Acute respiratory failure
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Acute Respiratory Failure. Yoon Jung Oh,M.D. Departments of Pulmonary and Critical Care Medicin Ajou University School of Medicine. Definition. Hypoxemic respiratory failure PaO 2 < 55 mmhg , FiO 2 ≥ 0.6 Acute : develops in min to hr

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Acute respiratory failure

Acute Respiratory Failure

Yoon Jung Oh,M.D.

Departments of Pulmonary and Critical Care Medicin

Ajou University School of Medicine


Acute respiratory failure

Definition

  • Hypoxemic respiratory failure

  • PaO2 < 55 mmhg , FiO2 ≥ 0.6

  • Acute : develops in min to hr

  • Chronic : develops over several days or longer

  • Hypercapnic respiratory failure

  • PaCO2 > 45 mmHg

  • Acute : develops in min to hr( pH < 7.3)

  • Chronic : develops over several days or longer

Hypercapnic and hypoxemic respiratory failure coexist.


Acute respiratory failure

Acute Respiratory Failure

PaCO2 < 45 mmHg

Type 1 respiratory failure

PaCO2 > 45 mmHg

Type II ventilatory failure

ABGA

  • Black

  • acute pulmonary embolism

  • vascular obstruction

  • R-L shunt

  • Black

  • COPD

  • Status asthmaticus

  • Alveolar hypoventilation

  • Drug overdose

  • Neuromuscular disease

CXR

  • White

  • Diffuse

  • ARDS

  • Pulmonay edema

  • Pulmonary fibrosis

  • Localized

  • Pneumonia

  • atelectasis

  • White

  • Diffuse

  • ARDS

  • Pulmonary edema

  • Pulmonary fibrosis

  • Localized

  • Pneumonia + COPD

  • Drug overdose


Acute respiratory failure

Ventilatory

demand

Ventilatory

supply

A

Ventilatory supply exceeds ventilatory demand.

Ventilatory

supply

Ventilatory

demand

B

Ventilatory supply equals ventilatory demand.

Ventilatory

supply

Ventilatory

demand

C

Ventilatory demand exceeds ventilatory supply.


Acute respiratory failure

TABLE 165-3 Factors That Increase Ventilatory Demand

Factors

Clinical Examples

Increased VD/VT

Increased Vo2

Increased RQ

Decreased Pa CO2

Acute asthma, emphysema, late phase of acute respiratory distress syndrome, pulmonary emboli

Fever, sepsis, trauma, shivering, increased work of breathing, massive obesity

Excessive carbohydrate feeding

Hypoxemia, metabolic acidosis, anxiety, sepsis, renal failure, hepatic failure

SOURCE: Data from Lanken. 23


Acute respiratory failure

TABLE 165-2 Factors That Diminish Ventilatory Supply

Factors

Examples

Decreased respiratory muscle strength

Muscle fatigue

Disuse atrophy

Malnutrition

Electrolyte abnormalities

Arterial blood gas abnormalities

Fatty infiltration of diaphragm

Unfavorable alteration in diaphragm length-tension

relationship

Increased muscle energy requirement

or decreasedsubstrate supply

High elastic work of breathing

High resistive work of breathing

Reduced diaphragm perfusion

Decreased motor neuron function

Decreased phrenic nerve output

Decreased neuromuscular transmission

Abnormal respiratory mechanics

Airflow limitation

Loss of lung volume

Other restrictive defects

Recovery from acute respiratory failure, high respiratory rates,

increased Pdi/Pdimax,* increased inspiratory time

Prolonged mechanical ventilation, following phrenic nerve

injury

Protein-calorie starvation

Low serum phosphate or potassium concentrations

Low pH, low PaO2, high PaCO2

Obesity

Flattened domes of diaphragm caused by hyperinflation

Low lung or chest wall compliance, high respiratory rate

Airway obstruction

Shock, anemia

Polyneuropathy, Guillain-Barré syndrome, phrenic nerve

transection or injury, poliomyelitis

Myasthenia gravis, use of paralyzing agents

Bronchospasm, upper-airway obstruction, excessive airway

secretions

After lung resection, large pleural effusion

Pain-limited inspiration; tense abdominal distention due to ileus

peritoneal dialysis fluid, or ascites


Acute respiratory failure

Pathophysiology(1)

Hypoxemic Respiratory Failure


Acute respiratory failure

Pathophysiology(2)

Hypercapnic Respiratory Failure


Acute respiratory failure

Case 1.1 F/30

Hx : 3년전 bronchial asthma 진단받았으며 3일전 URI 후

악화된 호흡곤란을 주소로 내원.

ABGA : pH 7.5 PaO2 50 mmHg, PaCO2 30 mmHg

HCO3 22 mmol/L at room air

O2 5 L/min  PaO2 65 mmHg

P/E : RR 30/min, use of accessory muscle

wheezing on whole lung field

CXR : hyperinflation


Acute respiratory failure

Diagnosis 1.

Acute hypoxemic respiratory failure

due to acute exacerbation of asthma


Acute respiratory failure

Case 1.2

병동에서 치료중 호흡곤란을 계속 호소함.

ABGA : pH 7.4 PaO2 65 mmHg PaCO2 40 mmHg

O2 sat 92%


Acute respiratory failure

Case 1.3

다음날 아침, 밤새 호흡곤란으로 한숨도 자지 못했다하며

지속적인 호흡곤란을 호소함.

ABGA : pH 7.35 PaO2 60mmHg PaCO2 50mmHg

O2sat 90%


Acute respiratory failure

Case 2. F/19

남자친구와 다툰 후 수면제 100알을 복용후 응급실로 내원.

ABGA : pH 7.25 PaO2 60mmHg PaCO2 70mmHg

HCO3 27 mmol/L O2sat 90%


Acute respiratory failure

Diagnosis 2

Acute hypercapnic respiratory failure

due to drug overdose


Acute respiratory failure

Case 3.1 M/67

50 pack year smoker, 평소 100m 정도 걸으면 심해지는 DOE 있었으며 최근 감기앓은 후 fever,cough,dyspnea 로 내원.

P/E : RR 28/min

wheezing on whole lung field

ABGA : pH 7.4 PaO2 50 mmHg PaCO2 50 mmHg

HCO3 28 mmol/L O2sat 85% at room air

Nasal O2투여후 O2 sat 92% 로 증가


Acute respiratory failure

Diagnosis 3.1

  • Chronic obstructive pulmonary disease

  • (Emphysema )


Acute respiratory failure

Case 3.2

응급실에서 산소를 투여한지 4시간 후 , 환자가 헛소리를 하고 자꾸 자려고만 한다고 보호자가 호소함.

ABGA : pH 7.2 PaO2 80 mmHg PCO2 90 mmHg

nasal O2 5L/min


Acute respiratory failure

Diagnosis 3.2

Acute hypercapnic respiratory failure

CO2 narcosis


Acute respiratory failure

Effector Components

CNS

Efferents

Perepheral

Nerves

Repiratory m.

Chest wall

Airway

Alveoli

Afferent

Integration

In CNS

Chemo-

receptors

PaO2

PaCO2

VA, VE


Acute respiratory failure

*PaO2 may decrease when pneumonia or atelectasis occurs as a complication

#P(A-a)O2 widens when pnumonia or atelectasis occurs as a complication

$VE declines when frank respiratory muscle failure occurs.


Acute respiratory failure

&PaCO2 may increase during an exacerbation


Acute respiratory failure

Treatment of Acute Respiratory Failure

  • Correct hypoxemia/respiratory acidosis

  • Patent upper airway

  • Adequate ventilation

  • Supplemental oxygen


Acute respiratory failure

Treatment of Respiratory Failure

  • Increase VA

  • Bronchodilator

  • Control of infection

  • Oxygen therapy


Acute respiratory failure

Ventilatory Failure

  • To decrease VCO2

  • Antipyretics

  • Cooling blanket

  • Decrease muscle activity

  • To increase VA

  • Prevent airflow obstruction

  • Respiratory training

  • Intubation & mechanical ventilation

  • Cautious administration of sedatives


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