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BRS YR2 > Respiratory Failure > Flashcards

Respiratory Failure Flashcards

1
Q

What is respiratory failure?

A

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

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2
Q

What failing parts of the nervous system that can cause respiratory failure?

A
  • CNS/brainstem
  • Peripheral nervous system
  • Neuromuscular junction
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3
Q

What are the failing respiratory muscles which can cause respiratory failure?

A
  • Diaphragm & thoracic muscles
  • Extra-thoracic muscles
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4
Q

What are the failing parts of the pulmonary system which can cause respiratory failure?

A
  • airway disease
  • alevolar-capillary
  • circulation
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5
Q

How has the epidemiology of chronic respiratory failure changed since the 1990s?

A

More prevelant, risen by 40%

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6
Q

What is the biggest risk factor of chronic respiratory failure for men?

A

smoking

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7
Q

What is the biggest risk factor of chronic respiratory failure for women?

A

household air pollution from solid fuels

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8
Q

What is the prevalence of acute respiratory failure?

A
  • 6-700 people/year
  • 30-40% mortality
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9
Q

What are the risk factors for chronic respiratory failure?

A
  • COPD
  • Pollution
  • Recurrent pneumonia
  • Cystic fibrosis
  • Pulmonary fibrosis
  • Neuro-muscular diseases
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10
Q

What are the risk factors for acute respiratory failure?

A
  • viral or bacterial infection
  • aspiration
  • trauma
  • pancreatitis
  • transfusion
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11
Q

What factors can increase the mortality of acute respiratory failure?

A
  • severity
  • age
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12
Q

Which dieseases can be classified as acute respiratory failure?

A
  • infection
  • aspiration
  • primary graft dysfunction
  • trauma
  • pancreatitis
  • sepsis
  • myasthenia/GBS
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13
Q

What possible diseases are classed as chronic respiratory failure?

A
  • COPD
  • Lung fibrosis
  • cystic fibrosis
  • lobectomy
  • muscular dystrophy
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14
Q

What are examples of acute on chronic respiratory failure?

A
  • Infective exacerbation (COPD, CF)
  • Myasthenic crises
  • Post-operative complications
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15
Q

Which area of the lung has greater ventilation and why?

A
  • bottom of lung
  • smaller transmural pressure
  • alveoli are smaller and more compliant
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16
Q

Which part of the lung has greater perfusion and why?

A
  • bottom of lung
  • higher intravascular pressure
  • more recruitment and less resistance
  • higher flow rate
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17
Q

Where will the bulk of gas exchange occur in the lungs?

A

Middle and bottom

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18
Q

What is compliance?

A

The tendency to distort under pressure

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19
Q

What is elastance?

A

The tendency to recoil to its original volume

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20
Q

What happens in type 1 (hypoxemic) respiratory failure?

A

PaO2 < 60
failure of oxygen exchange

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21
Q

What can cause type 1 respiratory failure?

A
  • collapse
  • aspiration
  • pulmonary oedema
  • fibrosis
  • pulmonary embolism
  • pulmonary hypertension
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22
Q

What happens in type 2 (hypercapnic) respiratory failure?

A

PaCO2 > 45
failure to exchange or remove carbon dioxide
- decreased alveolar minute ventilation
- dead space ventilation

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23
Q

What can cause type 2 respiratory failure?

A
  • CNS/PNS
  • muscle failure
  • airway obstruction
  • chest wall deformities
  • reduced minute ventilation
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24
Q

What happens in type 3 (perioperative) respiratory failure?

A
  • airway collapse due to low functional residual capacity
  • abnormal abdominal wall mechanics limiting chest movement
  • hypoxaemia OR hypercapnia
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25
Q

How do you prevent type 3 respiratory failure?

A
  • anaesthetic or operative technique
  • posture
  • incentive spirometry
  • analgesia
  • efforts to lower intra-abdominal pressure
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26
Q

What happens in type 4 (shock) respiratory failure?

A

poor lung perfusion in patients that are intubated and ventilated during shock (septic, cardiogenic, nuerologic)

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27
Q

How do you prevent type 4 respiratory failure?

A

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

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28
Q

What are the effects of ventilation on the heart?

A 
Increases thoracic pressure 
- reduced LV afterload
- increased RV preload and afterload
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29
Q

What are the 5 main origins of shortness of breath?

A
  • lower respiratory tract infections
  • aspiration
  • trauma
  • pulmonary vascular disease
  • extrapulmonary: pancreatitis; new medications
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30
Q

What form of lower respiratory tract infection can cause shortness of breath?

A
  • viral
  • bacterial
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31
Q

What form of trauma can cause shortness of breath?

A

transfusion

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32
Q

What form of pulmonary vascular disease can cause shortness of breath?

A
  • pulmonary embolus
  • haemoptysis
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33
Q

When is ventilation used?

A

Type IV respiratory shock

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34
Q

What is ARDS?

A

Acute respiratory distress syndrome

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35
Q

What are the pulmonary causes of ARDS?

A
  • aspiration
  • trauma
  • burns (inhalation)
  • surgery
  • drug toxicity
  • infection
36
Q

What are the extra-pulmonary causes of ARDS?

A
  • trauma
  • pancreatitis
  • burns
  • transfusion
  • surgery
  • BM transplant
  • drug toxicity
37
Q

what do the pulmonary causes of ARDS tend to effect?

A

The alveoli

38
Q

what do the extra-pulmonary causes of ARDS tend to effect?

A
  • systemic
  • cytokine release
39
Q

What cytokines signal the inflammation pathway in the alveoli?

A

TNF-a and IL-8

40
Q

What is a possible result of inflammation of the alveoli?

A
  • fluid build up (protein rich oedema)
  • degradation of surfactant
  • leukocyte migration
  • gas exchange becomes less efficient so patient deteriorates further
41
Q

What mechanisms cause a persistant, chronic pleural insufficiency?

A
  • infection
  • inflammatory response
  • immune response
42
Q

What is the significance of TNF signalling?

A
  • causes lung injury
  • inhibition leads to lung injury prevention
43
Q

What is involved in leukocyte activation and migration?

A
  • macrophage activation (in the alveoli)
  • neutrophil lung migration
44
Q

What are the 2 DAMPs involved in lung injury?

A

HMGB-1
RAGE

45
Q

What cytokines are released during lung injury?

A
  • IL-6
  • IL-8
  • IL-1B
  • IFN-y
46
Q

What is the role of cell death associated with ARDS?

A

necrosis in lung biopsies

47
Q

What mediators are associated with apoptosis?

A
  • FAS
  • FAS-I
  • BCI-2
48
Q

What forms of pharmacological interventions have been tried for ARDS?

A
  • steroids
  • salbutamol
  • surfactant (children)
  • N-Acetylcysteine
  • Nuetrophil esterase inhibitor
  • GM-CSF
  • Statins
49
Q

What forms of pharmacological interventions are being trialled for ARDS?

A
  • Mesenchymal stem cells
  • keratinocyte growth factor
  • microvesicles
  • high dose vitamin C, thiamine and steroids
  • ECCO2R
50
Q

Why is there limited evidence for treatment for ARDS?

A

because the disease is so heterogenous

51
Q

What is the key to treating ARDS?

A

that identification of the driving biological mechanism is key

52
Q

What are the three key aspects when managing ARDS?

A
  • treat the underlying disease
  • respiratory support
  • multiple organ support
53
Q

What options are available to treat the underlying cause?

A
  • inhaled therapies
  • steroids
  • antibiotics
  • anti-virals (got cold/during flu season)
  • drugs
54
Q

What inhaled therapies can be used to treat the underlying cause in respiratory failure?

A
  • bronchodilators
  • pulmonary vasodilators
55
Q

What drugs can be used to treat the underlying cause in respiratory failure?

A
  • pyridostigmine (muscular failure)
  • plasma exchange
  • IVIG
  • Rituximab
56
Q

What forms of respiratory support is available for those with ARDS?

A
  • physiotherapy
  • oxygen
  • nebulisers (salbutamol, saline)
  • high flow oxygen
  • non-invasive ventilation
  • mechanical ventilation
  • extra-corporeal support (ECMO)
57
Q

What forms of cardiovascular support is available for those with ARDS?

A
  • fluids
  • vasopressers
  • inotropes
  • pulmonary vasodilators (NO)
58
Q

What forms of renal support is available for those with ARDS?

A
  • haemofiltration
  • haemodialysis
59
Q

What forms of immune support is available for those with ARDS?

A
  • plasma exchange
  • convalescent plasma
60
Q

What are the consequences of ARDS?

A
  • poor gas exchange
  • inadequate oxygenation/poor perfusion
  • hypercapnoea
  • sepsis (sick with underlying infection)
  • inflammation
  • systemic effects
61
Q

What are the types of ventilation?

A
  • volume-controlled
  • pressure-controlled (most common)
  • assisted breathing modes
  • advanced ventilatory modes
62
Q

What respiratory support is necessary with ARDS?

A

mechanical intervention (ventilation)

63
Q

What are is the change in compliance with ARDS?

A
  • reduced in the injured lung
  • reaches peak volume slower, and peak volume is lower than that of a normal lung
  • takes longer to accept changes in the volume and pressure
64
Q

What is the significance of the the upper inflection point with ARDS?

A

above that pressure, additional alveolar recruitment requires disproportionate increases in applied airway pressure

65
Q

What is the lower inflection point with ARDS?

A

the minimum baseline pressure (PEEP) needed for optimal alveolar recruitment

66
Q

What are the negatives of ventilation?

A
  • PaCO2 control is difficult (Type II or high chest volume)
  • Positive end expiratory pressure due to poor emptying of the lung
  • V/Q mismatch
    ventilation w/o gas exchange
  • ventilator induced lung injury (reduced by decreasing driving pressure)
67
Q

What happens in a lung recruitment CT?

A
  • high pressure ventilator
  • low driving pressure
  • aim: open up the lung
68
Q

What does it mean when consolidation reduces during a lung recruitment CT?

A

there are recruitable alveoli present

69
Q

What is the risk of over distending the lung in a lung recruitment CT?

A
  • traps more gas
  • reduces perfusion
  • limit right ventricular function
  • damage via trauma
70
Q

What is ECMO?

A
  • extracorporeal membrane oxygenation
  • pumps and oxygenates a patient’s blood outside the body, allowing the heart and lungs to rest
71
Q

What are the guidelines used when trying to escalate treatment?

A

Murray score

  • PaO2
  • CXR
  • PEEP
  • Compliance
72
Q

What are the classifications of the Murray score?

A 
0 = normal
1-2.5 = mild
>2.5 = severe
>3 = ECMO
73
Q

Where can ECMO occur?

A

5 national centres

74
Q

What can be done to reduce the Murray score?

A
  • proning

-

75
Q

What is the national ARDS approach?

A
  • telephone/online referral
  • consultant case review
  • imaging transfer
  • advice
  • retrieval
  • transfer
  • ongoing management
76
Q

What is the inclusion criteria for ECMO?

A
  • severe respiratory failure
  • non-cardiac score (Murray score 3+)
  • positive pressure ventilation is not appropriate
77
Q

When may positive pressure ventilation not be appropriate?

A

eg: significant tracheal injury

78
Q

What is the exclusion criteria for ECMO?

A
  • contraindication to continuing treatment
  • significant co-morbidity (dependency to ECMO support)
  • significant life limiting co-morbidity
79
Q

What is the general requirement for ECMO?

A
  • reversible disease process
  • unlikely to lead to prolonged disability
80
Q

What happens in ECMO?

A
  • cannula from groin into the IVC
  • draw blood through a pump and artificial membrane
  • gas flow through oxygenator above allows for CO2 removal and supplementation of oxygen
  • re-enters via jugular vein/femoral vein into the right atrium
81
Q

What are the issues with ECMO?

A
  • time to access
  • referral system: geographical inequity
  • awareness of ECMO
  • obtaining access: (internal jugular, subclavian, femoral)
  • circuit
  • haemodynamics
  • clotting/bleeding (required)
  • expensive
  • infection of the cannula
  • epistaxis
  • haemolysis
  • haemoptysis
82
Q

Which criteria is used to classify ARDS?

A
  • timing
  • chest imaging
  • oedema origin
  • PF ratio
83
Q

What are the common causes to acute respiratory failure?

A
  • LRT infection
  • aspiration
  • trauma
  • pancreatitis
  • pulmonary vascular disease
  • TRALI
  • PE
84
Q

What are the 3 mechanisms of acute lung injury?

A
  • inflammation
  • infection
  • immune response
85
Q

What 2 imaging options are available for diagnosis and treatment of ARDS?

A
  • recruitment lung CT
  • lung USS
86
Q

What are the advantages of using ECMO?

A
  • improve oxygen delivery
  • improve carbon dioxide removal
  • rest lung
  • prevent ventilator associated lung injury
  • resolve respiratory acidosis
  • reduce multiple organ dysfunction arising from hypoxaemia and hypercapnoea

BRS YR2 (67 decks)

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