Monitoring Recovery from Respiratory Failure: Key Indicators and Concerns

How to monitor for respiratory failure?

Hello Dr.
Ke: My son was hospitalized for severe enterovirus infection for one month.
During his time in the ICU, he was intubated for treatment (with pneumonia as a complication), and after gradually regaining spontaneous breathing, he was switched to a positive pressure mask ventilator to assist with respiration.
He is currently at home recovering and rehabilitating (the chest X-ray taken at discharge showed some white patches in the lungs, and the doctor mentioned there was a lot of phlegm).
Three days before discharge, he was tested without the ventilator, and his heart rate and blood oxygen saturation were monitored (heart rate 90-130, blood oxygen 95-99).
To avoid any accidents, we rented a positive pressure mask ventilator to use at home and are monitoring his heart rate and blood oxygen saturation with the device.
During the day when he is awake, his heart rate is between 95-120, and his blood oxygen saturation is between 97-99 (he seems to be in good spirits).
At night, for the first four days, his heart rate was 80-105, and for the next six days, it was 65-100, with blood oxygen saturation between 95-98 (the above data is from the 10 days of monitoring after returning home, and he has not used the ventilator during this period).
Dr.
Ke, I would like to ask: 1.
Is my son's breathing normal? 2.
Is it sufficient to monitor heart rate and blood oxygen saturation at this stage? Some say we should also monitor carbon dioxide levels? 3.
Is it possible for him to have normal blood oxygen levels (96-98, monitored by the device) at night while having elevated carbon dioxide levels that could affect vital signs? 4.
If the third scenario occurs, how should we handle it? 5.
Under what circumstances (criteria) can we determine that my son's breathing has returned to normal and he no longer needs to rely on the ventilator? Thank you, Dr.
Ke, for taking the time to answer my questions.

A Xin, 30~39 year old female. Ask Date: 2009/09/02

Dr. Ke Zhengchang reply Pulmonology

1.
Although respiratory conditions were not mentioned, based on the heart rate and blood oxygen levels, it can be inferred that there is no respiratory distress.
In general, pediatric respiratory distress can be observed by checking for nasal flaring or retractions of the sternum during breathing.

2.
For your child, if the blood oxygen saturation is between 95% and 99% without supplemental oxygen (including no oxygen from a nasal cannula), this is considered acceptable.
It is normal for blood oxygen levels to occasionally drop slightly when a child is crying, but if they return to above 95% once the crying stops, that is also normal.
3.
Carbon dioxide levels are related to the respiratory rate and depth.
When carbon dioxide levels are too high, symptoms such as fatigue, drowsiness, and headaches may occur.
Based on your description, your child appears to be in good spirits, suggesting that there is likely no issue with elevated carbon dioxide levels.
4.
Regarding the future need for a ventilator, it is advisable to discuss the recorded observations from home—beyond just blood oxygen levels, including the child's energy levels, appetite, sleep, and respiratory rate—with the child's primary physician during follow-up visits.
This collaborative discussion will help make a safer decision.

Reply Date: 2009/09/02

More Info

Monitoring recovery from respiratory failure, especially in a pediatric patient who has undergone significant medical interventions, is crucial for ensuring a safe and effective recovery. Your concerns regarding your child's respiratory status and the use of a pressure support ventilator are valid and important to address. Let's break down your questions and provide a comprehensive understanding of the situation.

1. Is my child's breathing normal?
Based on the heart rate and oxygen saturation levels you've provided, it appears that your child's breathing is stable. Normal respiratory rates for children can vary, but if your child is maintaining oxygen saturation levels between 95-99% while awake and during sleep, this is generally considered acceptable. However, it's essential to monitor for any signs of respiratory distress, such as increased work of breathing, retractions, or changes in mental status.

2. Is monitoring heart rate and oxygen saturation sufficient?
While monitoring heart rate and oxygen saturation is crucial, it is also important to consider other factors, including the child's respiratory rate, effort, and overall clinical picture. Additionally, monitoring carbon dioxide (CO2) levels can provide valuable information about respiratory function. Elevated CO2 levels can indicate inadequate ventilation, which may not be reflected in oxygen saturation alone. If your child exhibits signs of lethargy, confusion, or difficulty breathing, further evaluation of CO2 levels may be warranted.

3. Can normal oxygen saturation coexist with high carbon dioxide levels?
Yes, it is possible for a patient to have normal oxygen saturation while experiencing elevated carbon dioxide levels. This situation can occur in cases of hypoventilation, where the body is not expelling CO2 effectively, leading to respiratory acidosis. Continuous monitoring of your child's clinical status is essential, and if you notice any concerning symptoms, it may be necessary to consult with a healthcare provider for further assessment.

4. What should we do if high CO2 levels are suspected?
If you suspect that your child may be experiencing elevated CO2 levels, it is crucial to seek medical advice promptly. Signs of high CO2 levels can include confusion, drowsiness, headache, or difficulty breathing. In some cases, supplemental oxygen or adjustments to the ventilator settings may be necessary to improve ventilation and reduce CO2 retention. If your child is using a pressure support ventilator, ensure that it is set correctly and that the mask fits well to prevent leaks.

5. When can we determine that my child's breathing has returned to normal and that he no longer needs the ventilator?
The decision to discontinue the use of a ventilator should be made collaboratively with your child's healthcare team. Factors to consider include stable oxygen saturation levels, the ability to maintain adequate ventilation without assistance, and the absence of respiratory distress. A gradual weaning process may be employed, where the healthcare team will monitor your child's response to reduced ventilatory support. Regular follow-up appointments will help assess your child's progress and determine the appropriate time to discontinue the use of the ventilator.

In conclusion, while your child's current heart rate and oxygen saturation levels are encouraging, continuous monitoring and communication with healthcare providers are essential for ensuring a safe recovery. Be vigilant for any changes in your child's condition, and do not hesitate to reach out to medical professionals if you have concerns. Your proactive approach to monitoring and understanding your child's health is commendable and will contribute significantly to their recovery process.

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