Your SlideShare is downloading. ×
Early Detection And Management Of Respiratory Failure
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Early Detection And Management Of Respiratory Failure

1,481

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,481
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
112
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Early Detection and Interventions in Respiratory Failure Dr Nigam Prakash Narain
  • 2. Definition: Respiratory Failure
    • Defined as inadequate gas exchange due to pulmonary or non-pulmonary causes leading to hypoxemia, hypercarbia or both.
    • Documented by PaCO 2 > 50 mm of Hg or PaO 2 < 50-60 mm of Hg .
  • 3. Status of ABG
    • Arterial Blood Gas analysis: single most important lab test for evaluation of respiratory failure .
  • 4. Respiratory Failure: Causes
    • Upper airways obstruction:
    • > Laryngomalacia
    • > Subglottic stenosis
    • > Laryngotracheobronchitis
    • > Tracheitis & Epiglottitis
    • > Retropharyngeal / Peritonsillar abscess
    • > Acute hypertrophic tonsillitis
    • > Diphtheria
    • > foreign body, trauma, vocal cord palsy
  • 5.
    • Lower airway obstruction:
    • > Bronchiolitis, Asthma, Foreign body
    • Alveolar and pleural disease:
    • > pneumonia, pulmonary edema, effusion
    • empyma, pneumothorax, ARDS
    • CNS causes:
    • > Infections, injury, trauma, seizures
    • > tetanus, SMA, Polio
    • > AIDP, Phrenic nerve injury
    • > Myasthenia gravis, botulism,
    • > Muscle dystrophies, Polymyositis
    • > Congenital myopathies, muscle fatigue
  • 6. Respiratory failure: clinical manifestations
    • Tachypnea
    • Exaggerated use of accessory muscles
    • Intercostal, supraclavicular and subcostal retractions
    • In neuromuscular disease, the signs of respiratory distress may not be obvious
    • In CNS disease, an abnormally low respiratory rate, and shallow breathing are clues to impending respiratory failure
  • 7. Presentation
    • Three distinctive clinical profiles have been suggested in children:
    • 1. Mechanical dysfunction of airways
    • 2. Neuromuscular dysfunction
    • 3. Breathing control dysfunction
    • A rapid assignment to one of these profiles facilitates early diagnosis and treatment
  • 8. Profile 1: Mechanical dysfunction of airways
    • Most common type
    • Results from alterations in the mechanical properties of the airways, lung parenchyma or chest wall.
    • Present with typical signs of respiratory distress:
    • increased effort, Tachypnea, retractions, accessory muscle use, nasal flaring, adventitious breath sounds, grunting
  • 9. Profile 2: neuromuscular disease
    • Results from myopathies involving resp muscles or polyneuropathies / phrenic nerve injuries
    • Associated with an increased neural output, but is not effectively translated into effective contractions
    • Tachypnea, shallow respiratory efforts and profound dyspnea are characteristic
  • 10. Profile 3: Alteration in control of breathing
    • Usually results from CNS injury / developmental deficits
    • Ondine’s curse, Apnea of prematurity, CNS injury / depression
    • Associated with decreased neural output to resp muscles, thus signs of respiratory distress are unusual, even with significant respiratory compromise
  • 11. Evaluation of Respiratory failure
    • The following parameters are important in evaluation of respiratory failure:
    • PaO 2
    • PaCO 2
    • Alveolar-Arterial PO 2 Gradient
    • P(A-a)O 2 Gradient = P I O 2 – PaCO 2 / R
    • where P i O 2 = partial pressure of inspired air,
    • R = 0.8
    • Hyperoxia Test
  • 12. PaO 2 / PaCO 2
    • Normal value depends on :
    • a. Position of patient during sampling
    • b. Age of patient
    • PaO 2 (Upright) = 104.2 -- 0.27 x age (Yrs)
    • PaO 2 (Supine) = 103.5 – 0.47 x age (Yrs)
    • PaCO 2 : normal value= 35-45 mm of Hg
    • unaffected by age/ positioning
  • 13. Alveolar-Arterial O 2 gradient
    • Normal P(A-a)O 2 gradient: 5-10 mm of Hg
    • A sensitive indicator of disturbance of gas exchange.
    • Useful in differentiating extrapulmonary and pulmonary causes of resp. failure.
    • For any age, an A-a gradient > 20 mm of Hg is always abnormal.
  • 14. Causes of Hypoxemia
    • Low P i O 2 ~ at high altitude
    • Hypoventilation ~ Normal A-a gradient
    • Low V/Q mismatch ~ A-a gradient
    • R/L shunt ~ A-a gradient
  • 15. Hypoventilation-Diagnosis
    • PaO 2
    • PaCO 2 is always increased
    • A-a gradient is normal ( ≤ 10 mm of Hg)
    • Hyperoxia Test : dramatic rise in PO 2
  • 16. V/Q mismatch- Diagnosis
    • PaO 2
    • A-a gradient is
    • PaCO 2 may or may not be elevated
    • Hyperoxia test : Dramatic rise in PaO 2
  • 17. R-L shunt: diagnosis
    • PaO 2 is
    • PaCO 2 is usually normal
    • A-a gradient is
    • Hyperoxia Test : Poor / No response
  • 18. Hypercapnia : Causes
    • Hypoventilation
    • Severe low V/Q mismatch: major mechanism of hypercapnia in intrinsic lung disease.
  • 19. Status of ABG
    • It is not possible to predict PaO 2 and PaCO 2 accurately using clinical criteria.
    • Thus, the diagnosis of Respiratory failure depends on results of ABG studies.
  • 20. Respiratory failure: Interventions
    • Supportive therapy
    • Specific therapy
  • 21. Supportive therapy
    • Secure the airway
    • Pulse oximetry
    • Oxygen: by mask, nasal cannula, head box
    • Proper positioning
    • Nebulization if indicated
    • Blood sampling: Routine, electrolytes, ABG
    • Secure IV line
    • CXR: upright AP & lateral views
  • 22. Hypoxemic / Non - Hypercapnic respiratory failure
    • The major problem is PaO 2.
    • If due to low V/Q mismatch; oxygen therapy.
    • If due to pulmonary intra-parenchymal shunts (ARDS), assisted ventilation with PEEP may be needed.
    • If due to intracardiac R-L shunt: O 2 therapy is of limited benefit. Surgical t/t is needed.
  • 23. Hypercapnic Respiratory failure
    • Key decision is whether mechanical ventilation is required or not.
    • In Acute respiratory acidosis: Mechanical ventilation must be strongly considered.
    • Chronic Resp acidosis: patient should be followed closely, mech ventilation is rarely required.
    • In acute-on-chronic respiratory failure, the trend of acidosis over time is a crucial factor.
  • 24. Mechanical Ventilation: Indications
    • PaO 2 < 55 mm Hg or PaCO 2 > 60 mm Hg despite 100% oxygen therapy.
    • Deteriorating respiratory status despite oxygen and Nebulization therapy
    • Anxious, sweaty lethargic child with deteriorating mental status.
    • Respiratory fatigue: for relief of metabolic stress of the work of breathing
  • 25. Mechanical Ventilation: Strategies
    • Non-Invasive Ventilation: CPAP / BIPAP
    • Invasive Ventilation: SIMV, A/C, PAV
    • Other approaches to mechanical ventilation:
    • a. High frequency ventilation (HFV)
    • b. Permissive Hypercapnia
    • c. Prone positioning
    • d. ECMO
  • 26. HFV
    • 3 types: Oscillatory, Jet & Flow interruption
    • Very small tidal volumes are used (<1ml/kg), very rapid rates (150-1000 bpm) and lower mean airway pressures are used.
    • This approach is used to minimize the possibility of barotrauma to airways.
    • Used if conventional ventilation fails to improve gas exchange
  • 27. Permissive Hypercapnia
    • Allows the PaCO 2 to rise into the 60-70 mm of Hg range, as long as the patient is adequately oxygenated (SaO 2 > 92%), and able to tolerate the acidosis.
    • This strategy is used to limit the amount of barotrauma and volutrauma to the patient.
  • 28. Prone positioning
    • Positioning the patient in the prone position has been shown to improve oxygenation and reduce ventilator induced lung injury.
    • However, the outcome may not be improved.
  • 29. ECMO
    • Used in the treatment of newborns and small infants with life threatening, refractory respiratory failure, unresponsive to mechanical ventilation.
    • Inhales nitric oxide may improve oxygenation by reducing increased pulmonary vascular resistance.
    • Inhaled NO is now being used in place of ECMO in NICU in some centers.

×