Patho-Physiology of Respiratory

Failure.

John KOLBE
Respiratory Services
Green Lane Hospital, &
Faculty of Health Sciences

University of Auckland.
• Someone told me that each
equation I included in the book
would halve the sales.

Stephen Hawking
“A Brief History of Time”: 1988.
 RESPIRATORY FAILURE
Def: When the lungs fail to adequately
oxygenate the arterial blood and/or fail to
prevent undue CO2 retention.

In practical Terms;
PaO2 < 8kPa (60 mmHg) (Hypoxic,TypeI)
PaCo2 > 6.6 kPa (50mmHg) (Hypercapnic,
Type II)
 Relationship of PaCO2 and
(Alveolar) Ventilation

PaCO2 = Vco2 k
VA
i.e. PaCO2  1
VA
Relationship of PaCO2 and (Alveolar) Ventilation

V CO 2  k
Pa CO 2 = 
VA

VT = VA + VD


k V CO 2
VE =
 
Pa CO 2 (1 - V D / V T )
• I could never make out what
those damned dots meant.

Lord Randolph Churchill

(referring to decimal points).
 Respiratory Drive

Neuromuscular Transmission

Load
HYPOVENTILATION
 Drive

 Neuromuscular
Transmission

 Muscle weakness/ (fatigue

= reversible)
+ LOAD.
 HYPERCAPNIA
 Hypoventilation
- Respiratory Drive
- Neuro-muscular (in)competence
(- Drive)
- Neuromuscular Transmission
- Muscle weakness/fatigue
- Abnormal load
 V/Q mismatch
(Multi-factorial)
 HYPOXIA
• Reduced F1o2
• Hypoventilation
• Diffusion
• V/Q mismatch
• R-L Shunt
 Alveolar-Arterial Oxygen
Gradient.

• Adequacy of Gas Exchange!

Alveolar-Arterial Oxygen Gradient.

PA CO 2
PA O 2 = (Pb  PH 2O )  FI O 2  +k
R
ie, at sea level, breathing air;
PAO2 = 20 - PaCO2/0.8
A-a Gradient = 20 - PaCO2/0.8 -PaO2

(Normal A-a gradient = 1-2 kPa)

 ALVEOLAR GAS EQUATION
PaO2 = (Pb - PH2O)  FIO2 - PaCo2 + k
R

 20 kPa -PaCo2
0.8

(Normal A-a gradient = 1-2 kPa)

 DIFFUSION
Depends on
- gas
- diffusion distance/thickness
- surface area
- (Hb)
- capillary volume
Use of CO
- diffusion (and not perfusion) limited
- soluble
- avidly binds to Hb  zero back pressure
 V/Q mismatch - most important cause
- 3 compartment model of Lung

V/Q = 00 V/Q = 1 V/Q = 0

Dead Space “Ideal” Shunt

 V/Q =  V/Q = 1 V/Q = 0

Co2 - N   
 
Cco2 - N   N

Compensatory
Hyperventilation (of V/Q = 1)
 
Worsening
Disease

Unable to
Undertake compensatory
Hyperventilation

Pa CO2
(pH is normalised by rental (and other)
mechanisms)

Dangers: - High inspired O2

- Monitoring O2 saturations only
 Relationship of PaCO2 and
(Alveolar) Ventilation

Ve = Va + Vd

Ve = k  Vco2
PaCo2 (1 - Vd/Vt)
 RIGHT TO LEFT SHUNTS
- distinguish from V/Q mismatch by
administration of 100% O2

- normally Pao2 rises to >600 mmHg

- role of - absorption atelectasis

- relaxation of hypoxic
vasoconstriction
• Science is built up of facts, as a house is
built of stones; but an accumulation of facts
is no more a science than a heap of stones is
a house.

Henri Poincare
“Science and Hypothesis”: 1905.
 
V CO 2  k
Pa CO 2 = 
VA


k V CO 2
VE =
 
Pa CO 2 (1 - V D / V T )