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CARDIORESPIRATORY 2 > RESPIRATORY FAILURE > Flashcards

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 epidemiology of chronic respiratory disease?

A

3rd leading cause of death however mortality, prevalence and DALY rates is dropping due to treatments becoming more effective

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3
Q

What is acute respiratory failure called?

A

Acute respiratory distress syndrome (ARDS)

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4
Q

How can respiratory failure/disease be classified?

A

Acute
Chronic
Acute on chronic

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5
Q

What does acute respiratory failure/disease entail?

A

Pulmonary: infection, acid aspiration, primary graft dysfunction

Extra-pulmonary: trauma, pancreatitis, sepsis
Neuro-muscular: myasthenia/GBS

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6
Q

What does chronic respiratory failure/disease entail?

A

Pulmonary: COPD, lung fibrosis, CF, lobectomy
Musculoskeletal: muscular dystrophy

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7
Q

What does acute on chronic respiratory failure/disease entail?

A

Infective exacerbation of COPD, CF
Myasthenic crises
Post operative (underlying respiratory disease and then undergo surgery)

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8
Q

How is respiratory failure physiologically classified

A 
Type I (hypoxemic)
Type II (hypercapnic)
Type III (perioperative respiratory failure)
Type IV (shock)
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9
Q

What does type I respiratory failure entail?

A

Hypoxemic (PaO2 < 60) - failure of O2 exchange:

  • Increased shunt fraction
  • Due to alveolar flooding
  • Supplemental oxygen doesn’t help much
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10
Q

What does type II respiratory failure entail?

A

Hypercapnic (PaCO2 > 45) - failure to remove CO2:

  • decreased alveolar minute ventilation
  • dead space ventilation
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11
Q

What does type III respiratory failure entail?

A

Perioperative:
- Increased atelectasis due to low function residual
capacity with abnormal abdominal wall mechanics
which limits the amount the chest can open up
- Hypoxaemia or hypercapnoea

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12
Q

How can type III respiratory failure be prevented?

A

Anesthetic or operative technique
Posture
Incentive spirometry
Analgesia (not tensing abdomen so intra-abdominal pressure lowers)

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13
Q

What does type IV respiratory failure entail?

A

Patients who are intubated and ventilated during shock:
- Septic, cardiogenic or neurologic causing poor
perfusion to lungs

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14
Q

How should type IV respiratory failure be managed?

A

Optimise ventilation to improve gas exchange and unload the respiratory muscles, lowering oxygen consumption

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15
Q

What are the effects of +ve pressure ventilation on the heart?

A 
Reduced afterload (good for left ventricle)
Increased pre-load (bad for right ventricle)
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16
Q

What are some causes of type I respiratory failure?

A 
Lung collapse
Aspiration
Pulmonary oedema
Fibrosis
Pulmonary embolism
Pulmonary hypertension
17
Q

What are some causes of type II respiratory failure?

A

Problems with nervous system, neuromuscular, muscle failure (muscles weak so can’t drive adequate tidal volumes/respiratory rates)
Airway obstruction e.g. COPD
Chest wall deformity e.g. trauma, ageing

18
Q

What are the chronic risk factors for respiratory failure?

A 
COPD
Pollution
Recurrent pneumonia
Cystic fibrosis
Pulmonary fibrosis
Neuro-muscular diseases
19
Q

What are the acute risk factors for ARDS?

A

Infection (viral/bacterial maybe both at some time)
Aspiration (when conscience level drops gastric contents into lungs)
Trauma
Pancreatitis
Transfusion

20
Q

What are the pulmonary causes of ARDS?

A 
Aspiration
Trauma
Burns: inhalation
Surgery
Drug toxicity
21
Q

What are the extra-pulmonary causes of ARDS?

A 
Trauma
Pancreatitis
Burns
Transfusion
Surgery
BM transplant
Drug toxicity
22
Q

What drives the inflammatory response in acute lung injury?

A

TNalpha, IL8, IL6 cause fluid build up (oedema) causing alveolar to be less efficient at expanding

Migrating neutrophils cause damage and oedema outside which increases the distance between alveoli and capillary

23
Q

What are some drugs which can be used for intervention of acute respiratory failure/ARDS?

A 
Steroids
Salbutamol
Surfactant (promising in children)
N-Acetylcysteine (increases viscosity of secretions so easier to clear)
Neutrophil esterase inhibitor
GM-CSF
Statins
24
Q

What are some therapies currently being trialled to help with acute respiratory failure/ARDS?

A 
Mesenchymal stem cells 
Keratinocyte growth factor
Microvesicles
High dose vitamin C, thiamine, steroids
ECCO2R (removal of CO2)
25
Q

What are the 2 endotypes of ARDS?

A

Hyper inflammatory ARDS

Hypo inflammatory ARDS

26
Q

What are some therapeutic interventions for respiratory failure?

A

Treating underlying disease:

  • Bronchodilators, pulmonary vasodilators
  • Steroids
  • Antibiotics
  • Anti-virals
  • Pyridostigmine, plasma exchange, rituximab

Respiratory support:

  • Physiotherapy
  • Oxygen (don’t give type II as can exacerbate it)
  • Nebulisers
  • High flow oxygen
  • Non-invasive ventilation
  • Mechanical ventilation
  • Extra-corporeal support if ^ fails (membrane lung oxygenates and gets rid of CO2)

Multiple organ support:
- Cardiovascular support e.g. fluids, vasopressors
- Renal support e.g. haemofiltration, haemodialysis
- Immune therapies e.g. plasma exchange, convalescent
plasma

27
Q

What are some ways respiratory support can be done for patients?

A

Non-invasive ventilation
Intubation
ECMO cannulation (extra-corporeal support)
Proning

28
Q

What are the effects and complications of ARDS?

A

Poor gas exchange –> low oxygenation, poor perfusion, hypercapnoea causing failure to highly metabolic organs

Infection –> sepsis
Inflammation
Systemic affects

29
Q

What changes can be seen in a pressure volume loop of a patient with ARDS?

A

Reduced compliance

Reduced upper inflection point (UIP) and lower inflection point (LIP)

30
Q

What happens if pressure is increased above the upper inflection point (UIP)?

A

Additional alveolar recruitment requires disproportionate increases in airway pressure which can cause lung damage and inflammation

31
Q

What is lower inflection point (LIP)

A

Minimum baseline pressure needed for optimal alveolar recruitment

Below this the lungs will collapse

32
Q

Why shouldn’t you put too much pressure on inhaled air and increase exhalation time for patients with tight airway diseases on the ventilator?

A

Patients with tight airway diseases don’t completely exhale meaning some air is trapped which can build up increasing pressure and volume preventing effective ventilation of patient

33
Q

What types of imaging can be done for patients with respiratory failure?

A

Lung CT, lung ultrasound

34
Q

How is severity of respiratory failure graded and scored?

A

Murray score taking average of all 4 parameters:

  • PaO2/FIO2
  • CXR
  • PEEP
  • Compliance
35
Q

What are the score boundaries on the Murray score?

A

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

36
Q

When is ECMO considered for patients?

A

When treatments fail and still have high Murray score

37
Q

Describe the procedure of ECMO

A

Large cannula passed up through femoral vein and IVC. Blood withdrawn via tubing to pump which pushes the blood across artificial membrane.

At the membrane gases flowed over the top allowing removal of CO2 and O2 perfusion. Blood then returned

Very invasive

CARDIORESPIRATORY 2 (8 decks)

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