Pemicu 6 KGD Aldi
Pemicu 6 KGD Aldi
Pemicu 6 KGD Aldi
Blok Kegawatdaruratan
Aldi Firdaus
405140098
LI
1. Menjelaskan ttg ARDS & Gagal Napas
RESPIRATORY FAILURE
RESPIRATORY FAILURE
• Definition
Respiration is gas exchange between the
organism and its environment. Function of
respiratory system is to transfer O2 from
atmosphere to blood and remove CO2 from
blood.
• Clinically
Respiratory failure is defined as PaO2 <60
mmHg while breathing air, or a PaCO2 >50
mmHg.
Respiratory Failure
Respiratory failure may be acute or chronic:
• Acute hypercapnic respiratory failure develops over
minutes to hours. The pH is usually therefore less than 7.3.
• Chronic respiratory failure develops over several days or
longer. There is sufficient time for renal compensation and
an increase in bicarbonate so the pH is usually only slightly
decreased.
• Clinical markers of long-standing hypoxaemia include
polycythaemia and cor pulmonale.
Classification of Respiratory Failure
Respiratory failure is Classifieds into type I or type II relates to
the absence or presence of hypercapnia respectively.
Type 1 respiratory failure is defined as hypoxemia
without hypercapnia, and indeed the PaCO2 may be normal or
low. It is typically caused by a ventilation/perfusion (V/Q)
mismatch; the volume of air flowing in and out of the lungs is not
matched with the flow of blood to the lungs. The basic defect in
Type 1 respiratory failure is failure of oxygenation characterized
by:
PaO2 decreased (< 60 mmHg
(8.0 kPa))
Impaired neuromuscular
The vast majority of patients in
acute respiratory failure due to function.
cardiogenic pulmonary edema
respond to measures to reduce Decreased respiratory drive
preload and afterload. caused by central nervous system
(CNS) depression.
Differential Diagnoses
Diffusion Abnormalities
V/Q Mismatch
Hypoxia
Respiratory Failure
Physical/ chemical injury
Activation Innate
Inflammatory Cascade
Cellular Infiltrate
Atelectasis
Oedema Fluid
Reduced Thoracic
Compliance +
Vasoconstriction
Hypoxia
Respiratory Failure
Physical/ chemical injury
Activation Innate
Inflammatory Cascade
Hypoxia
Respiratory Failure
Alveolar
Damage
Hypoxic
Capillary
Damage
Vasoconstriction
Leakage
↑Dead Space Oedema
Fluid
Hypoxia
Inflammatory
↓Thoracic
Cellular
Compliance
Infiltrates
V/Q
Atelectasis
Mismatch
Respiratory Failure
Atelectasis/
Reduced Lung
Compliance
• Resolution3
– Improvement of hypoxaemia
– Improved dead space and lung compliance
– Resolution radiographic abnormalities
– Can take up to 1 year
– Residual restrictive or obstructive picture
Long Term
• Chronic Respiratory Disease
• Muscle Fatigue
• Muscle Wasting
• Weakness
Treatment
• Ventilation
• Fluid Management
• Steroids
• Other Stuff
Ventilation
• Tidal Volumes
• PEEP
• Positioning
• Weaning Protocols
Tidal Volume
• Recommended 4-6ml/kg4
• High tidal volumes4
• Overdistention of alveoli
• Local inflammatory response resulting in systemic
inflammation
• TNF, IL6, IL10,
Tidal Volume 4
Status Asthmaticus
• Exacerbations of asthma feared by patients
life-threatening
• Controller therapy : prevent exacerbations
ICS* and combination inhalers (very
effective)
• Emphysema
• Chronic bronchitis
• Refractory (irreversible) asthma
• Severe bronchiectasis
Other names for COPD
• Chronic Obstructive Lung Disease (COLD)
• Loculated effusion = Fluid anatomically confined and not freely flowing in the
pleural space
– occur when there are adhesions between the visceral and the parietal pleurae.
• If >=1 exudative criteria are met AND the patient is clinically thought to have a
condition producing a transudative effusion measure the protein levels in the
serum – in the pleural fluid
– If this gradient> 31 g/L (3.1 g/dL) almost all such patients have a
transudative pleural effusion.
• If the fluid recurs after the initial therapeutic thoracentesis & presentation of the above
characteristics repeat thoracentesis
• If the fluid cannot be completely removed with the therapeutic thoracentesis :
– Insert a chest tube and instilling a fibrinolytic (e.g., streptokinase, 250,000 units)
– or performing thoracoscopy with the breakdown of adhesions.
– Decortication : when the above are ineffective.
Presentation :
• Aerobic bacterial pneumonia + pleural effusion acute febrile illness : chest pain,
sputum production, and leukocytosis.
• Anaerobic infections subacute illness : weight loss, a brisk leukocytosis, mild
anemia, history of some factor that predisposes them to aspiration.
DIAGNOSIS
• Most common symptom : Dyspnea frequently out of proportion to the size of the effusion.
• The pleural fluid is an exudate, and its glucose level ↓ if the tumor burden in the pleural
space is high.
• The diagnosis is usually made cytology of the pleural fluid.
– If negatif THORACOSCOPY (if malignancy is strongly suspected)
– At the time of thoracoscopy, a procedure such as pleural abrasion should be performed to effect a
pleurodesis.
– If thoracoscopy is unavailable NEEDLE BIOPSY of the pleura
Examination
• Chest radiograph : Treatment
– pleural effusion • Chest pain : opiates
– generalized pleural thickening, and • Shortness of breath : oxygen
– Shrunken hemithorax and/or opiates.
• Thoracoscopy
• Open pleural biopsy
Symptoms :
o Fever
o Weight loss
o Dyspnea
o Pleuritic chest pain.
EXAMINATION
• Chest radiograph : large pleural effusion
• Thoracentesis : milky fluid
• Biochemical analysis : triglyceride >1.2 mmol/L (110 mg/dL)
• No obvious trauma : lymphangiogram and a mediastinal CT scan to assess
the mediastinum for lymph nodes.
• Causes :
– Trauma : most common
– Rupture of a blood vessel
– Tumor
• Treatment :
– Tube thoracostomy allows continuous quantification of bleeding.
– If the bleeding emanates from a laceration of the pleura apposition of the
two pleural surfaces
– If the pleural hemorrhage > 200 mL/h thoracoscopy or thoracotomy.
2 goals :
1. To evacuate air from the pleural space, and
2. To prevent recurrence
Treatment
• Less invasive approaches (i.e., observation or simple aspiration) lower
success rates.
standard size (20–28F) thoracostomy tube.
larger tube size (≥28F) detectable pleural fluid or an anticipated need
for mechanical ventilation.
suction (with a pressure of 20 cm H2O) lung fails to reexpand after
drainage through a water-seal device or Heimlich valve for 24 to 48 hours.
• Ps is not a good operative candidate or refuses surgery pleurodesis
(attempted by mechanical pleural abrasion or by the intrapleural injection
of a sclerosing agent such as doxycycline).
Tension Pneumothorax
• This condition usually occurs during mechanical ventilation or resuscitative
efforts.
• The positive pleural pressure is life-threatening :
– Ventilation is severely compromised and
– The positive pressure is transmitted to the mediastinum decreased venous return to
the heart and reduced cardiac output.
Diagnosis :
• Difficulty in ventilation during resuscitation or high peak inspiratory
pressures during mechanical ventilation strongly suggests the
diagnosis.
• enlarged hemithorax with no breath sounds
• hyperresonance to percussion
• shift of the mediastinum to the contralateral side.
• the alveolar-pleural defect a one-way valve air pass into
the pleural space during inspiration trapping it there during
expiration progressive accumulation of intrapleural air and
increasingly positive intrapleural pressure compression of
the contralateral lung with asphyxia worsening hypoxia
• Intrapleural pressure exceeding 15 to 20 mm Hg decreased
diastolic filling & cardiac output hypoxia, acidosis, and
shock
Clinical Features
• Asphyxia and decreased cardiac output
• Tachycardia (often >120 beats/min) & hypoxia (common)
• Hypotension is a late and ominous finding
• Distention of the jugular veins (common, difficult to detect)
• Displacement of the trachea to the contralateral side
(uncommon finding, usually occurring only in the
immediately preterminal phase )
• etc
Treatment
• Medical emergency! (inadequate cardiac output or marked
hypoxemia).
• Suggest? decompressed intravenous catheter or by
immediate tube thoracostomy
– (temporizing procedure) : large-bore needle should be inserted into the
pleural space through the second anterior intercostal space large
amounts of gas escape from the needle after insertion (diagnosis is
confirmed).
– (definitive management) : thoracostomy tube (needle should be left in
place until tube is inserted).
• Obesity?
Diagnosis of Pneumothorax
• Chest radiograph
– standard
– CT scan gold standard
– Bedside ultrasound rapid and accurate
• Tension treatment should not be delayed (chest radiograph confirmed?
X)
• Pneumothorax susp standard radiograph not seen expiratory film
(occasionally helpful in identifying a small apical pneumothorax, routine
used does not improve diagnostic yield)
• critically ill patients for whom only a supine chest radiograph “deep
sulcus” (i.e., a deep lateral costophrenic angle) suggest pneumothorax.
Treatment of Pneumothorax
Simple observation or aspiration with a catheter to video-
assisted thoracoscopic surgery or thoracotomy :
• severity of signs
• presence of underlying pulmonary disease
• other comorbidities, history of previous pneumothoraces
• patient reliability, degree and persistence of the air leak,
and
• available follow-up monitoring
therapeutic options
Treatment of Pneumothorax
Observation simple aspiration small/standard/large caliber tube
water seal/+ Heimlich valve suction surgical intervention : resection
of bullae and pleurodesis (+video-assisted thoracoscopic surgery or
thoracotomy).