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Respiratory Failure. Dr Svitlana Zhelezna Clinical Teaching Fellow UHCW NHS Trust svitlana.zhelezna@uhcw.nhs.uk 2013/2014 academic year. Learning objectives:. Describe the clinical features, potential causes and management of respiratory failure

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respiratory failure

Respiratory Failure

Dr Svitlana Zhelezna

Clinical Teaching Fellow

UHCW NHS Trust

svitlana.zhelezna@uhcw.nhs.uk

2013/2014 academic year

learning objectives
Learning objectives:
  • Describe the clinical features, potential causes and management of respiratory failure
  • List indications/contraindications/complications of non invasive ventilation and understand its set up and monitoring
definition
Definition:

Acute respiratory failure occurs when pulmonary system is no longer able to meet the metabolic demands of the body

slide4
Type 1 Respiratory Failure

Hypoxaemic

pO2 < 8 kPa ON AIR

pCO2 <6.0 kPa

Type 2 Respiratory Failure

Hypercapnic

pO2 < 8 kPa ON AIR

pCO2 > 6.0 kPa

clinical signs
1. Respiratory compensation

Tachypnoea

Accessory muscles

Recession

Nasal flaring

2. Sympathetic stimulation

HR

BP (early)

sweating

3. Tissue hypoxia

Altered mental state

HR and BP (late signs)

4. Haemoglobin desaturation:

(SpO2 < 90%)

Clinical signs:
case 1
Case 1
  • 70 year old man referred to A&E by his GP
  • PC: SOB and productive cough 4/7
  • HPC: gradual onset over 4-6/12 but worse over the last 3-4 days.
  • SH: smoking 30 pack years.
  • O/E: O2 sats are 91% on air, RR 26, temp 37.8, BP 130/75, HR 89. Pt’s chest shows widespread bilateral wheeze throughout, reduced air entry LLL.

1. List your differential diagnosis and investigation tests.

2. What would be your initial management of this patient?

slide7
ABG:

pH 7.31

pO2 8.4 kPa (on 6L O2)

pCO2 5.9 kPa,

HCO3- 21 mmol/l

Lac 3.1

What is your interpretation?

initial management
Investigations:

ABG

FBC, U&E, LFTs

Peak flow

CXR

ECG

Sputum and Blood culture

Urine dip, Urine Microscopy

Treatment:

A-E - Sepsis!

Oxygen – high flow initially, consider

controlled to aim O2Sat

88-92% when stable

Nebulised bronchodilators

Steroids

Antibiotics

Fluids

Initial management:
copd background
COPD – Background:
  • Definition: COPD is predominantly caused by smoking and is characterised by airflow obstruction that: is not fully reversible and is usually progressive in the long term
  • COPD acute exacerbations:

Increasing dyspnoea

Increasing sputum volume

Increasing sputum purulence (change in character)

asthma background
Asthma – Background:

More than one of the following symptoms:

  • Wheeze, cough, difficulty breathing, frequent and recurrent chest tightness, worse at night and in the early morning;
  • Occur in response to, or are worse after, exercise or other triggers,
  • Personal/ Family history of atopic disorder and/or asthma
  • Widespread wheeze heard on auscultation
  • History of improvement in symptoms or lung function in response to adequate therapy.
severe asthma
LIFE THREATENING

PEF <33% best or predicted

SpO2 <92%

PaO2 <8 kPa

normal PaCO2 (4.6-6.0 kPa)

silent chest

cyanosis

poor respiratory effort

arrhythmia

exhaustion, altered conscious level

BP low

NEAR FATAL

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

Severe Asthma
criteria for referral to itu
Criteria for Referral to ITU

Refer any patient:

  • requiring ventilatory support
  • with acute severe or life threatening asthma,
  • failing to respond to therapy, evidenced by:

- deteriorating PEF

- persisting or worsening hypoxia

- hypercapnea

- ABG analysis showing low pH

- exhaustion, feeble respiration

- drowsiness, confusion, altered conscious state

- respiratory arrest

case 2
Case 2
  • 17 y.o. female student
  • PC: severe SOB, can not speak in full sentences
  • HPC: woke up at 4 am feeling SOB and started coughing, her housemate called ambulance
  • PMH: too breathless to give
  • O/E: Pt agitated, wide spread audible wheeze bilaterally, poor chest expansion, using accessory muscles, HR 100, BP 130/85, T 36,6, O2 sat 93%

What would be your differential diagnosis and initial management?

slide15
ABG:

pH 7.46

pO2 8.2 kPa (on 15L O2)

pCO2 2.8 kPa,

HCO3- 18 mmol/l

What is your interpretation?

initial management1
Initial Management

Oxygen – high flow 15L

Nebulised bronchodilators

Peak flow

ABG

FBC, U&E, LFTs,

Steroids

case 3
Case 3
  • 76 year old male
  • PC: SOB, 7/7 productive cough with phlegm
  • PMH: known COPD, LTOT at home 2L for 16/24.
  • On admission: RR 18, sats 85% on 2L oxygen, HR 110, BP 134/68, temp 38.5. RLL crackles, but widespread wheeze throughout both lung fields.
  • The paramedics gave him 5ml salbutamol nebs and 100mg IV hydrocortisone an hour ago, he was given IV abx first dose, but he is not improving as yet, but become drowsy
what next
What next?
  • Continue Nebulised Salbutamol
  • NIV (non-invasive ventilation)
niv non invasive ventilation
NIV – non-invasive ventilation
  • Definition:

NIV is the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway

types
Types:

Continuous Positive Airway Pressure CPAP

Treating Hypoxia Type 1 RF

Bi-level Positive Airway Pressure (VPAP/Stellar)

Treating Hypercapnia Type 2 RF

main goals of niv
Main goals of NIV
  • Correction of abnormalities in ABG’s (hypoxia and hypercapnia)
  • Maintaining alveolar ventilation and lung volume
  • Reduce the work of breathing
  • Avoiding respiratory muscle fatigue

NIV does not correct underlying disorder or condition!

medical conditions indications
Medical conditions/Indications:
  • Acute exacerbation of COPD

(pH 7.26 – 7.35 or patients with NIV as ceiling of care and considered not suitable for HDU/ITU care)

  • Morbid Obesity / Severe OSA / Alveolar Hypoventilation Syndrome
  • Chronic Neuromuscular Disease
  • Kyphoscoliosis / Chest wall deformity.
niv contraindications
NIV contraindications:
  • Respiratory arrest
  • Undrained pneumothorax
  • Impaired consciousness/confusion/aggressive behaviour
  • Chest wall trauma
  • Uncontrolled vomiting/distended abdomen/ excessive secretions
  • Facial trauma/surgery, burns or facial abnormalities that are likely to cause difficulty with appropriate mask fit.
  • Recent upper abdominal surgery or intestinal obstruction.
starting niv
Starting NIV:
  • Locations:

HDU/ITU, Respiratory ward A+E resus (Not usually on a general ward – the nursing staff will not know how to deal with it)

  • Settings:
    • Should be prescribed by a consultant
monitoring niv
Monitoring NIV:
  • Main actions:
    • Baseline ABG, RR, HR
    • Repeat ABG after one hour of starting
    • After every setting change, repeat ABG at 1 hour
    • Otherwise, every 4 hours, or if not well
  • Key points:
    • Aim minimum 6 hours treatment
    • Most people better by 24 hours on NIV
    • Weaning thereafter
complications of niv
Complications of NIV:
  • Pneumothorax,
  • Decreased pre-load – may drop BP
  • Increased risk of aspiration
  • Face mask discomfort
  • Anxiety + confusion
key message
Key message

Common contributors to RF

  • Type 1 (↓O2): Asthma and COPD
  • Type 2 (↓O2 and ↑CO2): COPD and life threatening asthma

NIV

  • is effective in treating ↑CO2
summary
Summary
  • worry if
      • RR > 30/min (or < 8/min)
      • unable to speak 1/2 sentence without pausing
      • agitated, confused or comatose
      • cyanosed or SpO2 < 90%
      • deteriorating despite therapy
  • remember
      • normal SpO2 does not mean severe ventilatory problems are not present
thank you

Thank you!

Any questions?