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!!!!! BRS YR2 !!!!! > Cardio - Respiratory Failure > Flashcards

Cardio - Respiratory Failure Flashcards

1
Q

What is respiratory failure?

A

Syndrome of inadequate gas exchange due to dysfunction of one or more components of the respiratory system

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2
Q

What are the 3 parts of the respiratory system that could be affected?

A

→ nervous system
→ respiratory muscle
→ pulmonary

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3
Q

What are the 3 ways of classifying respiratory failure?

A

→ acute
→ chronic
→ acute on chronic

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4
Q

What are the different types of acute respiratory failure?

A

→ pulmonary : infection, aspiration, primary graft dysfunction ( Lung Tx)
→ extra-pulmonary : trauma, pancreatitis, sepsis
→ neuro-muscular : myasthenia / GBS

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5
Q

What are some examples of chronic respiratory failure?

A

→ pulmonary / airways : COPD, lung fibrosis, CF, lobectomy

→ musculoskeletal : muscular dystrophy

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6
Q

What is acute on chronic respiratory failure?

A

→ infective exacerbation (e..g COPD, CF)
→ myasthenic crises
→ post-operative

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7
Q

What is ARDS?

A

Acute Respiratory Distress Syndrome

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8
Q

What factors are considered in order to classify ARDS?

A

→ timing : within 1 week of a known clinical insult or new or worsening symptoms
→ chest imaging : bilateral opacities - not fully explained by effusions, lobar / lung collapse, or nodules
→ respiratory failure not fully explained by cardiac failure or fluid overload
→ oxygenation levels determine severity

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9
Q

How is respiratory failure physiologically classified?

A

→ Type 1 or Hypoxemic

→ Type 2 or Hypercapnic

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10
Q

What is Type 1 respiratory failure?

A

→ Hypoxemic
→ failure of oxygen exchange
→ increased shunt fraction (QS / QT) due to alveolar flooding
→ hypoxemia refractory to supplemental oxygen

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11
Q

What oxygen levels are classified as Type 1 RF?

A

PaO2 < 60

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12
Q

What are the causes of Type 1 RF?

A 
→ collapse
→ aspiration
→ pulmonary odema
→ fibrosis
→ pulmonary embolism
→ pulmonary hypertension
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13
Q

What is Type 2 RF?

A

→ hypercapnic
→ failure to exchange or remove CO2
→ decreased alveolar minus ventilation
→ dead space ventilation

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14
Q

What CO2 levels classify as Type 2 RF?

A

PaCO2 > 45

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15
Q

What are the causes of Type 2 RF?

A 
→ nervous system
→ neuromuscular
→ muscle failure
→ airway obstruction
→ chest wall deformity
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16
Q

What is Type 3 RF?

A

→ peri-operative respiratory failure
→ Increased atelectasis (lung collapse) due to low functional residual capacity
→ (FRC) with abnormal abdominal wall mechanics
→ Hypoxaemia or hypercapnoea

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17
Q

How can Type 3 RF be prevented?

A

anesthetic or operative technique, posture,

incentive spirometry, analgesia, attempts to lower intra- abdominal pressure

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18
Q

What is Type 4 RF?

A

→ shock
→ Type IV describes patients who are intubated and ventilated during shock (Septic/cardiogenic/neurologic)
→ Optimise ventilation improve gas exchange and to unload the
respiratory muscles, lowering their oxygen consumption
→ Ventilatory effects on right and left heart
→ Reduced afterload (good for LV) Increased pre-load (bad for RV)

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19
Q

What are the risk factors for chronic RF?

A 
→ COPD
→ pollution
→ recurrent pneumonia
→ CF
→ pulmonary fibrosis
→ neuro-muscular diseases
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20
Q

What are the risk factors for acute RF?

A 
→ infection (viral, bacterial)
→ aspiration
→ trauma
→ pancreatitis
→ transfusion
21
Q

What are some pulmonary causes of ARDS?

A 
→ aspiration
→ trauma
→ burns (inhalation)
→ surgery
→ drug toxicity
→ INFECTION
22
Q

What are some extra-pulmonary causes of ARDS?

A 
→ Trauma
→ Pancreatitis
→ Burns (extra-thoracic)
→ Transfusion
→ Surgery
→ BM transplant
→ Drug Toxicity
→ INFECTION
23
Q

What are the 4 major steps that drive ARDS?

A

→ infection or damage to the lung
→ immune response form macrophage already existing in the lung occurs - release IL-6, IL-8 + TNF-alpha
→ inflammation occurs due to signalling pathway, causing oedema
→ leucocyte migration into alveolar causes oedema to worsen

24
Q

What has been the in vivo evidence for the mechanism of action for ARDS?

A 
→ TNF signalling implicated
→ leucocyte activation + migration
→ DAMP release
→ cytokine release of IL-6, IL-1B, IFN-y
→ cell death (becrosis in lung biopsies, apoptotic mediators, FAS, FAS-1, BCI-2)
25
Q

What are the pharmacological therapies currently being used?

A 
→ steroids
→ salbutamol
→ surfactant
→ N-Acetylcysteine
→ Neutrophil esterase inhibitor
→ GM-CSF
→ statins
26
Q

What pharmacological therapies are being trialled?

A 
→ mesenchymal stem cells
→ keratinocyte growth factor
→ microvesicles
→ high dose Vitamin C, thiamine, steroids (for sepsis)
→ ECCO2R
27
Q

What are the 3 principles of therapeutic interventions?

A

→ treat underlying disease
→ respiratory support
→ multiple organ support

28
Q

How do you treat the underlying disease?

A

→ inhaled therapies (bronchodilators, vasodilators)
→ steroids
→ antibiotics
→ anti-virals
→ drugs (pyridostigmine, plasma exchange, IViG, rituximab)

29
Q

How do you provide respiratory support for RF?

A 
→ physiotherapy
→ oxygen
→ nebulisers
→ high flow oxygen
→ non-invasive ventilation
→ mechanical ventilation
→ extra-corporeal support
30
Q

How do you provide multiple organ support?

A 
cardiovascular support:
→ fluids
→ vasopressors
→ inotropes
→ pulmonary vasodilators
renal support:
→ haemofiltration
→ haemodialysis
immune therapies:
→ plasma exchange
→ convalescent plasma
31
Q

What are the consequences of ARDS?

A

→ poor gas exchange (leads to inadequate oxygenation, poor perfusion + hypercapnia)
→ infection (can lead to sepsis)
→ inflammation (can lead to severe inflammatory response)
→ systemic effects

32
Q

What are some ARDS specific interventions?

A

respiratory support
→ intubation
→ ventilation

33
Q

What are the different aspects of ventilation?

A

→ volume controlled
→ pressure controlled
→ assisted breathing modes
→ advanced ventilatory modes

34
Q

What is the difference between compliance in a normal lung vs. an ARDS lung?

A

REDUCED in the injured lung compared to the normal

35
Q

smth about UIP

A

fjlvngdr

36
Q

smth about LIP

A

rdwlJFGHIEJKRHG

37
Q

What are the pitfalls of ventilation?

A

→ minute ventilation (PaC02 control, can cause a build-up)
→ alveolar recruitment (can affect positive end expiratory pressure)
→ V/Q mismatch = ventilation without gas exchange
→ ventilator induced lung injury due to high driving pressure

38
Q

What kind of imaging can guide + help ventilation therapy?

A

→ CT

→ ultrasound

39
Q

Why can a lung USS be preferable over a CT scan?

A

radiation dangers

40
Q

What scoring system can guide ventilation therapy?

A

Murray score

41
Q

What is the Murray score?

A 
an average of:
→ PaO2 / FI02 (on 100% oxygen)
→ CXR (chest x-ray)
→ PEEP (positive end expiratory pressure)
→ Compliance (ml/cmH2O)
0-4 points given to each
42
Q

How does the Murray score classify severity?

A

→ 0 = normal
→ 1-2.5 = mild
→ 2.5 = severe
→ >3 = ECMO

43
Q

What is the national ARDS approach?

A 
→ telephone or online referral to 1 of 5 national centres
→ consultant case review 
→ transfer of imaging
→ advice
→ retrieval
→ transfer
→ ongoing management
44
Q

What is the inclusion criteria for treatment in ARDS?

A

→ severe RF without a cardiac cause

→ positive pressure ventilation is not viable

45
Q

What is the exclusion criteria for treatment in ARDS?

A

→ contraindication to continuation of active treatment
→ significant co-morbidity (which could lead to dependency on ECMO support)
→ significant life-limiting co-morbidity
→ reversible disease process
→ unlikely to lead to prolonged disability

46
Q

Why is aetiology important in treating ARDS with ECMO?

A

→ people affected by FLU tend to recover quickly when on ECMO
→ people affected by SARS need to be observed on ECMO + data needs to be observed carefully

47
Q

How does ECMO work?

A

→ large cannula inserted through groin to femoral vein to take blood from IVC out to a pump
→ pump pushes blood through artificial membrane where gas exchange takes place
→ blood pumped back in through jugular axis into RA (right atrium)

48
Q

What are the issues with ECMO?

A 
→ time to access
→ geographical inequity of referral system
→ consideration for referral
→ cost + expense
→ obtaining access to internal jugular, subclavian or femoral
→ circuitry
→ haemodynamics
→ clotting / bleeding

!!!!! BRS YR2 !!!!! (72 decks)

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