Nothing is scarier for a parent than seeing their child in distress, struggling to breathe. Pediatric acute respiratory failure—or when there's an imbalance between a child’s need for oxygen and the amount of oxygen in their blood—is one of the top reasons children are admitted to an intensive care unit. 

Though it can be serious and sometimes life-threatening, more often acute respiratory failure can be treated successfully, and most children will recover and have no further consequences from the episode, and they are unlikely to have it again. 

At Yale Medicine, our physicians are determined to treat children with the most noninvasive techniques available, including the use of a cutting edge devices for intubation, one that has been shown to lead to fewer complications. 

Infants and young children have a higher risk of developing acute respiratory failure than adults because their respiratory systems are not fully developed. Their thoracic walls, which contain the lungs, are not fully formed, and the ribs that surround that area still contain cartilage and have not turned completely to bone.

Because of that, it can be difficult for a child to take a deep breath, as the area is not quite strong enough for a high demand of oxygen. Acute respiratory failure can occur in children for many reasons, but the most common causes include:

• Infection: Bacterial or viral infections such as the flu (a viral infection that affects the respiratory system) and sepsis (a bacterial infection that affects the blood) can exhaust the body of its oxygen stores, creating the imbalance in the blood that leads to acute respiratory failure.
• Asthma: Often allergies can lead to an asthma attack that can cause a child to struggle for breath.
• Reactive airway disease: Similar to asthma, this reversible condition is a narrowing of the airways often caused by allergens or infections.

“This is pretty easy to recognize,” says Josep Panisello, MD, a Yale Medicine pediatrician and medical director of the Pediatric Intensive Care Unit at Yale New Haven Children's Hospital. “If a child looks like he’s running a marathon, like he’s working very hard to breathe, and looks sick, then they should come to the emergency room.”

He notes that parents sometimes are concerned because a baby looks like he or she is breathing quickly, but breathing comfortably 50 to 60 times per minute in an otherwise healthy looking infant is normal. Parents should seek medical care when a child is struggling for air.

“What defines acute respiratory failure is the failure to sustain the normal work of breathing,” he says. “So if we have a child who is really pulling, the kid is sweating, he looks worried, it’s like he’s running but he’s getting out of breath, that is the definition of failure. The fact that the child is working to breathe, but it’s evident that he is not able to sustain that work.”

While doctors will probably be able to diagnose acute respiratory failure just by looking at a child who’s struggling for breath, they may also check the oxygen levels in the blood.

“Usually you don’t need anything other than looking at the patient—seeing that a kid is about to collapse,” Dr. Panisello says. “We try to be more precise and measure the oxygen and carbon dioxide in the blood, but it’s painful to stick a child to get the blood, and it may put them over the edge with the stress creating even more excess work of trying to compensate.”

“The treatment is largely symptomatic and supportive,” Dr. Pansiello says.

The first step is support, which means straightforward oxygen therapy to compensate for the lack of oxygen. If the patient needs more assistance—if the patient’s muscles aren’t up to the task of getting that extra oxygen, for example—the goal is to start with noninvasive respiratory support.

This can include high-flow nasal cannula, which delivers a larger amount of humidified oxygen than traditional oxygen therapy, and BiPAP (bilevel positive airway pressure) or CPAP (continuous positive airway pressure), which are machines that deliver pressurized air to help keep airways from collapsing.

“Over the last decade, noninvasive therapies have taken a huge leap forward,” Dr. Panisello says. “They’re all ways to increase respiratory support of the patient without having to put an artificial airway in the trachea. We can now get more and more children breathing normally with noninvasive support systems.”

When that’s not enough—if the patient’s condition continues to deteriorate—the next step is invasive mechanical ventilation. This requires endotracheal intubation, in which a tube is inserted into the trachea (also known as the windpipe) through the mouth or nose in order to open up the airway. The patient will then be provided oxygen through a ventilation machine.

Depending on the underlying cause of the acute respiratory failure, the symptomatic treatments will vary from antibiotics to treat infections, to albuterol inhaler or intravenous medications for asthma.

The length of time that treatment may be required in the intensive care unit will also vary. For example, if a child needs time for an infection to clear, he may be admitted to the hospital for a week or longer, while a child suffering from asthma may be released much sooner.

If acute respiratory failure is treated promptly, most children get well. Children with asthma may experience acute respiratory failure multiple times but are less likely to do so if they follow the medical regimen prescribed by their doctors.

“With no underlying conditions, you can support the condition and improve,” says Dr. Panisello. "Most children, the vast majority—even the ones who have been quite sick—they will improve and they will not come back to the ICU. They go back to very normal lives.”

For many years, Yale Medicine has worked to ensure not just successful treatment of children with acute respiratory failure, but treatment that is easier on them.

“We’ve been very aggressive in our approach to noninvasive support,” Dr. Panisello says.

The pediatric intensive care unit, he says, is staffed with caring and talented experts, which includes everyone from nurses to respiratory therapists to pediatric intensive care physicians.

Additionally, doctors at Yale Medicine Pediatrics are approaching ways to make risky procedures such as intubation safer. For example, they’ve implemented video laryngoscopy as standard of care throughout the pediatric intensive care unit. The most modern process, it allows doctors to visualize the airways by inserting a camera into the larynx, which has been shown to lead to fewer problems than a traditional laryngoscopy.

“The main thing is we’re working hard to reduce complications from acute respiratory failure,” he says.