Download - 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