Acute Respiratory Failure

Transcription

1 Acute Respiratory Failure יובל לאונוב

2 ? Respiratory failure?

3 Respiratory a o y failure Hypoxic Hypercapnic Hypoxemic Respiratory Failure (type I) Hypercapnic Respiratory Failure (type II)

4 Hypercapnic Respiratory Failure (type II) PUMP FAILURE pure Hypoventilation CNS depression Spinalp Neuro/Musc(ALS;G-B) Chest wall Upper aw Periph aw -COPD Fatigue

5 Hypoxemic Respiratory Failure (type I) Lung FAILURE

6 Hypoxemic Respiratory Failure (type I) LUNG FAILURE O 2 Parenchymal Pulm. Edema Pneumonia Contusion Atelectasis Cardiogenic ARDS

7 Hypoxemic Respiratory Failure (type I) LUNG FAILURE Parenchymal Pulm. Edema Pneumonia Contusion Atelectasis Cardiog ARDS Obstructive Asthma/COPD

8 Hypoxemic Respiratory Failure (type I) LUNG FAILURE Parenchymal Pulm. Edema Pneumonia Contusion Atelectasis Cardiog ARDS Obstructive Asthma/COPD

9 Hypoxemic Respiratory Failure (type I) LUNG FAILURE Parenchymal Pulm. Edema Pneumonia Contusion Atelectasis Cardiog ARDS Obstructive Vascular Asthma/COPD PE

10 LUNG FAILURE Hypoxemic Respiratory Failure Parenchymal Obstructive Vascular Pulm. P l Edema Pneumonia Contusion Atelectasis Asthma/COPD PE

11 ABG ph PO2 PCO2 Bicarb

12 Hypercapnic Respiratory Failure PaCO =V. 2 CO2 V. V A V T x RR V E -V D V D : dead space ventilation (area in the respiratory D system which is ventilated but has no perfusion)

13 ? חולה התקבל לחדר מיון מונשם ע"י מד"א ללא ספור ברור... מיד עם בואו מנשימים עם 100% חמצן. חמצן : לדקה ועל 100% עורקי עם קצב 10 גזים בדם

14 גזים בדם עורקי על 100% חמצן: איזה משפט מתאים לחולה: ABG ph 7.43 החולה ללא בעיה בחילוף הגזים בעיה קלה בחילוף הגזים לחולה לחולה בעיה קשה בחילוף הגזים PCO2 42 מה ה PaO 2 הנורמלי על 100% חמצן: PO mmhg PaO 2 = Bicarb PaO 2 = PaO 2 = PaO 2 =

15 במידה וצלום החזה נראה סה "כ תקין ללא אינפילטרטים אלבאולריים ABG ph 7.43 מה הפתולוגיה האפשרית להפרעה החמצונית PCO2 PO2 Bicarb mmhg - 22 לב קרדיו/ ARDS 1. אי ספיקת אסטמה או PE פנאומוניה/קונטוזיה אטלקטזיז

16 Hypoxic respiratory failure (type I) Hypoxemia: Abnormally low oxygen in the blood

17 A - agradient? Difference between Alveolar PAO 2 & arterial PaO2 A measure of efficacy of gas exchange Between alveoli & capillary P A O2 P a O2

18 What is a Normal A - a Gradient? Even normal lungs have some degree of: V/Q mismatching and a small quantity of right-to-left shunt, However, an increase in alveolar-to-arterial PO 2 above N mm Hg 2 indicates pulmonary disease as the cause of hypoxemia.

19 What is a Normal A - a Gradient? Increases with age Normal A - a = 0.25 (age) Increase with 0 2 % on 21% = gradient - 20 on 50% = gradient - 50 on 100% =gradient - 100

20 Alveolar l Gas Equation 760 mmhg 47 mmhg P A O 2 = (P atm P H20 ) x (FI0 2 ) - P a CO mmhg 21%

21 Alveolar l Gas Equation 760 mmhg 47 mmhg P A O 2 = (P atm P H20 ) x (FI0 2 ) - P a CO mmhg 40%

22 Alveolar l Gas Equation 760 mmhg 47 mmhg P A O 2 = (P atm P H20 ) x (FI0 2 ) - P a CO mmhg 100%

23 Assess Oxygenation by A a Gradient O 2 %x700 - P a CO 2 x Gradient room air - 1/4 age ( age 40 = ) 100% O2 - = % x5= 100 PaO2 40% x5= 200 O 2 % x 5 70% x5= % x5= 500

24 Assess Oxygenation by PO 2 /FIO 2 ratio 100/0.2 = 500 OK 100/0.3 = /0.4 = 250 ALI 100/0.5 =200 ARDS

25 SOFA score

26 Mechanisms of Hypoxia Low atm pressure Low FIO 2 Hypoventilation Hypoxemia Normal A a gradient Shunt Abnormal A a V/Q mismatch gradient

27 VENTILATION - PERFUSION RELATIONSHIP O2 V/Q=1 shunt shunt shunt

28 VENTILATION - PERFUSION RELATIONSHIP V/Q=1

29 VENTILATION - PERFUSION RELATIONSHIP V/Q=1 shunt shunt

30

31 Low PO2 FiO2

32 Low PO2 FiO2? PEEP

33

34 0 0

35 CPAP 0 5 0

36 exp insp Exp+PEEP i e 1 3