Respiratory Failure
Respiratory Failure
Respiratory Failure
Hypoxemic Hypercapnic
PaO 2 < 5 5~6 0 mmHg or Sa O2 < 90 % PaCO 2 > 4 5~5 0 mmHg
wit h FiO 2 > = 6 0%
Medulla
Pneumotaxic center
Dorsal respiratory group
Ventral respiratory group Dorsolateral pons
Nucleus parabrachialis medialis
Central chemoreceptors
Near the ventrolateral surface of the medulla
Stimulus: H+ of brain ECF (pH), PaCO2
Chemical Stimuli
Hypoxia peripheral receptors
Hypercapnea central receptors (80%)
Expiration: passive
Abdominal muscles:
(active expiration)
Lower T and L level
Intercostal muscles:
T (their own level)
Respiratory drive
O2 demand Motor neuron/nerve function
CO2 production Muscle strength
Dead space Respiratory mechanics
2. Hypoventilation
Conditions described in hypercapnic
respiratory failure
Oxygen therapy improve hypoxemia but may
worsen the hypoventilation
Hypoxic Respiratory Failure
Abnormal shunting:
Congenital defects in the heart or vessels
ASD, VSD, Pulmonary AVM
Lung atelectasis or consolidation
Pneumonia, Cardiogenic or Non-cardiogenic pulmonary edema
Resistant to O2 supply when shunt fraction of CO > 30%
Hypercapnia develops when shunt fraction > 60%
Hypoxic Respiratory Failure
4. Ventilation-Perfusion Mismatch
Vascular obstruction
Pulmonary embolism
Air-space consolidation
Pneumonia, Pulmonary edema
Hypoxic Respiratory Failure
5. Diffusion Impairment
Interstitial lung disease
Pulmonary fibrosis, Connective tissue
disease, Interstitial pneumonia, interstitial
pulmonary edema
ARDS. RDS
Obstructive lung disease
Emphysema, Asthma
↓FIO2
Ventilation
without
perfusion Hypoventilation
(deadspace
ventilation)
Diffusion
abnormality
Normal
Perfusion
without
ventilation
(shunting)
Hypercapnic Respiratory Failure
Spinal
Airway cord root
Nerve
Lung Nerve
Pleura
Neuromuscular
Chest junction
wall
Respiratory
muscle
Respiratory compensation
Sympathetic stimulation
Tissue hypoxia
Haemoglobin desaturation
Definition
Chronic inflammatory disorder
of bronchi characterized by
episodic, reversible
bronchospasm resulting from
an exaggerated
bronchoconstrictor response to
various stimuli
Asthma
Etiology
Allergens Fumes, smoke,
Occupational sprays
chemical Diurnal variation
Viruses Exercise, cold air
Genetic factors Fog
Prematurity Emotion
Lack breast feeding Allergens,
Smoking anaphylaxis
Viruses
Drugs - NSAID, Beta
Types of asthma
Extrinsic (Allergic/Immune)
Atopic - IgE
Occupational – IgG
Airway
Hyperresponsiveness Airflow Limitation
Risk Factors
(for exacerbation) Symptoms
Mechanisms of asthma
Edema
Excesive mucus
Bronchospasm
Obstructed
bronchiole
Factors in inflammatory
process
MEDIATORS CELL TYPES
HISTAMINE MAST CELLS
LEUCOCYTE C F MACROPHAGES
PROSTAGLANDINS EOSINOPHILS
LEUKOTRIENES T LYMPHOCYTES
PAF
KININS
Mast cell in asthma
Mast cell in asthma
Eosinophils in asthma
EOSINOPHIL RECRUITMENT IN ASTHMA
IL-5
Th2 cell Survival
IL-3, IL-5,
IL-4
Adhesion GM-CSF
VCAM-1
VLA4
Chemotaxis
Eotaxin,
RANTES, MCP-4
Activation
Bone
marrow CCR3
Basic
proteins
Airway vessel
Mediators
AIRWAY HYPERRESPONSIVENESS
T cell in asthma
Neural mechanisms
PARASYMPATHETIC
AFFERENT SENSORY
HISTAMINE
KININS
EFFERENT
BRONCHOCONSTRICTOR
MUCUS SECRETION
PATHOPHYSIOLOGY OF ASTHMA
Allergen
Eosinophil
Mucus plug
Epithelial shedding
Nerve activation
Subepithelial
fibrosis
Definition
COPD is a disease state characterised by
airflow limitation that is not fully reversible.
The airflow limitation is usually both
progressive and associated with an abnormal
inflammatory response of the lungs to
noxious particles or gases.
Includes
Emphysema
Chronic bronchitis
Risk factors for COPD
• Pneumonia is common
Cigarette smoke
? Alveolar macrophage
CD8+
MCP-1
lymphocyte
Neutrophil chemotactic factors
Cytokines (IL-8)
Mediators (LTB4)4))
Neutrophil
α 1-Antitrypsin
SLPI
Neutrophil elastase
Cathepsins
MMP-1
Granzymes
Perforins
Alpha1-Antitrypsin
Deficiency
Enzyme prevents loss of lungs’
elastic fibers
Deficiency – Pan-lobular
emphysema
Homozygous – PiZZ – 15-30% of
normal AAT levels (PiMM) Earlier
development of COPD
Airflow obstruction in early 40s
Accelerated by 10 to 15 years
occurs in 1:5000
Heterozygous – PiMZ – 50-80% -
smokers
Z allele – 3-5% population
MUCUS HYPERSECRETION IN COPD
Epithelium
Mucus • Acetylcholine
• Tachykinins
• Proteinases
neutrophil elastase
Goblet cell
hyperplasia
SP
• Cytokines
(TNF-α )
Cholinergic
nerve ACh
Sensory nerve
• Oxidants
N
Mucus gland hyperplasia
Cytokines • Growth factors
E ROS
• ↑ MUC genes
INFLAMMATION MUC5a, MUC8
Neutrophils
OVERLAP BETWEEN COPD AND ASTHMA
COPD ASTHMA
Neutrophils
Eosinophils
No AHR ~10%
AHR
“Wheezy bronchitis”
Asthma and COPD
Inflammation ASTHMA COPD