Patho-Physiology of Respiratory Failure.

John KOLBE
Respiratory Services Green Lane Hospital, & Faculty of Health Sciences University of Auckland.

 Someone told me that each equation I included in the book would halve the sales.

Stephen Hawking A Brief History of Time: 1988.

RESPIRATORY FAILURE
Def: When the lungs fail to adequately oxygenate the arterial blood and/or fail to prevent undue CO2 retention. In practical Terms; PaO2 < 8kPa (60 mmHg) (Hypoxic,TypeI) PaCo2 > 6.6 kPa (50mmHg) (Hypercapnic, Type II)

Relationship of PaCO2 and (Alveolar) Ventilation

PaCO2 i.e. = Vco2 k VA PaCO2 w 1 VA

Relationship of PaCO2 and (Alveolar) Ventilation

y

Pa CO 2 =

V CO 2 y k
y

VA
VT = VA + VD
y

VE =

k V CO 2
y y

Pa CO 2 (1 - V D / V T )

 I could never make out what those damned dots meant.

Lord Randolph Churchill (referring to decimal points).

Respiratory Drive

Neuromuscular Transmission

Load

HYPOVENTILATION
  qDrive qNeuromuscular Transmission Muscle weakness/ (fatigue = reversible) LOAD.

 +

HYPERCAPNIA
y Hypoventilation qRespiratory Drive Neuro-muscular (in)competence (qDrive) qNeuromuscular Transmission Muscle weakness/fatigue Abnormal load V/Q mismatch (Multi-factorial)

HYPOXIA
Reduced F1o2 Hypoventilation Diffusion V/Q mismatch R-L Shunt

Alveolar-Arterial Oxygen Gradient.

Adequacy of Gas Exchange!

Alveolar-Arterial Oxygen Gradient.

PA CO 2 +k PA O 2 = (Pb  PH 2O ) y FIO 2  R
ie, at sea level, breathing air; PAO2 = 20 - PaCO2/0.8 A-a Gradient = 20 - PaCO2/0.8 -PaO2 (Normal A-a gradient = 1-2 kPa)

ALVEOLAR GAS EQUATION

PaO2 = (Pb - PH2O) y FIO2 - PaCo2 + k R w 20 kPa -PaCo2 0.8 (Normal A-a gradient = 1-2 kPa)

DIFFUSION
Depends on - gas - diffusion distance/thickness - surface area - (Hb) - capillary volume Use of CO - diffusion (and not perfusion) limited - soluble - avidly binds to Hb @ zero back pressure

V/Q mismatch - most important cause 3 compartment model of Lung

V/Q = 00 Dead Space

V/Q = 1 Ideal

V/Q = 0 Shunt

V/Q = w Co2 Cco2 -

V/Q = 1 N

V/Q = 0 qq

q q N oo o N Compensatory Hyperventilation (of V/Q = 1)

 Worsening Disease Unable to Undertake compensatory Hyperventilation oPa CO2 (pH is normalised by rental (and other) mechanisms) Dangers: High inspired O2 Monitoring O2 saturations only

Relationship of PaCO2 and (Alveolar) Ventilation

Ve Ve = = Va + Vd k y Vco2 PaCo2 (1 - Vd/Vt)

RIGHT TO LEFT SHUNTS

distinguish from V/Q mismatch by administration of 100% O2 normally Pao2 rises to >600 mmHg role of absorption atelectasis relaxation of hypoxic vasoconstriction

 Science is built up of facts, as a house is built of stones; but an accumulation of facts is no more a science than a heap of stones is a house.

Henri Poincare
Science and Hypothesis: 1905.

Pa CO 2 =

V CO 2 y k
y

VA

VE =

k V CO 2
y y

Pa CO 2 (1 - V D / V T )