Respiratory Failure Abdul-Aziz Ontok, Fritzie Rasonable, April Suzette Exile

1. Respiratory Failure Abdul-Aziz Ontok, Fritzie Rasonable, April Suzette Exile

2. TOPIC OUTLINE • Definition • Epidemiology • Classification • Approach to the Patient with Respiratory Failure • Clinical Evaluation by Physiologic Principles • Specific Respiratory Failure Syndromes • Mechanical Ventilation

3. 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

4. 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

5. CLASSIFICATION By PathophysiologicDerrangement By its Acuity By Physiologic Deficit

6. Pathophysio. Derangement • Type I – alveolar flooding • Pulmonary edema • Heart failure • Intravascular volume overload • Acute lung injury • ARDS • Pneumonia • Alveolar hemorrhage

7. Pathophysio. Derangement • Type I – alveolar flooding • Type II – alveolar hypoventilation • Impaired CNS drive to breathe • Impaired strength of neuromuscular function in the respiratory system • Increased loads on the respiratory system

8. Pathophysio. Derangement • Type I – alveolar flooding • Type II – alveolar hypoventilation • Impaired CNS drive to breathe • Drug overdose • Sleep-disordered breathing • Hypothyroidism

9. Pathophysio. Derangement • Type I – alveolar flooding • Type II – alveolar hypoventilation • Impaired CNS drive to breathe • Impaired strength of neuromuscular function in the respiratory system • Impaired neuromuscular transmission • MG, Guillain-BarreSx, Phrenic nerve injury • Respiratory muscle weakness • Electrolyte derangements

10. Pathophysio. Derangement • Type I – alveolar flooding • Type II – alveolar hypoventilation • Impaired CNS drive to breathe • Impaired strength of neuromuscular function in the respiratory system • Increased loads on the resp. system • Resistive loads – bronchospasm • Reduced lung compliance – atelectasis • Reduced wall compliance - pneumothorax • Increased minute vent. req. – embolus

11. Pathophysio. Derangement • Type I – alveolar flooding • Type II – alveolar hypoventilation • Type III – lung atelectasis in the • perioperative period

12. 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

13. CLASSIFICATION By PathophysiologicDerrangement By its Acuity By Physiologic Deficit

14. Acuity • Acute Respiratory Failure • sudden, catastrophic event leads to life-threatening respiratory insufficiency • Chronic Respiratory Failure • gradual worsening of respiratory function that leads to progressive impairment of gas exchange • metabolic effects are partially compensated by adaptations in other systems

15. CLASSIFICATION By PathophysiologicDerrangement By its Acuity By Physiologic Deficit

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. APPROACH TO THE PATIENT • 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

23. APPROACH TO THE PATIENT • Measurement of respiratory rate • Observation of the depth and pattern of respiration • simultaneously note signs of respiratory distress: • alar flaring • pursed-lip breathing • use of accessory muscles • Palpation and Auscultation over each hemithorax

24. APPROACH TO THE PATIENT • 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 • 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

25. CLINICAL EVALUATION

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