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Phase 1b - Cardiovascular & Respiratory Medicine > Respiratory Failure > Flashcards

Respiratory Failure Flashcards

1
Q

Outline the epidemiology of Acute Respiratory Distress Syndrome (ARDS) (3).

A
  • 10% to 15% of patients admitted to the intensive care unit meet the criteria for ARDS, with an increased incidence among mechanically ventilated patients
  • Sex, ethnicity, and race have not been associated with the incidence of ARDS
  • The mortality of ARDS is approximately 30% to 50%
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2
Q

What are the risk factors for Acute Respiratory Distress Syndrome (ARDS) (Chronic 6 / Acute 5)?

A

Chronic:
* COPD
* Pollution
* Recurrent pneumonia
* Cystic fibrosis
* Pulmonary fibrosis
* Neuro-muscular diseases

Acute:
* Infection
* Viral
* Bacterial
* Aspiration
* Trauma
* Pancreatitis
* Transfusion

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3
Q

Outline the pathogenesis of Acute Respiratory Distress Syndrome (ARDS).

A

Secondary usually to:
* Sepsis with a pulmonary origin (most common)
* Pulmonary causes:
* Aspiration
* Trauma
* Burns: Inhalation
* Surgery
* Drug Toxicity
* Infection
* Extra-pulmonary:
* Trauma
* Pancreatitis
* Burns
* Transfusion
* Surgery
* BM transplant
* Drug Toxicity
* Infection

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4
Q

What are the pulmonary causes of Acute Respiratory Distress Syndrome (ARDS) (6)?

A
  • Aspiration
  • Trauma
  • Burns: Inhalation
  • Surgery
  • Drug Toxicity
  • Infection
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5
Q

What are the extra-pulmonary causes of Acute Respiratory Distress Syndrome (ARDS) (8)?

A
  • Trauma
  • Pancreatitis
  • Burns
  • Transfusion
  • Surgery
  • BM transplant
  • Drug Toxicity
  • Infection
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6
Q

What are the 5 driving causes of acute lung injury in Acute Respiratory Distress Syndrome (ARDS)?

A
  • The lung
  • Leucocytes
  • Inflammation
  • Infection
  • Immune response
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7
Q

Which immune cells are resident within the alveoli?

A
  • Resident macrophages
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8
Q

Outline the pathophysiology of Acute Respiratory Distress Syndrome (ARDS) (4 steps).

A
  1. Injury can damage the alveolar interstitium, therefore this causes the activation of resident alveolar macrophages, releasing IL-6, TNF-alpha and IL-8
  2. Cytokine release induces alveolar fluid accumulation (a protein rich oedema forms within the lung), reducing the effectiveness in expansion
  3. Migration of leukocytes (neutrophils) into the interstitium before entering the site of response - secretes proteases and inflammatory mediators
  4. Increases the distance between the alveoli and capillaries making gas exchange less efficient
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9
Q

Which cytokines are released by activated resident macrophages (3)?

A
  • IL-6
  • TNF-alpha
  • IL-8
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10
Q

Which immune cells respond to acute lung injury in Acute Respiratory Distress Syndrome (ARDS)?

A

Neutrophils

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11
Q

How does gas exchange become less efficient in individuals with acute lung injury in Acute Respiratory Distress Syndrome (ARDS)?

A
  • Recruited neutrophils release proteases, widening the edematous interstitium between the capillary and alveoli.
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12
Q

Which type of signalling is implicated in acute lung injury in Acute Respiratory Distress Syndrome (ARDS)?

A

TNF

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13
Q

Which Damage-associated molecular patterns (DAMPs) are released in acute lung injury Acute Respiratory Distress Syndrome (ARDS) (2)?

A
  • HMGB-1
  • RAGE
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14
Q

Which cytokines are released during acute lung injury in Acute Respiratory Distress Syndrome (ARDS) (4)?

A
  • IL-6
  • IL-8
  • IL-1B
  • IFN-y
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15
Q

Which apoptotic mediators are associated with acute lung injury in Acute Respiratory Distress Syndrome (ARDS) (3)?

A
  • FAS
  • FAS-I
  • BCL-2
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16
Q

Which mediators are elevated in hyperinflammatory endotype of Acute Respiratory Distress Syndrome (ARDS) (3)?

A
  • TNFR-1
  • IL-8
  • IL-6
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17
Q

In hyperinflamed endotype of Acute Respiratory Distress Syndrome (ARDS), which Damage-associated molecular patterns (DAMPs) are elevated (3)?

A
  • Epithelial predominant RAGE, ANG-2 and VEGF-D

Indicating significant induction of inflammation

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18
Q

Which necro-inflammatory mediator is expressed in the airway and elevated in Acute Respiratory Distress Syndrome (ARDS)?

A
  • IL-18
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19
Q

What purpose is performed by IL-18 (2 step)?

A
  1. IL-18 initiates pro-inflammatory NF-kB signalling, and is pivotal for T-cell differentiation and IFN-Y production
  2. Induces airway hyperresponsiveness and macrophage activation
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20
Q

What role is performed by VEGF-D (2)?

A

Relates to angiogenesis and cell-sprouting

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21
Q

What are the consequences of Acute Respiratory Distress Syndrome (ARDS)?

A
  • Poor gas exchange - inadequate oxygenation, poor perfusion, hypercapnoea
  • Infection - sepsis
  • Inflammation - inflammatory response
  • Systemic effects
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22
Q

How would a patient with Acute Respiratory Distress Syndrome (ARDS) present (11 / know 5)?

A
  • Hx of risk factors
  • Low oxygen saturation
  • Acute respiratory failure
  • Critically ill patient
  • Dyspnoea
  • Increased respiratory rate
  • Pulmonary crepitations
  • Low lung compliance
  • Fever
  • Cough
  • Pleuritic chest pain
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23
Q

What investigations are suggested in suspected Acute Respiratory Distress Syndrome (ARDS) (7)?

A
  • CXR
  • ABG
  • Sputum culture
  • Blood culture
  • Urine culture
  • Amylase
  • Lipase
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24
Q

What imaging is involved in Acute Respiratory Distress Syndrome (ARDS)?

A

CT
Lung USS (evaluate how expanded a lung is)

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25
Q

What would a CXR show in an Acute Respiratory Distress Syndrome (ARDS) patient?

A
  • Bilateral infiltrates
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26
Q

What would an ABG test show in an Acute Respiratory Distress Syndrome (ARDS) patient?

A
  • Low partial oxygen pressure (Hypoxaemia)
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27
Q

What would a sputum culture show in an Acute Respiratory Distress Syndrome (ARDS) patient?

A
  • Positive if underlying infection
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28
Q

What would a blood culture show in an Acute Respiratory Distress Syndrome (ARDS) patient?

A
  • Positive if underlying infection
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29
Q

What would a urine culture show in an Acute Respiratory Distress Syndrome (ARDS) patient?

A
  • Positive if underlying infection
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30
Q

What would an amylase and/or lipase show in an Acute Respiratory Distress Syndrome (ARDS) patient?

A
  • 3 times the upper limit of the normal range in cases of acute pancreatitis
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31
Q

What is the management of Acute Respiratory Distress Syndrome (ARDS) (3)?

A
  • Treat underlying disease
  • Respiratory support
  • Multiple organ support

Treat Underlying Disease:
* Inhaled therapies
* Bronchodilators
* Pulmonary vasodilators
* Steroids
* Antibiotics
* Anti-virals
* Drugs
* Pyridostigmine
* Plasma exchange
* IViG
* Rituximab

Respiratory Support:
* Physiotherapy
* Oxygen
* Nebulisers
* High flow oxygen
* Non invasive ventilation
* Mechanical ventilation
* Extra-corporeal support

Multiple Organ Support:
* Cardiovascular support
* Fluids
* Vasopressors
* Inotropes
* Pulmonary vasodilators
* Renal support
* Haemofiltration
* Haemodialysis
* Immune therapies
* Plasma exchange
* Convalescent plasma

32
Q

What specific intervention is made available for Acute Respiratory Distress Syndrome (ARDS)?

A

Intubation and ventilation

33
Q

What types of ventilation is available for the treatment of Acute Respiratory Distress Syndrome (ARDS) (4)?

A
  • Volume controlled
  • Pressure controlled
  • Assisted breathing modes
  • Advanced ventilatory modes
34
Q

What impact does Acute Respiratory Distress Syndrome (ARDS) have on lung compliance?

A
  • Is markedly reduced in the injured lung
35
Q

What type of scoring is used to evaluate the choice of therapy in Acute Respiratory Distress Syndrome (ARDS)?

A

Murray Score

36
Q

What parameters are used in the Murray score (4)?

A
  • PaO2
  • CXR
  • Positive end-expiratory pressure (PEEP)
  • Compliance

Compliance, ml/cm H₂O
Tidal Volume / ( Peak inspiratory pressure – Positive end-expiratory pressure )

37
Q

What Murray score is classed as an escalation to an ECMO?

38
Q

Who should be treated with an ECMO (3 parameters)?

A
  • Severe respiratory failure with non cardiac cause, when positive pressure ventilation is not appropriate
39
Q

Who is excluded from an ECMO?

A
  • Significant life limiting co-morbidity
40
Q

Where is an ECMO cannula typically inserted?

A

Inserted via the femoral vein –> leads to the inferior vena cava below the right atrium

41
Q

What is the purpose performed by an ECMO?

A
  1. The ECMO machine pumps blood from the patient’s body to an artificial lung (oxygenator) that adds oxygen to it and removes carbon dioxide
  2. The ECMO machine then sends the blood back to the patient via a pump with the same force as the heart, replacing its function
42
Q

What is respiratory failure?

A
  • Syndrome of inadequate gas exchange due to dysfunction of one or more components of the respiratory system
43
Q

Which aspects of the nervous system is affected by respiratory failure (3)?

A
  • CNS / Brainstem
  • Peripheral nervous system (PNS)
  • Neuromuscular junctions (Myasthenia gravis)
44
Q

Which respiratory muscles are affected by respiratory failure (2)?

A
  • Diaphragm and thoracic muscles
  • Extra-thoracic muscles
45
Q

Which aspects of the pulmonary system are affected by respiratory failure?

A
  • Airway disease
  • Alveolar-capillary disease - a vascular disease or damage to the area due to fibrosis
  • Circulation (pulmonary hypertension can impair vascular supply)
46
Q

Which parts of the world are predominantly affected by respiratory diseases (2)?

A
  • North America
  • Europe
47
Q

What is the largest risk factor for chronic respiratory failure in males?

48
Q

What is the largest risk factor for chronic respiratory failure in females?

A
  • Household air pollution from solid fuels
49
Q

What factors are classified as causes of acute respiratory failure (Pulmonary 3 / Extra-pulmonary 3 / Neuromuscular 1)?

A

Pulmonary:
* Infection
* Aspiration
* Primary graft dysfunction (Lung Tx)

Extra-pulmonary:
* Trauma
* Pancreatitis
* Sepsis

Neuromuscular:
* Myasthenia / GBS

50
Q

What factors are classified as causes of chronic respiratory failure (Pulmonary 4 / Musculoskeletal 1)?

A

Pulmonary / airways:
* COPD
* Lung fibrosis
* CF
* Lobectomy

Musculoskeletal:
* Muscular dystrophy

51
Q

What factors are classified as causes of acute on chronic respiratory failure (5)?

A
  • Infective exacerbation
  • COPD
  • CF
  • Myasthenia crises
  • Post-operative
52
Q

What is type 1 respiratory failure?

A

Hypoxemic (PaO2 < 60 at sea level)
* There is a failure of oxygen exchange
* Increased shunt faction (QS/QT)
* Due to alveolar flooding
* Hypoxemia refractory to supplemental oxygen

53
Q

What type of respiratory failure is associated with a failure of oxygen exchange?

A
  • Type I (hypoxaemic)
54
Q

What are the 6 possible causes of Type I (hypoxemic) respiratory failure?

A
  • Collapsed lung
  • Aspiration
  • Pulmonary oedema
  • Fibrosis
  • Pulmonary embolism
  • Pulmonary hypertension
55
Q

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

A
  • Type II (Hypercapnic)
56
Q

What is Type II (hypercapnic) respiratory failure?

A
  • Failure to exchange or remove carbon dioxide
57
Q

What are the 5 psosible causes of Type II (hypercapnic) respiratory failure?

A
  • Nervous system
  • Muscle failure
  • Airway obstruction
  • Chest wall deformity
  • Neuromuscular
58
Q

What is type III respiratory failure associated with?

A
  • Perioperative respiratory failure, there is an increased atelectasis due to low functional residual capacity with abnormal abdominal wall mechanics
    • Hypoxemia or hypercapnoea

Atelectasis: partial collapse or incomplete inflation of the lung

59
Q

How can type III (perioperative) respiratory failure be prevented (6)?

A
  • Anaesthetic
  • Operative technique
  • Posture
  • Incentive spirometry
  • Analgesia
  • Attempts to lower intra-abdominal pressure
60
Q

What is type IV respiratory failure associated with?

A
  • Type IV describes patients who are intubated and ventilated during shock (septic, cardiogenic, neurologic)

  • Ventilatory effects on right and left heart (Reduced afterload on left ventricle) due to positive pressure
61
Q

What treatment is available for type IV respiratory failure?

A
  • Optimise ventilation to improve gas exchange and to unload the respiratory muscles, lowering their oxygen consumption
62
Q

What are the chronic risk factors for respiratory failure (6)?

A
  • COPD
  • Pollution
  • Recurrent pneumonia
  • Cystic fibrosis
  • Pulmonary fibrosis
  • Neuro-muscular diseases
63
Q

What are the acute risk factors for respiratory failure (5)?

A
  • Infection - viral / bacterial
  • Aspiration - conscious level drops
  • Trauma - induces inflammatory responses
  • Pancreatitis
  • Transfusion
64
Q

What are the main causes of acute respiratory failure (5)?

A
  • Lower respiratory tract infection (viral or bacterial)
  • Aspiration
  • Trauma - transfusion
  • Pulmonary vascular disease (embolus, haemopysis)
  • Extrapulmonary - pancreatitis, new medications
65
Q

Which pharmacological interventions are available for the treatment of respiratory failure (7)?

A
  • Steroids
  • Salbutamol
  • Surfactant
  • N-acetylcysteine - reduces viscosity of secretions
  • Neutrophil esterase inhibitor
  • GM-CSF
  • Statins
66
Q

Which therapies for respiratory failure are being trialled (5)?

A
  • Mesenchymal stem cells
  • Keratinocyte growth factor
  • Microvesicles
  • High dose Vitamin c, thiamine, steroids
  • ECCO2R - removal of carbon dioxide
67
Q

How is the underlying disease treated in terms of respiratory failure (5)?

A
  • Inhaled therapies:
    • Bronchodilators and pulmonary vasodilators
  • Steroids
  • Antibiotics
  • Anti-virals
  • Drugs:
    • Pyidostigmine
    • Plasma exchange
    • IViG
    • Ritxuimab
68
Q

Which inhaled therapies are available for treating the underlying disease of respiratory failure (2)?

A
  • Bronchodilators
  • Pulmonary vasodilators
69
Q

Which drugs are used to treat the underlying disease of respiratory failure (4)?

A
  • Pyridostigmine
  • Plasma exchange
  • Intravenous immune globulin (IViG)
  • Rituximab
70
Q

What respiratory support is available for respiratory failure (7)?

A
  • Physiotherapy
  • Oxygen
  • Nebulisers
  • High-flow oxygen
  • Non-invasive ventilation
  • Mechanical Ventilation
  • Extra-corporeal support
71
Q

What function do nebulisers have in the support of respiratory failure?

A
  • Reduced mucous load
72
Q

What cardiovascular support is available during respiratory failure (4)?

A
  • Fluids
  • Vasopressors
  • Inotropes
  • Pulmonary vasodilators
73
Q

Which immune therapies are available for respiratory failure (2)?

A
  • Plasma exchange
  • Convalescent plasma
74
Q

What is the upper infection point?

A
  • Above this pressure, additional alveolar recruitment requires disproportionate increases in applied airway pressure
75
Q

What is the lower infection point (LIP)?

A
  • Can be thought of as a minimum baseline pressure [Post end-expiratory pressure (PEEP)] needed for optimal alveolar recruitment

Phase 1b - Cardiovascular & Respiratory Medicine (21 decks)

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