GAS EXCHANGE DISTURBANCE

Sumardi
Division of Pulmonology and Critical Care
Internal Medicine Departement
Faculty of Medicine, Public Health and Nursing GMU
Pulmonology Departement Sardjito General Hospital
 INTRODUCTION
Gas exchange in pulmonary system :
→ two major metabolic roles :
→ elimination of CO2
→ oxygenation of blood (haemoglobin)
→ alveolar membrane & capillary endothel
component
RESPIRATORY LUNG SYSTEM

- Respiratory tract
- Parenchym/alveoli
- Interstitial area

LUNG SYSTEM
[
RESPIRATORY TRACT IN GAS EXCHANGE
MUCOSAL COMPONENT IN GAS
EXCHANGE
Alveolar component in gas
exchange
⚫ Alveolar membrane
⚫ Cellular alveolar
membrane
 CLINICAL MANIFESTATION
(Respiratory Failure)
⚫ Present when the pulmonary system is no longer able to meet
the metabolic demands of the body (OXYGENATION
IMBALANCE)
⚫ Normal in room air PaO2 90-95 mmHG
⚫ HYPOXEMIA (in room air)
⚫ P Arterial oxygen (PaO2) : <80 mmHg
⚫ Oxygen saturation <92%
⚫ HYPERCAPNEA
⚫ Arterial Carbon dioxide (PaCO2) >60 mmHg
⚫ Lower tidal volume
⚫ MIXED
Respiratory Failure,
type:
Respiratory failure → acute / chronic
depending on the duration and the nature of
the compensation.
Acute Respiratory Failure may occur in a
person without previous lung disease or may
be superimposed on chronic respiratory
failure
 CAUSES OF
Acute Respiratory Failure (ARF)
◼ ARF develops in a variety of clinical settings:
◼ primary pulmonary insults
◼ other systemic nonpulmonary disorders
◼ Causes of ARF in adults are often
multifactorial.
◼ Mixed
 HYPOXEMIC ARF
Hypoxemic respiratory failure is seen in
patients with acute lung injury (ALI) or
acute pulmonary edema (cardial /
noncardial).
These disorders primarily interfere with the
pulmonary system's ability to adequately
oxygenate the blood as it circulates through
the alveolar capillaries.
 HYPERCAPNIC ARF
Hypercapnic respiratory failure is seen in
patients with:
◼ severe airflow obstruction,
◼ central respiratory failure, or
◼ neuromuscular respiratory failure.
 PATHOPHYSIOLOGY OF ARF:
Hypoxemia
◼ result of a mismatch of alveolar ventilation
and pulmonary perfusion
◼ cause progressive obstruction or atelectasis
result in less oxygen being available in distal
airways for uptake
◼ blood flow to such abnormal lung units
declines
◼ e.g., pneumonia, aspiration, lung edema, etc
 Hypoxemia
Other less common causes of hypoxemia
include:
◼ Decreased diffusion of oxygen across the
alveolocapillary membrane complex due to
interstitial edema, inflammation (lupus
pneumonitis, toxic gas injury), etc.
◼ Alveolar hypoventilation
◼ High altitude.
 HYPERCAPNEA
When gas flow to and from airways remains
adequate but blood flow is absolutely or
relatively diminished, C02 does not have
the opportunity to diffuse from the
pulmonary artery blood and C02-rich
blood is returned to the left atrium.
 HYPERCAPNEA
Increased deadspace ventilation may occur in:
◼ Hypovolemia: bleeding,severe diarhea
◼ pulmonary embolus,
◼ poor cardiac output, or
◼ when the regional airway pressure is
relatively higher than the regional perfusion
pressure produced by the regional
pulmonary blood flow
 Combination:
HYPERCAPNEA & HYPOXEMIA
Several related disease processes often
combine and act in concert or synergistically
to compound respiratory failure.
For example, the patient with chronic
pulmonary disease (COPD) and often has
associated heart failure (CHF) which
increases → worsens hypoxemia
ARF: alveolar/capilary system, type:
ARDS SHUNT EMBOLY
DISEASES INVOLVEMENT IN GAS
EXCHANGE
⚫ AIRWAY OBSTRUCTION:
⚫ FOREIGN BODIES
⚫ ATELECTASIS
⚫ PNEUMOTHORAX
⚫ ASTHMA & COPD
⚫ PARENCHYMAL LUNG DISEASES:
⚫ INFECTION: ARDS, bacterial, virus, fungi, parasite
⚫ ALVEOLAR VENTILATION DISTURBANCE:embolism
⚫ INTERSTITIAL LUNG DISEASES
⚫ Autoimmune: lupus, rheumatoid arthritis
⚫ Collagen disease: sarcoidosis, systemic sclerosis, IPF
 AIRWAY OBSTRUCTION…1
• FOREIGN BODY IN TRACHEA OR MAIN
BRONCHUS: aspiration of solid material eg.
food, blood, other solid material
• MUCOUS PLUG: difficult expectoration of
mucous or sputum, eg. lung abcsess rupture,
deep general anesthesia, paresis of chest wall
muscle
• Athelectasis: collaps lobus of lung
• Pneumothorax: air in the pleural space make
unilateral lung collaps
 AIRWAY OBSTRUCTION….2
SEVERE ASTHMA/STATUS ASTHMATICUS.
• Reversible airway obstruction, caused by
airway inflamation
• Not response to usual steroid tx
• Not response to anamnesis
• History of frequent exacerbation or emergency
• Cyanosis
• Wheeze to silent chest
• Saturation of O2 (SaO2)< 85%
 AIRWAY OBSTRUCTION….3
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD):
• Chronic bronchial inflamation caused by noxius gas inhalation
eg. Smoker, biomass, air polution.
• Pathology: irreversible destruction of bronchial wall and terminal
bronchus
• Symptoms : obstructive air ways with prolonged expiration,
wheeze, rales, crackles
• Progressive disease
• History of exacerbation and comorbidities
 ACUTE RESPIRATORY DISTRESS SYNDROME
(ARDS)

◼ ARDS is another type of acute respiratory

failure
◼ Increased alveolar capillary permeability
in ARDS have centered upon (non-cardial
lung edema)
◼ the neutrophil,
◼ the macrophage,
◼ the pulmonary vascular endothelium and
◼ The cytokine imbalance
 PATHOPHYSIOLOGY ARDS
◼ Neutrophil sequestration and migration
within the lung remain histologic hallmarks of
ARDS
◼ Chemotactic stimuli released within the lung
and the activation of neutrophils by
circulating mediators :
◼ TNFa ,
◼ IL-1, and
◼ IL-8
CASE : YOUNG WOMAN 26 yo
Early,fever,dyspnea,day 2
CASE : YOUNG WOMAN 26 yo
Advance:severe dyspnea,fever,day 3
CASE : YOUNG WOMAN 26 yo
Severe:apnea,septic shock,day 4
CASE : YOUNG WOMAN 26 yo
Recovery day 11
 CASE ARDS:
Woman pregnant 29 yo H1N1(+) Sleman (die)
Girl 18 yo, flu 3 days, dyspnea day 5
 GIRL 18 yo, flu 3 days,
dyspnea day 5, ARDS day 7
Case ARDS caused by Flu H1N1
• Half of population in small village have Flu
• Pregnant woman have symptoms & signs:
– Fever 2 days
– 29 years old
– Chills
– Cough
– Hospitalization in private hospital
– Day 3rd DYSPNEA
– Refer to Sardjito Hospital with severe dyspnea
– Die in ER after 4 hours ventilation
 LUNG EMBOLISM
⚫ ACUTE DYSPNEA
⚫ NORMAL LUNG PREVIOUSLY
⚫ HISTORY OF DEEP VEIN THROMBOSIS
(DVT)
⚫ ELDERLY
GAS EXCHANGE DISTURBANCE
(Scintigraph)
Gas exchange disturb normal lung

LUNG EMBOLISM
Normal Lung
 LUNG EMBOLISM
(contrast 3D scanning)

Embolism

Normal lung
 INTERSTITIAL LUNG DISEASE
⚫ CHRONIC DYSPNEA YEARLY
⚫ ARTHRITIS
⚫ SKIN INVOLVEMENT SARCOIDOSIS or
SYSTEMIC SCLEROSIS
⚫ STIFFNESS
INTERSTITIAL LUNG DISEASE
(High Definition CT Scan)
 CLINICAL MANIFESTATIONS OF
RESPIRATORY FAILURE
◼ Altered mental status ranging from agitation to
somnolence
◼ Evidence of increased work of breathing:
◼ nasal pharing
◼ use of accessory respiratory muscles
◼ intercostal/suprasternal/supraclavicular retraction
◼ Tachypnea
◼ Hyperpnea
◼ paradoxical or dysynchronous breathing pattern
◼ Cyanosis of mucosal membranes (tongue, mouth) or nail
beds
◼ Diaphoresis, tachycardia, hypertension and other signs
of "stress" catecholamine release
 MANAGEMENT CONSIDERATIONS

◼ Oxygen Supplementation
◼ Nasal Cannula
◼ Air-Entrainment Face Masks ("Venturi Masks")
◼ Aerosol Face Mask
◼ Reservoir Face Masks
◼ High Flow Nasal Canule (HFNC) Oxygenation

◼ Noninvasive Positive-Pressure Ventilation

 Pharmacologic Adjuncts
◼ 1.Beta2-Agonists
◼ 2.Anticholinergic Agents
◼ 3.Corticosteroids
◼ 4.Theophylline preparations
 KEY POINTS:
RESPIRATORY FAILURE
◼ result from primary pulmonary insults and from other
systemic nonpulmonary disorders
◼ hypoxic or hypercapnic failure reflecting the two major
functions of the lung
◼ most common pathophysiologic mechanism for hypoxic
acute respiratory failure is a ventilation/perfusion
imbalance
◼ failure to maintain an adequate alveolar ventilation is the
"common pathway" in most causes of hypercapni:
respiratory failure
◼ clinical signs of acute respiratory failure reflect the
multiorgan effects of hypoxia and hypercapnic acidosis as
well as the manifestations of the primary or secondary
process
 KEY POINT … continou ..
◼ Oxygen supplementation is commonly used
to treat the symptom of hypoxemia
◼ Noninvasive forms of mechanical ventilation
provide ail important therapeutic option for
reversing both forms of acute respiratory
failure in selected patients
◼ Multiple pharmacologic and therapeutic
adjuncts are important in treatment goals to
avoid intubation and mechanical
ventilation