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Cardio-Respiratory Care and Pulmonary Rehabilitation 5MPT2013 > Respiratory & Ventilatory Failure and theories of positive pressure > Flashcards

Respiratory & Ventilatory Failure and theories of positive pressure Flashcards

1
Q

Aims

A
  • Describe the concept, underlying pathophysiology, impairments and clinical presentations of type I and type II respiratory failure
  • Justify an evidence-based treatment plan for the management of a patient with type I and type II respiratory failure
  • Describe and explain the physiology, and relevant precautions and contraindications for using continuous positive airways pressure (CPAP), non-invasive positive pressure ventilation (NIV) and intermittent positive pressure breathing (IPPB)
  • Select and critically evaluate appropriate research evidence that explore the use of NIV in patients with COPD
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2
Q

Define respiratory failure?

aka type 1

A
  • Failure to maintain adequate gas exchange and is characterised by abnormalities of arterial blood gas tension.
  • Decreased PO2
  • Decreased or normal PCO2
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3
Q

What is Acute hypercapnic respiratory failure?

aka type 2

A
  • AHRF results from an inability of the respiratory pump, in concert with the lungs, to provide sufficient alveolar ventilation to maintain a normal arterial PCO2.
  • Co-existent hypoxaemia is usually mild and easily corrected.
  • PCO2 > 6.5 kPa and pH < 7.35
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4
Q

Which respiratory components can fail, in respiratory failure?

A

Associated with both the lungs and the respiratory muscle pump. So anything that effects the; Load, capacity or drive.

So that could be;

  • The lung itself.
  • Damage to pleura or the chest wall.
  • Nerve damage e.g. phrenic nerve.
  • NMJ via diseases such as Myasthenia Gravis.
  • Weak respiratory muscles.
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5
Q

What are the normal values for the following?

  • pH
  • PaO₂
  • PaCO₂
  • HCO₃¯
  • BE
A
  • pH 7.35 - 7.43
  • PaO₂ 10.7 - 13.3 kPa
  • PaCO₂ 4.7 - 6.0 kPa
  • HCO₃¯ 22 - 26 mmol
  • BE -2 - +2
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6
Q

What is the process and end result of untreated respiratory failure.

(Its the same for type 1 and 2, and describe in a flowchart like manor)

A
  • O₂ is fuel for tissue respiration / metabolism.
  • Lack of O₂ = hypoxemia
  • -> anaerobic metabolism
  • -> metabolic acidosis
  • -> Neurological and cardiovascular deterioration.
  • -> Cell hypoxia
  • -> Cell death.
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7
Q

Summarise type 1 respiratory failure (Hypoxemic)

A
  • Decrease in O₂ (<8kPa)
  • CO₂ normal or low
  • pH normal

Oxygenation failure (V/Q mismatch or diffusion impairment)

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8
Q

Summarise type 2 respiratory failure

Hypercapnic

A
  • Decrease in O₂ (<8kPa)
  • Increase in CO₂ (>6KpA)
  • Decrease in pH

Ventilatory failure (Failure with the respiratory pump)

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9
Q

What type of reparatory failure am I?

  • pH 7.43
  • PaCO₂ 7.5
  • PaCO₂ 5.5
  • HCO₃¯ 24
  • BE 0.5
A

Type 1

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10
Q

What type of reparatory failure am I?

  • pH 7.29
  • PaO₂ 7.6
  • PaCO₂ 8.1
  • HCO₃¯ 23
  • BE -1
A

Type 2 acute

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11
Q

What type of reparatory failure am I?

  • pH 7.36
  • PaO₂ 8.1
  • PaCO₂ 7.3
  • HCO₃¯ 31
  • BE +3
A

Type 2 chronic

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12
Q

What can cause type 1 respiratory failure?

A
  • Secretion retention.
  • Acute lobar collapse.
  • Fluid - Pleural effusion / Pulmonary oedema
  • Pneumonia
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13
Q

What can cause type 2 respiratory failure?

A
  • Decreased respiratory drive e.g., opiate overdose
  • impaired inspiratory muscle strength e.g. Neuromuscular disease.
  • Increased demand on system e.g. Acute ex COPD or COVID -19 pneumonia
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14
Q

What are the signs of Type 1 respiratory failure?

A
  • Tachypnoea (abnormally rapid breathing)
  • Tachycardia (abnormally rapid bpm)
  • Accessory muscle use
  • Cyanosis (peripheral v’s central)
  • Clammy
  • Altered mental state
  • Breathlessness.
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15
Q

What are the signs of Type 2 respiratory failure?

A

Same as type 1 plus;

  • Confusion
  • Headache
  • Bounding pulse
  • Vasodilation
  • Decreasing consciousness
  • Breathlessness
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16
Q

What are treatment aims for management of respiratory failure?

A

Treatment aims;

  • Increase capacity of system.
  • Reduce load on the system.
  • Optimise drive.
17
Q

What type of management would be appropriate for type 1 respiratory failure?

A
  • O₂ therapy
  • Humidification
  • Positioning (decrease load and increase capacity)
  • ## Non-invasive ventilation
18
Q

What type of management would be appropriate for type 2 respiratory failure?

A
  • O₂ therapy
  • Aim PO₂, SpO₂ 88-92%
  • Provides adequate tissue oxygenation without further increasing CO₂ retention.
  • Increase Capacity: Increase lung volumes - positioning, pain relief, secretion clearance, ventilatory support.
  • Decrease load: Decrease WOB - positioning, secretion clearance, ventilatory support.
  • Drive: Respiratory stimulants, remove respiratory depressants.
19
Q

What are the 3 types of PP (positive pressure) breathing?

A
  • Intermittent (IPPB)
  • Continuous (CPAP)
  • Non-invasive ventilation (NIV)
20
Q

What are the basic principles of Positive pressure breathing

A
  • Air pushed into the lungs during inspiration.
  • Intrathoracic pressure becomes positive.
  • Increases lung volumes/ tidal volume.
  • Offloads respiratory muscles.
  • Cardiovascular effects
  • decrease venous return.
  • decrease CO
  • decrease BP
  • Decrease organ perfusion.
21
Q

What are the principals of IPPB (Intermittent positive pressure breathing)?

What’s it used for?
What does it do?

A
  • Mainly used now to increase VT, and aid secretion clearance.
  • non-invasive
  • patient triggered
  • pressure cycled
  • passive expiration

Can control the rate and depth of breath delivered by machine, settings adjusted for each patient.

22
Q

How does IPPB (Intermittent positive pressure breathing) work?

FYI the device is aka “The Bird”

A
  • Increases VT
  • Mobilises secretions using collateral ventilation.
  • Reduces WOB
  • Ventilates uppermost areas (not a good thing as usually its the distal pathways which are least ventilated, so this is a weakness of the device)
23
Q

What patients are best suited to IPPB (Intermittent positive pressure breathing)?

A

Patients who have/ are;

  • reduced VT
  • Sputum retention
  • Lobar collapse
  • Increase WOB
  • fatigued
  • Weak cough
24
Q

What is the effect of IPPB on lung volumes; VT, FRC?

A
  • Increases VT.

- No effect on FRC.

25
Q

Continuous positive airway pressure (CPAP), what is it, what does it do?

A
  • Positive pressure applied throughout inspiration and expiration during spontaneous breathing.
  • Non-invasive
  • Splints open alveoli
  • Patient determines own RR and VT
26
Q

What is the effect of CPAP on lung volumes?
FRC
VT

A
  • FRC increases

- no effect on VT

27
Q

How does CPAP work?

A
  • Increase in intrathoracic pressure - splinting open alveoli
  • Increase in FRC
  • Improves oxygenation
  • Decreases WOB
  • A CON: can be noisy, uncomfortable, cause abdominal distention and reduce BP
28
Q

Which patients are best suited to CPAP?

suitable problems

A
  • Atelectasis (lungs collapse partially or completely).
  • Decreased FRC
  • Hypoxemia despite high FiO₂ levels
  • Type 1 respiratory failure
  • NOT type 2 RF if using high flow O₂ if concerns regarding O₂ sensitivity.
29
Q

Just a little note/fact regarding COVID-19

A
  • CPAP is the preferred form of non-invasive ventilatory support in the management of the hypoxemic COVID-19 patient. Its use does not replace invasive mechanical ventilation (IMV), but early application may provide a bridge to IMV.
  • NHS Guidance 2020
30
Q

What is NIV and what does it do?

A
  • Provision of a higher inspiratory and lower expiratory pressure in time with patients breathing.
  • Delivered via face or nasal mask.
  • Patient triggered
  • Pressure cycled
  • Can set back up rate to ventilate patient.
31
Q

What is the effect of NIV on lung volumes?

  • FRV
  • VT
A
  • Increases both.
32
Q

How does NIV work?

A
  • Delivers an inspiratory pressure (IPAP) and provides an expiratory pressure (EPAP).

The IPAP;

  • Offloads respiratory muscles
  • Increases VT
  • Aids elimination of CO₂
  • Decreases WOB

The EPAP;

  • Splints open alveoli
  • Improves oxygenation
  • Increases FRC.
33
Q

What patients / problems is NIV suited to?

A
  • Type 2 (hypercapnic) RF
  • Patients who are fatigued
  • Weaning from conventional mechanical ventilation.
34
Q

It is important to monitor patients who are on Positive pressure therapy, but what would you be monitoring?

A
  • Important to monitor effects / tolerance of treatment.
  • Should include: HR, BP, RR and pattern, SpO2, ABG’s.
  • Oxygen saturations alone is not enough to tell about ventilatory needs.
  • Equipment settings.
  • Mask fit / seal – check no leaks.
  • Skin condition / integrity
35
Q

What are the contraindications / precautions to Positive pressure?

Its a looooong list :(.

A
  • Undrained pneumothorax
  • Vomiting
  • Severe haemoptysis
  • Non-compliance of patient
  • Large air leak post op
  • Proximal tumour
  • Emphysematous bullae
  • Lung abscess
  • Active TB
  • Proximal airway obstruction
  • Raised ICP
  • haemodynamic instability
  • surgical emphysema
  • recent lung, oesophageal, facial surgery.
36
Q

What is the Evidence for NIV?

A

Cochrane NIV 2017;
essentially strong supportive evidence for its effectiveness and reduced mortality rate.

see end of LC at 1:03

Cardio-Respiratory Care and Pulmonary Rehabilitation 5MPT2013 (8 decks)

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