Acute Respiratory Failure

  • Kyle J. RehderEmail author
  • Jennifer L. Turi
  • Ira M. Cheifetz


Acute respiratory failure is a common diagnosis among critically ill children and a leading cause of morbidity, mortality, and health care expenditures in the pediatric critical care setting. This chapter examines the anatomic, developmental, and physiologic characteristics that place infants and children at risk for respiratory failure. Respiratory failure may commonly present as hypoxemia and/or hypercarbia, but may be caused by a wide array of disease processes. As such, the varied etiologies of pediatric acute respiratory failure are reviewed, including upper and lower airway obstruction, causes of hypoventilation, ventilation perfusion inequality, and diffusion impairment. The chapter concludes with a discussion of evaluation of respiratory failure and a summary of key treatment principles, including lung-protective strategies.


Acute Respiratory Failure Mechanical Ventilation Hypoxemia Hypercarbia 


  1. 1.
    Farias JA, et al. Mechanical ventilation in pediatric intensive care units during the season for acute lower respiratory infection. A multicenter study. Pediatr Crit Care Med. 2012;13:158–64.PubMedCrossRefGoogle Scholar
  2. 2.
    Hoyert DL, et al. Deaths: preliminary data for 2003. Natl Vital Stat Rep. 2005;53(15):1–48.Google Scholar
  3. 3.
    Dahlem P, van Aalderen WM, Bos AP. Pediatric acute lung injury. Paediatr Respir Rev. 2007;8(4):348–62.PubMedCrossRefGoogle Scholar
  4. 4.
    Rogers MC, Nichols DG. Textbook of pediatric intensive care. 3rd ed. Baltimore: Williams & Wilkins; 1996. xviii, 1710 p.Google Scholar
  5. 5.
    Cote CJ, Todres ID, et al. A practice of anesthesia for infants and children. 3rd ed. Philadelphia: W.B. Saunders Company; 2001.Google Scholar
  6. 6.
    Leung AK, Kellner JD, Johnson DW. Viral croup: a current perspective. J Pediatr Health Care. 2004;18(6):297–301.PubMedCrossRefGoogle Scholar
  7. 7.
    Roussos C, Macklem PT. The respiratory muscles. N Engl J Med. 1982;307(13):786–97.PubMedCrossRefGoogle Scholar
  8. 8.
    Tobin MJ. Respiratory muscles in disease. Clin Chest Med. 1988;9(2):263–86.PubMedGoogle Scholar
  9. 9.
    Roussos C, Koutsoukou A. Respiratory failure. Eur Respir J Suppl. 2003;47:3s–14.PubMedCrossRefGoogle Scholar
  10. 10.
    Tobin MJ. Principles and practice of mechanical ventilation. New York: McGraw-Hill, Inc; 1994. xv, 1300 p.Google Scholar
  11. 11.
    Taussig LM, Landau LI. Pediatric respiratory medicine. St. Louis: Mosby; 1999. xxiv, 1296 p.Google Scholar
  12. 12.
    Sieck GC, Fournier M. Diaphragm motor unit recruitment during ventilatory and nonventilatory behaviors. J Appl Physiol. 1989;66(6):2539–45.PubMedGoogle Scholar
  13. 13.
    Robertson Jr CH, Foster GH, Johnson Jr RL. The relationship of respiratory failure to the oxygen consumption of, lactate production by, and distribution of blood flow among respiratory muscles during increasing inspiratory resistance. J Clin Invest. 1977;59(1):31–42.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Rochester DF, Bettini G. Diaphragmatic blood flow and energy expenditure in the dog. Effects of inspiratory airflow resistance and hypercapnia. J Clin Invest. 1976;57(3):661–72.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Aubier M, et al. Respiratory muscle contribution to lactic acidosis in low cardiac output. Am Rev Respir Dis. 1982;126(4):648–52.PubMedGoogle Scholar
  16. 16.
    Sieck GC, Lewis MI, Blanco CE. Effects of undernutrition on diaphragm fiber size, SDH activity, and fatigue resistance. J Appl Physiol. 1989;66(5):2196–205.PubMedGoogle Scholar
  17. 17.
    Laghi F, Tobin MJ. Disorders of the respiratory muscles. Am J Respir Crit Care Med. 2003;168(1):10–48.PubMedCrossRefGoogle Scholar
  18. 18.
    Braun NM, Arora NS, Rochester DF. Respiratory muscle and pulmonary function in polymyositis and other proximal myopathies. Thorax. 1983;38(8):616–23.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Mehta S. Neuromuscular disease causing acute respiratory failure. Respir Care. 2006;51(9):1016–21; discussion 1021–3.PubMedGoogle Scholar
  20. 20.
    West JB. Respiratory physiology: the essentials. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 171.Google Scholar
  21. 21.
    Mansell A, Bryan C, Levison H. Airway closure in children. J Appl Physiol. 1972;33(6):711–4.PubMedGoogle Scholar
  22. 22.
    Marshall BE, et al. Hypoxic pulmonary vasoconstriction in dogs: effects of lung segment size and oxygen tension. J Appl Physiol. 1981;51(6):1543–51.PubMedGoogle Scholar
  23. 23.
    Scarpelli EM. Pulmonary physiology: fetus, newborn, child, and adolescent. 2nd ed. Philadelphia: Lea & Febiger; 1990. xi, 500 p.Google Scholar
  24. 24.
    Voelkel NF. Mechanisms of hypoxic pulmonary vasoconstriction. Am Rev Respir Dis. 1986;133(6):1186–95.PubMedGoogle Scholar
  25. 25.
    Benumof JL, et al. Interaction of PVO2 with PAO2 on hypoxic pulmonary vasoconstriction. J Appl Physiol. 1981;51(4):871–4.PubMedGoogle Scholar
  26. 26.
    Bates DV, Christie RV, Macklem PT. Respiratory function in disease; an introduction to the integrated study of the lung [by] David V. Bates, Peter T. Macklem [and] Ronald V. Christie. 2nd ed. Philadelphia: W.B. Saunders; 1971. xxi, 584 p.Google Scholar
  27. 27.
    Flori HR, et al. Pediatric acute lung injury: prospective evaluation of risk factors associated with mortality. Am J Respir Crit Care Med. 2005;171(9):995–1001.PubMedCrossRefGoogle Scholar
  28. 28.
    Mesiano G, Davis GM. Ventilatory strategies in the neonatal and paediatric intensive care units. Paediatr Respir Rev. 2008;9(4):281–8; quiz 288–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Peltekova V, et al. Hypercapnic acidosis in ventilator-induced lung injury. Intensive Care Med. 2010;36(5):869–78.PubMedCrossRefGoogle Scholar
  30. 30.
    Rimensberger PC. Mechanical ventilation in paediatric intensive care. Ann Fr Anesth Reanim. 2009;28(7–8):682–4.PubMedCrossRefGoogle Scholar
  31. 31.
    Rotta AT, Steinhorn DM. Conventional mechanical ventilation in pediatrics. J Pediatr (Rio J). 2007;83(2 Suppl):S100–8.CrossRefGoogle Scholar
  32. 32.
    Prodhan P, Noviski N. Pediatric acute hypoxemic respiratory failure: management of oxygenation. J Intensive Care Med. 2004;19(3):140–53.PubMedCrossRefGoogle Scholar
  33. 33.
    Turner DA, Arnold JH. Insights in pediatric ventilation: timing of intubation, ventilatory strategies, and weaning. Curr Opin Crit Care. 2007;13(1):57–63.PubMedCrossRefGoogle Scholar
  34. 34.
    Cheifetz IM, et al. Increasing tidal volumes and pulmonary overdistention adversely affect pulmonary vascular mechanics and cardiac output in a pediatric swine model. Crit Care Med. 1998;26(4):710–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Gajic O, et al. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med. 2004;32(9):1817–24.PubMedCrossRefGoogle Scholar
  36. 36.
    Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301–8.Google Scholar
  37. 37.
    Bidani A, et al. Permissive hypercapnia in acute respiratory failure. JAMA. 1994;272(12):957–62.PubMedCrossRefGoogle Scholar
  38. 38.
    Laffey JG, et al. Permissive hypercapnia–role in protective lung ventilatory strategies. Intensive Care Med. 2004;30(3):347–56.PubMedCrossRefGoogle Scholar
  39. 39.
    Rotta AT, Steinhorn DM. Is permissive hypercapnia a beneficial strategy for pediatric acute lung injury? Respir Care Clin N Am. 2006;12(3):371–87.PubMedGoogle Scholar
  40. 40.
    Randolph AG. Management of acute lung injury and acute respiratory distress syndrome in children. Crit Care Med. 2009;37(8):2448–54.PubMedGoogle Scholar
  41. 41.
    Wunsch H, Mapstone J, Takala J. High-frequency ventilation versus conventional ventilation for the treatment of acute lung injury and acute respiratory distress syndrome: a systematic review and cochrane analysis. Anesth Analg. 2005;100(6):1765–72.PubMedCrossRefGoogle Scholar
  42. 42.
    Hansell DR. Extracorporeal membrane oxygenation for perinatal and pediatric patients. Respir Care. 2003;48(4):352–62; discussion 363–6.PubMedGoogle Scholar
  43. 43.
    Zabrocki LA, et al. Extracorporeal membrane oxygenation for pediatric respiratory failure: survival and predictors of mortality. Crit Care Med. 2011;39(2):364–70.PubMedCrossRefGoogle Scholar
  44. 44.
    West JB. Ventilation/blood flow and gas exchange. 3rd ed. Oxford: Blackwell; 1977. p. 33–52.Google Scholar

Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  • Kyle J. Rehder
    • 1
    Email author
  • Jennifer L. Turi
    • 1
  • Ira M. Cheifetz
    • 1
  1. 1.Division of Pediatric Critical Care Medicine, Department of PediatricsDuke Children’s HospitalDurhamUSA

Personalised recommendations