of more than 15,000 and / or more than 5% of young forms of stab-type, accelerated ESR more than 20 mm / h, sore throat and raids (streptococcal tonsillitis is possible), earache (acute otitis media), nasal congestion for 2 weeks or more (sinusitis), enlarged lymph nodes (lymphadenitis), shortness of breath without obstruction (pneumonia). (See tab. 1, 2)

Table Selection of the starting drug for community-acquired pneumonia

Age, form Etiology Starting preparation Replace with inefficiency
1-6 months. Typical (febrile with infiltrative shadow) E. coli, other enterobacteria, staphylococcus, less commonly pneumococcus and H. influenzae type b Inside, iv: amoxicillin / iv clavulanate, i / m: ampicillin + oxacillin, or cefazolin + aminoglycoside In / in, in / m: cefuroxime, ceftriaxone, cefotaxime, lincomycin, vancomycin, carbapenem
6 months —6 years, typical uncomplicated (homogeneous) Pneumococcus (+ H.influenzae capsuleless, less commonly - type b) Inside: amoxicillin, smallpox, azithromycin, macrolide (with lactam intolerance) .V / m: penicillin Inside: amoxicillin / clavulanate, cefuroxime-axetil.In / in, v / m: penicillin, lincomycin, cefazolin, cefuroxime
6-15 years old, atypical (inhomogeneous) M. pneumoniae, C. pneumoniae Inside: azithromycin, macrolide Inside: other macrolide, doxycycline (> 12 years)
Table Selection of the starting antibiotic of nosocomial pneumonia

Age, form Etiology Starting preparation Replace with inefficiency
6-15 years complicated by pleurisy or destruction Pneumococcus, H. influenzae type b, rarely - streptococcus In / in, in / m: penicillin, ampicillin, cefuroxime, amoxicillin / clavulanate In / in, in / m: cephalosporin I-III generation, chloramphenicol + aminoglycoside
Therapy before pneumonia Probable causative agent Recommended Drugs
Not carried out Like community-acquired pneumonia The choice of the drug as a community-acquired infection
Penicillin, ampicillin Staphylococci plasm In / in, in / m: oxacillin, lincomycin, cefazolin, vancomycin Inside: macrolide
Cephalosporin I generation, oxacillin, lincomycin E. Coli, another gram-negative flora, resistant staphylococcus Inside, in / in: protected penicillins. In / in, in / m: aminoglycoside, cephalosporin 2-3 generations, vancomycin
Therapy before pneumonia Probable causative agent Recommended Drugs
Aminoglycoside Pneumococcus or resistant gram-negative flora, resistant staphylococcus In / in, in / m: penicillin, ampicillin, in the absence of effect: ceftriaxone, carbapenem, vancomycin, ureidopenicillins, rifampicin, according to vital indications - aminoglycoside in high doses (gentamicin 15 mg / kg / day; amikacin - 30-50 mg / kg / day).
Aminoglycoside + cephalosporin II — III generation Pseudomonas, serration, another gram-negative flora Staphylococcus aureus Parenteral: carbapenem, timentin, aztreonam, according to vital indications - aminoglycoside in high doses (gentamicin 15 mg / kg / day; amikacin - 30-50 mg / kg / day). Vancomycin, Rifampicin
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Respiratory failure

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