ACUTE RESPIRATORY

DISTRESS SYNDROME
and
OXYGEN THERAPY

Zulkifli. Dr., SpAn., MKes

Department of Anesthesiology and Reanimation
FK Unsri/ RSMH
OXYGEN THERAPY
Definitions
Oxygen therapy is given gas stream more
than 20% at pressure 1 atmosphere so that
concentration of oxygen increases in blood
Goals
Prevent and improve
hypoxemia
tissue hypoxia
Blood Gas Analyze
pH/PaCO2 /PaO2 / HCO3- /tCO2 / BE/ Sat O2
Indications
Hypoxemia
Increased work of breathing
Increased myocardial work
Pulmonary hypertension
Transport of patients
Cardiac or respiratory Arrest
Respiratory failure
Heart-Failure or infarct myocard
Shock
Metabolic increases
Post surgery
Contraindications
No absolute contraindications
Relative contraindications
relate to the dangers of hyperoxemia
Precautions/Hazards/Compli
cations
Oxygen Toxicity
Absorption atelectasis
Retrolental fibroplasia
Barotrauma
Fire hazzard
Hyperbaric oxygen Toxicity
Drying of the nasal and pharyngeal
mucosa
Oxygen Delivery
devices
Nasal
cannula
Increased
inspired
oxygen
fraction ~
40%
Oxygen Delivery
devices
Simple
mask
Increased
inspired
oxygen
fraction ~
45-60%
Oxygen Delivery
devices
Venturi mask
Partial
rebreather
Nonrebreather
Increased
inspired
oxygen
fraction ~ 60-
80%
Oxygen Delivery
devices
Mechanical
ventilation
Increased inspired
oxygen fraction ~
100%
Examples
Female/ 76 y.o/ inspired 3 liters Oxygen with
nasal cannule, lab. Finding : BGA :
7.34/45/98/23/25/-1/98
Ratio for PaO2 / fiO2 :
98/0.3 = 326
Examples
male/ 46 y.o/ mechanical ventilation with fiO 2
=100%, lab. Finding : BGA :
7.25/60/87/12/15/-8/92
Ratio for PaO2 / fiO2 :
87/1 = 87
Stopping oxygen
treatment
arterial oxygenation is adequate with the
patient breathing room air
ACUTE RESPIRATORY DISTRESS
SYNDROME
ARDS
Definitions
Acute Lung Injury
PaO2/FIO2 < 300 mmHg

ARDS
PaO2/FIO2 < 200 mmHg
ARDS
Epidemiology
Incidence:
5 71 per 100,000

Financial cost:
$5,000,000,000 per annum
ARDS
Pathophysiology
Profound inflammatory response
Diffuse alveolar damage
acute exudative phase (1-7 days)
proliferative phase (3-10 days)
chronic/fibrotic phase (> 1-2 weeks)
Interstitial/alveolar edema
Severe hypoxemia
due to intra-pulmonary shunt (V/Q = 0)
shunt ~ 25% - 50%
Increased airway resistance
ARDS
Pathophysiology
High ventilatory demands
high metabolic state
increased VD/VT
decreased lung compliance
NORMAL ALVEOLUS
Type I cell
Alveolar
macrophage
Endothelial
Cell

RBCs Type II
cell
Capillary
ARDS
Acute Exudative Phase
Basement membrane
disruption
Type I pneumocytes
destroyed
Type II pneumocytes
preserved

Surfactant deficiency
inhibited by fibrin
decreased type II production

Microatelectasis/alveolar
collapse
ARDS
Acute Exudative Phase
Basement membrane
disruption
Type I pneumocytes
destroyed
Type II pneumocytes
preserved

Surfactant deficiency
inhibited by fibrin
decreased type II production

Microatelectasis/alveolar
collapse
ARDS
Acute Exudative Phase
Basement membrane
disruption
Type I pneumocytes
destroyed
Type II pneumocytes
preserved

Surfactant deficiency
inhibited by fibrin
decreased type II production

Microatelectasis/alveolar
collapse
ARDS
Proliferative Phase
Type II pneumocyte
proliferate
differentiate into
Type I cells
reline alveolar walls

Fibroblast
proliferation
interstitial/alveolar
fibrosis
ARDS
Fibrotic Phase
Characterized by:
local fibrosis
vascular obliteration

Repair process:
resolution vs fibrosis
ARDS
Etiology
ARDS
Clinical Features
Acute dyspnea/tachypnea/cyanosis/cough
rhonchi/wheezing

Resistant hypoxemia
PaO2/FIO2 < 200 mmHg

CXR
diffuse, bilateral infiltrates

No evidence of LV failure
(PAWP < 18 mmHg
Management
Search and treatment of disorders precipitating ARDS
Respiratory support
Hemodynamic therapy
Specific therapy to lung damages
Supportive therapy
Anti inflammatory agents (Steroids may have a role)
Antioxidants
Surfactant replacement
Increased alveolar fluid removal
Effect sodium channels
Activate Na+-K+-ATPase pump
Respiratory Support
(Mechanical Ventilation)
NOT without risks, difficulty and hazards
Ventilator induced lung injury (VILI)
Ventilator associated pneumonia (VAP)
Decision to initial mechanical ventilation
Hazards conditional
Possible clinical considering
Benefits and goal
ARDS
Prognosis
Mortality
30% - 50%
Death from respiratory failure = 15% - 18%
Most common cause of death - sepsis/infection

Outcomes
Majority have near-normal lung function
Small % develop pulmonary fibrosis
Neuropsychiatric sequelae may be high