Acute Respiratory Failure

Cindy Kin
Trauma Conference
6 August 2007
Stanford Surgery

Acute Respiratory Failure

Failure in one or both gas exchange functions:

oxygenation and carbon dioxide elimination
In practice:
PaO2<60mmHg or PaCO2>46mmHg
Derangements in ABGs and acid-base status

Acute Respiratory Failure

Hypercapnic v Hypoxemic respiratory failure

ARDS and ALI

Hypercapnic Respiratory Failure

PaCO2 >46mmHg
Not compensation for metabolic alkalosis
(PAO2 - PaO2)
normal

Alveolar
Hypoventilation
PI max
Central
Hypoventilation

Neuromuscular
Problem

increased

V/Q abnormality
Nl VCO2
V/Q
Abnormality

VCO2
Hypermetabolism
Overfeeding

The Case of Patient RV

71M s/p L AKA revision.
PMH: CAD s/p CABG, COPD on home O2 and CPAP, DM,
CVA, atrial fibrillation
PACU: L pleural effusion, hypotension, altered mental status.
Sent to ICU for monitoring.
POD#1: RR overnight, intermittently hypoxic.
BiPAP 40%:
7.34/65/63/35/+10
Preintubation:
7.28/91/81/43

Hypercapnic Respiratory Failure

PaCO2 >46mmHg
Not compensation for metabolic alkalosis
(PAO2 - PaO2)
normal

Alveolar
Hypoventilation
PI max
Central
Hypoventilation

Neuromuscular
Problem

increased

V/Q abnormality
Nl VCO2
V/Q
Abnormality

VCO2
Hypermetabolism
Overfeeding

Hypercapnic Respiratory Failure

nlPI max

Alveolar
Hypoventilation

Central
Hypoventilation
Brainstem respiratory depression
Drugs (opiates)
Obesity-hypoventilation syndrome

PI max
Neuromuscular
Disorder

Critical illness polyneuropathy

Critical illness myopathy
Hypophosphatemia
Magnesium depletion
Myasthenia gravis
Guillain-Barre syndrome

Hypercapnic Respiratory Failure

PaCO2 >46mmHg
Not compensation for metabolic alkalosis
(PAO2 - PaO2)
normal

Alveolar
Hypoventilation
PI max
Central
Hypoventilation

Neuromuscular
Disorder

increased

V/Q abnormality
Nl VCO2
V/Q
Abnormality

VCO2
Hypermetabolism
Overfeeding

Hypercapnic Respiratory Failure

V/Q abnormality
Increased Aa gradient

VCO2

Nl VCO2

V/Q
Abnormality

Hypermetabolism
Overfeeding

Hypercapnic Respiratory Failure

V/Q abnormality
Increased Aa gradient

VCO2

Nl VCO2

V/Q
Abnormality
Increased dead space ventilation
advanced emphysema
PaCO2 when Vd/Vt >0.5
Late feature of shunt-type
edema, infiltrates

Hypermetabolism
Overfeeding

Hypercapnic Respiratory Failure

V/Q abnormality
Increased Aa gradient

VCO2

Nl VCO2

V/Q
Abnormality

Hypermetabolism
Overfeeding

VCO2 only an issue in pts with ltd

ability to eliminate CO2
Overfeeding with carbohydrates
generates more CO2

Hypoxemic Respiratory Failure

Is PaCO2 increased?
Yes

No

(PAO2 - PaO2)?

Hypoventilation
(PAO2 - PaO2)

Hypoventilation
alone

Yes

Hypovent plus
another
mechanism

Is low PO2
correctable
with O2?

Respiratory drive
Neuromuscular dz

No
Shunt

Yes
V/Q mismatch

No
Inspired PO2
High altitude
FIO2

The Case of Patient ES

77F s/p MVC.
Injuries include multiple L rib fxs, L hemopneumothorax
s/p chest tube placement, L iliac wing fx.
PMH: atrial arrhythmia, on coumadin. INR>2
HD#1
RR 30s and shallow. Pain a/w breathing deeply.
Placed on BiPAP overnight
PID#1
BiPAP 80%: 7.45/48/66/32/+10

Hypoxemic Respiratory Failure

Is PaCO2 increased?
Yes

No

(PAO2 - PaO2)?

Hypoventilation
(PAO2 - PaO2)

Hypoventilation
alone

Yes

Hypovent plus
another
mechanism

Is low PO2
correctable
with O2?

Respiratory drive
Neuromuscular dz

No
Shunt

Yes
V/Q mismatch

No
Inspired PO2
High altitude
FIO2

Hypoxemic Respiratory Failure

V/Q mismatch
PvO2>40mmHg

V/Q mismatch

PvO2<40mmHg

DO2/VO2
Imbalance
DO2: anemia, low CO
VO2: hypermetabolism

Hypoxemic Respiratory Failure

V/Q mismatch

SHUNT
V/Q = 0

Atelectasis
Intraalveolar filling
Pneumonia
Pulmonary edema

Intracardiac shunt
Vascular shunt in lungs

ARDS
Interstitial lung dz
Pulmonary contusion

Pulmonary embolus
Pulmonary vascular dz
Airway dz
(COPD, asthma)

DEAD SPACE
V/Q =

Hypoxemic Respiratory Failure

V/Q mismatch

SHUNT
V/Q = 0

Atelectasis
Intraalveolar filling
Pneumonia
Pulmonary edema

Intracardiac shunt
Vascular shunt in lungs

ARDS
Interstitial lung dz
Pulmonary contusion

Pulmonary embolus
Pulmonary vascular dz
Airway dz
(COPD, asthma)

DEAD SPACE
V/Q =

Hypoxemic Respiratory Failure

Acute Respiratory Distress Syndrome

Severe ALI
B/L radiographic
infiltrates
PaO2/FiO2 <200mmHg
(ALI 201-300mmHg)
No e/o L Atrial P;
PCWP<18

Hypoxemic Respiratory Failure

Acute Respiratory Distress Syndrome

Develops ~4-48h
Persists days-wks
Diagnosis:
Distinguish from
cardiogenic edema
History and risk
factors

Inflammatory
Alveolar Injury

Inflammatory
Alveolar Injury
Pro-inflmm cytokines
(TNF, IL1,6,8)

Inflammatory
Alveolar Injury
Pro-inflmm cytokines
(TNF, IL1,6,8)

Neutrophils - ROIs
and proteases
damage capillary
endothelium and
alveolar epithelium

Inflammatory
Alveolar Injury
Pro-inflmm cytokines
(TNF, IL1,6,8)

Neutrophils - ROIs
and proteases
damage capillary
endothelium and
alveolar epithelium
Fluid in interstitium
and alveoli

Inflammatory
Alveolar Injury
Pro-inflmm cytokines
(TNF, IL1,6,8)

Neutrophils - ROIs
and proteases
damage capillary
endothelium and
alveolar epithelium
Fluid in interstitium
and alveoli
Impaired gas exchange
Compliance
PAP

Hypoxemic Respiratory Failure

Acute Respiratory Distress Syndrome

Exudative phase
Diffuse alveolar damage

Proliferative phase

Fibrotic phase

Hypoxemic Respiratory Failure

Acute Respiratory Distress Syndrome
Direct Lung Injury
Infectious pneumonia
Aspiration, chemical pneumonitis
Pulmonary contusion, penetrating lung injury
Fat emboli
Near-drowning
Inhalation injury
Reperfusion pulmonary edema s/p lung transplant

Hypoxemic Respiratory Failure

Acute Respiratory Distress Syndrome
Indirect Lung Injury
Sepsis
Severe trauma with shock/hypoperfusion
Burns
Massive blood transfusion
Drug overdose: ASA, cocaine, opioids,
phenothiazines, TCAs.
Cardiopulmonary bypass
Acute pancreatitis

Hypoxemic Respiratory Failure

Acute Respiratory Distress Syndrome
Complications
Barotrauma
Nosocomial pneumonia
Sedation and paralysis persistent MS
depression and neuromuscular weakness

Hypoxemic Respiratory Failure

Acute Respiratory Distress Syndrome
861 patients, 10 centers
Randomized
Tidal Vol 12mL/kg PDW,
PlatP<50cmH2O
Tidal Vol 6mL/kg PDW,
PlatP<30cmH2O
NNT 12

31% mortality v 39.8%

65.7% breathing without assistance by day 28 v 55%
Significantly more ventilator-free days
Significantly more days without failure of nonpulmonary
organs/systems