Respiratory failure | incapability to maintain oxygen to tissues

It is stated as “incapability to maintain either the normal transfer of oxygen to tissues or normal release of Co2 from the tissues is known as Respiratory failure

Explanation about Respiratory failure

This disease occurs either pump failure which causes hypercapnia or lung abnormality which causes hypoxemia. The hypercapnic may result in inattentive imperfection, discouragement, central nervous system, a variation of energy demands, etc.

The hypercapnic disease may occur either acutely or acutely upon carbon dioxide retentivity. This disease is caused by the fault of damage of neuromuscular transmission, by the fault in CNS and tiredness of respiratory muscles. It is a disease that is caused by the failure of both or sometimes 1 gas exchange function. For example elimination of carbon dioxide from mixed blood.

Respiratory system work in two parts:

  •     Lungs:

The lung is a gas exchange organ.

  •     Pump:

Pump oxygenates the lungs.

The pump contains a chest wall, chest wall includes respiratory muscles. It may include a respiratory controller in the central nervous system. A pathway (peripheral nerve and spinal nerve) etc.

Background

It is a group of many symptoms that occur together, these are indicative of underlying such as disease. It fails its sometimes single or some time it’s both gas exchange. A function such as oxygenation, carbon dioxide elimination.

It is divided into two types:

  •     Hypercapnic
  •     Hypoxemic

Causes:

Respiratory failure can be caused by certain conditions that affect breathing. The conditions by which respiratory failure is caused may affect the supporting muscles, bones tissues, or nerves of the breathing process. These conditions can also affect the lungs directly. These conditions are as follows:

  •     Disorders of lungs which include cystic fibrosis, a chronic obstructive pulmonary disorder, pulmonary embolism, and pneumonia.
  •     The spine problems e.g. curve in the spine which is also called scoliosis may cause respiratory failure. Spine problem affects bones and muscles involved in breathing.
  •     ALS (amyotrophic lateral sclerosis) stroke and injuries of spinal cords can also cause respiratory failure as these can affect the muscles and nerves involved in the breath process.
  •     Smoke from harmful fires and fumes can cause inhalation injuries which leads to respiratory failures.

Symptoms of Respiratory failure

Carbon dioxide and oxygen levels in the blood and the causes of respiratory failures are the factors on which symptoms of respiratory failure depend.

If the level of oxygen is low in the blood it develops a condition of breath shortness and air hunger.it is the condition in which the patient feels that he cannot breathe even an insubstantial amount of air. The skin fingernails and lip color turn bluish.

If the level of carbon dioxide in the blood causes the breathing process to be rapid and confused.

The patients having respiratory failure are usually sleepy or they have less consciousness. They can also face irregular heartbeat problems. The patients face all these problems because the oxygen supply to their heart and brain is not enough.

Diagnosis:

Respiratory failures can be diagnosed based on the following:

  •     The medical history of patients.
  •     Checking the abnormal sound by listening to the lungs.
  •     They also listens to the heart of the patient to check irregular heartbeat problem.
  •      The doctor also has a look at skin fingernails and lips color whether it is bluish or not.
  •     Some tests are also conducted in diagnosis. These tests include:

1.The test for measurement of co2 and oxygen present in the blood which is called arterial blood test. For this test, blood is usually taken as a sample from the wrist.

2.Pulseoximetry test is also used for diagnosis. In this test, a tiny sensor is used for the measurement of oxygen in the blood. This sensor is usually attached to one and of a finger or ear.

Treatment:

Its treatment is dependent on:

  •     Severity of respiratory failure
  •     Causes of respiratory failure
  •     Also the acute or chronic form of the disease

The acute type of failure is a medical emergency. The patient is admitted to ICU in a hospital for treatment.

If respiratory failures are chronic then often treated at home. If the chronic failure has a serious severity then it may require a long term treatment at a care center.

In any case, the main objective is to normalize the supply of oxygen to the lungs as well as other organs of the body. The objectives also include the normal removal of carbon dioxide from body organs

Different techniques of treatment involve tracheostomy, ventilator, oxygen therapy, NPPV, intravenous fluids, medicines used for discomfort pulmonary rehabilitation, etc.

Some Respiratory Diseases:

1.Asthma:

Before talking about Asthma, let’s talk a little bit about the respiratory system. So, a normal human being can take in oxygen needed by all body cells through his air passages Air enters from the nose or mouth to the pharynx Larynx, and then to the lungs through the throat After the throat, it is sent to the bronchioles and then towards the alveoli And, at last, it mixes up with the blood. The inner lining is called Mucosa in the bronchioles of an asthmatic patient. Asthma can also be caused by genetic factors and environmental factors.

What happens during an Asthma attack?

the patient usually coughs a lot and produces the wheezing sound they also have chest pain and their skin color sometimes changes So, after the mucosa is inflamed, the smooth rings of muscles become narrower and because of the pollens, more mucosa is produced after that is done, the mucosa blocks the air passages. The result of Asthma usually stays the same as the irritated airways narrowing the cause of this irritation that causes an Asthma attack to vary from person.

Unless of course there is a cure for that and since the patient can’t exhale properly, there will be the excess of air or in other words inflation, and over time, the body can die due to the lack of oxygen. Asthma isn’t that easy to cure, but due to the advancements in science, Doctors have found a way to deal with it so what they do is that they use inhalers,

Types of inhalers:

1.One of them is the Metered Dose Inhaler.

2.2nd is the Dry Powder Inhaler.

  1. Emphysema:

These disorders are differentiated from asthma in that the airway constriction and inflammation are reversible in asthma. The most common subtypes of COPD include emphysema and chronic bronchitis. The flow of air through the bronchial tree is directly proportional to the driving pressure and inversely proportional to the resistance.

In emphysema:

In emphysema decreased elastic recoil leads to decreased driving pressure and therefore decreased airflow through the bronchial tree.

In chronic bronchitis:

In chronic bronchitis increased resistance from bronchial constriction throughout the bronchial tree leads to decreased airflow. Many patients with COPD have components of both emphysema and chronic bronchitis.

Emphysema is defined by the destruction of the lung parenchyma leading to enlargement of the air spaces. While fibrosis is common to interstitial pneumonia, this is not the predominant pathology seen in emphysema. However, there can be some increase in collagen and fibrosis.

Pathogenesis of emphysema:

The pathogenesis of emphysema is not completely understood. Inflammatory cells, neutrophil macrophages, in particular, are responsible for delivering elastases, matrix metalloproteinase, and other proteases to the lung tissue. And this suggests that information is a key part in the development of emphysema. Inflammation also leads to edema, increased mucus production, and this further serves to narrow the airways. The beta-2 receptors are responsible for constriction and dilation of the conducting airways. There has been some demonstration of hypersensitivity and stimulation of these receptors in the development of emphysema. Of note, tobacco is a known irritant that activates the beta-adrenergic pathway.

Symptoms:

The key symptoms associated with emphysema include worsening shortness of breath and chronic cough. On examination, patients with emphysema tend to have hyper-resonance to percussion and rhonchi, wheezes, and crackles on auscultation. Patients with end-stage disease

May adopt positions that relieve dyspnea.

For example, patients may lean forward. They may enhance the breathing with evidence of muscle use to breathe, expiration through pursed lips, and paradoxical retraction of the lower inner spaces during inspiration. And this is referred to as Hoover’s sign.

The advanced disease leads to loss of vasculature in the destroyed alveolar wall which in turn causes

Increased pulmonary pressures are secondary to the decreased area for blood flow. Increased pulmonary pressure then leads to right ventricular failure and a phenomenon known as corpulmonale. As the disease progresses end-stage cachexia can occur.

Assessment of patients:

Assessment of patients with emphysema can happen in many ways. Pulmonary function tests are crucial to establish the diagnosis and to assess severity and response to therapy.

A chest x-ray is most notable for flattened diaphragms and expanded lungs later in the course of the disease, but maybe normal earlier on. CT scan can allow for better viewing of the lung parenchyma and may identify bullous changes. As the disease progresses, secondary polycythemia occurs as a response to chronic hypoxemia. Evaluation of oxygen saturation and an ABG is useful in establishing the need for therapy and oxygen supplementation.

The natural progression of the disease begins with mild hypoxemia followed by hypercapnia. Over time there’s resetting of the chemoreceptors which allow for a higher level of CO2 in the blood. As mentioned earlier, PFTs are the mainstay of assessment for emphysema. Testing identifies the airflow obstruction with the reduced maximum expiratory flow that characterizes emphysema and is known as the FEV1.

This decrease in FEV1 is out of proportion to the decrease in FVC, and this ultimately leads to a significant drop in the ratio. Increased lung volumes from hyperinflation caused by the decrease in elastic recoil can be seen on pulmonary function tests as well. The GOLD staging system is widely used to categorize patients by disease severity.

With this system results from pulmonary function tests help to assign severity stage. The reduced FEV1 to FVC ratio of less than 70 percent predicted is necessary to classify a patient as having COPD, while the FEV1 is the main determinant of the severity of illness.

Complications:

A large part of caring for patients with emphysema is helping to avoid complications such as pneumonia. Influenza vaccination should be administered each year. This is the most effective intervention aimed at reducing morbidity and mortality from COPD. The pneumococcal vaccine should also be given to adults with emphysema.

Smoking cessation:

Smoking cessation is crucial to prevent further lung disease and cessation of tobacco use can lead to some degree of disease regression.

Medical interventions:

Medical interventions are aimed at relieving airway obstruction.

There are two types of medications that will result in bronchodilation. Sympathomimetics targets the beta-adrenergic receptors, while anticholinergic agents target the acetylcholine system. Both of these agents come in both short and long-acting preparations. Anti-inflammatory agents can be administered in either inhaled or systemic preparation.

Systemic therapy:

Systemic therapy comes in both oral and IV forms. Though chronic use of inhaled steroids does not seem to prolong survival, it does help to improve symptoms and to decrease exacerbations.

Systemic steroids:

Systemic steroids are used in acute exacerbation. Mucolytics can help to loosen mucus so that it’s more easily cleared from the airways.

Other potential agents:

Other potential agents that can be used for emphysema are listed here.

Pulmonary rehab:

Pulmonary rehab helps to improve quality of life and this largely focuses on nutrition, since malnutrition and cachexia can lead to decreased muscle strength and an altered immune system. Surgical options are available, but are not largely used at this time.

Oxygen supplementation:

Oxygen supplementation is the only intervention that has been shown to improve survival. The mainstay of management for emphysema is pursued in a stepwise fashion, depending on the severity as defined by the GOLD stage. Bronchodilators and glucocorticoids are the most studied and widely-used medications.

In summary:

Emphysema is one of the subtypes of chronic obstructive pulmonary disease. Emphysema is characterized by decreased elastic recoil and air space enlargement that leads to irreversible obstruction of airflow. Pulmonary function testing is the best method of evaluating the severity of illness and will identify the degree of obstruction and increased lung volumes.

GOLD staging system:

The GOLD staging system is used to stratify patients based on the severity of the disease and this is then used to determine appropriate therapy. Key management of emphysema includes smoking cessation, prevention of complications, and relief of airway obstruction using bronchodilators and anti-inflammatory agents.

  1. Bronchiolitis:

Specifically, the virus of RSV, or respiratory syncytial virus, infects the epithelial cell lining in small airways and is the most common virus associated with the above-mentioned disease process of bronchiolitis. RSV is an enveloped, single-stranded RNA virus.

Who is going to get this infection?

So most inpatient admissions are for patients who are less than one year of age. There are certain risk factors for severe RSV disease processes, including some co-morbidities, like congenital heart disease, Bronchopulmonary dysplasia, often associated with premature birth, cystic fibrosis, or other chronic lung diseases, immunodeficiency, congenital anomalies, and, again, as we mentioned, prematurity. Interestingly, this disease process does have a seasonal occurrence, with most infections occurring in midwinter, from January to March in the United States.

Diagnosis:

Diagnosis is solely a clinical diagnosis. You base your diagnosis on a good history and physical exam. Including prematurity, age less than 12 weeks at the time of presentation, cardiac disease, or immunosuppression. Chest X-rays are only useful to rule out other diagnoses if you’re considering other processes like pneumonia or asthma. Many times, an RSV antigen may be sent. This is obtained from a nasal swab. But it rarely alters the clinical management of your patient.

Chest X-ray:

To demonstrate a chest X-ray for bronchiolitis, you can see that there are kinds of non-specific bilateral densities and some atelectasis in the right upper lobe. This is a chest X-ray that’s pretty classic for bronchiolitis. But again, this is not necessary for your diagnosis.

Treatment:

Treatment strategies are varied. Generally, most of our care is supportive. A quarter of infants may respond transiently to bronchodilators but this is not required treatment. You may want to try this treatment and then discontinue use of it if it’s not helpful. Corticosteroids, which are thought to decrease the inflammation, as you may see in patients with bronchospasm, are not effective in this disease process.

Antiviral agents will not effectively treat RSV. And antibacterial agents should only be considered if a concurrent bacterial infection is suspected.

Supportive management:

In general, again, supportive management is the most common method of treatment that we’ll use, including oxygen and IV fluids. Again, supportive care may require hospitalization. Some factors to consider are the ability of the infant to feed orally given the degree of tachypnea.

Generally, we’ll use a rule of greater than 60 times a minute for a respiratory rate to switch over to IV fluids instead of oral fluid intake. Also, the ability of the infant to maintain O2 saturation is greater than 90% is also a factor in considering whether or not to hospitalize a patient. And of course, we should consider underlying comorbidities that increase the risk of severe disease.

Prevention:

Prevention is key. As this is an infectious process, education about transmission of respiratory infections within the family, good hand washing. Some patients may receive prophylaxis for children with chronic lung disease. This is a vaccine that can be given on an outpatient basis to prevent patients at high risk from acquiring the infection. And avoiding second-hand smoke exposure is also helpful.

 

In summary, severe disease includes those with chronic cardiopulmonary diseases, premature infants, or patients who are suffering from conditions that cause them to be immunosuppressed. The diagnosis is made on basis of history and physical exam. And our treatment measures generally include supportive measures, although a trial of bronchodilators may be used. Prevention is key and is based on vaccination against RSV for at-risk patients and standard handwashing precautions.

Influenza:

The main difference between the common cold and the flu is the body aches, where you feel like you’ve been hit by a mac truck.

Prevention:

One of the ways to prevent getting the flu is getting your flu shot every year. The flu vaccine is recommended for ages six months and up.

The flu virus mutates quickly, so that’s why the vaccine changes every year. Even though the flu vaccine is not always 100% effective, it decreases the severity of the virus.

Precautions:

Precautions to take to prevent the flu are frequent handwashing with soap and water, cover your cough and sneeze, avoid touching your face, disinfect surfaces and objects possibly contaminated by the flu. If you have flu symptoms, seek medical attention right away. You may qualify for antivirals that decrease the severity of the flu as well as the duration of the flu. Drink lots of fluids with electrolytes to boost your energy and decrease body aches as well as headaches. Take a fever reducer as directed, and rest.

  1. Pneumothorax:

There are four main causes of pneumothoraces.

  • The first is a primary, spontaneous pneumothorax, which involves a pneumothorax caused by an unknown etiology in the setting of normal lung parenchyma.
  • The next is a 2nd spontaneous pneumothorax. This is a pneumothorax that occurs in the setting of known lung disease.
  • Third is a traumatic pneumothorax caused by trauma to the chest.
  • And lastly, they are iatrogenic pneumothoraces, which are caused often by health care providers performing procedures such as placement of central lines.

Patients with pneumothoraces present in a variety of ways.

  • They can be, in many cases, asymptomatic if the pneumothorax is small.
  • If the pneumothorax is large, and particularly if it is a tension pneumothorax, it can result in circulatory collapse.
  • Patients also present with acute chest pain that is often pleuritic, as well as sudden dyspnea.

Signs:

Vital signs may indicate tachycardia. Tachypnea, diaphoresis, and decreased breath sounds on the side of the pneumothorax are also found.

Diagnosis:

Patients who are hemodynamically unstable or critically ill require a prompt clinical diagnosis to enact appropriate treatment.

 

This typically involves listening for breath sounds on the side of the suspected pneumothorax. Additionally, diagnosis can be made and is more frequently made with a basic chest X-ray.

This can demonstrate air in the intrapleural space and adjacent collapse of the lung, as is seen here on this chest radiograph demonstrating the right-sided pneumothorax.

Treatment:

The treatment of pneumothorax is varied depending on the clinical situation. A tension pneumothorax is a surgical emergency. A tension pneumothorax occurs when air fills the pleural space, collapsing the lung and causing associated mediastinal shift to the contralateral side. This results in hemodynamic instability. A tension pneumothorax is treated with immediate needle decompression upon diagnosis.

Typically, a 14- to 16-gauge needle is used. This will decompress the air in the pleural space and alleviate the mediastinal shift and remove some of the air on the side of the pneumothorax. This is, however, a temporizing measure, and then a standard chest tube must be placed after the needle decompression. 

The typical treatment for pneumothorax is a placement of a chest tube, or what is also called tube thoracostomy before we get into the procedure of performing a tube thoracostomy one must be aware that it can be a dangerous procedure associated with other complications.

Complications:

Associated complications occur in up to 21% of patients, and include improper tube placement, pneumonia, empyema, and recurrent pneumothorax. On the bottom left-hand side, we see a picture of the distal portion of a chest tube. And on the right side, we see the Pleur-evac, which is the device that the chest tubes are connected to that collect air, and can provide suction as well as an air-water barrier.

The technique of performing tube thoracostomy:

The technique of performing tube thoracostomy begins with adequate pain control and sedation for the patient. These are very painful procedures, and are mini thoracotomies, and are associated with a significant amount of pain. When possible, conscious sedation can alleviate the pain and anxiety associated with the procedure. Local anesthesia is always used with infiltration of the subcutaneous tissues above the periosteum and the pleura itself.

In patients who may not fully cooperate, or who are particularly anxious, gentle hand restraints may be useful to prevent inadvertent contamination of the sterile field. A sterile field is created typically in the mid or anterior axillary line in the fourth or fifth interspace. One dose of antibiotics, such as a first-generation cephalosporin, is given at the time of insertion. Tube selection varies based on the indication for the procedure.

For a pneumothorax, a smaller 20 to 24 French chest tube can be used, as only air has to be drained.

For hemothorax or larger fusions, a larger tube, such as a 32 to 36 French chest tube, should be used.

The skin incision can be made at the nipple level in the anterior to the mid-axillary line in the fifth intercostal space.

Blunt dissection is then used to dissect through the subcutaneous tissues and muscle just over a rib using a Kelly clamp. The reason it is key to go above the rib is that the neurovascular bundle lives below each rib, and placing a tube in this area can lead to bleeding.

 The pleura is then punctured with the tip of the Kelly clamp, being careful not to injure any internal structures. After a hole is made, digital inspection is performed of the pleura to make sure there are no local adhesions and that the pleural cavity has been entered. Next, the tube is placed at the end of a curved clamp and inserted into the pleural cavity.

 Typically, the tube is inserted posteriorly and apically to drain any effusions. The chest tube is then closed to a closed suction drainage system, typically a Pleur-evac canister, and placed at negative 20 millimeters mercury of suction. The tube is then secured in place with one or two sutures to prevent dislodgement.

 Lastly, a portable chest x-ray is obtained to determine and confirm the accurate placement of the chest tube. Tube removal is variable and can occur within one day to many weeks after placement depending on the indication and patient’s clinical condition.

Most providers keep the tube to suction for at least 24 hours to cause the apposition of the pleura, and then take the tube off suction and place it to a simple water seal.

 

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