Define acute respiratory failure

Identify patients requiring mechanical

ventilation

Discuss the mechanics and physiology of

positive pressure ventilation
 Compare/contrast the risks and benefits of
noninvasive vs. invasive positive pressure
ventilation

List contraindications for noninvasive

positive pressure ventilation

Discuss the common presentation,

radiographic and histologic findings, and
management principles in patients with
ARDS
 What is ventilation?

Movement of air in and out of the lungs

Inhalation and exhalation
Negative intrathoracic pressure
Air follows pressure gradient
Set by need to eliminate CO2
Tidal volume and respiratory rate
 Work of breathing can be increased by:
Need for increased ventilation
Exercise
Sepsis/acidosis

Increased mechanical load

Decreased lung compliance
Increased airway resistance
 What is respiration?

Gas exchange
Diffusion of oxygen into the blood
Diffusion of carbon dioxide out of the blood
Interstitial disease effects this
Efficient exchange requires perfusion to aerated
alveoli (V/Q matching)
Shunting-venous blood mixes unaltered with
oxygenated blood
Arterial hypoxemia refractory to FiO2
 Occurs in 130-140/100,000 hospital
admissions
In-hospital mortality of 36%
Definition:
Inadequate gas exchange
Hypoxemia
Hypercarbia
Both
All taken in context of patient presentation!!!
 78 year old male from a nursing home
HPI: Fever, cough with green sputum,
shortness of breath getting worse over 4 days
Vital signs:
T-102.3; HR-132; RR-28; BP- 100/60; Pulse ox:
89% on room air
Physical examination:
Lethargic, responsive to painful stimuli
Heart tachycardic, regular, no murmur
Lungs, rhonchi left base
 CBC: ABG:
WBC: 13,000 pH: 7.32; PaO2: 56;
Hgb: 12 PaCo2: 50; HCO3: 18

HCT: 35
PLT 248
Chem 7:
Na: 150; K: 4.8;
Cl: 104; Bicarb: 16
BUN: 50; Creat: 2.1;
Glucose: 205
 CBC: ABG:
WBC: 13,000 pH: 7.32; PaO2: 56;
Hgb: 12 PaCo2: 50; HCO3: 18

HCT: 35
PLT 248
Chem 7:
Na: 150; K: 4.8;
Cl: 104; Bicarb: 16
BUN: 50; Creat: 2.1;
Glucose: 205
1. Acute CHF 25% 25% 25% 25%

2. Acute
exacerbation
COPD
3. Acute
Pneumonia
4. ARDS

1 2 3 4
1. Yes 50% 50%
2. No

1 2
 72 year old female who lives at home
HPI: SOB worsening for 3 days, cough with green
sputum; no fever
Vital signs:
T-98.9; HR-128; RR-28; BP- 120/60; Pulse ox: 89%
on room air
Physical examination:
Awake, 3 word dyspnea, cooperative
Heart: tachycardic, regular, no murmur
Lungs: BS decreased, prolonged expiratory
phase with expiratory wheeze
 CBC: ABG:
WBC: 11,000 pH: 7.38; PaO2: 56;
Hgb: 12 PaCo2: 55; HCO3: 18

HCT: 35
PLT 248
Chem 7:
Na: 146; K: 4.8;
Cl: 104; Bicarb: 30
BUN: 20; Creat: 1.8;
Glucose: 205
1. Acute CHF 25% 25% 25% 25%

2. Acute
exacerbation
COPD
3. Acute
Pneumonia
4. ARDS

1 2 3 4
1. Yes 50% 50%
2. No

1 2
 75 year old man, lives at home
HPI: SOB worsening for 3 days, nonproductive
cough; feels worse lying down
Vital signs:
T-98.9; HR-128; RR-28; BP- 160/68; Pulse ox: 89%
on room air
Physical examination:
Awake, 3 word dyspnea, anxious and agitated
Heart: tachycardic, +S3,+S4
Lungs: expiratory wheeze; rales bilateral bases
 CBC: ABG:
WBC: 11,000 pH: 7.38; PaO2: 56;
Hgb: 12 PaCo2: 55; HCO3: 22

HCT: 35
PLT 248
Chem 7:
Na: 142; K: 4.8;
Cl: 104; Bicarb: 22
BUN: 20; Creat: 2.1;
Glucose: 205
1. Acute CHF 25% 25% 25% 25%

2. Acute
exacerbation
COPD
3. Acute
Pneumonia
4. ARDS

1 2 3 4
1. Yes 50% 50%
2. No

1 2
 Air forced into central airways
increases pressure
Air follows pressure gradient
Inflates lungs
Lung inflates- device stops forcing air
Intra-alveolar pressure> central airway
pressure
Air follows pressure gradient
Exhalation!
 Improves gas exchange
Improves V/Q matching
Decreased physiologic shunt
Decreases work of breathing
Decreases preload and afterload
Redistributes pulmonary fluid
Out of alveoli
Reverses hypoventilation
 CPAP
Constant pressure throughout
5-15 cm H2O

BiPap
Higher pressure during inhalation, lower in
exhalation
8-10cmH2O/ 3-4 Cm H2O
May be more comfortable
 Cardiac or respiratory arrest
Uncooperative patient
Patient unable to protect airway
Severely impaired consciousness
Facial deformity/trauma/surgery
Prolonged duration
Facial pressure sores
Recent esophageal anastomosis
 Hypoxemia
Vomiting/aspiration
Bleeding
Pneumothorax
Cardiac dysrhythmia/arrest
Hypoxiabradycardia
Unrecognized esophageal intubation
 Volume control vs. Pressure control
Pressure usually used in pediatrics or weaning
Patient must be breathing spontaneously

Volume settings
Controlled Mechanical Ventilation(CMV)
Set volume at set rate--no extra breaths
Asynchrony
Assist Control
Set volume, set rate, pt. can trigger set volume
Synchronized Intermittent Mandatory Ventilation(SIMV)
Set volume and rate, pt. triggers own volume
Generally used in weaning
 Tidal Volume
Set at 6-8ml/kg
Respiratory rate
Fraction of inspired oxygen (FiO2)
Lowest amount needed for support
Positive End Expiratory Pressure (PEEP)
Improves VQ matching
Reduces preload
Elevates plateau pressures
Increases intracranial pressure
 Patient is hypoxic?
Increase FiO2
Increase PEEP

Patient is hypercarbic?
Increase TV
Increase Respiratory rate
 Sedation!!!!

Prophylaxis for DVT/PE

Nutritional support

Treat underlying disease

 A previously healthy 42 year old man has
been in the ICU after a major car
accident. He had surgery for bilateral
femur fractures and was diagnosed with
a traumatic brain injury. He is on a
ventilator. On his second postoperative
day he is becoming increasingly
hypoxic.
 ABG on 100% FiO2:
pH: 7.35;
PaO2: 90;
PaCO2: 38;
HCO3: 22
1. Acute CHF 25% 25% 25% 25%

2. Acute
exacerbation
COPD
3. Acute
Pneumonia
4. ARDS

1 2 3 4
 Diffuse lung injury due to direct or
indirect lung injury
Sepsis
Pneumonia
Trauma
Multiple transfusions
Aspiration of gastric contents
Drug overdose
 Exudative
Damage to alveolar capillary junction
Inflammatory response
Proteinaceous edema in alveoli
Formation of hyaline membrane whorls
 Exudative
Edema in dependent portions of lungs
Atelectasis-collapse of lung sections
Decreased compliance
Loss of surfactant
Shunting and hypoxemia
Usually occurs within 12-36 hours
CXRdiffuse interstitial infiltrates
Normal cardiac size
Heterogeneous distribution
 Proliferative
Days 7-21
Usually recover enough to come off of vent
May remain hypoxic, dyspneic and
tachypneic
Proliferation of type II pneumocytes
Reparative
May end at this stage and improve
 Fibrotic
Many will recover in 3-4 weeks without
reaching this phase
May require long-term O2 or ventilation
Extensive alveolar and interstitial fibrosis
Progressive pulmonary hypertension
 Use lower tidal volumes on vent
6ml/Kg
Set PEEP to minimize FiO2
Prone position
Increased oxygenation but can worsen mortality
Fluid management
Less is more!
Steroids
High dose not supported
Moderate does +/-
Surfactant, Nitric oxide, other NSAIDs
No benefit
 Ventilation ---inhalation exhalation

Respiration---gas exchange

Respiratory failure
Hypoxemia, hypercarbia + patient
presentation
 Air flow follow pressure gradient from
high to low
Normal respirationnegative intrathoracic
pressure
Mechanical ventilation-positive pressure

NIPPV should be used when possible

Awake, cooperative, protecting airway
Able to tolerate work of breathing
Septic, acidoticintubation preferrable
 Adult Respiratory Distress Syndrome
Acute lung injury and inflammation
Severe refractory hypoxia
Diffuse alveolar infiltrates
Hyaline membranes
Management
Conservative fluid therapy
Lower tidal volume
No benefit from high dose steroids, surfactant,
prone position controversial