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Respiratory Failure. 1.Abstracts. Respiratory failure, whether acute or chronic, is a frequently faced problem and a major cause of death in our country. For example, mortality from COPD, which ends in death from respiratory failure, continues to increase.

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1 abstracts
1.Abstracts
  • Respiratory failure, whether acute or chronic, is a frequently faced problem and a major cause of death in our country.
  • For example, mortality from COPD, which ends in death from respiratory failure, continues to increase.
  • More than 70% of the deaths in patients with pneumonia are attributed to respiratory failure.
2 definition
2.Definition
  • Respiratory failure affects the lung’s ability to maintain arterial oxygenation or carbon dioxide(CO2) elimination.
  • It is defined as a condition in which this gas exchange deteriorates below the usual level, so that arterial oxygen tension decreases, with or without an abnormal rise in arterial carbon dioxide tension.
3 classification
3.Classification
  • acute respiratory failure
  • chronic respiratory failure
  • Type Ⅰrespiratory failure
  • Type Ⅱrespiratory failure
  • Central respiratory failure
  • peripheral respiratory failure
classification type respiratory failure
Classification :Type Ⅰrespiratory failure
  • Type Ⅰrespiratory failure is also called hypoxic respiratory failure, which means that severely reduces arterial oxygen tension(PaO2<60mmHg), CO2 retention is not exist.
classification type respiratory failure6
Classification : Type Ⅱrespiratory failure
  • Type Ⅱrespiratory failure is also meant that hypercapnic-hypoxic respiratory failure.
  • Arterial blood gas values shows that arterial carbon dioxide tension is more than 50 mmHg and arterial oxygen tension is less than 60 mmHg
  • Type Ⅱrespiratory is mainly caused by hypoventilation.
pathogenesis
Pathogenesis
  • we have known that the lungs’ ability is gas exchange. The gas exchange involves not only oxygenation but also carbon dioxide elimination.
pathogenesis9
Pathogenesis
  • Respiratory failure is mainly associated with pulmonary gas exchange and pulmonary ventilation.
slide10
1. pulmonary gas exchange is mainly determined by ventilation-perfusion(V/Q) ratios and diffuse ability
  • V/Q mismatch: An effective lung gas exchange needs not only sufficient lung ventilation and lung blood volumes but also an adequate V/Q ratios.

Usually, the volume of ventilation is 4 liters/min. The volume of lung blood is 5 liters/min. So the ratios is 0.8

slide11
Any of the factors influenced the ratios may mainly cause hypoxemia respiratory failure.

For example, V/Q>0.8, including emphysema,pulmonary embolism.(无效腔)

V/Q<0.8, including atelectasis, severe COPD.(动静脉分流)

slide12
Diffuse ability

Diffusion abnormality mainly influence oxygen exchange.

2 pulmonary hypoventilation
2.Pulmonary hypoventilation
  • It may cause hypercapnic-hypoxic respiratory failure.
  • Pulmonary hypoventilation includes restrictive hypoventilation and obstructive hypoventilation.
restrictive hypoventilation
restrictive hypoventilation
  • Some diseases influenced central nervous system, peripheral nervous system, chest wall respiratory muscles and pulmonary compliance may all cause restrictive hypoventilation.
  • Such as brain stem lesion, altered neuromuscular transmission(guillain-barre syndrome), muscle weakness(malnutrition, shock, hypoxemia, hypokalemia), decreased lung compliance(infection, atelectasis, interstitial fibrosis, acute lung injury), decreased chest wall compliance(chest wall trauma, pleural effusion, pneumothorax).
obstructive hypoventilation
obstructive hypoventilation.
  • COPD and asthma are the most common disease associated to obstructive hypoventilation.
  • Increased airway resistance(upper airway obstruction, increased bronchial secretions and edema),
slide16
In our clinical work, multifactors involve in the course of respiratory failure. For example, a COPD patient with severe pulmonary infection, his pulmonary gas exchange ability and pulmonary ventilation are all abnormal.
slide17

V/Q mismatch

hypoxic

Diffuse ability

.

restrictive hypoventilation

  • hypercapnic-hypoxic.
  • obstructive hypoventilation.
pathophysiology
Pathophysiology
  • Hypoxia and hypercapnic may influence functions of many important organs and systems, including respiratory system, cardiovascular system, central nerve system,blood system and digestive system and renal function.
pathophysiology19
Pathophysiology
  • The unbalance of acid-alkalose metabolic and dielectric abnormality are usually exist in the course of respiratory failure.
clinical manifestations
Clinical manifestations
  • Clinical signs include not only symptoms associated with primary diseases but also those caused by hypoxic and hypercapnic-hypoxic respiratory failure.
slide22

Clinical manifestations of hypoxia and hypercapnia

HYPOXEMIA HYPERCAPNIA

Tachycardia Somnolence

Tachypnea Lethargy

Anxiety Restlessness

Altered mental status Slurred speech

Confusion Headache

Cyanosis Asterixis

Hypertension Papilledema

Hypotension Coma

Bradycardia unbalance of acid-alkalose metabolic

Seizures

Lactic acidosis

diagnosis
Diagnosis
  • According to history, clinical manifestations, physical examination and blood gas analysis, we can diagnose respiratory failure. Especially arterial blood gas analysis may reveal hypoxemia and hypercapnia.
diagnosis standard
Diagnosis standard
  • The diagnosis standard include:
  • Type Ⅰ respiratory failure:PaO2 <60mmHg
  • Type Ⅱrespiratory failure:PaCO2 >50mmHg, PaO2 <60mmHg.
  • In the condition of oxygen therapy, PaO2/Fi O2<300mmHg indicates respiratory failure.
treatment
Treatment
  • The principle of treatment includes
  • primary disease treatment
  • airway maintenance
  • correction of hypoxemia and hypercapnia
  • management of symptoms caused by hypoxemia and hypercapnia.
1 airway maintenance and enhance the volume of ventilation
(1)Airway maintenance and enhance the volume of ventilation
  • Assurance of an adequate airway is key in the patient with respiratory failure.
  • correctly use of bronchodilators
  • In severe cases intubation and mechanical ventilation may be used.
slide27
To most of the chronic respiratory failure, correctly use of bronchodilators is very important.

Table 2.

Bronchodilators Route Dose

salbutamol MDI and spacer 400-600g q1-4h

Aerosol solution 2.5-7.5mg q1-4h

Ipratropium MDI and spacer 80-120g q4-6h

Aerosol solution

Theophylline IV 5.6mg/kg 0.3-0.6mg/kg/hr

oral

slide28
Mechanical ventilation

The aim of mechanical ventilation is to improve hypoxemia and to prevent hypercapnia. When do you select mechanical ventilation? This is a question we always meet in our clinical work.

1.progressive elevation in PaCO2>70-80mmHg

2.severe hypoxemia, after oxygen therapy, PaO2<40mmHg

3.respiratory rates>35 per minute or severe breathlessness

4.severe metabolic acidosis or pulmonary encephalopathy

slide29
How to select artificial airway?

face mask or nasal noninvasive intermittent positive pressure ventilation are delivered to augment alveolar ventilation and reducing the work of breathing.

If hypoventilation can not be effectively reverses by noninvasive methods, intubation must be adopted. When artificial ventilation is required for more than 2 weeks, a tracheotomy is often required.

Tracheotomy carries some risk of bleeding, pneumothorax, and local infection and incidence of aspiration.

2 antiinfectious therapy
(2)Antiinfectious therapy
  • Repeated bronchial and pulmonary infection is a major cause of chronic respiratory failure.
  • About 90% of COPD patients with respiratory failure is caused by acute bronchial or pulmonary infection.
  • Infection may also increase bronchial secretion and CO2 production.
  • So antiinfectious therapy is an important method to treat respiratory failure.
slide31
Select effective antibiotics

According to sputum culture, we can select sensitive antibiotics

  • Using combined antibiotics

Because of multibacteria infection, it needs several kind of antibiotics. For example, we may combine second or third generation cephalosporin to aminoglycoside or fluoroguinolone.

3 oxygen therapy
(3)Oxygen therapy
  • The goal of oxygen therapy is to improve PaO2. It makes PaO2>60mmHg.
  • In general, the lowest FiO2 achieving adequate oxygenation. sometimes, arterial oxygen saturation>90% should be used.
slide33
The methods of oxygen therapy:

nasal prongs 1-3L/min to chronic respiratory failure

venti mask 1-3L/min

For type 1 respiratory failure, we can elevate the percentage of oxygen to maintain the PaO2.

We can use higher inspirated fration of oxygen in type 1 respiratory failure oxygen therapy. But in type 2 respiratory failure we must select lower inspirated fration of oxygen .

4 acid base and electrolytes disturbance
(4)Acid-base and electrolytes disturbance
  • There are many factors lead to acid-base and electrolytes disturbance.
  • These factors include severe pulmonary infection, hypoxemia or (and) hypercapnia. So airway maintenance, antibiotic therapy and use of bronchodilators are beneficial to treat it.
the acid base disorder types in respiratory failure
The acid-base disorder types in respiratory failure
  • Usually the disorders are compound types.
  • It is difficult to judge the type of disorder according to the clinical symptoms and signs. Arterial blood gas analysis is the major method to judge the type of disorder.
how to judge the acid base disorder
How to judge the acid-base disorder

the acid-base index.

  • PH
  • PaCO2
  • HCO3-

the index of respiratory

the metabolism

treatment of acid base disorders
Treatment of acid-base disorders
  • looking for the etiology of the disorder

is the most important .

respiratory acidosis
Respiratory acidosis
  • It is most commonly encountered in clinical practice of respiratory diseases.(COPD)
  • It is essential to improve alveolar ventilation, while alkaline supplement is not necessary.
  • For example: PH:7.32;PCO276mmHg;

PO276mmHg SO2%94%

BE13.9 HCO3- 41mmol/L

respiratory acidosis complicated with metabolic acidosis
Respiratory acidosis complicated with metabolic acidosis
  • First of all, the cause of metabolic acidosis should be clarified and treated, such as severe hypoxia may lead to increase in lactic acid or it is due to renal dysfunction or diabetic ketoacidosis.
  • If the level of PH is less than 7.2, alkaline drugs should be treated.
  • 5%NaHCO3(ml)=[normal HCO3-(mmol/L)-actual HCO3-(mmol/L)] ×0.2×weight(Kg)
respiratory acidosis complicated with metabolic acidosis40
Respiratory acidosis complicated with metabolic acidosis
  • Arterial gas analysis:

PH:7.20;PCO276mmHg;

PO256mmHg SO2%86%

BE-7; HCO3- 20mmol/L

respiratory acidosis complicated with metabolic alkalosis
Respiratory acidosis complicated with metabolic alkalosis
  • PH:7.28;PCO276mmHg;

PO266mmHg SO2%92%

BE5.1; HCO3- 33.8mmol/L

6 corticosteroids
(6)Corticosteroids
  • Methyprednisone is usually used to reduce the airway inflammation, and to improve FEV!. The treatment is recommended in all patients but it is not used for a longer time.
7 gastrointestinal bleeding treatment
(7)Gastrointestinal bleeding treatment

Because of hypoxemia, hypercapnia and by using corticosteroids, gastrointestinal bleeding always be happened.

The treatment mathod include correct hypoxemia and hypercapnia, use of H2-blocker and some block bleeding drugs.

1 definition
1.Definition
  • ARDS, which is a from of acute lung injury often seen in previously healthy patients,
  • It is characterized by rapid respiratory rates and a sensation of profound shortness of breath, and accompanied by severe arterial hypoxemia.
2 pathogenesis
2.Pathogenesis
  • ARDS can result from many disorders, including systemic or pulmonary infection,(viral, bacterial, fungal, ect.), aspiration, inhalation of toxins, metabolic disorders and severe sepsis or septic shock.
  • The initial insult cause release of cytokines, mediators from cell membranes and activation of a number of cascades with injury to the pulmonary endothelium.
slide51
ARDS is invariably associated with increased liquid in the lungs.
  • It is a form of pulmonary edema, distincts from cardiogenic pulmonary edema. Since hydrostatic pressure are not elevated.
3 clinical manifestations
3.Clinical manifestations
  • The early manifestations are an increased respiratory rates. Usually respiratory rates are more then 28 per minute. Sometimes the patient may be free of respiratory signs.
  • Cough and sputum production. Because of severe hypoxemia
  • cyanosis is a common physical signs in ARDS patients.
  • Tachycardia
slide53
X-ray shows a progressive, usually symmetrical, fluffy alveolar infiltrate that progresses to involve all potions of the lung. X-ray features of ARDS may be divided into three stages:

First stage- sometimes normal, sometimes small patches may be exist

Second stage- diffused small or large patches, usually in lower lung field

Third stage- pulmonary infiltrate involved all potions of the lung, called ‘white lung’

arterial blood gas analysis
Arterial blood gas analysis
  • Arterial blood gas analysis shows
  • PaO2/FiO2<300mmHg andPaO2<60mmHg.(ALI),
  • PaO2/FiO2<200mmHg(ARDS)
acid base disorders
acid-base disorders
  • Respiratory alkalosis
  • Metabolic acidosis
  • Respiratory acidosis
4 diagnosis
4.Diagnosis
  • There is a disorder which may lead to ARDS. For example, severe infection ects.
  • According to clinical manifestation, X-ray, arterial blood gas analysis, we can make a diagnosis.
the main diagnosis standard includes
The main diagnosis standard includes:
  • A factor which may leads to ARDS
  • The onset is acute. Tachypnea is exist.
  • Hypoxia
  • Chest X-ray shows pulmonary infiltrate involved two lungs.
  • PCWP<=18mmHg or except cardiogenic pulmonary edema.
5 treatment
5.Treatment(一)
  • Treatment of initial disorders which lead to ARDS
  • Improve hypoxemia

Severe arterial hypoxemia is a characteristic clinical sign of ARDS. In genaral, the lowest inspired fration of oxygen(FiO2) should be used to give the desired result. There are multiple means for delivering O2, including soft nasal prongs, simple face masks. But in the condition of ARDS, these methods are not effective. Mechanical ventilatory support should be used early to improve hypoxemia.

slide61
Use of PEEP

PEEP means positive end-expiratory pressure. It helps maintain alveolar potency in the presence of destabilizing factors and therefore reverses hypoxemia and atelectasis by improving V/Q matching.

PEEP level between 5-15cmH2O are safe and effective.

use of peep
Use of PEEP
  • The physiologic effects of PEEP include:
  • 1.redistribution of capillary blood flow, resulting in improved V/Q matching;
  • 2. The recruitment of previously collapsed alveoli and prevention of their collapse during exhalation.
slide63
Another treatments are similar to those chronic respiratory failure, including antiinfectious therapy, administration of corticosteroid, acid-base and electrolytes disturbance.
treatment64
Treatment(二)
  • Control the input of liquid
  • Use of Corticosteroids
  • Nutritional support therapy
mechanical ventilatory support
Mechanical ventilatory support

(1)Artifical airways

Endotracheal intubation is usually adopted during mechanical ventilation. Intubation should be by the orotracheal or nasotracheal route is highly controversial.

slide67
Orotracheal tubes are larger and easier to place in an emergency but are harder to stabilizer and are more uncomfortable.
  • Nasotrached tubes are better tolerated and oral hygiene, but have greater airway resistance and more difficult to suction
  • when tracheotomy must be used, the period of mechanical ventilatory is more than 4 to 6 weeks.
  • Ventilatory support may be achieved by nasal mask. Nasal mask include an awake, cooperative patient.
slide68
(2)The mode of mechanical ventilatory
  • Controlled ventilation, CMV
  • Assist-control ventilation, A-CMV
  • Intermittent mandatory ventilation, IMV
  • Synchronized intermittent mandatory ventilation, SIMV
  • Pressure support ventilation, PSV
  • Mandatory minute ventilation, MMV

Continuous positive airway pressure, CPAP/positive end-expiratory pressure, PEEP

  • Biphasic positive airway pressure, BiPAP
complications
complications
  • Ventilator-induced lung injury
  • Ventilator associated pneumonia
summary
Summary
  • 呼吸衰竭的定义、病因、分类
  • 呼衰的发病机理
  • 呼衰的临床表现、诊断和处理原则
  • 呼衰时酸碱失衡的处理
  • ARDS的主要病理生理特点
  • ARDS的诊断和处理原则
slide71
选择题
  • 1、慢性肺心病人,血 PH7.51,PaCO2:60mmHg,HCO3:38mmol/L,Na:134mmol/L,Cl:76mmol/L,K:2.4mmol/L, 下列哪项诊断最合适?

A、呼吸性酸中毒代偿 B、呼吸性酸中毒失代偿 C、呼吸性酸中毒+代谢性碱中毒 D、呼吸性酸中毒+代谢性酸中毒 E、代谢性碱中毒

slide72
2、呼吸衰竭时缺氧与二氧化碳潴留的最主要发病原理是:2、呼吸衰竭时缺氧与二氧化碳潴留的最主要发病原理是:

A、通气/血流比例失调 B、弥散功能障碍 C、肺泡通气量不足 D、氧耗量增加 E、肺内动静脉分流增加

slide73
3、慢性阻塞性肺气肿病人发生缺氧的主要机理是:3、慢性阻塞性肺气肿病人发生缺氧的主要机理是:

A、肺组织弹力减退 B、通气与血流比例失调 C、肺动脉分流异常 D、弥散功能

slide74
4、早期二氧化碳蓄积,血压、脉搏的变化应该是:4、早期二氧化碳蓄积,血压、脉搏的变化应该是:

A、血压下降,脉搏减慢 B、血压上升,脉搏增快 C、血压不变,脉搏减慢 D、血压上升,脉搏减慢 E、血压下降、脉搏增快

slide75
5、下列血气分析指标哪项符合呼衰的诊断?

A.PaO2<60mmHg,PaCO2>50mmHg

B.PaO2>60mmHg,PaCO2<35mmHg

C.PaO2<56.25mmHg,PaCO2>55mmHg

D. PaO2>50mmHg, PaCO2<35mmHg

case report
Case report
  • 男性,59 岁,
  • 主诉:咳嗽、咯痰 20 年,加重 10 天,昏睡一天。
  • 现病史:患者自20余年前始出现咳嗽、咯痰,以冬季发作为主,每年发作约持续3个月左右,本次自10天前开始出现咳嗽、咯痰加重,痰量较多,以黄痰为主,并于入院当天出现昏睡,家属遂送院就诊。
  • 查体:昏睡中,呼之醒,明显紫绀,呼吸 10 次每分,表浅,双肺闻 干湿罗音,心率 110 次每分,BP:16/11Kpa
  • 血气分析 PaO2:32mmHg,PaCO2:80mmHg,PH:7.293,
case report77
Case report
  • 诊断
  • 诊断依据