R28 Respirology

Respiratory Failure

Toronto Notes 2010

Pathophysiology
disruption of alveolar capillary membranes -7 leaky capillaries -7 interstitial and
alveolar pulmonary edema -7 reduced compliance, V / Q mismatch, shunt, hypoxemia,
pulmonary HTN
Clinical Course
A. Exudative Phase
first 7 days of illness after exposure to ARDS precipitant
alveolar capillary endothelial cells and type I pneumocytes are injured, resulting in loss
of normally tight alveolar barrier
patients develop
dyspnea
tachypnea
increased work of breathing
these result in respiratory fatigue and eventually respiratory failure
(see Hypoxemic Respiratory Failure)
B. Proliferative Phase
day 7-21
may still experience dyspnea, tachypnea, fatigue, and hypoxemia
some patients develop fibrotic lung changes
most patients clinically improve and are able to wean off mechanical ventilation
C. Fibrotic Phase
some patients will enter a fibrotic phase that may require long-term support on
supplemental oxygen or even mechanical ventilation
if fibrosis present, associated with increased mortality

Treatment
treat underlying disorder (e.g. antibiotics if infection present)
mechanical ventilation using low tidal volumes 6 ml / kg) to prevent barotrauma and
use optimal amount of PEEP (positive end-expiratory pressure) to keep airways open and
allow the use of lower levels of oxygen
may consider using prone ventilation and/or inhaled nitric oxide if conventional
treatment is failing
fluids and inotropic therapy (e.g. dopamine, vasopressin) if cardiac output inadequate
pulmonary-arterial catheter now seldom used for monitoring hemodynamics
mortality: 30-40%, usually due to non-pulmonary complications
sequelae of ARDS include residual pulmonary impairment, severe debilitation,
polyneuropathy and psychologic difficulties, which gradually improve over time
most survivors eventually regain near-normal lung function, often with mildly reduced
diffusing capacity

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Tracheostomy

Tracheostomy should be considered

in patients who require ventilator
support for extended periods of time
Shown to improve patient comfort
and give patients a better ability to
participate in rehabilitation activities

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Positive End Expiratory Pressure (PEEP)

Positive pressure applied at the

end of ventilation which opens up
collapsed alveoli decreasing VlQ
mismatch
Used with all invasive modes of
ventilation

Mechanical Ventilation

see Anesthesia, A11

artificial means of supporting ventilation and oxygenation
mechanically ventilated patients may require some sedation and / or analgesia
general indications
hypoxemic respiratory failure
hypercapnic respiratory failure
specific indicators for mechanical ventilation
acute ventilation failure / acute respiratory acidosis
refractory hypoxemia
reduced level of consciousness
facilitation of surgical procedures
ventilator strategies
the target tidal volume, respiratory rate, PEEP and ratio of inspiratory to expiratory
time are all determined based on the underlying reason for mechanical ventilation
hypoxemic respiratory failure: ventilator provides supplemental oxygen and helps
improve V /Q mismatch and decreases intrapulmonary shunt
hypercapnic respiratory failure: ventilator augments alveolar ventilation; may
decrease the work of breathing, allowing respiratory muscles to rest
ventilatory modes
assist-control ventilation (ACV) (often initial mode of ventilation)
every breath is delivered with a pre-set tidal volume
inspiration may be triggered by patient effort, or if no effort is detected within
a specified amount of time the ventilator will initiate the breath
synchronous intermittent mandatory ventilation (SIMV)
ventilator provides breaths at fixed rate and tidal volume
patient can breathe spontaneously between ventilator breaths
PEEP is still applied and therefore spontaneous breaths may still be supported
pressure support ventilation (PSV)
patient initiates all breaths and the ventilator supports each breath with a
pre-set inspiratory pressure
useful for weaning off vent

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Monitoring Ventilatory Therapy

Pulse oximetry, end-tidal CO,

concentration
Regular arterial blood gases
Assess tolerance to ventilation regularly
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Management of pneumothorax in
patients on mechanical ventilation
chest tube.

Toronto Notes 2010

Respirology R29

Respiratory Failure/Neoplasms

pressure control ventilation (PCV)

a minimum frequency is set and patient may trigger additional breaths above
the ventilator
all breaths delivered at a preset constant inspiratory pressure
noninvasive ventilation (NIV)
achieved without intubation by using a nasal mask with:
- BiPAP (bilevel positive airway pressure): a wave of increased pressure
on inspiration and lower constant pressure on expiration
- CPAP (continuous positive airway pressure): constant pressure
complications of mechanical ventilation
barotrauma
pneumothorax, tension pneumothorax, pneumomediastinum, subcutaneous
emphysema, ventilator-induced lung injury (from the use of high tidal
volumes - can resemble ARDS)
ventilator associated pneumonia (nosocomial pneumonia)
patients intubated 72 hours are at high risk of acquiring pneumonia
common organisms include enteric Gram-negative rods, anaerobes, S. aureus
hypotensison (decreased CO)
increased intrathoracic pressure with decreased venous return that usually
responds to intravascular volume repletion
stress ulcers
may be prevented with H2-blocker prophylaxis
tracheal stenosis
laryngeal dysfunction

Neoplasms
Approach to the Sol itary Pul monary Nodule
also see Diagnostic Medical Imaging. DM7
Definition
a round or oval, sharply circumscribed radiographic lesion up to 3-4 cm which may or
may not be calcified and is surrounded by normal lung
Table 22. Differential Diagnosis for Benign vs. Malignant Solitary Nodule
Benign (70%)

Malignant (30%)

Infectious granuloma (histoplasmosis, coccidiomycosis, TB, atypical mycobacteria)

Other infections (bacterial abscess, PCp, aspergilloma)
Benign neoplasms (hamartoma, lipoma, fibroma)
Vascular (AV maormation, pulmonary varix)
Developmental (bronchogenic cyst)
Inflammatory (Wegener's granulomatosis, rheumatoid nodule, sarcoidosis)
Other (hematoma, infarct, pseudotumour, rounded atelectasis, lymph nodes, amyloidoma)

Bronchogenic carcinoma

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Pulmonary neoplasms may present as a
solitary pulmonary nodule identified
incidentally on a radiographic study
( - 1 0% of cases) or as a symptomatic
disease (mostly).

Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Small cell carcinoma
Metastatic lesions

Breast
Head and neck
Melanoma
Colon
Kidney
Sarcoma
Germ cell tumours
Pulmonary carcinoid

Investigations (see Figure 11)

CXR: always compare with previous CXR (see Table 23)
CT thorax
sputum cytology: usually poor yield
biopsy (bronchoscopic or percutaneous) or excision (thoracoscopy or thoracotomy): if
clinical and radiographic features do not help distinguish between benign or malignant
lesion
in a patient considered at risk for lung cancer, biopsy may be performed regardless
of radiographic features
if a biopsy is non-diagnostic, whether to observe, re-biopsy or resect will depend
on the level of suspicion
watchful waiting: repeat CXR and or CT scan at 3, 6, 12 months
PET scan not yet routine but can help distinguish benign from malignant nodules

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Terminology

"nodule" < 3 cm
"mass" >3 cm