HYPOXEMIA:

DDX:

1. Hypoventilation (CNS depression, narcotics, obseisty hypoventilation syndrome, respiratory muscle weakness)
a. Normal A-a gradient
b. Elevated CO2 as well
c. Corrected by oxygen supplementation
2. V/Q mismatch: (COPD, asthma, PE, interstitial lung disease)
a. Increased A-a gradient
b. Hypoxia improved relatively low levels of oxygen
3. Right to left shunt (anatomic shunts-intra cardiac/AV; physiologic shunt-pneumonia, ARDS, atelectasis
a. Does not/difficult to correct with oxygenation
4. Reduced diffusion impairment (pulmonary fibrosis, PJP, emphysema)
a. Hypoxia worsens with activity
b. Corrects easily with O2
5. Reduced inspired oxygen tension (ie high altitude
a. Corrects easily with O2

HYPERCAPNIA:

1. Hypoventilation
2. V/Q abnormalities: advanced stages of emphysema when deadspace accounts for more than 50% of total ventilation
Vd/Vt>50%
3. Increased CO2 production/under excretion
4. Overfeeding: esp carbohydrates

ARDS:

1. Acute onset
2. Bilateral infiltrate on frontal chest xray
3. PaO2/FiO2</= 300mmHg (previous requirement </= 200mmHg)
4. No evidence of Left heart failure or fluid overload
5. Presence of predisposing condition
*PAWP no longer used as criteria because it is not a measure of capillary hydrostatic pressure. If used, it will lead to
overdiagnosis of ARDS

Management of ARDS: Lung protective ventilation:

Old days: TV 12-15ml/kg. however functional lung volumes reduced during ARDS. More volume is delivered to markedly reduced
available lung and results in overdistention, rupture of distal airspaces

New way: low tidal volume: limit the risk of trauma. Peep reduces risk of atelectrauma

a. TV=6ml/kg based on predicted body weight (not actual)

b. PEEP of at least 5cm water to prevent collapse of small airways at end of expiration and cyclic opening/closing of
small airway resulting in sheer stress.
c. Permissive hypercapnia: due to low volume ventilation, there is a reduction in CO2 elimination, leading to
respiratory acidosis and hypercapnia. Clinical trials show that PaCO2 of 60-70 and pH 7.2-7.25 are safe in most
patient. Target is pH 7.3-7.45. Increase RR if pH<7.15

Fluid management in ARDs: conservative vs. liberal

-no significant difference in 60day mortality between liberal vs conservative fluid management

-however pts in fluid conservative strategy had improved oxygenation index and lung injury score, as well as increase in ventilator
free days.

-subsequent study showed that cognitive impairment was markedly impaired in conservative group although mortality was
similar in both strategies