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cardio and resp yr 2 > respiratory failure > Flashcards

respiratory failure Flashcards

1
Q

what is acute resp failure called?

A

acute respiratory distress syndrome

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2
Q

why is there limited data on acute respiratory distress syndrome? (ARDS)

A

Because it has heterogenous presentations and also the policies for ventilations and management when someone presents with it vary a loott

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3
Q

is ARDS common? is it fatal?

A

yes and yes (30-40% mortality) more serious in oolder people- more fatal

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4
Q

critical features to classify as ARDS

A

TIMING: needs within 1 week from new clinical insult or worsening

sides: both sides

needs to not be fully explained by smth like heart failure (problem needs to stem from lungs)

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5
Q

cseverity classifications and how do you manipulate internationa numbers for uk numbers?

A

mild
moderate
severe

numbers on slide divided by approx 6.5

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6
Q

what is ventilation and perfusion in this context?

A

ventilation refers to alveolar gas exchanges

perfusion is the blood flow in pulmonary capillaries

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7
Q

which part of the liung is there more ventilation and why

A

at the bottom because there is

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8
Q

what are the two types of resp failure

A

type 1: hypoxia (failure to get oxygen)
type 2: hypercapnea (failure to remove co2)

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9
Q

CAUSES of type 1 resp failure

A

1)increased shunt fraction (QS/ QT) HEART failure - this is hypoxemia refractory to supplemental oxygen (independant - to suppl oxygen bc it has to do with blood circulation)

2) ALVEOLAR FLOODING (aspiration of smth - acid,-> membrane doesnt work-> oedema, fluid bc heart failure! or scarred membrane fron othe rreason

pulmonary oedema
pulmonary embolism
pulm hypertension

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10
Q

2 types of causes for type 2 resp failure

A

1) decreased alveolar minute ventilation (air getting to alveoli less- due to slow breathing- unconsious ect)_

2) dead space ventilation- less air getting to alveoli due to contriction of airways (asthma, COPD)

nervous syst
neuromuscular
muscle failure
chest wall deformity

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11
Q

what are some drugs that have already been tested for resp failure adn didnt rl work

A

steroids, salbutamol (surfactant) , surfactant, N-Acetylcysteine (cheap and easy) , neutrophil esterase inhibitor, GM-CSF, statins

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12
Q

some of the treatments being tried out now

A

keratinocyte growth factor (repair factor)

mesenchymal stem cells (ex-vivo benefit) (cells loosely connected in extracellular matrix)

steroids- going back to this

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13
Q

how much evidence is there on ARDS

A

not much- see ipad for what 3 key studies are syaing

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14
Q

what is a relevant sub- phenotype sin patients that has been associated with ARDS outcomes

A

hyper and pro inflammatory endotypes, hyperinflammatory patients do worse (these are sort of patent differences- form person to person- medcine is headed in that more personalized management way)

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15
Q

why is it important to research these sub phenotypes

A

so we can treat the specific parts of disease better for each one

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16
Q

three types of therapeutic intervention (in terms of the aspect of your disease being targeted)

A

treating underlying disease
repspiratory support
multiple organ support

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17
Q

what drugs do you treat underlying disease with

A
  • treating underlying disease:
    bronchodilators
    pulmonary vasodilators

steroids
antibiotics
antivirals

systemic drugs (immunotherpies n other)
Pyridostigmine
Plasma exchange
IViG
Rituximab

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18
Q

approaches for repsiratory support

A

Physiotherapy
Oxygen
Nebulisers (inhaling a drug)
High flow oxygen
Non- invasive ventilation

Mechanical ventilation
Extra-corporeal support (Extra corporeal membrane oxygenation - ECMO: you remove blood, oxygenate it and oout back in to support heart AND lungs- very high risk)

19
Q

multiple organ support approaches and organ systems to target

A

Cardiovascular support
Fluids
Vasopressors
Inotropes

**Pulmonary vasodilators**

Renal support
Haemofiltration
Haemodialysis

Immune therapies
Plasma exchange
Convalescent plasma

20
Q

what is the order of respiratory support interventions as ARDS gets progressively worse

A

1) conservative fluid management and low volume ventilation
2) increasing positive end expiratory pressure (like an air stent into lungs trying to recruit as many alveoli as possible)
3) neuromuscular blockage and if its not working well prone them
4) inhaled pulmonary vasodilator
5) ECMO

21
Q

the sequelae (consequences) of ARDS

A

-POOR GAS EXCHANGE : poor oxygenation and perfusion, hypercapnoea

  • infection: sepsis
  • inflammation - inflammatory responce

-systemic effects (sleep, heart, kidney ect due to v high co2, you can die of multi organ failure)

22
Q

what are the 4 types of ventilation

A

volume controlled
pressure controlled
assisted breathing modes
advanced ventilatory modes

23
Q

which type of ventilation is not used in uk and why?

A

pressure controlled ventlation because its dangerous to control pressures bc lung may colapse (see pressure volume loop)

24
Q

how does the patient volume loop change form normal to ARDS lung

A

moves down and to the right

25
Q

how is compliance depicted/ quantified in / from a pressure volume loop

A

its the incline of the extrapolation of the straight line of inspiration

26
Q

what does UIP stand for and signify

A

upper inflection point

its the top part before the straight line becomes flatter on the inspiration side of loop (bottom). it signifies that after this pressure the alveoli need disproportionately lagre amounts of pressure to fill

27
Q

what is LIP

A

lower inflection point: lowest pressure at which there can be optimal alveolar recruitment

28
Q

what colour is air in CT

A

black - more black: better

29
Q

what is lung ct used to see

A

if theres air in lumgs or if they are not properly ventilated

30
Q

what do you use lung iltrasound for

A

see if fluid or air infectin or stuff like that

31
Q

what is the murray score

A

score used to guide escalation of therapy (determine who needs escalation/ refferal)

32
Q

factors involved in murray score

A

1) oxygen levels
2) CXR (x-ray scan)- how many quadrants are infiltrated
3) PEEP - the more you need the more points
4) compliance - the more the better

33
Q

how do you calculate murray score

A

add up all points and divivde by 4 (average of the 4 factors)

34
Q

score range - normal- needing ecmo

A

0= nrpmal
1-2.5 mild
2.5 severe
3- ecmo

35
Q

can patients get ecmo in every hospital in UK?

A

NO, there are 6 centeres that deal with this stuff

36
Q

what is the national ARDS aproach

A

since onmly 6 national centres, when someone has murray score >3 or really low ph (<7.2)
1) telephone or online repheral
2) consultant case review
3) send imaging
4) advice from special hospital
5) retrieval if needed- take them to the other hospitl by ambulance
6) transfer back to your hospital after ecmo/ special management
7) continue treatment on your hospital tll they get better

37
Q

what is another case in which you should give ecmo (other than murray score >3)

A

when positive pressure ventilation is not appropriate for ex due to significant tracheal injury

38
Q

who should you NOT gibe ecmo to

A

1) someone who wouldnt be able to continue active treatment after ecmo due to a significant co morbidity (this also could mean they could become dependent to ecmo)

2) someone who would get a disability that theyr enot ok with getting

39
Q

success rate of ecmo in uk?

A

very high

40
Q

why may success rate of ecmo in uk be better than other countries

A

bc very refinedcriteria on who gets ecmo

41
Q

how does ecmo work?

A

1) CANNULA THROUGH IVC

2) blood goes from IVC into a centrifugal pump (has little magnet to spin inside to reduce sheer stress: make sure layers are not separating)

3) then sent to oxygenator where pure oxygen is passed across the top of the membrane and blood turns from purple/ blue to bright red

4) blood inserted back into RIGHT heart (so lungs are nooot bypassed)

42
Q

what evidence is there for ecmo in literature and in uk clinical data?

A

literature: not that much evidence, 1 big trial started was stopped and data not stat sign

buttt

in uk lower mortality shown than lit- maybe bv of selection criteria
so ecmo used widely in uk

43
Q

disadvantages od f ecmo

A
  • prob with equity- centres are only 6 spread so u might live far and spend longer time getting there- getting sicker
  • technically hard - haemodynamics, clotting and bleeding, access to internal jugular and other veins ect
  • very expensive

cardio and resp yr 2 (10 decks)

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