1、Respiratory-Failure-呼吸衰竭Respiratory Failure第一頁，共四十九頁。Respiratory-Failure-呼吸衰竭1.AbstractsnRespiratory failure, whether acute or chronic, is a frequently faced problem and a major cause of death in our country. For example, mortality from COPD, which ends in death from respiratory failure, continues t

2、o increase.nMore than 70% of the deaths in patients with pneumonia are attributed to respiratory failure.第二頁，共四十九頁。Respiratory-Failure-呼吸衰竭2.DefinitionnRespiratory failure is functional acute or chronic disorder caused by any condition that affects the lungs ability to maintain arterial oxygenation

3、or carbon dioxide(CO2) elimination.nIt is defined as a condition in which this gas exchange deteriorates below the usual level, so that arterial oxygen tension decreases, with or without an abnormal rise in arterial carbon dioxide tension.第三頁，共四十九頁。Respiratory-Failure-呼吸衰竭3.ClassificationsnGenerally

4、 both acute and chronic respiratory failure may be divided into two main categories:第四頁，共四十九頁。Respiratory-Failure-呼吸衰竭Type respiratory failurenType respiratory failure is also called hypoxic respiratory failure, which means that severely reduces arterial oxygen tension(PaO20.8, including emphysema,p

5、ulmonary embolism. V/Q0.8, including atelectasis, severe COPD.第十頁，共四十九頁。Respiratory-Failure-呼吸衰竭nDiffuse ability Diffusion abnormality mainly influence oxygen exchange.第十一頁，共四十九頁。Respiratory-Failure-呼吸衰竭2.Pulmonary hypoventilationnIt may cause hypercapnic-hypoxic respiratory failure. Pulmonary hypov

6、entilation includes restrictive hypoventilation and obstructive hypoventilation.nSome diseases influenced central nervous system, peripheral nervous system, chest wall respiratory muscles and pulmonary compliance may all cause restrictive hypoventilation.第十二頁，共四十九頁。Respiratory-Failure-呼吸衰竭Some commo

7、n conditions that may cause ventilatory failure with hypercapneanThese conditions include brain stem lesion, altered neuromuscular transmission(guillain-barre syndrome), muscle weakness(malnutrition, shock, hypoxemia, hypokalemia),increased airway resistance(upper airway obstruction, increased bronc

8、hial secretions and edema), decreased lung compliance(infection, atelectasis, interstitial fibrosis, acute lung injury), decreased chest wall compliance(chest wall trauma, pleural effusion, pneumothorax).第十三頁，共四十九頁。Respiratory-Failure-呼吸衰竭nCOPD and asthma are the most common disease associated to ob

9、structive hypoventilation.nIn our clinical work, multifactors involve in the course of respiratory failure. For example, a COPD patient with severe pulmonary infection, his pulmonary gas exchange ability and pulmonary ventilation are all abnormal.第十四頁，共四十九頁。Respiratory-Failure-呼吸衰竭PathophysiologynHy

10、poxia and hypercapnic may influence functions of many important organs and systems, including respiratory system, cardiovascular system, central nerve system,blood system and digestive system and renal function.第十五頁，共四十九頁。Respiratory-Failure-呼吸衰竭 Clinical manifestationsnClinical signs include not on

11、ly symptoms associated with primary diseases but also those caused by hypoxic and hypercapnic-hypoxic respiratory failure.nHypoxemia and hypercapnia mainly influence the function of important organs, including respiratory system, central nervous system, cardiovascular system, digestive system, renal

12、 functions.第十六頁，共四十九頁。Respiratory-Failure-呼吸衰竭nThe unbalance of acid-alkalose metabolic and dielectric abnormality are usually exist in the course of respiratory failure.nTable 1. Clinical manifestations of hypoxia and hypercapnia.第十七頁，共四十九頁。Respiratory-Failure-呼吸衰竭 Clinical manifestations of hypoxi

13、a and hypercapnia HYPOXEMIA HYPERCAPNIA Tachycardia Somnolence Tachypnea Lethargy Anxiety Restlessness Altered mental status Slurred speech Confusion Headache Cyanosis Asterixis Hypertension Papilledema Hypotension Coma Bradycardia Seizures Lactic acidosist第十八頁，共四十九頁。Respiratory-Failure-呼吸衰竭 Diagnos

14、isnAccording to history, clinical manifestations,physical examinations and blood gas analysis, we can diagnose respiratory failure. Especially arterial blood gas analysis may reveal hypoxemia and hypercapnia. 第十九頁，共四十九頁。Respiratory-Failure-呼吸衰竭DiagnosisnThe diagnosis standard include:nType respirato

15、ry failure:PaO2 50mmHg, PaO2 60mmHg.nIn the condition of oxygen therapy, PaO2/Fi O270-80mmHg2.severe hypoxemia, after oxygen therapy, PaO235 per minute or severe breathlessness4.severe metabolic acidosis or pulmonary encephalopathy第二十四頁，共四十九頁。Respiratory-Failure-呼吸衰竭(2)Antiinfectious therapynRepeate

16、d bronchial and pulmonary infection is a major cause of chronic respiratory failure. About 90% of COPD patients with respiratory failure is caused by acute bronchial or pulmonary infection. Infection may also increase bronchial secretion and CO2 production. So antiinfectious therapy is an important

17、method to treat respiratory failure.第二十五頁，共四十九頁。Respiratory-Failure-呼吸衰竭nSelect effective antibiotics According to sputum culture, we can select sensitive antibioticsnUsing combined antibiotics Because of multibacteria infection, it needs several kind of antibiotics. For example, we may combine seco

18、nd or third generation cephalosporin to aminoglycoside or fluoroguinolone.第二十六頁，共四十九頁。Respiratory-Failure-呼吸衰竭(3)Oxygen therapynThe goal of oxygen therapy is to improve PaO2. It makes PaO260%. In general, the lowest FiO2 achieving adequate oxygenation. sometimes, arterial oxygen saturation90% should

19、 be used.第二十七頁，共四十九頁。Respiratory-Failure-呼吸衰竭The methods of oxygen therapy: nasal prongs 1-3L/min to chronic respiratory failure venti mask 1-3L/minFor type 1 respiratory failure, we can elevate the percentage of oxygen to maintain the PaO2.We can use higher inspirated fration of oxygen in type 1 re

20、spiratory failure oxygen therapy. But in type 2 respiratory failure we must select lower inspirated fration of oxygen .第二十八頁，共四十九頁。Respiratory-Failure-呼吸衰竭(4)Acid-base and electrolytes disturbancenThere are many factors lead to acid-base and electrolytes disturbance. These factors include severe pul

21、monary infection, hypoxemia or (and) hypercapnia. So airway maintenance, antibiotic therapy and use of bronchodilators are beneficial to treat it.第二十九頁，共四十九頁。Respiratory-Failure-呼吸衰竭(5)Use of respiratory stimulant drugs第三十頁，共四十九頁。Respiratory-Failure-呼吸衰竭(6)CorticosteroidsnMethyprednisone is usually

22、used to reduce the airway inflammation, and to improve FEV!. The treatment is recommended in all patients but it is not used for a longer time.第三十一頁，共四十九頁。Respiratory-Failure-呼吸衰竭(7)Gastrointestinal bleeding treatmentBecause of hypoxemia, hypercapnia and by using corticosteroids, gastrointestinal bl

23、eeding always be happened.The treatment mathod include correct hypoxemia and hypercapnia, use of H2-blocker and some block bleeding drugs.第三十二頁，共四十九頁。Respiratory-Failure-呼吸衰竭(8)Nutritional support therapy第三十三頁，共四十九頁。Respiratory-Failure-呼吸衰竭Acute Respiratory Distress Syndrome ARDS第三十四頁，共四十九頁。Respirat

24、ory-Failure-呼吸衰竭1.Definition ARDS, which is a from of acute lung injury often seen in previously healthy patients, is characterized by rapid respiratory rates and a sensation of profound shortness of breath, and accompanied by severe arterial hypoxemia.第三十五頁，共四十九頁。Respiratory-Failure-呼吸衰竭2.Pathogene

25、sisnARDS can result from many disorders, including systemic or pulmonary infection,(viral, bacterial, fungal, ects.), aspiration, inhalation of toxins, metabolic disorders and severe sepsis or septic shock.nThe initial insult cause release of cytokines, mediators from cell membranes and activation o

26、f a number of cascades with injury to the pulmonary endothelium.第三十六頁，共四十九頁。Respiratory-Failure-呼吸衰竭nARDS is invariably associated with increased liquid in the lungs. It is a form of pulmonary edema, distincts from cardiogenic pulmonary edema. Since hydrostatic pressure are not elevated.第三十七頁，共四十九頁。

27、Respiratory-Failure-呼吸衰竭3.Clinical manifestationsnThe early manifestations are an increased respiratory rates. Usually respiratory rates are more then 28 per minute. Some times the patient may be free of respiratory signs.nCough and sputum production. Because of severe hypoxemia, cyanosis is a commo

28、n physical signs in ARDS patients.第三十八頁，共四十九頁。Respiratory-Failure-呼吸衰竭nX-ray shows a progressive, usually symmetrical, fluffy alveolar infiltrate that progresses to involve all potions of the lung. X-ray features of ARDS may be divided into three stages:First stage- sometimes normal, sometimes small

29、 patches may be existSecond stage- diffused small or large patches, usually in lower lung fieldThird stage- pulmonary infiltrate involved all potions of the lung, called white lungnArterial blood gas analysis shows PaO2/FiO2300mmHg and PaO260mmHg.(ALI), PaO2/FiO2200mmHg(ARDS) 第三十九頁，共四十九頁。Respiratory

30、-Failure-呼吸衰竭4.DiagnosisnThere is a disorder which may lead to ARDS. For example, severe infection ects.nAccording to clinical manifestation, X-ray, arterial blood gas analysis, we can make a diagnosis.第四十頁，共四十九頁。Respiratory-Failure-呼吸衰竭The main diagnosis standard includes:nA factor which may leads

31、to ARDSnThe onset is acute. Tachypnea is exist.nHypoxianChest X-ray shows pulmonary infiltrate involved two lungs.nPCWP=18mmHg or except cardiogenic pulmonary edema.第四十一頁，共四十九頁。Respiratory-Failure-呼吸衰竭5.TreatmentnTreatment of initial disorders which lead to ARDSnImprove hypoxemia Severe arterial hyp

32、oxemia is a characteristic clinical sign of ARDS. In general, the lowest inspired fration of oxygen(FiO2) should be used to give the desired result. There are multiple means for delivering O2, including soft nasal prongs, simple face masks. But in the condition of ARDS, these methods are not effecti

33、ve. Mechanical ventilatory support should be used early to improve hypoxemia.第四十二頁，共四十九頁。Respiratory-Failure-呼吸衰竭nUse of PEEPPEEP means positive end expiratory pressure. 第四十三頁，共四十九頁。Respiratory-Failure-呼吸衰竭Use of PEEPnThe physiologic effects of PEEP include:n1.redistribution of capillary blood flow,

34、 resulting in improved V/Q matching; 2. The recruitment of previously collapsed alveoli and prevention of their collapse during exhalation.第四十四頁，共四十九頁。Respiratory-Failure-呼吸衰竭nAnother treatments are similar to those chronic respiratory failure, including antiinfectious therapy, administration of corticosteroid, acid-base and electrolytes disturbance.第四十五頁，共四十九頁。Respiratory-Failure-呼吸衰竭Mechanical ventilatory support(1)Artifical airwaysnEndotracheal intubation is usually adopted during mechanical ventilation. Intubation should be b