Download MBBS Pulmonary Medicine Presentations 6 Respiratory Failure Lecture Notes

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and Chronic

Pulmonary medicine

A 55 years old, smoker male having

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exertional breathlessness, cough with scanty

expectoration since 4-5 years. Now

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presented with worsening dyspnea since 4

days following upper respiratory tract

infection.

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History

HOPI
Cough
Expectoration

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Breathlessness
Systemic symptoms

History

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Past History

Allergic History

Medication History

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Family History

Personal History
Examination

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General Physical Examination
Drowsy, oriented to person but not to

time and place

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Vitals:
PR ? 100, BP ? 90/60 mmHg, RR- 30/min
Spo2 ? 89 % RA

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Systemic Examination:

Inspection :
Barrel shaped chest,
tracheal descent present,

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widened intercostal space,
intercostal retraction present,
apex impulse shifted downward

Palpation:

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Widened intercostal space,
apex beat shifted downward
Percussion:
B/L hyperresonant note,
Liver shifted downward

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Auscultation:
B/L wheezing present

Investigation

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ABG

Chest X-ray PA View

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Routine investigations


ABG

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pH ? 7.208

pCO2 ? 67.3

pO2 ? 47.5

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SO2 ? 72.1

HCO3 ? 27.1

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Chest Xray


Complete Hemogram

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Management
Respiratory failure

Respiratory failure is a condition in which the

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respiratory system fails in one or both of its gas-

exchanging functions; that is,

Oxygenation, and

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Carbon dioxide elimination

Patho-physiology
Classification of Respiratory failure
Type I (hypoxemic) respiratory failure:

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Type II (hypercapnic) respiratory failure:

? COPD

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COPD
Severe asthma

? Pneumonia

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Drug overdose

? Pulmonary edema

Poisonings

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? Pulmonary fibrosis

Myasthenia gravis

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? Asthma

Polyneuropathy

? Pneumothorax

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Poliomyelitis

? Pulmonary embolism

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Primary muscle disorders
? Pulmonary arterial hypertension

Porphyria

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Cervical cordotomy

? Pneumoconiosis

Head and cervical cord injury

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? Granulomatous lung diseases

Primary alveolar hypoventilation

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? Cyanotic congenital heart disease

Obesity-hypoventilation syndrome

? Bronchiectasis

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Pulmonary edema

? Acute respiratory distress syndrome (ARDS)

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ARDS
? Fat embolism syndrome

Myxedema

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Tetanus

? Kyphoscoliosis
? Obesity

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ABG

pH ? 7.411

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pH ? 7.208

pCO2 ? 32.8

pCO2 ? 67.3

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pO2 ? 31.0

pO2 ? 47.5

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SO2 ? 49.6

SO2 ? 72.1

HCO3 - 20.5

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HCO3 ? 27.1

The presence of markers of chronic hypoxemia (e.g.,

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polycythemia or cor pulmonale) provides clues to a long

-standing disorder, whereas abrupt changes in mental

status suggest an acute event.

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Marker of chronic hypercapnia ? Bicarbonate levels


Hypoxemic Respiratory failure

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Alveolar hypoventilation

Normal alveolar?arterial oxygen gradient

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Ventilation?perfusion mismatch,

Shunt, and

Diffusion limitation

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Hypercapnic Respiratory failure
Ventilatory supply Versus demand

Ventilatory supply : maximal spontaneous ventilation that

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can be maintained without development of respiratory

muscle fatigue. AKA maximal sustainable ventilation

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(MSV)

Ventilatory demand : spontaneous minute ventilation,

which, when maintained constant, results in a stable

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PaCO2

A 70-kg adult has an MVV of about 160 L/ min, an MSV

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of 80. L/min, and, under basal conditions, a Ve of

approximately 6 to 7 liters per minute (90 mL/kg/ min).

Normal y, therefore, there is a 10- to 15-fold difference

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between resting V.e and MSV.

In disease states, the V. e requirement may approach a

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markedly reduced MSV.

Further reductions in MSV result in ventilatory demand

exceeding supply, and hypercapnia occurs.

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Approach to the patient

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Clinical suspicion:
Signs of

underlying disease process ? pneumonia, pulmonary edema,

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asthma, COPD, cor pulmonale etc

Hypoxemia- restlessness, anxiety, tachycardia, dyspnea, cyanosis,

use of accessory muscles, arrhythmias, seizures etc

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Hypercapnia ? Confusion, drowsiness, somnolence, asterixis,

tachycardia etc
ABG :

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PaO2
PaCO2
AaDO2
pH
HCO3

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O2 saturation

Difference between Acute & Chronic
Principles of Management

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1. Triage decision
OPD
Ward
HDU
ICU

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? At one end of the spectrum is the patient with fulminant hypoxemic

respiratory failure, metabolic acidosis, and imminent cardiovascular

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collapse, who needs emergent intubation, mechanical ventilation,

and admission to a critical care unit.

? At the other end of the spectrum is the patient with COPD and

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chronic, compensated hypercapnic respiratory failure, who

requires observation in an intermediate care unit.

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2. Airway Management:

Intubation and mechanical ventilation

Non invasive ventilation (Pros & Cons)

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3. Correction of Hypoxemia and Hypercapnia

Hypoxemia : most life-threatening aspect of acute respiratory

insufficiency

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Goal is ? assure adequate oxygen delivery to tissues (Generally

PaO2 > 60 mmHg),

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Coronary or cerebrovascular disease (a slightly higher level)

Hypercapnia:

NIV/Invasive

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4. Search of an underlying cause
Monitoring patients with acute respiratory

failure

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Simple observation of respiratory rate, tidal volume.
Use of accessory muscles, and presence of paradoxical

breathing movements provides evidence of worsening

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respiratory failure and the need for intubation and

mechanical ventilation

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On mechanical ventilation, the patient must be care-

ful y monitored for ventilator-associated complications.

In addition, placement of indwel ing arterial and venous

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catheters, patient immobilization, and use of a broad

range of pharmacologic agents present additional

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potential threats to the acutely il patient

Thank you