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(cardioresp) 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 is the predominant feature of respiratory failure?

A

shortness of breath

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3
Q

which two systems can be involved in respiratory failure?

A

nervous system, respiratory system (respiratory muscles)

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4
Q

which parts of the nervous system can be involved in respiratory failure?

A

brainstem/CNS, peripheral nervous system, neuromuscular junction

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5
Q

which parts of the musculoskeletal system can be involved in respiratory failure?

A

diaphragm, thoracic muscles, extra-thoracic muscles

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6
Q

which parts of the pulmonary system can be involved in respiratory failure?

A

airways, alveolar capillaries

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7
Q

what is the epidemiology of chronic respiratory failure?

A

the 3rd leading cause of death around the world

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8
Q

what is the biggest risk factor for chronic respiratory failure in men?

A

smoking

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9
Q

what is the biggest risk factor for chronic respiratory failure in women?

A

household air pollution from solid fuels (i.e. from cooking)

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10
Q

what are some possible causes for a decrease in mortality from respiratory failure?

A

patients living longer

treatments working/getting better

patients dying of other diseases

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11
Q

what is the acute type of respiratory failure?

A

acute respiratory distress syndrome

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12
Q

what is ARDS?

A

life-threatening condition wherein the lungs become severely inflamed and fluid builds up within the lungs impairing oxygen transport, significantly and dangerously lowering blood oxygen levels

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13
Q

what is the prevalence of ARDS in the UK?

A

6-7 per 100,000

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14
Q

how do people with ARDS present usually?

A

heterogenous disease presentation (i.e. can present w different conditions - infective exacerbation of COPD, worsening of pulmonary hypertension, pneumonia)

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15
Q

how is ARDS classified?

A

using the ARDS Berlin definition

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16
Q

what four aspects are there to the ARDS Berlin definition?

A

timing, chest imaging, origin of oedema and oxygenation

Two Can Out One

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17
Q

what is the ARDS Berlin definition in terms of timing?

A

should be within 1 week of known clinical insult or new/worsening respiratory symptoms

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18
Q

what is the ARDS Berlin definition in terms of chest imaging?

A

bilateral opacities present (not caused by pleural effusion, lung collapse or nodules)

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19
Q

what is the ARDS Berlin definition in terms of origin of oedema?

A

oedema should not be caused by cardiac conditions

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20
Q

what is the ARDS Berlin definition in terms of oxygenation?

A

different levels of oxygenation - mild, moderate and severe

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21
Q

what are the three classifications of respiratory failure?

A

acute
chronic
acute on chronic

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22
Q

what are the three causes of acute respiratory failure?

A

pulmonary (infection, aspiration, primary graft dysfunction)

extra-pulmonary (trauma, pancreatitis, sepsis)

neuromuscular (myasthenia, GBS)

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23
Q

what are the pulmonary causes of acute respiratory failure?

A

infection, aspiration, primary graft dysfunction

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24
Q

what are the extra-pulmonary causes of acute respiratory failure?

A

trauma, pancreatitis, sepsis

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25
Q

what are the neuromuscular causes of acute respiratory failure?

A

myasthenia gravis, GBS (Guillain-Barre syndrome)

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26
Q

what are the causes of chronic respiratory failure?

A

pulmonary (COPD, lung fibrosis, cystic fibrosis, lobectomy)

musculoskeletal (muscular dystrophy)

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27
Q

what are the pulmonary causes of chronic respiratory failure?

A

COPD, cystic fibrosis, lung fibrosis, lobectomy

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28
Q

what are the neuromuscular causes of chronic respiratory failure?

A

muscular dystrophy

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29
Q

what are the possible causes of acute on chronic respiratory failure?

A

infective exacerbation of COPD/CF

myasthenia crises

post operative

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30
Q

what are the two types of respiratory failure?

A

type I respiratory failure (hypoxemic)

type II respiratory failure (hypercapnic)

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31
Q

what is type I respiratory failure also known as?

A

hypoxemic respiratory failure

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32
Q

what is type II respiratory failure also known as?

A

hypercapnic respiratory failure

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33
Q

how does type I respiratory failure occur?

A

failure of oxygen exchange due to damage to lung tissue

= damaged tissue is insufficient for efficient oxygenation of the blood BUT is enough to enable carbon dioxide to be excreted

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34
Q

how does type II respiratory failure occur?

A

failure to exchange or remove carbon dioxide

= when alveolar ventilation is insufficient to allow efficient carbon dioxide excretion

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35
Q

what are the expected blood oxygen and blood CO2 levels in hypoxemic RF?

A

low oxygen

normal/low CO2

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36
Q

what are the expected blood oxygen and blood CO2 levels in hypercapnic RF?

A

low oxygen

high CO2

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37
Q

what are the causes of type I respiratory failure?

A

lung collapse

aspiration

pulmonary oedema

lung fibrosis

pulmonary embolism

pulmonary hypertension

38
Q

what are the causes of type II respiratory failure?

A

neuromuscular causes

muscle failure

airway obstruction

chest wall deformity

nervous system impairment

39
Q

what PaO2 is expected in hypoxemic RF?

A

PaO2 < 60

40
Q

what PaCO2 is expected in hypercapnic RF?

A

PaCO2 > 45

41
Q

how can pulmonary oedema cause respiratory failure and which type?

A

build-up of fluid around the lung increases diffusion distance, impairing the efficient oxygenation of blood = type I (hypoxemic) respiratory failure

42
Q

how can muscle failure cause respiratory failure and which type?

A

muscle failure/weakness results in an inability to drive adequate tidal volumes and a sufficiently high respiratory rate = inability to remove CO2 well = type II respiratory failure

43
Q

which type of respiratory failure is associated with decreased alveolar minute ventilation?

A

type II respiratory failure (hypercapnic)

44
Q

which type of respiratory failure is associated with an increased shunt fraction?

A

type I respiratory failure (hypoxemic)

45
Q

what is the shunt fraction?

A

the percentage of blood put out by the heart that is not completely oxygenated (increased in hypoxemic respiratory failure)

46
Q

what is alveolar minute ventilation?

A

the volume of gas inhaled and exhaled from a person’s lungs per minute (decreased in hypercapnic respiratory failure)

47
Q

what is type III respiratory failure?

A

(hypoxemic and hypercapnic) respiratory failure seen in patients around the time of surgery (perioperative respiratory failure)

low functional residual capacity + abnormal abdominal wall mechanics = airways cannot stay open = increased atelectasis (collapse of lungs)

48
Q

what is type IV respiratory failure?

A

respiratory failure resulting from shock (septic/cardiogenic/neurologic)
= patients intubated/ventilated

wherein the body cannot provide oxygen adequately or maintain blood pressure for sufficient levels of pulmonary perfusion

49
Q

define atelectasis

A

complete or partial collapse of the entire lung or lobe of lung

occurs when the alveoli within the lung become deflated or possibly filled with alveolar fluid

50
Q

how can type III respiratory failure be prevented?

A

analgesia, posture, correct anaesthetic or operative technique

51
Q

what is functional residual capacity and why is it physiologically important?

A

the volume in the lungs at the end of passive expiration

physiologically important as it is responsible for keeping the small airways open and prevent complete emptying of the lung during each respiratory cycle

52
Q

why does atelectasis occur?

A

reduced functional residual capacity + abnormal abdominal wall mechanics

53
Q

what is type IV respiratory failure usually secondary to?

A

cardiac instability

54
Q

explain how cardiac instability leads to type IV respiratory failure

A

pressure in chest raised

pressure difference bw LV and thorax is less = less afterload = better for LV

pressure diff bw RV and thorax in increased = increased preload - worse for RV as it is harder to fill w blood and contractiliy reduced

= reduced perfusion of the lungs + peripheral pooling of the blood + reduce central return of blood to pulmonary vasculature SO type IV respiratory failure

55
Q

what is the usual state of patients in type IV respiratory failure?

A

intubated/ventilated during shock (sepsis, cardiogenic, neurogenic)

56
Q

what are the risk factors for acute respiratory failure?

A

infection (viral, bacterial)

aspiration

trauma

pancreatitis

transfusion

57
Q

what are the risk factors for chronic respiratory failure?

A

pollution, COPD, recurrent pneumonia, cystic fibrosis, pulmonary fibrosis, neuromuscular diseases

(genetics = alpha-1-antitrypsin deficiency)

58
Q

what are the pulmonary causes of ARDS?

A

infection -

trauma -

surgery -

drug toxicity -

burns (inhalation) -

aspiration

59
Q

what are the extra-pulmonary causes of ARDS?

A

infection -

trauma -

surgery -

drug toxicity -

burns (inhalation) -

pancreatitis

transfusion

bone marrow transplant

60
Q

define pulmonary causes (in terms of ARDS)

A

from airways down to alveoli

61
Q

define extra-pulmonary causes (in terms of ARDS)

A

systemic disease, anything that activates neutrophils/macrophages/cytokine release

62
Q

define extra-pulmonary causes (in terms of ARDS)

A

systemic disease, anything that activates neutrophils/macrophages/cytokine release

63
Q

what are the three components of acute lung injury?

A

infection, inflammation and immune response

64
Q

explain the pathogenesis of acute lung injury

A

injury to the interstitium

macrophages activated either by infection or inflammation

release cytokines (IL6, IL8, TNFa)

protein-rich alveolar fluid oedema + degradation of surfactant = impairs expansion of alveoli

leukocyte migration to alveoli + secretion of proteases and inflammatory mediators = more damage to tissues + increased oedema

oedema = increased diffusion distance = inefficient gas exchange = respiratory failure

65
Q

what are the three aspects to therapeutic intervention in ARDS?

A

treat underlying disease

respiratory support

multiple organ support

66
Q

what pharmacological interventions are available to treat ARDS?

A

inhaled therapies (bronchodilators like salbutamol, pulmonary vasodilators)

steroids

antibiotics, antivirals

N-acetylcysteine

67
Q

what respiratory support is available to treat ARDS?

A

physiotherapy

oxygen

nebulisers

high flow oxygen

non-invasive ventilation

mechanical ventilation

extra-corporeal support

68
Q

what multiple organ support is available to treat ARDS?

A

cardiovascular = pulmonary vasodilators, fluids, ionotropes

renal = haemofiltration, haemodialysis

immune = convalescent plasma therapy, plasma exchange

69
Q

what cardiovascular support is available for ARDS patients?

A

fluids, ionotropes, vasopressors, pulmonary vasodilators

70
Q

what renal support is available for ARDS patients?

A

haemofiltration, haemodialysis

71
Q

what immune support is available for ARDS patients?

A

convalescent plasma therapy, plasma exchange

72
Q

how does poor pulmonary perfusion cause respiratory failure?

A

poor perfusion = poor gas exchange = poor oxygenation + hypercapnia = respiratory failure

73
Q

what types of ventilation are available for ARDS patients?

A

volume controlled

pressure controlled

assisted breathing modes

advanced ventilatory modes

74
Q

what is compliance (in lungs)?

A

a measure of lung expandability

75
Q

what is the upper inflection point?

A

above this pressure any additional alveolar recruitment requires disproportionate increases in applied airway presssure

76
Q

what is the lower inflection point?

A

the minimum baseline pressure needed for optimal alveolar recruitment

77
Q

how does the compliance vary in a healthy lung vs an ARDS lung?

A

healthy lung has high compliance (as elasticity of alveoli maintained)

ARDS lung (tissue and surfactant damaged + oedema develop) has much lower compliance

78
Q

how does the upper inflection point vary in a healthy lung vs an ARDS lung?

A

the UIP of the healthy lung is lower than that of an ARDS lung as lung is much stiffer

79
Q

how does the lower inflection point vary in a healthy lung vs an ARDS lung?

A

the LIP of the healthy lung is lower than that of an ARDS lung as lung is much stiffer

80
Q

which imaging modalities can be used to guide ARDS and respiratory failure management?

A

CXR, lung ultrasound, lung CT

81
Q

how is ARDS severity graded?

A

Murray score = takes into account four factors (PaO2, CXR, PEEP, compliance)

82
Q

what four factors are taken into account in a Murray score?

A

oxygen partial pressure (PaO2)

CXR

PEEP

compliance

(on christmas, people carol)

83
Q

what does a Murray score determine?

A

ARDS severity and the need for ECMO

84
Q

what does each Murray score mean?

A

0 = normal
1 - 2.5 = mild (proning treatment)
2.5 = severe (proning treatment)
3 = ECMO

85
Q

what is the inclusion criteria for ECMO?

A

sever respiratory failure (w a non-cardiac cause)

Murray lung injury score greater than 3

where positive pressure ventilation is not appropriate (i.e. significant tracheal injury)

86
Q

what is the exclusion criteria for ECMO?

A

contraindication to continuation of active treatment

significant co-morbidity

87
Q

what are the two essential requirements for ECMO treatment?

A

must be a reversible disease process

+ must be unlikely to lead to prolonged disability

88
Q

explain how ECMO occurs

A

pass very large cannula through femoral vein (GROIN)

slot it just below IVC below right atrium and then draw blood our of body through tubing

runs blood through pump that enables removal of CO2 and oxygenation of blood

pumped back into body

(can also do so via the jugular vein and down into the RA = jugular axis)

89
Q

what are the advantages of ECMO?

A

improve oxygen delivery

improve carbon dioxide removal

rest lung and prevent ventilator associated lung injury

resolve respiratory acidosis

reduce multiple organ dysfunction arising from hypoxaemia and hypercapnia

90
Q

what are the disadvantages of ECMO?

A

not universally available/inequity of provision of care

bleeding: intra-cerebral, venepuncture sites

infection

expensive

invasive

brs (phase 1b) (71 decks)

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