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  • 7/28/2019 Acute Resp Failure

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    Acute Respiratory Failure

    NADEESHA BANDARA

    GROUP 7

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    Acute Respiratory Failure

    Failure in one or both gas exchange functions:oxygenation and carbon dioxide elimination

    In practice:PaO246mmHg

    Derangements in ABGs and acid-base status

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    Acute Respiratory Failure

    Hypercapnic v Hypoxemic respiratory failure

    ARDS and ALI

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    Hypercapnic Respiratory Failure

    (PAO2 - PaO2)

    AlveolarHypoventilation V/Q abnormality

    PI max

    increasednormal

    Nl VCO2

    PaCO2 >46mmHg

    Not compensat ion for metabol ic alkalosis

    Central

    Hypoventilation

    Neuromuscular

    Problem

    VCO2

    V/Q

    Abnormality

    Hypermetabolism

    Overfeeding

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    The Case of Patient RV

    71M s/p L AKA revision.PMH: CAD s/p CABG, COPD on home O2 and CPAP, DM,CVA, atrial fibrillation

    PACU: L pleural effusion, hypotension, altered mental status.

    Sent to ICU for monitoring.

    POD#1: RR overnight, intermittently hypoxic.

    BiPAP 40%: 7.34/65/63/35/+10

    Preintubation: 7.28/91/81/43

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    Hypercapnic Respiratory Failure

    (PAO2 - PaO2)

    AlveolarHypoventilation V/Q abnormality

    PI max

    increasednormal

    Nl VCO2

    PaCO2 >46mmHg

    Not compensat ion for metabol ic alkalosis

    Central

    Hypoventilation

    Neuromuscular

    Problem

    VCO2

    V/Q

    Abnormality

    Hypermetabolism

    Overfeeding

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    Hypercapnic Respiratory Failure

    Alveolar

    Hypoventilation

    Brainstem respiratory depressionDrugs (opiates)

    Obesity-hypoventilation syndrome

    PI maxCentral

    HypoventilationNeuromuscular

    Disorder

    nlPI max

    Critical illness polyneuropathyCritical illness myopathy

    Hypophosphatemia

    Magnesium depletion

    Myasthenia gravis

    Guillain-Barre syndrome

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    Hypercapnic Respiratory Failure

    (PAO2 - PaO2)

    AlveolarHypoventilation V/Q abnormality

    PI max

    increasednormal

    Nl VCO2

    PaCO2 >46mmHg

    Not compensat ion for metabol ic alkalosis

    Central

    Hypoventilation

    Neuromuscular

    Disorder

    VCO2

    V/Q

    Abnormality

    Hypermetabolism

    Overfeeding

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    Hypercapnic Respiratory Failure

    V/Q abnormality

    Increased Aa gradient

    Nl VCO2

    VCO2

    V/Q

    Abnormality

    Hypermetabolism

    Overfeeding

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    Hypercapnic Respiratory Failure

    V/Q abnormality

    Increased Aa gradient

    Nl VCO2

    VCO2

    V/Q

    Abnormality

    Hypermetabolism

    Overfeeding

    Increased dead space ventilation

    advanced emphysema

    PaCO2 when Vd/Vt >0.5 Late feature of shunt-type

    edema, infiltrates

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    Hypercapnic Respiratory Failure

    V/Q abnormality

    Increased Aa gradient

    Nl VCO2

    VCO2

    V/Q

    Abnormality

    Hypermetabolism

    Overfeeding

    VCO2 only an issue in pts with ltdability to eliminate CO2

    Overfeeding with carbohydratesgenerates more CO2

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    Hypoxemic Respiratory Failure

    Is PaCO2 increased?

    Hypoventilation (PAO2 - PaO2)?

    Hypoventilationalone

    Respiratory driveNeuromuscular dz

    Hypovent plusanother

    mechanism

    Shunt

    Inspired POHigh altitud

    FIO2

    (PAO2 - PaO2) No

    NoYes

    Is low PO2correctable

    with O2?

    V/Q mismatch

    No Yes

    Yes

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    The Case of Patient ES

    77F s/p MVC.Injuries include multiple L rib fxs, L hemopneumothoraxs/p chest tube placement, L iliac wing fx.

    PMH: atrial arrhythmia, on coumadin. INR>2

    HD#1RR 30s and shallow. Pain a/w breathing deeply.

    Placed on BiPAP overnight

    PID#1

    BiPAP 80%: 7.45/48/66/32/+10

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    Hypoxemic Respiratory Failure

    Is PaCO2 increased?

    Hypoventilation (PAO2 - PaO2)?

    Hypoventilationalone

    Respiratory driveNeuromuscular dz

    Hypovent plusanother

    mechanism

    Shunt

    Inspired POHigh altitud

    FIO2

    (PAO2 - PaO2) No

    NoYes

    Is low PO2correctable

    with O2?

    V/Q mismatch

    No Yes

    Yes

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    Hypoxemic Respiratory Failure

    V/Q mismatch

    V/Q mismatch DO2/VO2Imbalance

    PvO2>40mmHg PvO2

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    Hypoxemic Respiratory Failure

    V/Q mismatch

    SHUNTV/Q = 0

    DEAD SPACEV/Q =

    Atelectasis

    Intraalveolar filling

    Pneumonia

    Pulmonary edema

    Pulmonary embolus

    Pulmonary vascular dz

    Airway dz

    (COPD, asthma)

    Intracardiac shunt

    Vascular shunt in lungs

    ARDS

    Interstitial lung dz

    Pulmonary contusion

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    Hypoxemic Respiratory Failure

    V/Q mismatch

    SHUNTV/Q = 0

    DEAD SPACEV/Q =

    Atelectasis

    Intraalveolar filling

    Pneumonia

    Pulmonary edema

    Pulmonary embolus

    Pulmonary vascular dz

    Airway dz

    (COPD, asthma)

    Intracardiac shunt

    Vascular shunt in lungs

    ARDS

    Interstitial lung dz

    Pulmonary contusion

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    Hypoxemic Respiratory Failure

    Acute Respiratory Distress Syndrome

    Severe ALI

    B/L radiographicinfiltrates

    PaO2/FiO2

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    Hypoxemic Respiratory Failure

    Acute Respiratory Distress Syndrome

    Develops ~4-48h

    Persists days-wks

    Diagnosis: Distinguish from

    cardiogenic edema

    History and riskfactors

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    InflammatoryAlveolar Injury

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    InflammatoryAlveolar Injury

    Pro-inflmm cytokines

    (TNF, IL1,6,8)

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    InflammatoryAlveolar Injury

    Pro-inflmm cytokines

    (TNF, IL1,6,8)

    Neutrophils - ROIsand proteasesdamage capillaryendothelium and

    alveolar epithelium

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    InflammatoryAlveolar Injury

    Fluid in interstitiumand alveoli

    Pro-inflmm cytokines

    (TNF, IL1,6,8)

    Neutrophils - ROIsand proteasesdamage capillaryendothelium and

    alveolar epithelium

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    InflammatoryAlveolar Injury

    Fluid in interstitiumand alveoli

    Impaired gas exchange Compliance

    PAP

    Pro-inflmm cytokines

    (TNF, IL1,6,8)

    Neutrophils - ROIsand proteasesdamage capillaryendothelium and

    alveolar epithelium

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    Hypoxemic Respiratory Failure

    Acute Respiratory Distress Syndrome

    Exudative phase Fibrotic phaseProliferative phase

    Diffuse alveolar damage

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    Hypoxemic Respiratory Failure

    Acute Respiratory Distress Syndrome

    Direct Lung Injury

    Infectious pneumonia

    Aspiration, chemical pneumonitis

    Pulmonary contusion, penetrating lung injury

    Fat emboli

    Near-drowning

    Inhalation injury

    Reperfusion pulmonary edema s/p lung transplant

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    Hypoxemic Respiratory Failure

    Acute Respiratory Distress Syndrome

    Indirect Lung Injury

    Sepsis

    Severe trauma with shock/hypoperfusion

    Burns

    Massive blood transfusion

    Drug overdose: ASA, cocaine, opioids,phenothiazines, TCAs.

    Cardiopulmonary bypass

    Acute pancreatitis

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    Hypoxemic Respiratory Failure

    Acute Respiratory Distress Syndrome

    Complications

    Barotrauma

    Nosocomial pneumonia

    Sedation and paralysis persistent MSdepression and neuromuscular weakness

    H i R i F il

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    Hypoxemic Respiratory Failure

    Acute Respiratory Distress Syndrome

    861 patients, 10 centers

    Randomized

    Tidal Vol 12mL/kg PDW,PlatP