RESPIRATORY FAILURE (ACUTE)

Dora M Alvarez MD LH 2004

Acute RF
Definitions - Physiology Assessment - clinical picture Case Studies Indications for Intubation. Respiratory Support

Definitions
Acute Respiratory Failure: Any disruption in the function of the respiratory system Respiratory Function:
DELIVER ADEQUATE OXYGEN TO OR REMOVING CARBON DIOXIDE FROM
THE PULMONARY CAPILLARY BED

OR BOTH

Many causes
Respiratory Failure ( Survival 75%-90%) Shock

Cardiopulmonary Failure (Survival 7% -11%) Cardiovascular recovery Neurological impairment Neur..recovery

Death

The Assessment of Respiratory Function

Gas Exchange

CO2

VBG ? O2

ABG

VBG? Ph 7.35 CO2 45 O2 45 O2

CO2

ABG Ph 7.4 CO2 40 O2 90-100

Gas Exchange

O2
PaCO2 = VC02/ MVV

CO2

Pa CO2: partial pressure of arterial CO2 VC02: CO2 production MVV: Minute Volume Ventilation MVV = TV x RR PaCo2

MVV = TV x RR TV = 6 -7 ml/kg RR = 12 bpm (> 15 yo- Adult) 50 Kg Adolescent / Adult

T V

R R

M V PO V a 2 C

30 l 0m

1 30 mNm 2 60 l o a r l N N N N

Gas Exchange Pa O2

CO2

Pulse -Oxymetry: Measure light absorption

Falsely High ..... CO (has high affinity for Hb and has the similar light absorption

Falsely Low ..MetaHeb

(Hemoglobinopathies: ie Sickle Cell disease 2nd to abnormal OxyHb affinity

CO oximetry: uses more different wave light absorption. ABG (cBG) /

The alveolar-arterial oxygen (A-a)

(A-a) gradient is a useful measure of the efficiency of oxygenation. It compares the diffusion of oxygen from the patient's alveoli to his or her pulmonary capillaries with diffusion in an idealized model of the lung without ventilation/perfusion inequalities or cyclical variations in ventilation or circulation.

A-a Gradient
Calculation of this value incorporates a measure of alveolar ventilation (alveolar CO2, approximated as arterial CO2), therefore it is unaffected by hyper- or hypoventilation.

The A-a gradient can be calculated from the following formula:

A-a gradient = FiO2 x (pAtm-pH2O) - (paCO2/R) +

[paCO2 x FiO2 x (1-R)/R] - paO2,

where pAtm = 760 mmHg x exp ( -altitude in meters/7000 ) [3], and pH2O = 47 mmHg x exp ( (Temperature in centigrade-37)/18.4 ) [4].

 Arterial pCO2 in mmHg: 40

Arterial pO2 in mmHg: 90 Percent of inspired O2 (%): 21 (Fraction of inspired O2: 0.21 )

Respiratory quotient: 0.8 Patient's temperature in F: 98.6(or in C: 37.0 )

Approximate elevation in feet:0(or in meters: 0 )

A-a gradient in mmHg: 10

 Normal A-a gradient values have not been well established, but Tend to increase with age Are slightly higher on 100 percent oxygen than on room air.

ARF
In the absence of intra-cardiac shunt. Pa02 < 50 mm hg PC02 > 50 mmHg Increase a-a gradient (>300) Increase Pao2/Fio2 < 200 (normal >400) (Pao2 60 on fio2 of 0.6 = 100)

Respiratory Assessment
1. Mental Status (Is patient being sedated) 2. RR (according to age) 3. Work of breathing (retraction, nasal flaring, paradoxic breathing) 4. Chest movement-Air-entry 5. Adventitious sounds (Stridor-wheezes, crackles) 6. Oxygen requirements 7. Cardiovascular status, (Compensatory mechanisms: HR, BP, perfusion) 8. Peak Flow 9. ABG

Respiratory Assessment
Is the patient Ventilating well? >> Normal PCO2
Normal ventilatory effort Increase work of breathing
Able to compensate Is patient getting exhausted >> Impending respiratory

failure

Is the patient oxygenating well? >> Normal Pa O2

Assess oxygen requirement A-a gradient Vs PaO2/FiO2 >> Hypoxic respiratory failure?

Respiratory Center and Upper Airway

Nasal Obstruction: URI-FBCongenital

CNS depression Trauma Infection Drug OD

Nasopharyngeal Area
Congenital Cleft Palate

Adenoids Oropharyngeal Area

Tonsils RPA-FB
Larynx: Epiglottitis Croup syndrome

Intra-thoraxic/ Extrapulmonary Airway

- wheezing, Inspi. and Exp Intraluminal Wall Extrinsic compression

Intrathoracic/ Intrapulmonary
- Wheezing Expiratory Intraluminal Wall Extrinsic compression

Chest Wall
Flail (compliance)
Chest Trauma Hypotonia (GB) Stiff (compliance) Burns

Alveolar (Alveolar filling process)

Pneumonia Pulmonary Edema Hemorrhages

Case 1
15 mo. Old, admitted to PICU with dx of croup, mild respiratory distress.
Previously healthy

2 days hx of URI with low grade fever, increasing barking cough, tachypnea decrease PO intake
Monday 5PM

Alert, vigorous cry, barking cough, persistent stridor during sleep, increases with crying:
VS: 100.2 F, RR 30 O2 sat, 96 % RA,

PE, Lung: fair air entry; inspiratory stridor when crying

Studies:

5 PM
Increase Respiratory distress
Persistent stridor Increased retractions.

O2 Sats in RA 90 %

Rx: Humidified Oxygen: Mode of deliver? How much?, Percentage of O2 NPO, IV fluid Meds: Racemic epi, Decadron

Oxygen Delivery Systems

Low Flow:
Nasal Cannula:
no more than 5L/min Each L/min delivers ~ 4 % Oxygen > RA At low flows, no need to humidify

Simple Mask
Use for an emergency / transport Deliver ~ 30% at 6-8 L/min

NASAL CANNULA
O2 Flow each L/min Flow increases the inspired FiO2 by ~ 4 % (over the 21 % Room Air FiO2 at sea level) 24 % 28 % 31 % 35 % 38 %

1 L/min 2 L/min 3 L/min 4 L/min 5 L/min

DO NOT GO HIGHER THAN 5 L/MIN; especially if no humidified oxygen is being use it may cause Nose bleeding.

Simple mask (low flow system)

Can deliver up to 40 - 60 % FiO2 (at Flow 6 to 10 L/min)
~ FiO2 being delivered

O2 Flow 6 L/min
7 L/min

40 %

44 %

8 L/min

50 %

9 L/min

55 %

10 L/min

60 %

Oxygen Delivery Systems

Middle Flow: > 35 % < 50 %
Simple Mask
Use for an emergency / transport Deliver ~ 30% at 6-8 L/min

Venturi (Venti-Mask)
Color attachment determines the Oxygen deliver From 25 % to 50 % At low flows, no need to humidify

Venturi Mask: uses the venturi system, mixing different flows of 100% Fi02 with room air in different color adaptors: O2 Flow 4 L/min 5 L/min 6 L/min 7 L/min 8 L/min 10 L/min Color Adaptor Blue Yellow White Green Pink Orange ~ FiO2 being delivered 24 % 28 % 31 % 35 % 40 % 50 %

HIGH FLOW OXYGEN

Aerosol / humidified mask (can be adjusted to deliver 21 to 100 % FiO2 and it is the preferred method to deliver oxygen in the PICU, because we can easily follow the trend ofthepatientsoxygenrequirements. Non rebreeding mask (high flow delivered system with reservoir, it deliver between 80 to 100% FiO2. This delivering System is use mainly for transport and for initially emergency care and patient stabilization.

OTHERS
Oxyhood
Humidified 21% to 100 % Variable

Croupette / Tent

11:30 PM Suddenly Increase coughing spell with worsening stridor, severe respiratory distress,

Rx: Extra Vapo, no improvement - Hypoactive, pale, diaphoretic - Saturation 75 % on oxygen by mask - HR 180

- Intubation with a smaller ET tube than indicated for age and size. - Keep it well sedated - Continue steroids x 24 hours - Look for signs of aspiration.

CROUP SYNDROME UAO Stridor (Laryngeal Obstruction)

Viral Croup Spasmodic croup (Hyperreactive UAW) Epiglottitis Laryngomalacia FB

Febrile, Toxic looking, drooling,

Urgent/ Semi elective intubation done in the OR

Case 2
5 yo s/p T&A for OSAS admitted to PICU for observation.
Friday 2 PM Awake crying, clear voice, Breathing comfortable, (mouth breathing) Afebrile Sat. 98% RA Lung, good air entry Hemodynamically stable, IV in place

Rx: - Clear fluids ( T&A diet) - IV fluids - Humidified O2/Air as tolerated - Pain meds.

10 PM - Sleeping with loud snore, severe retractions, O2 Sat 70 %. HR 140

Try to wake him, unable. Given oxygen, O2 sat increased to 80 %.

Post Op complication of T&A for OSAS

Residual Obstruction 2nd to
nasopharyngeal tissue swelling. (Uvula) Collapsable nasopharynx (patient oversedated)

Respiratory depression 2nd to pain medication Post release of Obstruction Pulmonary Edema Hemorrhage

Rx:
Reverse drug effect if narcotic oversedation. Nasopharyngeal Airway Bi-Pap Back to OR if significant bleeding. Intubation

Case 3
10 yo MVA with head trauma, LOC Concussion, Normal head CT. Admitted to PICU for observation. Previously healthy

Saturday 10 PM Alert, oriented x 3, GCS 15 C-R stable, no other injuries Rx: NPO, IV Fluids

Sunday 8 AM

- Vomited a few times - Sleeping - RR, unlabored 15 / min - O2 Sats 90 % RA - Lungs clear to auscultation - HR 80/ min

PE:

- Difficult to arouse - Pupils sluggish reactive

Rx: - Open airway - O2

- Intubate / Mannitol - Repeat Head CT - Call Neurosurgery team?

Early sign of herniation

Decrease Mental status Respiratory depression >> upper airway obstruction >>>> Desaturations Sluggish pupillary reaction Triad:
Alter mental status- Bradycardia Hypertension

Patient at risk of herniation

CNS Trauma. HEAD CT CAN BE NORMAL CNS Infections DKA Severe hyponatremia / hypernatremia dehydration.

Case # 4
5 yo with status asthmaticus in severe respiratory distress.
Sunday 6 PM - Awake, irritable in severe respiratory distress - RR 60 - Severe retractions, with nasal flaring - O2 Sat when receiving Nebs. 90% - HR 180

Rx: - Oxygen (with Nebs) - Continuously (back to back) Nebs treatments - IV Solu-Medrol - NPO - IV Fluids - Studies: >>

ABG when on Nebulizer

Ph:7.25 PCO2:49 PO2:100 Sat: 98% Bic15 BE-10
CxR Hyperinflation only

Complication in CxR in patient with LAO

Pneumomediastinum Lobar collapse Pneumothorax

Case # 5 6 yo with severe muscle weakness 2nd to GB

Monday 12 noon - Alert, oriented, unable to sit up with out help - RR 18 O2 Sat 100 % RA - Talking with a good tone of voice - Fair to Good cough and gag effort - Lung: good air entry

Rx: - CR monitoring
- IV in place - IVGG order - Clear fluids - Bed side PFT: NIP (Negative Insp. Pressure MVV)

Tuesday 7 AM

- Patient seems irritable,uncomfortable

- RR 18 unlabored - O2 Sats. 90 % in RA - Lungs clear

-Poor cough effort - voice softer

Studies:

ABG on oxygen:

Ph7.15 PC02:60 P02:60 02 Sat80% Bic:20 BE:-2

Patients with Neuromuscular dysfunction do not show respiratory distress

Case # 6 7 yo with ACS, bilateral infiltrates in moderate respiratory distress

Friday 4 PM Alert, uncomfortable, sick looking RR 60, mild SC retraction, flaring and granting. O2 100 % on non-rebreathing mask Lungs. Decrease breath sounds over the whole left lung, crackles and bronchophony Studies:

ABG on Partial Rebreathing mask (>80%)

Ph 7.47 PCO2 30 PaO2 100 O2 Sat: 98 % Bic 25 BE -2

ABG on PRM

Ph 7.47 PCO2 30 PaO2 100

A-a gradient(N <20) 7 x 80 = 480 50 = 430 PaO2 / FiO2(N 400)

O2 Sat: 98 %
Bic 25 BE -2

100 / 0.8 = 125

CBC
WBC 21 K H/H 6 / 19 Plat. 250

Rx
NPO IV Fluid Transfusion / exchange transfusion BI-PAP >>> Intubation

HYPOXIC RESPIRATORY FAILURE

1. Pa O2 < 60 (O2 Sat < 85%)on FiO2 > 60 %

2. Increase A-a Gradient > 300

3. Decrease PaO2 / FiO2 < 150

Rx
NPO IV Fluid Transfusion / exchange transfusion BI-PAP >>> Intubation

HYPOXIC RESPIRATORY FAILURE

1. Pa O2 < 60 (O2 Sat < 85%)on FiO2 > 60 %

2. Increase A-a Gradient > 300

3. Decrease PaO2 / FiO2 < 150

Buddy