Pathophysiology of Respiratory Failure

2. Pathophysiology of Respiratory Failure
Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
ERS National Delegate of Egypt

4. Non Respiratory Functions
Biologically Active Molecules:
*Vasoactive peptides
*Vasoactive amines
*Neuropeptides
*Hormones
*Lipoprotein complexes
*Eicosanoids

5. Non Respiratory Functions
Haemostatic Functions

Lung defense :
*Complement activation
*Leucocyte recruitment
*Cytokines and growth factors
Protection
Vocal communication
Blood volume/ pressure and pH regulation

6. Respiratory Functions
*Oxygenation

*CO2 Elimination

8. Definition

*Failure in one or both gas exchange functions:
oxygenation and carbon dioxide elimination

*In practice:
PaO2<60mmHg or PaCO2>50mmHg

*Derangements in ABGs and acid-base status

9. Definition
Respiratory failure is a syndrome of
inadequate gas exchange due to
dysfunction of one or more essential
components of the respiratory system

10. Types of Respiratory Failure
Type 1 (Hypoxemic ): * PO2 < 60 mmHg on room air.
Type 2 (Hypercapnic / Ventilatory): *PCO2 > 50
mmHg
Type 3 (Peri-operative): *This is generally a subset of
type 1 failure but is sometimes considered
separately because it is so common.
Type 4 (Shock): * secondary to cardiovascular
instability.

11. The respiratory System
Lungs Respiratory pump
Pulmonary Failure
• PaO
2
• PaCO
2 N/
Ventilatory Failure
• PaO
2
• PaCO
2
Hypoxic
Respiratory
Failure
Hypercapnic
Respiratory
Failure

12. Cardiogenic pulmonary edema
Pneumonia
pulmonary
ARDS
extra pulmonary
ARDS
Atelectasis
Post surgery
changes
Aspiration
Trauma
Infiltrates in
immunsuppression
Hypoxic
Respiratory
Failure
Pulmonary
fibrosis

13. Type 3 (Peri-operative)
Respiratory Failure
Residual anesthesia effects, post-
operative pain, and abnormal
abdominal mechanics contribute to
decreasing FRC and progressive
collapse of dependant lung units.

14. Type 3 (Peri-operative)
Respiratory Failure
Causes of post-operative atelectasis include;
*Decreased FRC
*Supine/ obese/ ascites
*Anesthesia
*Upper abdominal incision
*Airway secretions

15. Type 4 (Shock)
Type IV describes patients who are intubated and
ventilated in the process of resuscitation for
shock
•Goal of ventilation is to stabilize gas
exchange and to unload the respiratory
muscles, lowering their oxygen consumption
*cardiogenic
*hypovolemic
*septic

16. Hypoxemic Respiratory Failure (Type 1)
Causes of Hypoxemia

1.Low FiO
2
(high altitude)
2.Hypoventilation
3.V/Q mismatch (low V/Q)
4.Shunt (Qs/Qt)
5.Diffusion abnormality
6.low mixed venous oxygen due to cardiac
desaturation with one of above mentioned
factors.

17. Physiologic Causes of
Hypoxemia
Low FiO
2
is the primary cause
of ARF at high altitude and
toxic gas inhalation
Hypoxemic Respiratory Failure (Type 1)

18. Physiologic Causes of Hypoxemia


However, the two most common causes of
hypoxemic respiratory failure in the ICU are
V/Q mismatch and shunt. These can be
distinguished from each other by their
response to oxygen. V/Q mismatch
responds very readily to oxygen whereas
shunt is very oxygen insensitive.
Hypoxemic Respiratory Failure (Type 1)

19. V/Q: possibilities
0

1
∞
V/Q =1 is “normal” or “ideal”

V/Q =0 defines “shunt”

V/Q =∞ defines “dead space” or “wasted ventilation”

20. Hypoxemic Respiratory Failure (Type 1)
V/Q Mismatch
V/Q>1 V/Q<1

V/Q=o V/Q=∞

21. Why does “V/Q mismatch” cause
hypoxemia?
Low V/Q units contribute to
hypoxemia
High V/Q units cannot compensate
for the low V/Q units
Reason being the shape of the
oxygen dissociation curve which is
not linear

22. Hypoxic respiratory failure
Gas exchange failure
Respiratory drive responds
Increased drive to breathe
–Increased respiratory rate
–Altered Vd /Vt (increased dead space etc)
–Often stiff lungs (oedema, pneumonia etc)
Increased load on the respiratory pump which
can push it into fatigue and precipitate
secondary pump failure and hypercapnia

23. Hypoxemic Respiratory Failure (Type 1)

Types of Shunt
1.Anatomical shunt
2.Pulmonary vascular shunt
3.Pulmonary parenchymal shunt

24. Hypoxemic Respiratory Failure (Type 1)

Common Causes for Shunt
1.Cardiogenic pulmonary edema
2.Non-cardiogenic pulmonary edema
(ARDS)
3.Pneumonia
4.Lung hemorrhage
5.Alveolar proteinosis
6.Alveolar cell carcinoma
7.Atelectasis

25. Causes of increased dead space ventilation
*Pulmonary embolism
*Hypovolemia
*Poor cardiac output, and
*Alveolar over distension.

26. Ventilatory Capacity versus Demand
Ventilatory capacity is the maximal
spontaneous ventilation that can be
maintained without development of
respiratory muscle fatigue.

Ventilatory demand is the spontaneous minute
ventilation that results in a stable PaCO
2
.
Normally, ventilatory capacity greatly
exceeds ventilatory demand.

27. Ventilatory Capacity versus Demand
Respiratory failure may result from either a
reduction in ventilatory capacity or an
increase in ventilatory demand (or both).

Ventilatory capacity can be decreased by a
disease process involving any of the
functional components of the respiratory
system and its controller. Ventilatory
demand is augmented by an increase in
minute ventilation and/or an increase in
the work of breathing.

28. Components of Respiratory System
*CNS or Brain Stem *Nerves
*Chest wall (including pleura, diaphragm)
* Airways * Alveolar–capillary units
*Pulmonary circulation

29. Type 2 ( Ventilatory /Hypercapnic
Respiratory Failure)

Causes of Hypercapnia
1.Increased CO
2
production (fever,
sepsis, burns, overfeeding)
2.Decreased alveolar ventilation
decreased RR
decreased tidal volume (Vt)
increased dead space (Vd)

30. Hypercapnic Respiratory Failure
Depressed drive: Drugs, Myxoedema,Brain stem lesions
and sleep disordered breathing
Impaired neuromuscular transmision: phrenic nerve
injury, cord lesions, neuromuscular blokers,
aminoglycosides, Gallian Barre syndrome, myasthenia
gravis, amyotrophic lateral sclerosis, botulism
Muscle weakness: fatigue, electrolyte Derangement
,malnutrition , hypoperfusion, myopathy, hypoxaemia
Resistive loads; bronchospasm, airway edema
,secretions scarring ,upper airway obstruction,
obstructive sleep apnea
Lung elastic loads:PEEPi, alveolar edema, infection,
atelectasis
Chest wall elastic loads:pleural effusion, pneumothorax,
flail chest, obesity,ascites,abdominal distension

31. Why does “V/Q mismatch” cause
hypoxemia?
•Low V/Q units contribute to
hypoxemia
•High V/Q units cannot compensate
for the low V/Q units
•Reason being the shape of the
oxygen dissociation curve which is
not linear

32. Hypoxic respiratory failure
•Gas exchange failure
•Respiratory drive responds
•Increased drive to breathe
–Increased respiratory rate
–Altered Vd /Vt (increased dead space etc)
–Often stiff lungs (oedema, pneumonia etc)
Increased load on the respiratory pump which can
push it into fatigue and precipitate secondary
pump failure and hypercapnia

33. Hypoxemic Respiratory Failure (Type 1)

Types of Shunt
1.Anatomical shunt
2.Pulmonary vascular shunt
3.Pulmonary parenchymal shunt

34. Hypoxemic Respiratory Failure (Type 1)

Common Causes for Shunt
1.Cardiogenic pulmonary edema
2.Non-cardiogenic pulmonary edema
(ARDS)
3.Pneumonia
4.Lung hemorrhage
5.Alveolar proteinosis
6.Alveolar cell carcinoma
7.Atelectasis

35. Causes of increased dead space
ventilation
*Pulmonary embolism
*Hypovolemia
*Poor cardiac output, and
*Alveolar over distension.

36. Ventilatory Capacity versus Demand
Ventilatory capacity is the maximal
spontaneous ventilation that can be
maintained without development of
respiratory muscle fatigue.

Ventilatory demand is the spontaneous minute
ventilation that results in a stable PaCO
2
.
Normally, ventilatory capacity greatly
exceeds ventilatory demand.

37. Ventilatory Capacity versus Demand
Respiratory failure may result from either a
reduction in ventilatory capacity or an
increase in ventilatory demand (or both).

Ventilatory capacity can be decreased by a
disease process involving any of the
functional components of the respiratory
system and its controller. Ventilatory
demand is augmented by an increase in
minute ventilation and/or an increase in the
work of breathing.

38. Components of Respiratory System
*CNS or Brain Stem *Nerves
*Chest wall (including pleura, diaphragm)
* Airways * Alveolar–capillary units
*Pulmonary circulation

39. Type 2 ( Ventilatory /Hypercapnic
Respiratory Failure)

Causes of Hypercapnia
1.Increased CO
2
production (fever,
sepsis, burns, overfeeding)
2.Decreased alveolar ventilation
•decreased RR
•decreased tidal volume (Vt)
•increased dead space (Vd)

40. Hypercapnic Respiratory
Failure
•Depressed drive: Drugs, Myxoedema,Brain stem lesions
and sleep disordered breathing
•Impaired neuromuscular transmision: phrenic nerve
injury, cord lesions, neuromuscular blokers,
aminoglycosides, Gallian Barre syndrome, myasthenia
gravis, amyotrophic lateral sclerosis, botulism
•Muscle weakness: fatigue, electrolyte Derangement
,malnutrition , hypoperfusion, myopathy, hypoxaemia
•Resistive loads; bronchospasm, airway edema
,secretions scarring ,upper airway obstruction,
obstructive sleep apnea
•Lung elastic loads:PEEPi, alveolar edema, infection,
atelectasis
•Chest wall elastic loads:pleural effusion, pneumothorax,
flail chest, obesity,ascites,abdominal distension

41. Hypercapnic Respiratory Failure
(PAO2 - PaO2)

Alveolar
Hypoventilation
V/Q abnormality
NIF N P0.1
increased
normal
N VCO2
PaCO2 >50 mmHg
Not compensation for metabolic alkalosis
Central
Hypoventilation
Neuromuscular
Problem
VCO2
V/Q
Abnormality
Hypermetabolism
Overfeeding
NNIF  P0.1

42. Hypercapnic Respiratory Failure
Alveolar
Hypoventilation
Brainstem respiratory depression
Drugs (opiates)
Obesity-hypoventilation syndrome
NIF
Central
Hypoventilation
Neuromuscular
Disorder
N NIF
Critical illness polyneuropathy
Critical illness myopathy

Hypophosphatemia
Magnesium depletion

Myasthenia gravis
Guillain-Barre syndrome

43. NIF (negative inspiratory force). This is a measure
of the patient's respiratory system muscle
strength.
It is obtained by having the patient fully exhale.
Occluding the patient's airway or endotracheal
tube for 20 seconds, then measuring the maximal
pressure the patient can generate upon
inspiration.
NIF's less than -20 to -25 cm H2O suggest that the
patient does not have adequate respiratory muscle
strength to support ventilation on his own.
Evaluation of Hypercapnia

44. P0.1 max. is an estimate of the patient's
respiratory drive.
This measurement of the degree of pressure drop
during the first 100 milliseconds of a patient
initiated breath. A low P0.1 max suggests that the
patient has a low drive and a central
hypoventilation syndrome.
Central hypoventilation vs. Neuro-
muscular weakness
central = low P0.1 with normal NIF
Neuromuscular weakness = normal P 0.1 with low
NIF
Evaluation of Hypercapnia

45. n The P (A—a)O2 ranges from 10 mm Hg in young
patients to approximately 25mm Hg in the elderly while
breathing room air.

n P (A-a)O2 if greater than > 300 on 100% =
Shunt < 300 = V/Q mismatch

• RULE OF THUMB
The mean alveolar-to-arterial difference [P(A—a)o2]
increases slightly with age and can be estimated ~ by the
following equation:

Mean age-specific P(A—a)O2 age/4 + 4

A-a Gradient

46. Increased Work of Breathing
Work of breathing is due to physiological work and
imposed work.
Physiological work involves overcoming the elastic forces during
inspiration and overcoming the resistance of the airways and lung
tissue

Imposed Work of Breathing
In intubated patients, sources of imposed work of breathing include:

n the endotracheal tube,
n ventilator Circuit
n auto-PEEP due to dynamic hyperinflation with airflow obstruction, as is
commonly seen in the patient with COPD.
Increased Work of Breathing
n Tachypnea is the cardinal sign of increased work of breathing

n Overall workload is reflected in the minute volume needed to maintain
normocapnia.

47. Rationale for ventilatory assistance
 Respiratory load
 Respiratory muscles
capacity
Alveolar hypoventilation
 PaO
2 and  PaCO
2


Abnormal
ventilatory drive

48. Mechanical ventilation unloads the
respiratory muscles
Respiratory load Respiratory muscles


Mechanical
ventilation