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Interventions in Respiratory
Failure
Dr Nigam Prakash Narain
Status of ABG
Arterial Blood Gas analysis: single
most important lab test for evaluation
of respiratory failure.
Respiratory failure:
clinical manifestations
Tachypnea
Exaggerated use of accessory muscles
Intercostal, supraclavicular and subcostal
retractions
In neuromuscular disease, the signs of
respiratory distress may not be obvious
In CNS disease, an abnormally low
respiratory rate, and shallow breathing are
clues to impending respiratory failure
Presentation
Three distinctive clinical profiles have
been suggested in children:
1. Mechanical dysfunction of airways
2. Neuromuscular dysfunction
3. Breathing control dysfunction
A rapid assignment to one of these profiles
facilitates early diagnosis and treatment
PaO2 / PaCO2
Normal value depends on :
a. Position of patient during sampling
b. Age of patient
PaO2 (Upright) = 104.2 -- 0.27 x age (Yrs)
PaO2 (Supine) = 103.5 0.47 x age (Yrs)
PaCO2 : normal value= 35-45 mm of Hg
unaffected by age/ positioning
Alveolar-Arterial O2 gradient
Normal P(A-a)O2 gradient: 5-10 mm of Hg
A sensitive indicator of disturbance of gas
exchange.
Useful in differentiating extrapulmonary
and pulmonary causes of resp. failure.
For any age, an A-a gradient > 20 mm of
Hg is always abnormal.
Causes of Hypoxemia
1. Low PiO2 ~ at high altitude
2. Hypoventilation ~ Normal A-a gradient
3. Low V/Q mismatch ~ A-a gradient
4. R/L shunt ~ A-a gradient
Hypoventilation-Diagnosis
PaO2
PaCO2 is always increased
A-a gradient is normal ( 10 mm of Hg)
Hyperoxia Test : dramatic rise in PO2
Hypercapnia :
Causes
Hypoventilation
Severe low V/Q mismatch: major
mechanism of hypercapnia in intrinsic lung
disease.
Status of ABG
It is not possible to predict PaO 2 and
PaCO2 accurately using clinical criteria.
Thus, the diagnosis of Respiratory failure
depends on results of ABG studies.
Respiratory failure:
Interventions
Supportive therapy
Specific therapy
Supportive therapy
HFV
3 types: Oscillatory, Jet & Flow interruption
Very small tidal volumes are used
(<1ml/kg), very rapid rates (150-1000
bpm) and lower mean airway pressures
are used.
This approach is used to minimize the
possibility of barotrauma to airways.
Used if conventional ventilation fails to
improve gas exchange
Permissive Hypercapnia
Allows the PaCO2 to rise into the 60-70
mm of Hg range, as long as the patient is
adequately oxygenated (SaO2> 92%), and
able to tolerate the acidosis.
This strategy is used to limit the amount of
barotrauma and volutrauma to the patient.
Prone positioning
Positioning the patient in the prone
position has been shown to improve
oxygenation and reduce ventilator induced
lung injury.
However, the outcome may not be
improved.
ECMO
Used in the treatment of newborns and
small infants with life threatening,
refractory respiratory failure, unresponsive
to mechanical ventilation.
Inhales nitric oxide may improve
oxygenation by reducing increased
pulmonary vascular resistance.
Inhaled NO is now being used in place of
ECMO in NICU in some centers.