Professional Documents
Culture Documents
FAILURE
高雄長 庚醫院 胸腔 內科 王逸熙
EFFECTIVE GAS EXCHANGE
HYPERCAPNIA HYPOXEMIA
HYPERCAPNIA HYPOXEMIA
( “PUMP FAILURE” ) ( “LUNG FAILURE” )
Central Peripheral
Airways Alveolar
Nerve Nerve
Component Component
System System/
Component Chest Bellows
component
Type 1 Acute Respiratory Failure
• Primary problem is impaired gas
exchange
• Primary gas exchange
abnormality seen in this setting
is hypoxemia
Type 2 Acute Respiratory Failure
• Abnormality in type 2 ARF is impaired
ventilation
• Unable to generate sufficient minute
ventilation to clear CO2---hypercapnia
Causes of Acute Respiratory Failure
Type 1 respiratory failure Type 2 respiratory failure
1950s--- polio
1960s--- COPD
1970-1980--- surgery
1990s--- postoperative:20-30 %
nonoperative:70-80 %
Respiratory conditions:20-25%
Cardiac conditions: 20 %
Infection or sepsis: 20%
Trauma and neurological disorders: 10-15%
Acute Respiratory Distress Syndrome
•Acute onset
•Bilateral pulmonary infiltrate on
CxR
•PaO2/ FiO2 <200
•Absence of left heart failure
Risk Factor of ARDS
Sepsis
Aspiration of gastric contents
Pulmonary contusion
Pneumonia
Near drowning
Smoke inhalation/burn
Trauma
Pancreatitis
Multiple transfusions
Pulmonary embolism
Disseminated intravascular coagulation
Clinical Disorders Associated with ARDS
Direct Lung Injury Indirect Lung Injury
Aspiration of gastric contents Severe sepsis
Pulmonary contusion Major trauma
Toxic gas (smoke) inhalation Multiple long-bone
fractures
Near-drowning Hypovolemic shock
Diffuse pulmonary infection Hypertransfusion
Acute pancreatitis
Drug overdose
Reperfusion injury
Post-lung transplantation
Post-cardiopulmonary
bypass
Outcome of ARDS
• Short term mortality--- 40-60%
– No significant improvement in recent days
• Prognosis with ARDS vary in relation to premorbid factors
– Cirrhosis, HIV, organ transplantation, malignancy
• Development of nonpulmonary organ dysfunction---poor prognostic
sign
• ARDS patients generally die from multiple organ dysfunction rather
than progressive respiratory failure
• Prognosis according to disease---pneumonia, sepsis
• Better prognosis according to disease---multiple trauma
• Old age related to poor prognosis
Long-Term survival of ARDS
•90-day mortality: 41.2%
•Younger patients and patient with trauma
–Little increase in long term mortality
•Underlying malignancy and other
comorbidity
–Significant increase long term mortality
Long-Term Morbidity of ARDS
• Reduction in lung volumes
• Reduction in diffusing capacity
• Increase in airway resistance
• Improvement in lung function within 1 year
• Significant impairment of lung function in long
term in 4 % of patient
• Factors related to long term impairment
–Prolong positive pressure ventilation
–High FiO2
–Increasing age
–Severity of hypoxemia during acute illness
Quality of Life after ARDS
Assurance of an adequate
airway
Whether emergent intubation or
not?
Correction of Hypoxemia and Hypercapnia