RESPIRATORY FAILURE TYPE- I AND TYPE II DR ZAHOOR

RESPIRATORY FAILURE What is Respiratory failure? Respiratory failure is the condition when pulmonary gas exchange fails to maintain normal arterial O2 and CO2 levels. There are TWO types of Respiratory failure - Type I - Type II

Respiratory failure What is Type - I Respiratory failure ? There is Arterial Hypoxemia with normal or low CO2. eg Pneumonia Acute Asthma What is Type II Respiratory failure ? There is Arterial Hypoxemia with Hypercapnia. eg. Acute severe asthma Acute exacerbation of COPD

RESPIRATORY FAILURE What is normal Arterial PO2 and PCO2 and what happens in Type I and Type II to these values ? Normal PaO2-10.6 -13.3 KPa (80- 100mmHg) Normal PaCO2 – 4.8- 6.1KPa (36-46 mmHg )

RESPIRATORY FAILURE Blood Gases in TYPE -1 Respiratory failure - PaO2 less than 8KPa ( 60 mmHg ) Hypoxia - PaCO2 less than 6.6 KPa (50 mmHg ) Normal or low CO2 Blood Gases in Type – II Respiratory failure PaO2 less than 8KPa ( 60 mmHg ) Hypoxia PaCO2 more than 6.6 Kpa ( 50 mmHg ) Raised CO2

RESPIRATORY FAILURE Causes of ACUTE TYPE-1 Respiratory failure Acute asthma Pneumonia Pulmonary oedema Pneumothorax Pulmonary embolus Lobar collapse ARDS

RESPIRATORY FAILURE Causes of CHRONIC TYPE-I Respiratory failure(cont ) Emphysema Lung fibrosis Brain stem lesion Right to left shunt

RESPIRATORY FAILURE Causes of TYPE II ACUTE Respiratory failure Acute severe asthma Acute exacerbation COPD Narcotic drugs Upper airway obstruction Acute neuropathies/ paralysis Flail chest

RESPIRATORY FAILURE Causes of TYPE II CHRONIC Respiratory failure COPD with exacerbation Sleep apnoea Kyphoscoliosis Myopathies/ muscular dystrophy Ankylosing spondylitis

RESPIRATORY FAILURE Management of Acute Type I Respiratory failure . Management of cause eg Pneumonia, Bronchial asthma, High O2 concentration 40-60% by mask It will relieve hypoxia by increasing the alveolar PO2 in poorly ventilated lung.

RESPIRATORY FAILURE Management of Acute Type II Respiratory failure Acute type II respiratory failure is an EMERGENCY . It requires immediate intervention

RESPIRATORY FAILURE Distinguish between Type II respiratory failure patient who have Rapid respiratory rate and accessory muscle recruitment – who can not move sufficient air. And those with reduced respiratory effort eg Respiratory depression .

RESPIRATORY FAILURE 1- In high respiratory effort Type II respiratory failure cause may be Upper airway obstruction from foreign body Laryngeal obstruction ( Angioedema , vocal card paralysis ) CONSIDER Heimlich maneuver Immediate intubation Emergency tracheostomy They may be life saving

RESPIRATORY FAILURE 2- Patient with type II respiratory failure may have reduced level of consciousness , cause may be CO2 narcosis Sedative poisoning Intracerebral hemorrhage Head injury ( affecting respiratory center ) Treatment will be for the cause eg opiate antagonist, but should not delay mechanical ventilation in required cases

CHRONIC AND ACUTE ON CHRONIC TYPE II RESPIRATORY FAILURE The most common cause of chronic type II respiratory failure is COPD . In chronic cases there is no persisting academia because kidneys retain HCO-3 correcting PH to normal. If there is Acute exacerbation in chronic case of COPD than respiratory failure with academia and respiratory distress, drowsiness and coma occurs.

Management of Acute on Chronic Type II Respiratory Failure Aim of treatment is to achieve a safe PaO2 , more than 7KPa ( 52 mmHg ) without increasing PaCO2 and acidosis. Do Arterial blood gases X- Ray chest

MANAGEMENT Acute on Chronic Type II Respiratory Failure ( Cont ) Maintenance of airway Controlled O2 therapy-start 24% Venturimask our aim is to get PaO2 more than 7KPa ( 52 mmHg ) Treat precipitating cause eg Antibiotics for infection Nebulized bronchodilators Physiotherapy / Pharyngeal suction Diuretics

RESPIRATORY FAILURE IMPORTANT Some patient with severe chronic COPD and type II respiratory failure may become dependent on Hypoxic drive for their breathing. In these patients lower concentration of O2 24- 28% should be used ( to avoid worsening depression of respiration )

Acute On Chronic Type II Respiratory Failure Progress of Patient If PaCO2 continues to rise or patient can not achieve a safe PaO2 without severe hypercapnia and acidosis than Mechanical Ventilatory support may be required.

Acute on Chronic Type II Respiratory Failure Management (cont ) Note – Doxapram slow I/V infusion , is respiratory stimulant and occasionally used in acute on chronic type II respiratory failure and low respiratory drive. Patients who are conscious with adequate respiratory drive may benefit from Non- invasive ventilation (NIV )- It is positive pressure ventilation delivered through face mask

Home Ventilation For Chronic Respiratory Failure Type II In Chronic Respiratory failure Type II, when PaO2 is less than 7.3 ( 55mmHg ) home ventilation is good for long term treatment . O2 at 2L/min via nasal prongs is given continuously for 15- 19 hours daily.

LUNG TRANSPLANTATION Lung transplantation is now established treatment in selected patients with advanced lung disease, unresponsive to Medical treatment. Single Lung Transplant is done in Advanced Emphysema Lung Fibrosis

LUNG TRANSPLANTATION ( cont ) Bilateral Lung Transplantation is done in Cystic fibrosis Bronchiectasis Because single transplanted lung is vulnerable to cross infection in these cases.

LUNG TRANSPLANTATION ( cont ) After Lung Transplantation Prognosis is improving with modern immunosuppressive drugs it is over 60%, 5 year survival in some U.K centres

Lung Transplantation Drugs used to prevent Lung rejection . Short term ( Prevent Acute rejection) Corticosteriods Maintenance Treatment to prevent Chronic Rejection Ciclosporin Mycophenolate Tacrolimus

CASE HISTORY An 80 year old male having history of smoking since last 40 years is admitted with dyspnoea. He had fever with green sputum for last 5 days .The patient is confused unable to give proper history. His daughter tells normally he is independent and walks about 3 km every morning. He has not done walking since last week. He is normally not breathless.

CASE HISTORY (cont) EXAMINATION Patient is disoriented. He has fever of 39.2oC, Resp rate 32/ min and O2 saturation of 80%. His heart rate 110/min. BP 120/65 mmHg. WBC count 18000/ mm3, ( 90% N ) CHEST EXAMINATON There is reduced expansion of right lower chest where crackles and pleuritic rub are audible. There is no wheeze and Expiration is not prolonged

CASE HISTORY ( cont) Q-1 What is the diagnosis ? Exacerbation of COPD Community acquired pneumonia Lung cancer Empyema Q- 2 How much O2 should be given to patient? None 24% 35% High flow O2 with a non-rebreath mask with reservoir bag (FiO2 :6O% to 100%)

CASE HISTORY ( cont) Q- 3The patient became increasingly drowsy. ABG is performed on high flow O2 and results are shown. pH – 7.25 PaO2 – 8kPa PaCo2 – 8.5 kPa Hco3- - 24mmol/L SaO2 – 90% Which of the following is correct? Change to 40% O2 Change to 28% O2 Take off O2 altogether Patient needs to be intubated and mechanically ventilated.

Answers Answer – B - Community acquired pneumonia Q – 2 Answer – D - High flow O2 with a non-rebreath mask with reservoir bag Q – 3 Answer – D Patient needs to be intubated and mechanically ventilated.

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