respiratory failure abdul-aziz ontok, fritzie rasonable, april suzette exile
TRANSCRIPT
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Respiratory FailureAbdul-Aziz Ontok, Fritzie Rasonable, April Suzette Exile
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TOPIC OUTLINE Definition Epidemiology Classification Approach to the Patient with
Respiratory Failure Clinical Evaluation by Physiologic
Principles Specific Respiratory Failure Syndromes Mechanical Ventilation
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DEFINITION Failure of gas exchange due to inadequate
function of one or more essential components of the respiratory system
Manifest as: Hypoxemia – PO2 <60 mmHg (↓ O2) Hypercarbia – PCO2 >45 mmHg (↑ CO2) Combination of the two*
As respiratory demand exceeds functional capacity of the respiratory system, respiratory failure evolves
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EPIDEMIOLOGY Common diagnosis among patients in ICU
Associated with poor prognosis
137:100,000 ind. or 360,000/year (U.S.)
36% of these individuals fail to survive
Incidence and Mortality increase with age and presence of co-morbid conditions
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CLASSIFICATION
1. By Pathophysiologic Derrangement
2. By its Acuity
3. By Physiologic Deficit
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Pathophysio. Derangement Type I – alveolar floodingoPulmonary edema• Heart failure• Intravascular volume overload• Acute lung injury
ARDSoPneumoniaoAlveolar hemorrhage
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Pathophysio. Derangement Type I – alveolar flooding Type II – alveolar hypoventilationo Impaired CNS drive to breatheo Impaired strength of neuromuscular
function in the respiratory systemo Increased loads on the respiratory
system
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Pathophysio. Derangement Type I – alveolar flooding Type II – alveolar hypoventilationo Impaired CNS drive to breathe• Drug overdose• Sleep-disordered breathing• Hypothyroidism
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Pathophysio. Derangement Type I – alveolar flooding Type II – alveolar hypoventilationo Impaired CNS drive to breatheo Impaired strength of neuromuscular
function in the respiratory system• Impaired neuromuscular transmission
MG, Guillain-Barre Sx, Phrenic nerve injury
• Respiratory muscle weaknessElectrolyte derangements
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Pathophysio. Derangement Type I – alveolar flooding Type II – alveolar hypoventilationo Impaired CNS drive to breatheo Impaired strength of neuromuscular
function in the respiratory systemo Increased loads on the resp. system• Resistive loads – bronchospasm• Reduced lung compliance – atelectasis• Reduced wall compliance - pneumothorax• Increased minute vent. req. – embolus
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Pathophysio. Derangement Type I – alveolar flooding Type II – alveolar hypoventilation Type III – lung atelectasis in the
perioperative period
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Pathophysio. Derangement Type I – alveolar flooding Type II – alveolar hypoventilation Type III – lung atelectasis in the
perioperative period Type IV – hypoperfusion of respiratory
muscles in patients in shock
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CLASSIFICATION
1. By Pathophysiologic Derrangement
2. By its Acuity
3. By Physiologic Deficit
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Acuity Acute Respiratory Failureo sudden, catastrophic event leads to life-
threatening respiratory insufficiency Chronic Respiratory Failureo gradual worsening of respiratory
function that leads to progressive impairment of gas exchange
ometabolic effects are partially compensated by adaptations in other systems
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CLASSIFICATION
1. By Pathophysiologic Derrangement
2. By its Acuity
3. By Physiologic Deficit
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Physiologic Deficit Nervous System – controller dysfunction Musculature – pump dysfunction Airways – airway dysfunction Alveolar Units – alveolar dysfunction Vasculature – pulm. vascular dysfunction
Failure of any one of these components can lead to respiratory failure
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Physiologic Deficit Nervous System – controller dysfunction• Sedative medications• Chronic obstructive lung disease• Hypothermia post operatively• Brainstem stroke
Musculature – pump dysfunction Airways – airway dysfunction Alveolar Units – alveolar dysfunction Vasculature – pulm. vascular dysfunction
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Physiologic Deficit Nervous System – controller dysfunction Musculature – pump dysfunction• Botulism• Myasthenia Gravis• Guillain-Barre syndrome• Postoperative pain
Airways – airway dysfunction Alveolar Units – alveolar dysfunction Vasculature – pulm. vascular dysfunction
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Physiologic Deficit Nervous System – controller dysfunction Musculature – pump dysfunction Airways – airway dysfunction• Asthma• Emphysema• Bronchitis• Endobronchial mass/stricture
Alveolar Units – alveolar dysfunction Vasculature – pulm. vascular dysfunction
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Physiologic Deficit Nervous System – controller dysfunction Musculature – pump dysfunction Airways – airway dysfunction Alveolar Units – alveolar dysfunction• Pneumonia• Pulmonary edema• Pulmonary hemorrhage• ARDS
Vasculature – pulm. vascular dysfunction
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Physiologic Deficit Nervous System – controller dysfunction Musculature – pump dysfunction Airways – airway dysfunction Alveolar Units – alveolar dysfunction Vasculature – pulm. vascular dysfunction• Acute pulmonary embolus• Pulmonary hypertension• Arteriovenous malformation
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APPROACH TO THE PATIENT1. Determination of upper airway patency
Unconscious (occlusion of the tongue) Head tilt-chin lift maneuver
Unable to dislodge foreign object Subdiaphragmatic thrust
Suction secretions/vomitus Secure airway with endotracheal tube if
necessary Perform tracheostomy/cricothyroidotomy
if airway cannot be secured with ETT
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APPROACH TO THE PATIENT2. Measurement of respiratory rate3. Observation of the depth and pattern of
respiration simultaneously note signs of respiratory
distress: alar flaringpursed-lip breathinguse of accessory muscles
4. Palpation and Auscultation over each hemithorax
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APPROACH TO THE PATIENT5. Supplement findings with ABG
measurement• Oximetry provides rapid way to determine blood
oxygen content but does not provide information regarding alveolar ventilation and PCO2; do ABG
6. Implement initial therapy before specific etiology is diagnosed and treated• Supplemental oxygen might be all that is needed• Artificial ventilation if patient is in distress
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CLINICAL EVALUATIONDYSFUNCTION TEST FINDINGS IN DYSFUNCTION
Controller Respiratory rate <12/min in presence of hypoxia or hypercarbia and acidemia
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CLINICAL EVALUATIONDYSFUNCTION TEST FINDINGS IN DYSFUNCTION
Controller Respiratory rate <12/min in presence of hypoxia or hypercarbia and acidemia
Pump Inspection,Vital Capacity, Inspiratory Force
Presence of paradoxical respiratory motions VC < 10 mL/kg IF < -20 cm water
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CLINICAL EVALUATIONDYSFUNCTION TEST FINDINGS IN DYSFUNCTION
Controller Respiratory rate <12/min in presence of hypoxia or hypercarbia and acidemia
Pump Inspection,Vital Capacity, Inspiratory Force
Presence of paradoxical respiratory motionsVC < 10 mL/kgIF < -20 cm water
Airway Auscultation Presence of wheezing or rhonchi
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CLINICAL EVALUATIONDYSFUNCTION TEST FINDINGS IN DYSFUNCTION
Controller Respiratory rate <12/min in presence of hypoxia or hypercarbia and acidemia
Pump Inspection,Vital Capacity, Inspiratory Force
Presence of paradoxical respiratory motionsVC < 10 mL/kgIF < -20 cm water
Airway Auscultation Presence of wheezing or rhonchi
Alveolar Chest XR Alveolar infiltrates
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CLINICAL EVALUATIONDYSFUNCTION TEST FINDINGS IN DYSFUNCTION
Controller Respiratory rate <12/min in presence of hypoxia or hypercarbia and acidemia
Pump Inspection,Vital Capacity, Inspiratory Force
Presence of paradoxical respiratory motionsVC < 10 mL/kgIF < -20 cm water
Airway Auscultation Presence of wheezing or rhonchi
Alveolar Chest XR Alveolar infiltrates
Pulm. Vascular JVP, ECG JVD, RBBB