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Respiratory Failure Flashcards

1
Q

What is adult respiratory distress syndrome

A

Fluid accumulation in alveoli due to increased permeability

Non cardiac pulmonary oedema

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2
Q

What are pulmonary causes of adult respiratory distress

A 
Pneumonia
Direct lung injury 
Smoke inhalation
Vasculitis
Aspiration
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3
Q

What are other causes of RDS

A 
Sepsis
Shock
Massive haemorrhage
Blood transfusion - within 6 hours usually known as TRALI
Trauma
Head injury = sympathetic = pulmonary hypertension
DIC
Pancreatitis
Liver failure
Bypass
Drugs / toxins
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4
Q

What are symptoms of RDS

A 
Acute + severe
SOB
Tachycardia
Tachypnoea
Cyanosis
Bilateral crackles - fine
Low sats
Hyperaemia
Multi-organ failure
Signs of hypercapnia if rises
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5
Q

What are symptoms if on ventilatory

A

Rising ventilatory pressure

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6
Q

What is the criteria for diagnosing RDS

A

Within 1 week of trigger
Pulmonary oedema on CXR (not explained by collapse or effusion)
Non-cardiogenic cause
PaO2 <40kPa

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7
Q

How do you treat RDS

A 
ITU
Oxygen
Negative fluid balance - diuretic / haemodialysis 
Ventilation - low TV 
CPAP but most need ventilation
Organ support 
Vasopressor to maintain CO 
Nutrition
Treat cause
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8
Q

What are complications of RDS

A

Scarring

Decreased lung function

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9
Q

What causes atelectasis (collapse)

A

Post-op
Obstructed airway - COPD / asthma
Basal alveolar collapse

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10
Q

When should you consider atelectasis post op

A

72 hours

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11
Q

What are the symptoms

A 
SOB
Hypoxaemia
Resp difficulty 
Decreased expansion
Decreased breath sounds
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12
Q

How do you treat

A

Chest physio

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13
Q

What is type 1 respiratory failure

A

PaO2 <8

PaCo2 normal

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14
Q

What causes type 1 respiratory failure

A

V/Q mismatch
Hypoventilation
Abnormal diffusion
R-L shunt

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15
Q

What can cause a V/Q mismatch (poor perfusion due to barrier to gas exchange)

A 
Pneumonia
Pulmonary oedema
PE
Asthma
Emphysema
Fibroids
RDS
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16
Q

What are the symptoms of type 1

A 
Features of cause 
Features of hypoxia
Restless
SOB
Agitated
Confusion
Cyanosis
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17
Q

What happens in long standing type 1

A

Polycythaemia
Hypertension
Cor pulmonale

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18
Q

How do you Dx

A 
FBC, U+E, CRP
ABG
CXR
Sputum and blood 
Spirometry
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19
Q

How do you treat type 1

A 
Treat cause 
Oxygen 
Monitor O2 with ABG and increase if CO2 stable
Assisted ventilation if PaO2 <8
CPAP
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20
Q

Why do you want to control O2 delivery even in type 1

A

As want to be able to see if condition worsens and sats drop

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21
Q

Why is CPAP only indicated in type 1

A

Decreases ventilation as no pressure differenece
Can’t be used in type 2 which is due to decreased ventilation
Useful for pulmonary oedema as pushes fluid out

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22
Q

What does CPAP do

A

Stops lungs collapsing so increases O2 delivery

Can be delivered through high flow nasal cannula - 40l

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23
Q

What is O2 a good marker of

A

Diffusion i.e. in oedema / infection

24
Q

What is CO2 a good marker of

A

Poor ventilation

Very soluble so shouldn’t be affected by diffusion issues

25
Q

What is type 2 resp failure

A

PaO2 <8

PaCO2 >6

26
Q

What causes type 2 respiratory failure

A 
Alveolar hypoventilation with or without V/Q mismatch
Ventilation issue 
Asthma
COPD
OSA
Fibrosis 
Drugs
CNS tumour
Trauma 
Neuromuscular
Thoracic wall disease
27
Q

How does type 2 present

A 
Hypercapnia 
Headache
Peripheral vasodilation
Tachycardia
Bounding pulse
Tremor
Papilloedema
Confusion
Drowsy
Coma
28
Q

How do you treat type 2

A 
Treat underlying cause
Beware of hypoxic drive
Controlled O2
Check ABG regularly
Consider NIPPV if CO2 rising
Bipap
Intubation if this fails
ECMO
29
Q

What do you start at

A

24%

30
Q

What do you aim sats to be

A

88-92%

31
Q

Consequences

A

Acidosis

32
Q

What is cor pulmonale

A

RHF due to pulmonary hypertension caused by respiratory disease

33
Q

What causes cor pulmonale

A

Chronic lung disease

  • COPD = most common
  • Fibrosis
  • Severe asthma
  • Bronchiectasis
  • CF
Pulmonary vascular
- PE 
- Vasculitis
- PPH
- ARDS 
- Sickle
Neuromuscular - MS / MG
Chest deformity / scoliosis 
Hypoventilation - OSA / adenoids
Cerebrovascular
34
Q

What are symptoms of cor pulmonate

A 
Asymptomatic 
Dyspnoea = main Sx
Fatigue
Syncope
CYanosis 
Tachycardia
Raised JVP
RV heave
Loud P2
Pansystolic murmur - tricuspid regurgitation 
Hepatomegaly 
Peripheral oedema
35
Q

How do you investigate

A

FBC - polycythaemia
ABG
CXR
ECG - RAD / RVH

36
Q

Wha will CXR show

A

Enlarged RA and RV

Prominent pulmonary arteries

37
Q

How do you treat cor pulmonale

A 
Treat cause
Treat res failure
Treat cardiac failure
LTOT often needed 
Venesection if haemocrit >55%
Heart and lung transplant in the young
38
Q

What causes chronic ventilatory failure

A 
Extreme OSA
COPD 
Bronchiectasis
Chest wall abnormality
Resp muscle weakness e.g. MND
Central hypoventilation
39
Q

What are the symptoms of chronic ventilatory failure

A 
SOB
Orthopnoea
Oedema 2 cor pulmonale 
Morning headache due to rise in CO2
Chest infection
Disturbed sleep
40
Q

What does blood gas show

A

Elevated CO2

Decreased O2

41
Q

How do you investigate chronic ventilatory failure

A

Lung function test
Overnight oximetry
CO2 monitoring
Spirometry

42
Q

Spirometry shows

A

Restrictive

Drop in vital capacity lying flat

43
Q

How do you treat

A

Non-invasive ventilation
Oxygen
Tracheostomy if pH <7.25

44
Q

Indications for non-invasive ventilation

A

COPD with pH 7.25-7.35
Type 2 res failure
Cardiopulmonary oedema resistant to CPAP
Weaning from tracheostomy

45
Q

What excludes cardiac cause for ARDS

A

Normal capillary wedge pressure

46
Q

When is ventilation indicated

A

pH <7.25

47
Q

What is CPAP

A

Continuous +Ve airway pressure

Keeps airway expanded so air can move in and out

48
Q

What are indications for CPAP

A

OSA
CCF
Acute pulmonary oedema

49
Q

What is BiPAP

A

Bilevel +Ve airway pressure

Involves high or low pressures to correspond to ventilation

50
Q

When is it used

A

Type 2 resp failure
Usually due to COPD
If pH <7.35 despite medical therapy

51
Q

What does non-invasive ventilation mean?

A
  • Non-invasive ventilation (NIV) delivers ventilatory support to improve respiratory failure via an inter- face that does not cross the larynx.
52
Q

What is CPAP?

A
  • CPAP applies a constant pressure throughout the respiratory cycle and works by splinting open and recruiting collapsed alveoli, thus reducing pulmonary circulatory shunting and improving lung compli- ance.
  • This improves oxygenation and reduces the work of breathing.
  • CPAP is often included under NIV, technically it does not provide ventilatory support as there is no assistance with inspiration.
53
Q

Indications for CPAP [3]

A
  • Worsening Type 1 respiratory failure by either bridging to or avoiding intubation.
  • Acute cardiogenic pulmonary oedema by improving lung compliance and oxygenation when drug treatment has been optimised. CPAP also assists in the translocation of interstitial fluid to the alveolar capillaries surrounding the alveoli, further improving gas exchange.
  • In the domiciliary setting, CPAP can be used as a treatment of obstructive sleep apnoea/ hypoapnoea syndrome (OSAHS) by splinting open the airways and improving oxygenation.
54
Q

Indications for NIV [3]

A
  • Acute exacerbation of COPD
  • Decompensated OSA
  • Respiratory failure secondary to neuromuscular weakness or chest wall deformity.
55
Q

Patient monitoring on non-invasive ventilation or CPAP [2]

A
  • For both CPAP and NIV, there should be continuous pulse oximetry and ECG monitoring for the first 2 hours, and regular RR, pulse, BP measurements and assessments of consciousness.
  • ABG should be taken as a minimum at 1, 4 and 12 hours after the initiation of NIV. This will guide changes in settings, escalation plans to intubation and ceilings of treatment.
56
Q

Contraindications for non-invasive ventilation [7]

A
  1. Impaired consciousness or confusion – the patient will not be able to trigger sufficient breaths and should be assessed for intubation immediately.
  2. Life-threatening hypoxaemia.
  3. Haemodynamic instability or arrest. NIV reduces preload so can lower blood pressure further, so patients should be considered for admission to ICU.
  4. Facial surgery or burns.
  5. Undrained pneumothorax: the positive pressure ventilation may convert a simple pneumothorax to
    a tension pneumothorax.
  6. Vomiting.
  7. Inability to protect airway, e.g. GCS < 8.

Respiratory (14 decks)

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