Oxygenation Failure Dyspneic Patient Oxygen Therapy ARDS Jan Maláska • 63 yo female patient • She collapsed aprox. 14 days ago • Now she complaints about chest pain on right side • Due to worsening dyspnea an examination and differential disgnosis is ongoing at local hospital 1. What do you think about the working diagnosis? 2. Which examination, imaging methods and lab test you want to schedule? Dyspnea 1. Pulmonary - COPD, astma bronchiale, pneumonia. 2. Heart- AHF, valvular problems, TED 3. Blood disease- Anaemia, SCD 4. Neuromuscular- dystrophia, Myasthenia Gravis 5. Others – obesity, ascites, surgery, trauma, goiter 6. Psychogenic Dyspnea -examination • Physical Examination Dyspnea - diagnostics • Lab-tests – ABG – BC – Liver Enzymes – BUN, creat, Na, K, Cl, Mg, Ca, P – CRP, PCT – Cardiac enzymes, BNP, pro-BNP – D-dimers Dyspnea – imaging methods – Chest X-ray – ECG – ECHO – Abdominal US – spirometry – Lung CT – CT-angiography Key Clinical Exam Findings A. Airways patent B. Respiratory Rate aprox. 27 breaths/min C. BP 84/55 HR 131 (b.p.m.) D. Alert, not fully orientated Lab results on admission How many organs are in dusfunction or failure? SOFA score (Sequential Organ Failure Assessment) Laboratoř při příjmu • alteration in mental status • systolic blood pressure ≤100 mm Hg • respiratory rate ≥22/min http://www.qsofa.org/ • Fracture of two ribs on the right side (from 5th to 7th ) • Lung contusion with large infiltration on the right side Actual clinical findings • SpO2 85% • TK 90/45, p. 131/min • AKI Patient is admitted to ICU • Diagnosis is sCAP • Major problems?: 1. Hyposaturation 2. Hypotension 3. AKI Which equipment you choose? Which flow? Which goal? What is the maximal flow? What about the gases from central distribution? průtok O2 (l/min) FiO2 (%) 0 21 1 25 2 29 3 33 4 37 5 41 6 45 Kyslíkové brýle průtok O2 (l/min) FiO2 (%) 7 65% 8.15 70-80% Maska se zpětným vdechováním průtok O2 (l/min) FiO2 (%) 6 55-60 8 60-80 10 80-90 12 90 15 90-100 *za podmínky že nekolabuje rezervoár Maska bez zpětného vdechování Several Hours after Admisson in ICU Transport of O2 and CO2 Alveolar Ventilation (exchange of CO2 between alveoli and environment) Transport of O2 a CO2 in the blood Diffusion (diffusion of O2 from alveolus into blood ) LEFT SHIFT: Hypokapnia Hypothermia Alkalosis Lower DPG RIGHT SHIFT: Hyperkapnia Fever Acidosis Higher DPG Oxyhaemoglobinsaturation(%) VA/Q = 0 Compartment 1 Compartment 2 Compartment 3 Q = 0 VA = 0 Deoxygenated blod from Pulmonary vein Shunt Arterial Blood Alveolar VA/Q = 1 VA/ Q = ∞ Types of Respiratory Failure? Oxygenation Failure Basily due to failure of alveolocapillary transport. Ventilatory failure Due to failure of „muscle pump“ of the chest (disorders of CNS, chest, respiratory muscles, neuro-muscular junction) paO2 (spO2, saO2) pCO2 (ETCO2) 1. V/Q mismatch 2. Increase in pulmonary shunt 3. Diffusion abnormalities Increase inVD/VT mismatch CT scan after admission Day 2. • Patient is still tubed • diagnostic fibroscopy with BAL is performed • BAL - bronchoalveolar lavage – aprox. 150 ml of normal saline is instilled and alveoli are washed • Ongoing haemodynamic stabilisation • Improving in oxygenation • Sedation is withdraw • A IHD is performed on day 3 • Etiological is prooved? Any Idea? What is Artificial ventilation? • Artificial ventilation is an organ support. • Ventilatory machine partially or completelly secures the flow throughout respiratory system. Reduction of adverse affects of arteficial ventilation 1. Normalise oxygenation (PaO2 > 60 mmHg = 8 Kpa, Sa02>90%) 2. Maintain adequate ventilation, typically a PaCO2 of 35-45 mmHg= 4,5-6,0 Kpa 3. Normalise acid-base balance 4. Reduce patient WOB 5. Lowering VO2 Clinical Goals Physiological Goals To reach the preset goals of oxygenation and ventilation Indication for Arteficial Ventilation Oxygenation  PaO2<70 mmHg (9 Kpa) despite oxygen therapy  P/F index PaO2/FiO2 < 200 mmHg Lung Mechanics  DF > 35/min Ventilation  Apnea  PaCO2 > 55 mmHg (7,5 Kpa) Two basic modes of Artificial Ventilation 1. Non-invasive Ventilation (NIPPV) 2. Invasive Possitive Presure ventilation (IPPV) 1. Non-invasive Ventilation (NIPPV) 2. Invasive Possitive Presure ventilation (IPPV) Generations of Artificial Ventilators • I. Generation: mechanical regulatory unit – OXYLOG 1000 • II. Generation: partially electronic regulatory unit - OXYLOG 2000 III. Generation • Electronic feed-back • Out-of-date IV. Generation VENTILATORY REGIMENS 1. REGIMENS w/FULLY VENTILATORY SUPP. 1. CMV or VCV – Volume Control Ventilation 2. PCV – Pressure Control Ventilation 3. PRVC – PRESSURE regulated VOLUME control 2. REGIMENS w/PARTIALLY VENTILATORY SUPP. 1. PS or SPONT (PSV, ASB)– Pressure Support 2. SIMV 3. BIPAP nebo DuoPAP – Bilevel Positive Airway Pressure 4. CPAP – Continuous Positive Airway Pressure P (DRIVING) I:E Trigger f PEEP FiO2 PCV – PRESSURE CONTROL VENTILATION Vt I:E Trigger f PEEP FiO2 CMV – CONTROL MANDATORY VENTILATION PS or SPONT – PRESSURE SUPPORT P support Trigger PEEP FiO2 CHEST X-ray after 2 days AFTER SEVERAL DAYS ARE WE TALKING ABOUT ARDS? • R.T.H. Laennec • First published report about ARDS • „Idiopathic lung oedema“ • ...œdème pulmonaire sans insuffisance cardiaque... Lancet. 1967 Aug 2;2(7511):319-23. Autopsy: • Atelectasis • Vascular congestions • Haemorhagy • Lung Oedema • Hyaline membranes Chest X-rays ARDS - BACKROUND I. PULMONARY – PRIMARY- ARDS: a) Aspiration of gastric content b) Pneumonia c) Inhalation trauma d) Lung Contusions e) Near-Drowning f) I/R injury after lung transplant ARDS - BACKROUND II. EXTRA-PULMONARY – SECONDARY - ARDS : a. Sepsis/Septic Shock b. MODS in Shock c. Pancreatitis (SIRS) d. Massive Blood Products Therapy (TRALI) e. Drug Poisoning Timing of ARDS therapy T.Thompson Prone positioning Fibrosis in late-ARDS HE – Lung Fibrosis © MUDr.Moulis PAU FNB HE VG ARDS TREATMENT I. NON-PHARMACOLOGICAL 1. Arteficial Ventilation– Vt=6 ml/iBW, PEEP, FiO2 2. PRONE POSITIONING 3. FLUID REGIMEN – „dry lungs“ II. PHARMACOLOGICAL ARDS TREATMENT I. NON-PHARMACOLOGICAL (IPPV) II. PHARMACOLOGICAL 1. Corticosteroids 2. Surfactant 3. NO 4. Prostaglandine E1 III. SUPPORTIVE