RESPIRATORY DISTRESS

RESPIRATORY FAILURE
⌘

MENALDI RASMIN
DEPT.OF PULMONOLOGY & RESPIRATORY MEDICINE
FAC.OF MEDICINE, UNIVERSITAS INDONESIA
NATIONAL RESPIRATORY REFFERAL HOSPITAL PERSAHABATAN

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 Respiratory Failure
Incidence & Prevalence : difficult to determine
Europe – Incidence of acute life-threatening RF between 77,6%-88,6%
cases per 100.000 population per year
UK - 2,9%

Represents a syndrome

Types : Chronic Respiratory Failure

Acute Respiratory Failure
[including Acute on CRF]

Respiratory system : the lungs & the respiratory muscle pump

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Suh ES, Hart. Respiratory Failure. Medicine 2012;40(6): 293-297
Respiratory Failure

Is the consequence of :
lung failure leading to hypoxemia or,
respiratory muscle pump failure resulting in hypercapnia

Management :
Improve oxygenation and or ventilation
(to resolve hypoxemia and hypercapnia)
Treat the underlying disease (condition)

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Suh ES, Hart. Respiratory Failure. Medicine 2012;40(6): 293-297
 Type 1. Hypoxaemic Respiratory Failure

Ventilation-Perfusion e.g COPD, asthma, PE. Pulmonary embolus,

Mismatch pulmonary oedema, CF, BE

Anatomical R L Shunt HYPOXEMIA Impaired Diffusion

e.g pulmonary arteriovenous malformation, e.g diffuse parenchymal disease

pneumonia

Low partial Pressure of Alveolar

Inspired Oxygen Hypoventilation

e.g flying e.g opiate overdose

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Suh ES, Hart. Respiratory Failure. Medicine 2012;40(6): 293-297
Type 2. Hypercapnic Respiratory Failure : an imbalance between neural respiratory drive,
the load on the respiratory muscles and capacity of thr respiratory muscles

DRIVE FAILURE
Cortical Brainstem

HIGH LOAD
Resistive Elastic threshold

TRANSMISSION & ACTION

FAILURE
Spinal cord,
Peripheral nerves
Neuromuscular junction
Respiratory muscle

RESPIRATORY MUSCLE
PUMP FAILURE
Type 2 hypercapnic
respiratory failure

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Suh ES, Hart. Respiratory Failure. Medicine 2012;40(6): 293-297
 RESPIRATORY FAILURE
VENTILATORY PUMP FAILURE CHEST WALL DISEASE
Abnormal ventilatory control Scoliosis
Drug overdose Ankylosing spondylitis
Cerebrovascular disease Obesity
Sleep

NEUROMUSCULAR DISEASE INEFFICIENT GAS EXCHANGE

Diaphragmatic paralysis Obstructive lung disease
Guillaine-Barre syndrome Restrictive lung disease
Myasthenia gravis Pneumonia
Muscular dystrophy Pulmonary edem

MUSCLE FATIGUE

7 Danztker DR. Respiratory Failure. In: Danztker, MacIntyre,Bakow.Eds.

Comprehensive Respiratory Care. W.B.SAUNDERS COMPANY;1995:726736
Research
Acute Respiratory Failure in the Elderly: Etiology, Emergency
diagnosis and Prognosis
Ray P, Birolleau S, Lefort Y, Becquemin M-H, Beigelman C, Isnard R, Teixeira A, Arthaud M, Riou B, Boddaert J. Critical Care 2006;10:1-12

Results : Subject : 514 pts aged (mean +/- SD 80 +/-9 yrs)

Causes : cardiogenic pulmonary edema (43%), CAP (35%), acute exacerbation of chronic
respiratory disease (32%), pulmonary embolism (18%), acute asthma (3%)
Incidence Hospital Mortality: 16%
Missed diagnosis in the Emergency Department: 101 pts (20%)
The accuracy of the diagnosis of the Emergency Physician :
ranged between cardiogenic pulmonary edema 0,76 to 0,96 for asthma
Inappropriate treatment: 162 pts (32%)  lead to a higher Mortality (25% vs
11%; p 0,001) hypercapnia 45 mmHg (OR 2,79, p0,004), CCR 50 ml/mnt (OR 2,37, p0,
013), elevated NT-proBNP (OR 2,06, p 0,046), clinical signs of ARF (OR 1,98, p
0,047)

Conclusion : inappropriate initial treatment in the

Emergency room was associated with increased mortality
in elderly patients with ARF
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 Proporsi 10 Penyakit Terbanyak
Pada Gagal Napas Akut
KARAKTERISTIK DAN KELUARAN PASIEN GAGAL NAPAS AKUT DI RSUP PERSAHABATAN TAHUN 2015
Rasmin M, Elhidsi M, Syahputra W

60
50
40
30
Total
20
Dengan ventilator[51]
10 Tanpa ventilator [99]
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 Inspirator Expiratory Bulbar
y muscle muscle muscle
weakness weakness weakness

Ventilatory Cough Upper airway

disfunction dysfunction disfunction

Diurnal Sleep
Pneumoni
Ventilation Disordered
a
Failure Breathing

Figure 1. Pathogenesis of respiratory disfunction in patients with neurologic disease

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Benditt JO,Boltano LJ. Pulmonary Issues In Patients with Chronic Neuromuscular Disease. Am J Respir Crit Care Med 2013;187:1046-1055
 Hypophosphatemia
Hypophosphatemia : (<2.5 mg/dl or 0,81 mmol/L)1 .
1.Lee JW. Fluid and Electrolyte Disturbances in Critically Ill Patients. Electrolyte Blood Press 2010;8:72-81

A continous infusion of 10 mmol phosphorous (KH2PO4)

significantly increase serum phophorous, accompanied by a
marked increase in the transdiaphragmatic pressure after phrenic
stimulation2
2
Aubier M, Murciano D, Lecocguig Y, Viires N,Jacquens Y, Squara P, Pariente N.
Effect of Hypophosphatemia On Diaphragmatic Contractility In Patints With
Acute Respiratory Failure. The New England Journl of Medicine 2015;313(7): 420-424

Hypophosphatemia in AECOPD3 : Morbidity

Rate 56,72% Significantly higher
percentage of failure-to-wean from MV: hypo-34,
21 >< normo-10,34 (P < 0,05) Associated with respiratory
muscular weakness, reflected by a decrease in
TV,3Zhao
reduced
Y, Li Z, Shistatic
Y, Cao G, lung
Meng F, compliance, impaired
Zhu W, Yang G. Effect of Hypophosphatemia on the Withdrawal pulmonary
of Mechanical Ventilation
function – leading to weaning failure
in Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease. BIOMEDICAL REPORTS 2016;4:413-416

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Indications for Airway Management
ABSOLUTE INDICATIONS
•Apnea
•Acute airway obstruction
•Hypoxia
•Penetrating trauma, expanding hematoma of the neck

STRONG RELATIVE INDICATIONS

•Closed head injury
•Shock
•Thoraxic trauma

RELATIVE INDICATIONS
•The combative or intoxicated patients
•Maxillofacial injuries

Johannigman JA. Prehospital Respiratory Care.

In: Danztker, MacIntyre,Bakow.Eds.
12 Comprehensive Respiratory Care.
W.B.SAUNDERS COMPANY;1995:1090-1114
 Respiratory Distress
An observable corollary to dyspnea1
is the physical or emotional suffering that results from
experience of dyspnea

Respiratory Rate2 :
25-29 bpm – Mortality Rate of 21%
above 27 bpm – important predictor
of cardiac arrest

Treatment of dyspnea1:
prevention
underlying disease
palliation of symptom distress

1. Campbell ML. Terminal Dyspnea and Respiratoey Distress.

Crit Care Clin 2004;20:403-417 13
2. Smith I, MacKay J, Fahrid N. Respiratory Rate Measurement: a Comparison of Methods.British Journal of Healthcare Assistants;2011:05(01):18-23
 RESPIRATORY DISTRESS
Careful physical examination :
Patient appearance : anxiety, restlessness. agitation,
diaphoresis, (cyanosis),
dyspnea crisis2
Respiratory effort & rate :
ability to speak, chest wall excursion, tachypnea
accessory muscles of respiration,
sternal & supraclavicular retractions
Ausculatory findings : stridor, tracheal deviation,

Johannigman JA. Prehospital Respiratory Care.

In: Danztker, MacIntyre,Bakow.Eds.
Comprehensive Respiratory Care. 14
W.B.SAUNDERS COMPANY;1995:1090-1114 2.American Thoracic Society Documents 2013
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166.908 EMS encounters:
19.858 : Respiratory Distress (RD) (11,9% ; 95% CI: 11,7-12,8%)
9.964 (50%)  hospitalized
3.094 (30%) – required Intensive Care
948 (10%) – died prior to discharge
1.501 (15%) – reseived invasive MV

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166.908 EMS encounters:
19.858 : Respiratory Distress (RD) (11,9% ; 95% CI: 11,7-12,8%)
9.964 (50%)  hospitalized
The (30%)
3.094 Most Common
– required Primary
Intensive Discharge
Care Diagnosis
Among
948 (10%) Prehospital
– died RespiratoryDistress :
prior to discharge
1.501 (15%) – reseived invasive MV
CHF 16%
Pneumonia 15%
COPD 11%
Acute Respiratory Failure 13%

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 Respiratory Disorders
RESPIRATORY IMPAIRMENT Respiratory disfunction clinically
significant to produce
discomfertness

RESPIRATORY INSUFFICIENCY Respiratory disturbance, strong

enough to hamper daily certain
activities, that can be measured
from the mechanic of breathing and
or from gas exchange

RESPIRATORY DISTRESS Increase & worsening respiratory

effort that can be seen from clinical
appearance

RESPIRATORY FAILURE Disturbance of 1 (one) aspect or

more respiratory function & life
threatening
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 Why Do We Need RICU ?
More than 35% ICU pts : purely respiratory cases

Respiratory failure in Pneumonia is 34,8%

Shortening time to ICU,

since >75% pts come from the ward and, >15% pts from
EU

ICU’s outcome :
shortening LOS pulmonary pts 1-3 days (43,8%)
shortening the use of MV, 1-3 days (70,69%)

Rasmin M. Charateristic of RS Persahabatan ICU Patients With Tight Supervision of the Pulmonology Resident in Training.2001

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 Karakteristik dan Keluaran Pasien Gagal Napas Akut :
Studi Potong Lintang Dari Rumah Sakit Rujukan Respirasi Nasional
Rasmin M, Elhidsi M,Yahya WS. Dept.Pulmonologi & Kedokteran Resirasi FKUI-RSUP Persahabatan, 2015

9,53%

14% 61,90%

86%

25,87%

Gagal Napas Akut saat masuk RS

Total subyek: 150 Gagal Napas Akut saat perawatan

Pascabedah
51 ps (34% dg VM
99 ps (66%) tanpa VM Penyakit pernapasan sbg penyakit dasar
Lain-lain
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 Respiratory ICU
A must, in a hospital with mayority pulmonary patients,
especially where interventional procedures & thorax
surgery is provided

Respiratory monitoring

Airway management : patency, clearance-effective cough

Oxygen therapy : conventional, NIV, MV

Management of underlying diseases, comorbid(s) :

respiratory/lung diseases-disorders, cardiovascular,
neuromuscular, fluid-electrolyte, metabolic-endocrin

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 Conclusions
Respiratory Failure: represents a syndrome

Is the consequence of :
lung failure leading to hypoxemia or,
respiratory muscle pump failure resulting in hypercapnia

Predisposing factors: pulmonary diseases, cardiovascular

problems, neuromuscular diseases & problems,
hypophosphatemia. Inappropriate treatment in the EU

The need of Respiratory ICU (RICU)

The goals : Improve oxygenation and or ventilation

(to resolve hypoxemia and hypercapnia)
Treat the underlying disease (condition)

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Thank You

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