Respiratory Failure

byBy

Dr. Adel HamadaLecturer of Chest Diseases

Faculty of Medicine Zagazig University

It is a condition in which the lung cannot

fulfill its primary function of maintaining

adequate gas exchange leading to PaO2 less

than 60mmHg and/or PaCO2 more than 50

mmHg .

Definition

- Hypxemia without hypercapnia.

-Level of PaO2 is less than 60mmHg at rest. While breathing

room air at see level-As severe pneumonia and ARDS.

-Hypoxemia with hypercapnia.-As 1. Depression of Respiratory centre-2. Disease of the respiratory bellows-3. COPD

Type I R.F (Hypoxaemic R.F):

Type II R.F (Hypercapnic R.F) :as

Gases Values

PaO2 80-100mmHg.

PaCO2 35- 45mmHg.

PH 7.35 - 7.45

HCO-3 22 -27 ml equivalent

SaO2 97-99%.

Normal values of arterial blood gases

Where P = partial pressure, a = arterial, O2= oxygen, CO2 = carbon dioxide, HCO-

3 = serum bicarbonate level, SaO2 = oxygen saturation of arterial blood

Pathogenesis

Type I1- ventilation

perfusion mis-match

2- Shunt effect

Type IIAlveolar

Hypoventilation

Causes of alveolar hypoventilation

generator Pump Effector organ

Presentation of respiratory failure

hypoxemia

hypercapneaBoth

Manifestation of precipitating cause

Plus

Dyspnea

Impaired mental status

headache

Tachycardia

Papiledema

Cyanosis

Lung examination

Symptoms

signs

Tremors

Treatment of respiratory failure

A B C D EMaintain adequate

oxygen delivery

Mechanical ventilation if indicated

Treatment of cause

Life threatening conditions

Acute severe asthma

COPD exacerbation

Severe pneumonia

Acute Respiratory Distress Syndrome

Acute massive pulmonary embolism

Acute severe asthma

An exacerbation of COPD is:

“an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.”

Manage Exacerbations: Key Points

The most common causes of COPD exacerbations are viral upper respiratory tract infections and infection of the tracheobronchial tree.

Diagnosis relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms that is beyond normal day-to-day variation.

The goal of treatment is to minimize the impact of the current exacerbation and to prevent the development of subsequent exacerbations.

Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are usually the preferred bronchodilators for treatment of an exacerbation.

Systemic corticosteroids and antibiotics can shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay.

COPD exacerbations can often be prevented.

Manage Exacerbations: Key Points

Impact on symptoms

and lungfunction

Negativeimpact on

quality of life

Increasedeconomic

costs

Acceleratedlung function

decline

IncreasedMortality

EXACERBATIONS

Consequences Of COPD Exacerbations

Manage Exacerbations: Assessments

Arterial blood gas measurements (in hospital): PaO2 < 8.0 kPa with or without PaCO2 > 6.7 kPa when breathing room air indicates respiratory failure.Chest radiographs: useful to exclude alternative diagnoses. ECG: may aid in the diagnosis of coexisting cardiac problems. Whole blood count: identify polycythemia, anemia or bleeding. Purulent sputum during an exacerbation: indication to begin empirical antibiotic treatment.Biochemical tests: detect electrolyte disturbances, diabetes, and poor nutrition.Spirometric tests: not recommended during an exacerbation.

Manage Exacerbations: Treatment Options

Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%. Bronchodilators: Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 30-40 mg prednisolone per day for 10-14 days is recommended.

Antibiotics should be given to patients with:

Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence.

Who require mechanical ventilation.

Manage Exacerbations: Treatment Options

Noninvasive ventilation (NIV):

Improves respiratory acidosis, reduces respiratory rate, severity of dyspnea, complications and length of hospital stay.

decreases mortality and needs for intubation.

Manage Exacerbations: Treatment Options

Manage Exacerbations: Indications for Hospital Admission

Marked increase in intensity of symptoms Severe underlying COPD Onset of new physical signs Failure of an exacerbation to respond to

initial medical management Presence of serious comorbidities Frequent exacerbations Older age Insufficient home support

Severe pneumonia

ATS/IDSA Recommendations for Empirical Antibiotic Treatment of Community-Acquired Pneumonia

Definition:Form of acute lung injury characterized by non cardiogenic pulmonary

edema and refractory hypoxemia that is produced by neutrophil-

mediated cytotoxicity to lung cells (alveolar epithelium and capillary

endothelium) as a result of a wide variety of insults to the lung, either

directly or indirectly

Acute Respiratory Distress Syndrome

The Berlin Definition of Acute Respiratory Distress Syndrome

ETIOLOGY OF ARDS

Clinical Disorders Associated with Development of (ARDS)

RESCUE STRATEGIES FOR REFRACTORY

HYPOXEMIA

MANAGEMENT OF ARDS

VENTILATORY MANAGEMENT

SUPPORTIVE TREATMENT

Acute massive pulmonary embolism

Risk factors of pulmonary embolism

Treatment

Anticoagulant

Thrombolytic Therapy if haemodynamically unstable

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YOU