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Respiratory failure

Respiratory (ventilation-pulmonary) deficiency is characterized by such disturbances, in which pulmonary gas exchange is worsened or occurs at the cost of excessive energy costs.

Types of respiratory failure:

1) ventilation;

2) distribution-diffusion (shunt diffusion, hypoxemic);

3) mechanical.


I degree. Dyspnea varies without the participation of ancillary muscles in the act of breathing; in rest, as a rule, is absent. Cyanosis is perioral, unstable, worsening with anxiety, disappearing with respiration 40-50% oxygen; pallor of the face. The arterial pressure is normal, less moderately elevated. The ratio of the pulse to the number of breaths is 3.5-2.5: 1; tachycardia. The behavior is restless or unbroken.

II degree. Dyspnoea at rest is constant, with the participation of ancillary muscles in the act of breathing, pulling in of the compliant places of the chest; may be with the predominance of inhalation or exhalation, i.e. wheezing, a groaning exhalation. Cyanosis is a perioral face, the hands are constant, does not disappear when breathing 40-50% oxygen, but disappears in the oxygen tent; generalized pallor of the skin, sweating, pallor of the nail beds. The arterial pressure is increased. The ratio of the pulse to the number of breaths is 2-1.5: 1, tachycardia. Behavior: lethargy, somnolence, adynamia, followed by short periods of excitation; decreased muscle tone.

III degree. Dyspnoea expressed (respiratory rate - more than 150% of the norm); surface respiration, periodic bradypnoe, desynchronization of breathing, paradoxical breathing. Reduction or absence of respiratory noise on inspiration. Cyanosis generalized; there is a cyanosis of the mucous membranes, lips, does not pass through breathing with 100% oxygen; generalized marbling or pale skin with blue; sticky sweat. Blood pressure is reduced. The ratio of the pulse to the number of breaths varies. Behavior: lethargy, somnolence, consciousness and reaction to pain are suppressed; muscular hypotension, coma; convulsions.

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 dyscirculatory disorders.

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

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

5. Renal failure.

Differential diagnostics. Acute bronchiolitis in children

The first year of life is performed with bronchial asthma, bronchiolitis obliterans, congenital vascular and heart defects, congenital fractional 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 aspirating food in the respiratory tract, parasitic pneumonia. Obstructive syndrome is manifested by increased respiration rate to 70 per 1 minute or more; anxiety of the child, changing postures in search of the most convenient; a noticeable exhalation of the tension of the intercostal muscles; the appearance of labored breathing with the retraction of the compliant places of the chest; central cyanosis (one of the signs - cyanosis of the tongue); decrease in PO2; an increase in the ROS2.

Treatment. Treatment of obstructive syndrome: constant oxygen supply through the nasal catheter or nasal cannula, administration of b-agonists in the aerosol (2 doses without a spacer, preferably 4-5 doses via a spacer with a capacity of 0.7-1 L), parenterally or inwardly: salbutamol ( ventolin), terbutaline (bricanil), fenoterol (berotek), berodual (fenoterol + ipratropium bromide), orciprenaline (alupent, astomopent). Along with the b-agonist, one of the corticosteroid drugs, prednisolone (6 mg / kg, at the rate of 10-12 mg / kg / day) is injected. In the absence of the effect of the administration of b-agonists, euphyllin is used together with corticosteroids intravenously (after a loading dose of 4-6 mg / kg, constant infusion at a dose of 1 mg / kg / h). IV infusion of fluid is carried out only if there are signs of dehydration. The effectiveness of therapeutic measures is judged by reducing the respiratory rate (by 15 or more per 1 minute), reducing the intercostal tension and the intensity of expiratory noise.

Indications for mechanical ventilation in obstructive syndrome:

1) weakening of respiratory noise on inspiration;

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

3) reduction of pain reaction;

4) the fall of PaO2 is lower than 60 mm Hg. p.

5) an increase in RaCO2 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 beginning of transcription of RNA) from the first year of life, the course of 4-5 days - arbidol (the same mechanism + interferon inductor), with a 6-year age - 0.1, over 12 years - 0.2, course - 3-5 days - amixin is used in children older than 7 years. When adenovirus infection locally (intranasal, conjunctivitis), ointments are used: oxolin ointment 1-2%, florenal 0.5%, bonafthon 0.05%.

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

3. Inductors of interferon:

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

2) amixin (tyloron) - ribomunil (in the acute stage of respiratory disease is used according to the scheme (1 bag 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 are not

use - amidipirin, antipyrine, phenacetin, acetylsalicylic acid (aspirin). Currently, only paracetamol, ibuprofen are used as antipyretic drugs, and when it is necessary to quickly reduce the temperature of the lytic mixture, 0.5-1.0 ml of 2.5% solutions of aminazine and promethazine (pipolpene ) or, less desirably, analgin (50% solution, 0.1-0.2 ml / 10 kg body weight.) Symptomatic therapy: antitussives are indicated only in cases when the disease is accompanied by an unproductive, painful, painful cough , leading to a violation of sleep, appetite and total exhaustion of the child. They are used in children of any age with laryngitis, acute bronchitis, and other diseases accompanied by a painful, dry, persistent cough.It is preferable to use non-narcotic antitussive drugs Mucolytic drugs are used in diseases accompanied by a productive cough with thick, viscous, hard-to-separate sputum. acute bronchitis is better to use mucoregulators - derivatives of carbocysteine ​​or mucolytic drugs with expectorant effect. Mucolytic drugs can not be used with antitussive drugs. Expectorants are indicated if the cough is accompanied by a thick, viscous sputum, but its separation is difficult. Counter-cough preparations of central action.

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

2) non-narcotic: sinecode (butamyrate), glavent (glaucine hydrochloride), fervex from dry cough (also contains paracetamol and vitamin C).

Non-narcotic antitussive preparations of peripheral action: libexin (prenoxdiazine hydrochloride), levoprint (levropropizin).

Antitussive combination drugs: tussinplus, stoptussin, broncholitin (glaucin, ephedrine, citric acid, basil oil).

Mucolytic means.

1. Actually mucolytic preparations:

1) a proteolytic enzyme;

2) dornase (pulmosim);

3) acetylcysteine ​​(ACC, mucobene);

4) carbocysteine ​​(bronkatar, mucodin, mukoprint, fluvik).

2. Mucolytic preparations with expectorant effect:

1) bromhexine (bisolvon, broxine, solvine, flagamine, fulpene);

2) Ambroxol (Ambrobe, Ambrohexal, Ambrolan, Lazolvan, Ambrosan).

3. Expectorants:

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

2) glyceram (licorice);

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

4) koldreks (terpinhydrate, paracetamol, vitamin C).
Bronchodilators are used for obstructive

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

1) salbutamol (ventolin);

2) fenoterol (berotek);

3) salmeterol (long-acting);

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

In the program "ARD in children: treatment and prevention" (2002) it is said that the use of EUFILLIN is less desirable because of possible side effects. Anti-inflammatory drugs. Inhaled glucocorticosteroids:

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

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

3) flunisolide (ingacort);

4) fluticasone (fliksotid).

Nonsteroidal 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 (blockers of histamine H1 receptors).

Preparations of the first generation: diazolinum, dimedrolum, pifolen, suprastin, tavegil, fenistil.

Preparations of the second generation: zirtek, claritin, semprex, telphast, erius.


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

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

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

Indications for the appointment of ribomunil.

1. Inclusion in rehabilitation complexes:

1) recurrent diseases of ENT organs;

2) recurrent respiratory diseases;

3) often ill 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 intravenous administration, registered and approved for use in the Russian Federation.

1. Normal human immunoglobulins (standard) for intravenous administration:

1) normal human immunoglobulin for intravenous 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) Bijan VI (Pharma Biajini S. p. A, Italy);

8) vigam-liquid (Bio Products Laboratory, Great Britain);

9) Vigam-C (Bio Products Laboratory, United Kingdom).

2. Immunoglobulins for intravenous administration, enriched with antibodies of IgM class, - pentaglobin (Biotest Pharma GmbH, Germany).

Non-medicamentous methods of treatment.

1. LFK.

2. Electroprocedures (UHF, UHF, 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, moist compress in otitis (subjective relief). Greasing with fat is not effective and should not be applied. Gorchichniki, banks, burning plasters and rubbing are painful, fraught with burns and allergic reactions.

Conditions that are not indications for the use of antibiotics in ARVI.

1. General disorders: body temperature less than 38 C or more 38 C for less than 3 days, febrile convulsions, decreased appetite, headache, myalgia, herpetic eruptions.

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

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

Signs of a probable bacterial infection: body temperature above 38 ° С from 3 days or more, asymmetry of wheezing in auscultation, chest entrainment, severe toxicosis, leukocytosis more than 15,000 and / or more than 5% of young forms of stab, accelerated ESR more than 20 mm / h, pain in the throat and plaque (streptococcal angina possible), ear pain (acute otitis), nasal congestion for 2 weeks or more (sinusitis), lymphadenitis (lymphadenitis), dyspnoea without obstruction (pneumonia). (See Tables 1 and 2)

Table Selection of the starting drug for community-acquired pneumonia

Age, form Etiology Starting product Replacement if ineffective
1-6 months, typical (febrile with infiltrative shadow) E. coli, other enterobacteria, staphylococcus, less often - pneumococcus and H. influenzae type b Inside, in / in: amoxicillin / clavulanate iv, / m: ampicillin + oxacillin, or cefazolin + aminoglycoside In / in, / m: cefuroxime, ceftriaxone, cefotaxime, lincomycin, vancomycin, carbapenem
6 months -6 years, typical uncomplicated (homogeneous) Pneumococcus (+ H.influenzae is encapsulant, less often - type b) Inside: amoxicillin, smallpox, azithromycin, macrolide (with lactam intolerance). W / m: penicillin Inside: amoxicillin / clavulanate, cefuroxime-aksetil.V / in, m / 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 starting antibiotic for intra-hospital pneumonia

Age, form Etiology Starting product Replacement if ineffective
6-15 years, complicated by pleurisy or destruction Pneumococcus, H. influenzae type b, rarely - streptococcus In / in, / m: penicillin, ampicillin, cefuroxime, amoxicillin / clavulanate In / in, in / m: cephalosporin I-III generation, levomycetin + aminoglycoside
Therapy before pneumonia Probable pathogen Recommended products
Not conducted As a prehospital pneumonia Choice of the drug as a pri-hospital infection
Penicillin, ampicillin Staphylococcicoplasm In / in, / m: oxacillin, lincomycin, cefazolin, vancomycin Inside: macrolide
Cephalosporin I generation, oxacillin, lincomycin E.Coli, another gram-negative flora, resistant staphylococcus aureus Inside, in / in: protected penicillins. In / in, / m: aminoglycoside, cephalosporin 2-3 generations, vancomycin
Therapy before pneumonia Probable pathogen Recommended products
Aminoglycoside Pneumococcus or resistant Gram-negative flora, resistant to staphylococcus aureus In / in, in / m: penicillin, ampicillin, in the absence of effect: ceftriaxone, carbapenem, vancomycin, ureidopenicillins, rifampicin, according to vital indications - aminoglycoside in high doses (gentamycin 15 mg / kg / day, amikacin 30-50 mg / kg / day).
Aminoglycoside + cephalosporin II-III generation Pseudomonas, serration, other gram-negative floraResistant staphylococcus aureus Parenterally: 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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