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Respiratory Disorders Associated With Acute Respiratory Failure

By

Prof. Adel Mohamad Saeed

Professor of Chest Diseases
Ain Shams University

Definition:
The term Acute Respiratory Failure (A.R.F ) is used clinically to indicate a disease or disorder of the respiratory system , recent in onset, which has resulted in a level or pattern of external gas exchange that is inadequate for the metabolic needs of the body .

This deficiency is reflected in arterial hypoxemia, hypercapnia and respiratory acidosis. If the initiating mechanism is not arrested, corrected & reversed the abnormalities in the blood gases are apt to progress to intolerable levels. There is no precise level of arterial Po2 or Pco2 that defines [ARF]. However, an arterial Pao2< 50-60 mmHg can be life threatening because further impairment of gas exchange can cause a drop in Pao2 to levels that would compromise Oxygen Delivery [Do2] to vital organs.

Acute rise of PaCo2 to >50 mmHg i.e. Acute Hypercapnia with Respiratory Acidosis result in mental confusion, depressed sensorium that end in coma and death. The effects of acute hypoxemia and acute hypercapnia may overlap, resulting in severe C. N. S depression .

The respiratory apparatus consists of two components : 1- Pump system: includes the entire ventilatory apparatus [Respiratory Center, Thoracic Cage, Air ways]. 2- Gas Exchange system : pulmonary parenchyma [alveoli with alveolar air & alveolo-capillary membrane.

Respiratory Failure can therefore be divided into : Pump Failure or hypercapnic respiratory failure with Co2 retention. Lung Failure or gas exchange failure with arterial hypoxemia i.e. hypoxemic respiratory failure.

Lung Failure (Hypoxemic Respiratory Failure):

Adult respiratory distress syndrome ARDS. Cardiogenic pulmonary edema. End stage pulmonary fibrosis, resulting from different fibrotic lung diseases. Massive Pulmonary Embolism. Severe Pneumonia.

Pump Failure ( Hypercapnic Respiratory

Failure ): Neuromuscular disease, atrophic or pseudo hypertrophic myopathies. Guillain Barre syndrome. Myasthenia gravis. Amyotrophic lateral sclerosis. Cervical quadriplegia. Botulism.

Respiratory Poliomyelitis. Bilateral diaphragmatic paralysis. Hereditary myopathies. Multiple sclerosis. Collagen vascular disease e.g. vanishing lung syndrome in SLE. Central nervous disorders C.V.S. Drug over dose. Head trauma.

Hypothyroidism e.g. myxedema coma. Brain stem infarction& brain neoplasm. Disorders of the chest bellows. Kyphoscoliosis & Chest wall deformities. Chest trauma and Flail Chest. Tension pneumothorax. Massive pleural effusion. Airway obstruction.

Acute severe asthma. COPD Disease" "Chronic Obstructive Pulmonary

Anaphylaxis Cystic fibrosis Upper airway obstruction e.g. Epiglottitis & F.B inhalation.

Hypercapnia due to hypercapnic respiratory failure can arise in one of two ways:

1) Alveolar hypoventilation secondary to a

subnormal low minute ventilation . 2) Ventilation-Perfusion (V /Q ) mismatch .

Pathophysiologic mechanisms in Acute Respiratory Failure:

Mechanism Global alveolar hypoventilation Ventilation perfusion mismatch Shunt Diffusion abnormality Type of failure Pump Feature Hypercapnia

Pump and /or lung Hpercapnia and /or hypoxemia Lung Hpoxemia Lung Hpoxemia

BASIC PRINCIPLES OF OXYGEN TRANSPORT Gas exchange in the lungs concerns ventilation, perfusion and diffusion. Arterial hypoxemia may occur because of: A decrease in PIO2. Alveolar hypoventilation. Ventilation/perfusion disturbance. Impaired diffusion at the alveolar capillary barrier.

180 160 140 120 100 80 60 40 20 0

Atm. air Tracheal Alveolar Arterial (Dry) Gas Gas blood Tissue Venous blood

150.7

150

100

99

40

40

Oxygen Delivery and Utilization

DO2 = CO x CaO2 x 10
DO2 = O2 delivery, ml/min. CO = Cardiac output L/min. CaO2 = O2 content of arterial blood ml/dl.

CaO2 = ([Hb] x 1.34 x Sa O2%) + (PaO2 x 0.003)

Hb = Hemoglobin conc. gm/dl. 1.34 = O2 carrying capacity of Hb at 37C ml/gm. Sat. O2% = Percentage saturation of Hb with O2. 0.003 = Solubility coefficient for O2.

Delivery system

Description Flow rate of 1-6 L/min Delivers approx 4%/L Prongs insert 1 cm into each nare Comfortable and inexpensive Patient can eat and talk

L/min flow rate delivers FIO22 1 L/min = 24% 2 L/min = 28% 3 L/min = 32% 4 L/min = 36% 5 L/min = 40% 6 L/min = 44%

Complications Delivered FIO22 depends on tidal volume and ventilatory rate Nasal passages must be patent Easily dislodged May irritate nasal passages and eyes at higher flow rates

Nasal cannula

Flow rates are variable Clear plastic mask with different adapters that determine FIO22 Venturi Provides exact oxygen concentrations
** mask** Inspired concentrations do not vary

2 L/min = 24% 3 L/min = 28% 4 L/min = 31% 6 L/min = 35% 8 L/min = 40% 12 L/min = 50% 14 L/min = 55% Same as for simple mask

with ventilatory rate and tidal volume 10 L/min = 45% Delivery device of choice for COPD patients depending on hypoxic drive

Need minimum of 5 L/min to adequately flush carbon dioxide and avoid rebreathing Use cautiously on comatose Flow rate of 5patients 8 L/min 5-8 L/min Must fit securely to patient's Simple * mask * Clear plastic, = 50-60% face to avoid entrainment of room air and dilution of must fit tightly inspired FIO22 on patient's Increased risk of aspiration Less comfortable than nasal face cannula Easily removed

Flow rate of 6-10 Flow should be rate of 6-10 L/min sufficient to keep Partial Clear palstic mask reservoir bag rebreathing that incorporates inflated on mask** reservoir bag into 6-10 L/min = 55-70% inspiration system to deliver Other oxygen complications concentrations > same as for simple 60% mask Flow rate of 10-12 Flow should be L/min sufficient to keep Clear plastic mask reservoir bag inflated on Nonrebreath with reservoir bag * and 2 one-way 10-12 L/min = 80-100% inspiration ing mask * one-way valves (1 on mask Other and 1 between complications reservoir bag and same as for simple mask mask

Advantages and disadvantages of oxygen sources

Oxygen Oxygen source source Advantages Advantages Disadvantages Disadvantages User-unfriendly User-unfriendly Heavy with small capacity Heavy with small capacity Limited freedom of movement Limited freedom of movement Requires frequent delivery Requires frequent delivery Relatively high cost Relatively high cost Requires electricity Requires electricity Produces vibrations and noise Produces vibrations and noise Unreliable at > 3 l/min Unreliable l/min Critical storage conditions Critical storage conditions Requires regular maintenance Requires regular maintenance Not universally usable Not universally usable Spontaneous evaporation Spontaneous evaporation Requires regular delivery Requires regular delivery Dependent on storage container Dependent on storage container Various types incompatible Various types incompatible Reliable Reliable Easy maintenance Easy maintenance Cylinders High purity oxygen Cylinders High purity oxygen No additional noises No additional noises Much experience Much experience User-friendly User-friendly Safe Safe Concentrator No delivery problem Concentrator No delivery problem Universally usable Universally usable Relatively low cost Relatively low cost User-friendly User-friendly Easy to transport Easy to transport Liquid oxygen High purity oxygen Liquid oxygen High purity oxygen Reliable Reliable Easy maintenance Easy maintenance

Oxygen Therapy in Acute exacerbation of COPD:

Rationale: low flow O2 by nasal cannula or ventura mask is given during acute vent. failure to achieve PaO2 of 60 Hg and SaO2 of 92%. Intubation is indicated on the basis of objective undersirable effects of respiratory acidosis (PH< 7.20) ,consciousness level deterioration or development of arrhythmias. O2 induced hypercapnia is related to an increase in (VD/VT) or (V/Q) mismatch. NPPV significantly decreased the rate of intubation.

Domiciliary O2 & Long Term Oxygen Therapy Indications of LTOT:

Chronic airflow obstruction specially if PaCO2 > 45 mmHg. Advanced interstitial pulmonary disease. Advanced pulmonary malignancy. Advanced cystic fibrosis. Severe congestive heart failure. Cong. cyanotic heart disease. (Breslin et al., 1991).

Patients who need oxygen

Cardio pulmonary Resuscitation [CPR] in Respiratory or Cardio pulmonary arrest. Fluid in the alveoli . Pulmonary edema .
Pneumonia . Near drowning . Chest trauma .

 Collapsed alveoli (alveolar atelectasis ) as in cases of : a) Airway obstruction : Any unconscious patient. Choking & FB inhalation. b) Failure to take deep breaths : Severe pain as in rib fracture & severe pleurisy ) . Paralysis of the respiratory muscles .

Depression of the respiratory center (head injury ,drug overdose ) c) Collapse of an entire lung (pneumothorax or massive pleural effusion )

Other gases in the alveoli :

a) Smoke inhalation . b) Toxic inhalations . c) Carbon monoxide poisoning .

Any patient in cardiac arrest. Any patient complaining of shortness of breath . Any patient in shock . any patient with signs of respiratory insufficiency . Any patient breathing fewer than 10 times / minute i.e. bradypnea.

Any patient complaining of chest pain . Any patient suspected to be suffering a stroke . ( Caroline , 1995 )

Adverse Effects of O2 Therapy

These may be related to the device used e.g. nasal irritation, epistaxis, conjunctivitis inspissated secretions or barotrauma and volutrauma associated with mech. ventilation. O2 induced hypercopnia in COPD is due to V/Q mismatch. Hyperoxia produces pulmonary toxicity through production of O2 free radicals (O2-, OH-, O1, H2O2) at a rate that overwhelmes the antioxidant defences. O2 free radicals damage cell membranes, enzymes and nucleic acids leading eventually to cell death.