acute respiratory failure
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Acute Respiratory Failure. 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. Acute Respiratory Failure. - PowerPoint PPT PresentationTRANSCRIPT
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Acute Respiratory Acute Respiratory
FailureFailure
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Acute Respiratory FailureAcute Respiratory Failure
• Failure in one or both gas exchange functions: oxygenation and carbon dioxide elimination
• In practice:
PaO2<60mmHg or PaCO2>46mmHg
• Derangements in ABGs and acid-base status
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Acute Respiratory FailureAcute Respiratory Failure
• Hypercapnic v Hypoxemic respiratory failure
• ARDS and ALI
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Hypercapnic Respiratory FailureHypercapnic Respiratory Failure
(PAO2 - PaO2)
Alveolar Hypoventilation
V/Q abnormality
PI max
increasednormal
Nl VCO2
PaCO2 >46mmHgNot compensation for metabolic alkalosis
CentralHypoventilation
NeuromuscularProblem
VCO2
V/Q Abnormality
HypermetabolismOverfeeding
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The Case of Patient RVThe 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/+10Preintubation: 7.28/91/81/43
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Hypercapnic Respiratory FailureHypercapnic Respiratory Failure
(PAO2 - PaO2)
Alveolar Hypoventilation
V/Q abnormality
PI max
increasednormal
Nl VCO2
PaCO2 >46mmHgNot compensation for metabolic alkalosis
CentralHypoventilation
NeuromuscularProblem
VCO2
V/Q Abnormality
HypermetabolismOverfeeding
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Hypercapnic Respiratory FailureHypercapnic Respiratory Failure
Alveolar Hypoventilation
Brainstem respiratory depression Drugs (opiates) Obesity-hypoventilation syndrome
PI max
CentralHypoventilation
NeuromuscularDisorder
nlPI max
Critical illness polyneuropathyCritical illness myopathy
HypophosphatemiaMagnesium depletion
Myasthenia gravisGuillain-Barre syndrome
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Hypercapnic Respiratory FailureHypercapnic Respiratory Failure
(PAO2 - PaO2)
Alveolar Hypoventilation
V/Q abnormality
PI max
increasednormal
Nl VCO2
PaCO2 >46mmHgNot compensation for metabolic alkalosis
CentralHypoventilation
NeuromuscularDisorder
VCO2
V/Q Abnormality
HypermetabolismOverfeeding
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Hypercapnic Respiratory FailureHypercapnic Respiratory Failure
V/Q abnormalityIncreased Aa gradient
Nl VCO2
VCO2
V/Q Abnormality
HypermetabolismOverfeeding
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Hypercapnic Respiratory FailureHypercapnic Respiratory Failure
V/Q abnormalityIncreased Aa gradient
Nl VCO2
VCO2
V/Q Abnormality
HypermetabolismOverfeeding
• 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 FailureHypercapnic Respiratory Failure
V/Q abnormalityIncreased Aa gradient
Nl VCO2
VCO2
V/Q Abnormality
HypermetabolismOverfeeding
• VCO2 only an issue in pts with ltd ability to eliminate CO2
• Overfeeding with carbohydrates generates more CO2
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
Is PaCO2 increased?
Hypoventilation (PAO2 - PaO2)?
Hypoventilation alone
Respiratory driveNeuromuscular dz
Hypovent plus another
mechanism
Shunt
Inspired PO2
High altitudeFIO2
(PAO2 - PaO2) No
NoYes
Is low PO2 correctable
with O2?
V/Q mismatch
No Yes
Yes
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The Case of Patient ESThe Case of Patient ES
77F s/p MVC. Injuries include multiple L rib fxs, L hemopneumothorax s/p chest tube placement, L iliac wing fx. PMH: atrial arrhythmia, on coumadin. INR>2
HD#1 RR 30s and shallow. Pain a/w breathing deeply.Placed on BiPAP overnight
PID#1BiPAP 80%: 7.45/48/66/32/+10
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
Is PaCO2 increased?
Hypoventilation (PAO2 - PaO2)?
Hypoventilation alone
Respiratory driveNeuromuscular dz
Hypovent plus another
mechanism
Shunt
Inspired PO2
High altitudeFIO2
(PAO2 - PaO2) No
NoYes
Is low PO2 correctable
with O2?
V/Q mismatch
No Yes
Yes
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
V/Q mismatch
V/Q mismatch DO2/VO2 Imbalance
PvO2>40mmHg PvO2<40mmHg
DO2: anemia, low COVO2: hypermetabolism
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
V/Q mismatch
SHUNTV/Q = 0
DEAD SPACEV/Q = ∞
AtelectasisIntraalveolar filling Pneumonia Pulmonary edema
Pulmonary embolusPulmonary vascular dzAirway dz (COPD, asthma)
Intracardiac shuntVascular shunt in lungs
ARDSInterstitial lung dzPulmonary contusion
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
V/Q mismatch
SHUNTV/Q = 0
DEAD SPACEV/Q = ∞
AtelectasisIntraalveolar filling Pneumonia Pulmonary edema
Pulmonary embolusPulmonary vascular dzAirway dz (COPD, asthma)
Intracardiac shuntVascular shunt in lungs
ARDSInterstitial lung dzPulmonary contusion
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
Acute Respiratory Distress Syndrome
• Severe ALI• B/L radiographic
infiltrates• PaO2/FiO2 <200mmHg
(ALI 201-300mmHg)• No e/o L Atrial P;
PCWP<18
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
Acute Respiratory Distress Syndrome
• Develops ~4-48h• Persists days-wks• Diagnosis:
– Distinguish from cardiogenic edema
– History and risk factors
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Inflammatory Alveolar Injury
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Inflammatory Alveolar Injury
Pro-inflmm cytokines (TNF, IL1,6,8)
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Inflammatory Alveolar Injury
Pro-inflmm cytokines (TNF, IL1,6,8)
Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
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Inflammatory Alveolar Injury
Fluid in interstitium and alveoli
Pro-inflmm cytokines (TNF, IL1,6,8)
Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
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Inflammatory Alveolar Injury
Fluid in interstitium and alveoli
• Impaired gas exchange Compliance PAP
Pro-inflmm cytokines (TNF, IL1,6,8)
Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
Acute Respiratory Distress Syndrome
Exudative phase Fibrotic phaseProliferative phase
Diffuse alveolar damage
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Hypoxemic Respiratory FailureHypoxemic 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 FailureHypoxemic 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 FailureHypoxemic Respiratory Failure
Acute Respiratory Distress Syndrome
Complications• Barotrauma
• Nosocomial pneumonia
• Sedation and paralysis persistent MS depression and neuromuscular weakness
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Hypoxemic Respiratory FailureHypoxemic Respiratory Failure
Acute Respiratory Distress Syndrome
• 861 patients, 10 centers• Randomized• Tidal Vol 12mL/kg PDW,
PlatP<50cmH2O• Tidal Vol 6mL/kg PDW,
PlatP<30cmH2O• NNT 12
• 31% mortality v 39.8%• 65.7% breathing without assistance by day 28 v 55%• Significantly more ventilator-free days• Significantly more days without failure of nonpulmonary
organs/systems