Respiratory failure: a syndrome in which the respiratory system fails in one or both of the functions of gas exchange, which are oxygenation and carbon dioxide elimination. It can be classified as hypoxemic (type 1), hypercapnic (type 2), or a combination of both.

Respiratory failure can be acute or chronic. The etiology of acute respiratory failure is often determined to be pneumonia, bronchiolitis, croup, trauma, or exacerbation of a chronic condition such as asthma.

• Chronic respiratory failure: a condition in which the inability to effectively exchange carbon dioxide and oxygen results in chronically low oxygen levels or chronically high carbon dioxide levels. Usually the underlying etiology is chronic lung disease such as cystic fibrosis, neuromuscular disorders, or muscular dystrophy. Diagnosis requires the use of home oxygen or ventilator support, or having baseline SaO2 < 88% on room air or pCO2 > 50 with normal pH.
• Acute respiratory distress syndrome (ARDS): often considered the end stage of acute respiratory failure, occurring when fluid builds up in the alveoli which prevents the lungs from filling with enough air. This leads to less oxygen reaching the bloodstream and organs, reducing organ function. ARDS patients have a moderate to severe impairment of oxygenation as defined by the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PaO2/FiO2). Chest imaging exhibits bilateral opacities/pulmonary edema not explained by cardiac failure or fluid overload.

Diagnostic Criteria for Acute Respiratory Failure in Pediatric Patients

• Pediatric patients often present differently than adults and can also decompensate more quickly. Children may present with the following:
• Lethargy or irritability
• Appear anxious or demonstrate inability to concentrate
• May prefer positioning to aid in breathing (i.e sitting up, leaning chest/head forward)
• Mouth breathing, drooling
• Interrupted feeding and diet patterns
• Generally, oxygen saturation <88% on room air is supportive of acute hypoxemic respiratory failure. ABGs are rarely measured when assessing children’s respiratory function. However, diagnostic ABG levels include:
• PaO2 of < 60 mmHg on room air
• Acute increase in pCO2 of 10-15 mmHg
• pH decreasing to 7.32 or less
• PaO2 / FiO2 (PF) ratio of < 200 or < 300
• Intubation/mechanical ventilation is not required to support the presence of acute respiratory failure. An acute respiratory condition and any of the following treatments may support the presence of acute respiratory failure:
• Supplemental oxygen with FiO2 ≥ 0.30–0.35 to maintain SpO2 ≥ 90%
• Any level of high-flow nasal cannula
• Any level of nasal continuous positive airway pressure (nCPAP) or nasal bilevel positive airway pressure (BiPAP) (except for obstructive sleep apnea)
• Provider documentation often describes the patient’s symptoms and assessment without stating the words “acute respiratory failure.” If clinical indicators support the presence of acute respiratory failure, a query should be sent.
• For example, “acute respiratory distress”, “acute exacerbation”, “respiratory insufficiency”, “respiratory acidosis” are frequently used terms that may not capture the patient’s true complexity.
• Providers frequently use templated notes that are copied/pasted into subsequent notes. This is a great opportunity for CDI to provide education on customizing these templates.
• Templated notes often have statements such as “no acute distress”, and “normal appearance” which can suggest that the patient did not have respiratory failure. 

Additional Tips:

• Chapter-specific coding guidelines (particularly with newborns) that provide sequencing direction take precedence when determining the principal diagnosis.

• A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital.

• Although acute respiratory failure always has an underlying cause, do not default to the etiology as the principal diagnosis. The circumstances of the admission must be considered. Respiratory failure may be listed as either the principal or a secondary diagnosis.

• For acute respiratory failure due to COVID-19, assign code U07.1, COVID-19, followed by code J96.0-, Acute respiratory failure.

• If the documentation is not clear as to whether acute respiratory failure and other conditions are equally responsible for occasioning the admission, query the provider for clarification.

• Common respiratory failure risk factors to look out for in pediatric patients include: young age, premature birth, immunodeficiency, chronic pulmonary/cardiac/neuromuscular diseases, anatomic abnormalities, cough/rhinorrhea/other URI symptoms, and lack of immunizations.

• Other conditions that are not pulmonary in nature which may lead to acute respiratory failure include: status epilepticus leading to encephalopathy and decreased respiratory drive, a traumatic head injury or anoxic brain injury that stops respiratory drive, and septic shock.

References:

Pediatric Acute Lung Injury Consensus Conference Group. (2015). Pediatric acute respiratory distress syndrome: Consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Critical Care Medicine, 16(5), 428–439. https://doi.org/10.1097/PCC.0000000000000350

Springer, S. C. (2012, December 5). Pediatric respiratory failure. Medscape. https://emedicine.medscape.com/article/908172-overview

Savage, L. (2017). Pediatric CDI Building Blocks for Success (pp. 64–71). HCPro.