Respiratory Support (non-invasive and invasive) and Blood Gas Analysis

Respiratory failure
1. Hypoxemic (pneumonia, PE, ARDS, pneumothorax) vs hypercarbic (severe asthma, drug
overdose, brain/cervical spine injury, obesity leading to hypoventilation, decreased
strength)
a. Mechanisms of
hypoxemia
i. Hypoventilation
see above
ii. V/Q mismatch
perfused
areas not being
ventilated;
ventilated areas
not being
perfused
iii. Right-to-left
shuntanatomic vs. physiologic
iv. Diffusion limitation
v. Decreased FiO2Im on a mountain!
2. Acute vs chronic
3. Presentation: dyspnea, altered mental status, hypoxia, hypercarbia, tachycardia,
tachypnea, accessory muscle use
4. Work-up: blood gas analysis, chest xray, renal
Markers of oxygenation:
1. Lactate
2. PaO2/FiO2 ratio
3. Oxygenation index: MAP*FiO2/PaO2
Acute respiratory distress syndrome (ARDS)
Diagnosed by the following criteria:
1. Symptom onset within one week
2. bilateral opacities with pulmonary edema
3. respiratory failure not explained by heart failure or volume overload
4. decreased arterial PaO2/FiO2 ratio on a PEEP greater than or equal to 5:
mild ARDS: 201 300 mmHg
moderate ARDS: 101 200 mmHg
severe ARDS: less than or equal to 100 mmHg
Modes of respiratory support
1. Nasal cannula
2. High flow nasal cannula
a. Provides very little PEEP especially if the mouth is open
3. CPAP
a. Reduced upper airway obstruction, stimulation for apnea, decrease WOB
4. BPAP
a. Above benefits and larger tidal volumebetter for hypercarbia
5. Mechanical ventilation
a. SIMV PC + PS
i. SIMV =synchronized intermittent mandatory ventilation
ii. Set pressure, variable volume
iii. Pressure support to overcome tube resistance
b. SIMV PRVC
i. Test breathdelivered tidal volumechange pressure based on delivered
tidal volume
ii. Tidal volume is set

iii. Constant pressure throughout inspiration (like pressure control)

c. HFOV

d. APRV

e. NAVA-Neurally adjusted ventilatory assist

-NAVA catheter captures the activity of the diaphragm (Edi)
-Set PEEP, FiO2, and NAVA level (determines amount of support)
Blood gas analysis
1. Is the pH normal? (acidosis vs alkalosis)
2. What is the pCO2 (controlled by respiratory system) and HCO3- (controlled by the renal
system)?
a. If there is a metabolic acidosis, calculate the anion gapremember MUDPILES!
b. No anion gap- usually RTA or GI losses; hyperchloremia
c. Calculate the osmolar gap
3. Is there compensation and is it adequate?