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Acute Respiratory Insufficiency Acute Respiratory Failure (ARF)

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Problems in the lung-parenchyma itself Acute respiratory failure Acute Lung Injury, Acute Respiratory Distress Syndrome (ALI/ARDS) Acute bronchospasm severe asthma ... – PowerPoint PPT presentation

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Title: Acute Respiratory Insufficiency Acute Respiratory Failure (ARF)


1
Acute Respiratory InsufficiencyAcute Respiratory
Failure (ARF)
  • Dr.Judit Méray
  • Institute of Anesthesiology and Intensive Therapy

2
Acute respiratory failure
  • The goal of breathing is to fill the blood with
    the sufficient amount of oxygen necessary for the
    tissues and clear the blood of carbon dioxide
  • ARF the insufficiency of the breathing to
    fulfill the above task- that is insufficient
    respiratory performance of the lungs

3
Oxygen consumption
  • Resting oxygen consumption work load
  • (physical metabolic) requirements
  • Hypoxia
  • Hypoxemic
  • reduction of FIO2 (mountain sickness)
  • Ventilation/diffusion failure
  • Shunting - anatomic R?L-shunts -circulation
    without ventilation atelectasis!!!
  • Stagnation - mixed SatvO2?
  • Ischemic
  • Anemic
  • Histotoxic

4
CO2 elimination
  • Arterial CO2 level (PaCO2) depends on the
    metabolic production rate (VCO2) and the
    alveolar clearing alveolar ventilation (VA)
  • PaCO2 k VCO2/VA
  • Under normal circumstances these values are
    relatively constant

5
Acute respiratory failure
  • - Not an independent entity it is always a
    consequence of various pathologic processes
  • - The cause can be mechanical insufficiency of
    the breathing or alveolo-capillary dysfunction
    (hypercapnic and hypoxic types of respiratory
    insufficiency)

6
Classification of respiratory insufficiency
  • According to time length (duration) chronic or
    acute
  • According to ventilatory pump -function partial
    or global
  • According to origin obstructive or
    restrictive

7
Acute respiratory failure
  • Classification
  • Acute/ chronic respiratory failure
  • acute exacerbation of a chronic process
  • Partial or total (global) ARI (hypoxia alone
    or hypercapnia)
  • Ventilation/ Diffusion/ Perfusion abnormalitie
    s
  • Obstructive or restrictive RI

8
Alveolar phase of breathing
Membrane Intracellular fluid Hgb molecule
erythrocyte
9
Causes of ventilation problems
  • Central CNS spinal cord
  • Injuries
  • Drug action - e.g. opioids!
  • Neurologic, neuromuscular, muscular failures
  • E.g. myasthenia gravis, Gillain Barré sy.,
    muscle relaxants
  • Mechanical causes
  • Thoracic cage rib fractures, burns, scars
  • Compression of the lungs hydrothorax,
    hemothx, pneumothx
  • Airway obstruction
  • Upper airway obstruction foreign body,
    stenosis
  • Lower airways bronchospasm, asthma..
  • Problems in the lung-parenchyma itself

10
Acute respiratory failure
  • Acute Lung Injury, Acute Respiratory Distress
    Syndrome (ALI/ARDS)
  • Acute bronchospasm severe asthma
  • Acute on chronic airflow limitation acute
    exacerbation of COPD
  • Severe pneumonia
  • Pulmonary embolism
  • Pulmonary edema
  • Aspiration, inhalation

11
Clinical signs of respiratory insufficiency
  • dyspnoea
  • use of ventilatory auxiliary muscles
  • cyanosis
  • progressive elevation of the resp. rate
  • tachycardia
  • agitation, confusion, somnolentia, coma

12
Diagnosis
  • Inspection dyspnoea, thoracic movements, etc.
  • Respiratory rate (VC, FEV?)
  • Pulsoximetry (capnometria?)
  • Blood gases (arterial, venous) irepeated!
  • Reaction to oxygen inhalation?
  • Asthma peak flow
  • Further investigations
  • Thorax X ray? CT, MRI
  • Sputum - bacteriology, serology
  • Laboratory testing
  • ECG, US (TEE?)

13
Acute lung injury, Acute respiratory distress
syndrome (ALI/ARDS)
  • Diffuse lung disease with severe hypoxia-
    characterized by loss of ventilated alveoli
    (loss of surfactant activityedema of the lung
    tissue)
  • ? reduced ventilated lung-capacity
  • ? reduced compliance
  • ? severe hypoxemia (intrapulmonary shunts)

14
ALI/ARDS
15
ALI/ARDS
  • Diagnosis
  • Thorax x-ray /CT
  • Severe hypoxia not reacting on oxygen
    inhalation
  • PaO2/FiO22 lt 300 (ALI) or 200 (ARDS)
  • Lung compliance?
  • Diffuse bilateral infiltration caused not by LV
    insufficiency (Paop ? 18 Hgmm)
  • American/European Consensus Comittee 1994

16
Causes of ALI/ARDS
  • Pulmonary Extrapulmonary
  • - infektion/pneumonia - sepsis
  • - aspiration/inhalation - trauma
  • - near drowning - TRALI
  • - contusion - CPB

17
ALI/ARDS
  • A complex interaction between the cells and the
    inflammatory mediators - lesion of epithelial
    cells, alveolar macrophags and endothelial cells
  • exsudation - edema, inflammation, coagulation
    disorders
  • proliferative phase regeneration
  • fibrotic phase -

18
Acute bronchospasm, severe asthmatic attack
  • Components of the insufficiency
  • Bronchospasmus
  • Edema of the bronchiolar mucous membranes
  • Secretion sticky secretions
  • Obscruction of small bronchioli
  • Air trapping Exhalation incomplete
  • The pressure never returns to zero! "dynamic
    hyperinflation" (TLC?, RV?, FRC?)
  • Lung inflation - intrinsic or autoPEEP
  • Respiratory work elevated - Exhaustion!

19
12
20
16
Arterial blood gases
PaCO
PaO
Severity
2
2
Mild
Medium
Severe
Normal
Life danger!
21
Pneumonia
infective infiltration of the lungs
  • Epidemiology
  • Home aquired
  • Community aquired (CAP)
  • Hospital aquired (HAP)
  • Ventilator aquired (VAP)
  • Infective agent
  • Bakterial - pneumocc., haemophylus, stacc.,
    mycoplasma
  • Viral pneumonia (influenza, adenovirus, etc.)
  • Clinical appearance
  • Typic pneumonia (sudden beginning, high fever,
    productive cough)
  • Atypic pneumonia (less characteristic symptoms)

22
Pulmonary embolism
characteristics
  • Non specific symptoms
  • 2/3 false diagnosis
  • Risk factors draw attention to the possible
  • diagnosis
  • Potencially lethal
  • Mortality 30, if adequately treated 2-8 (15)
  • Preventable

23
(No Transcript)
24
Clinical picture
Probability of PE
Hospital resident
Ambulant patient
US?
ECG, Thx X-ray
D-dimer
normal
high
Thoracic CT
Renal insufficiency, allergy to contrast
material V/Q scan (ventilation/perfusion)
positive
?
normal
normal
DV-US

PE
-
PE improbable
PE improbable
pulm. angiogr.?
25
Pulmonary edema
  • Dynamic balance state
  • intravascular interstitial alveolar
    compartments
  • Starling equation (fluid movement through
    semipermeable membranes)
  • Qf K /(Pc Pi) s(Pc Pi)/ K
    filtration coefficient, s protein permeability
    Pc, Pi capillary interstitial oncotic
    pressure
  • Factors
  • Alveolocapillary membrane permeability
  • Hydrostatic pressure in the capillaries
  • Onkotic pressure in the interstitium
  • Capacity of the lymph-system

26
Common causes of pulmonary edema
  • Cardial edema main cause is the elevated
    hydrostatic pressure in the pulmonary vessels
    (AMI, IHF, CMP, MS, MI, hypertensive
    crisis)
  • Nono cardiac causes
  • Chemical irritation (gases,fumes, aspiration of
    acidic gastric content, etc.)
  • Fluid overload
  • Followinf upper airway obstruction, near drowing
  • Pneumothx (interstitial neg.pressure?),
    re-expansion
  • High altitude
  • Infection, sepsis
  • Pharmacons, toxins (sedato-hypnotica,
    salicylate overdose, paraquate)
  • ..

27
Therapy
  • Elimination of the cause
  • Half-sitting position
  • Oxygen therapy
  • Positive pressure ventilation (IPPV, PEEP)
  • in case of hypercapnia, severe hypoxia
    Gyógyszeres th
  • Morphine 5-10 mg IV
  • Furosemide 20-40 mg IV
  • TNG sublinqual 0,3-0,6 mg, or spray or IV
    infusion
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