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FAILURE
RESPIRATORY FAILURE
• Definition
Respiratory insufficiency is the clinical-
biological syndrome arising from the inability of
the respiratory system to provide adequate
hematosis, both at rest and during effort .
Respiratory insufficiency is not a disease but a
functional disorder caused by diseases of the
airways, lungs, pleura, chest wall or
neuromuscular system.
RESPIRATORY FAILURE
Classification
Classification of respiratory insufficiency
is performed after:
A. The time required for the occurrence
of hypoxemia and hypercapnia:
a. Acute respiratory failure,
b. Chronic respiratory insufficiency
RESPIRATORY FAILURE
Definition.
BA is an inflammatory airway disease
characterized by:
1. hyperactivity of the tracheo-bronchial
tree at different triggers;
2. generalized airway obstruction, which
can spontaneously (reversibly) or under
treatment subcede;
2. BRONCHIAL ASTHMA
Pathophysiology
Diffuse and reversible bronchial
obstruction of the airway is due to:
- spasm of bronchial smooth muscle
(bronchospasm);
- wall edema,
- vascular congestion
- very viscous bronchial secretions.
2. BRONCHIAL ASTHMA
Clinical forms
Bronchial asthma presents under 3
major forms:
A. Episodic asthma (with intermittent
episodes).
B. Asthma status.
C. Chronic bronchial asthma.
2. BRONCHIAL ASTHMA
• Clinical presentation:
The crisis suddenly starts with: expiratory dyspnea,
dry coughing and wheezing. Crises occur frequently at
night, in cold seasons or under polluted atmosphere
(dust, smoke).
The trigger agent is usually identified by the
anamnesis. Initially the patient is bradypneic so that he
later becomes polypneic, orthopneic.
- The thorax is stretched, blocked in the inspiratory
position, with the amplitude of low respiratory
movements, lower intercostal circulation and prolonged
expiration;
2. BRONCHIAL ASTHMA
- Percussion highlights: pulmonary hypersonority, low lung bases
and negative Hirtz maneuver;
- Auscultation detects: diminished vesicular murmur, prolonged
expiration, fine sibilant rales in both breathing times, sometimes
with basal subcrepitant rales;
- Cardiac examination shows: normal or increased heart rate and
normal or high blood pressure; Spontaneously or under treatment
(inhaled bronchodilator), the patient emerges from the crisis.
Classic, each episode ends with exacerbation of cough, which
becomes productive, expectorating being mucous, adherent,
reduced quantitatively .
The intercritical patient is asymptomatic and does not require
treatment.
B. Asthmatic status (acute
asthma)
Defines the asthma crisis:
- persistent,
- prolonged (> 24 hours),
- refractory to appropriate bronchodilator
therapy, initiated in the emergency room
and which
- requires hospitalization in an intensive
care clinic.
B. Asthmatic status (acute
asthma)
The trigger factors of asthma are:
- viral respiratory infections;
- Exposure to a high concentration allergen /
irritant;
- intense physical stress at low temperatures;
- using aspirin / non-steroidal anti-inflammatory
drugs (NSAIDs);
- Sudden discontinuation of corticosteroid
therapy / excessive use of beta-
sympathomimetics
B. Asthmatic status (acute
asthma)
Clinical
Subjective
The patient describes:
- expiratory dyspnea that persists despite
bronchodilator treatment;
- wheezing, initially during exhale, then in both
respiratory phases, and finally disappears, indicating a
severe degree of bronchial obstruction;
- the absence of cough because the patient can not
expire, the chest being fixed to the maximum
inspiration.
B. Asthmatic status (acute
asthma)
Objective
- The patient is polyphenic (30 breaths / min),
orthopneic, cyanotic, anxious (causes the
feeling of imminent asphyxia);
- hyperinflated thorax, blocked in the
inspiration, intercostal draft and action of
accessory respiratory muscles
(sternocleidomastoid and intercostal);
- decreased amplitude of respiratory
movements;
B. Asthmatic status (acute
asthma)
- pulmonary hypersonority, with lowered
lung bases
- diminished vesicular murmur, with few
sibilant rales.
- tachycardia;
- paradoxal pulse present.
C. Chronic bronchial
asthma
It occurs in a patient with intermittent
asthma, where obstructive episodes
appear more and more frequently due to
recurrent respiratory infections, ultimately
resulting in infectious bronchial asthma.
C. Chronic bronchial
asthma
• Clinical presentation
Subjectively the patient accuses:
- chronic coughing, mucous or mucopurulent
expectoration, and persistent or effort expiratory
dyspnea;
- On this background, intense dyspnea and cough with
abundant mucopurulent expectoration appear.
Objective
- emphysematous thorax, hypersonority, with
diminished vesicular murmur, prolonged expiration,
permanent sibilant and subcrepitants rales.
C. Chronic bronchial
asthma
Differential diagnosis is primarily done
with COPD: in chronic BA, FEVS1
values after administration of an inhaler
bronchodilator show an improvement of
more than 12% (200 ml) from baseline.
C. Chronic bronchial
asthma
Paraclinic
1. Spirometry records an obstructive ventilator
dysfunction with low FEVS1 reversible after
inhalation of bronchodilators (> 12% or 200
ml).
2. Peakflowmetry measures PEF variability
(PEF - peak expiratory flow or maximum
expiratory flow) over a day and compares
these values to each other. The high variability
(over 20%) of PEF values indicates the
presence of bronchial asthma.
3. Inducing test (to determine bronchial
reactivity) using bronchoconstrictors.
C. Chronic bronchial
asthma
4. Gasometry:
- slight / moderate BA: PaO2 and PaCO2 -
normal, but with respiratory alkalosis;
- severe BA: very low PaO2; Normal PaCO2.
The combination of increased PaCO2 (
hypercapnia) with respiratory acidosis and
symptoms of respiratory failure (polypnea and
cyanosis) indicate the need for mechanical
ventilation
C. Chronic bronchial
asthma
5. Skin allergy tests are required to identify the
allergen involved;
6. Immunological tests indicate IgE titres elevated in
allergic BA;
7. Pulmonary radiography highlights:
a. hyperinflation of the lungs
b. decrease of vascular drawing in the periphery of
lung fields;
c. exclusion of other diseases that mimic asthma;
d. Complications of bronchial asthma (pneumothorax),
which do not allow the recovery of lung function.
C. Chronic bronchial
asthma
8. Hemogram shows the nominal
leukocyte count, with increased
percentage of eosinophils (allergic BA) or
neutrophils (infectious BA).
9. The sputum examination may reveal
the presence of Curshmann spirals and
Leyden crystals in allergic asthma
3. CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD)
• Definition
COPD is a complex pathological concept
that defines the clinical forms commonly
encountered in medical practice and is
characterized by the association of:
- bronchial and obstructive phenomena
(COB) with
- Pulmonary hyperinflation (PE)
phenomena.
3. CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD)
Essential features
- current (or past) smoker;
- chronic productive cough, persistent, 2
months / year, 2 consecutive years (CB)
and dyspnea (PE);
- bronchial rallies, decreased vesicular
murmur and prolonged expiration;
- Limiting respiratory flows to FVT.
3. CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD)
Classification
Depending on the dominant clinical
manifestations, two clinical forms of
COPD have been described
- predominantly emphysematous and
- predominantly bronchial type.
A. Predominantly emphysematous or pink
puffers (PP); COPD type A
Clinical
Subjective:
long history of:
• dyspnea at effort;
• dry cough;
• minimal mucous expectoration;
• rare respiratory infectious episodes.
Predominantly emphysematous or
pink puffers (PP); COPD type A
Objective
General Inspection
• Asthenic patients, underweight, with
discrete cyanosis, orthopneic, intensely
polypneic, using accessory expiratory
muscles (stay in a sitting position, lean
forward, leaning on there hands at the
edge of the bed).
Predominantly emphysematous or
pink puffers (PP); COPD type A
Respiratory system
• inspection: emphysematous thorax;
• palpation: low amplitude of respiratory
movements, low pectoral murmur;
• percussion: pulmonary hypersonority, lowered
lung bases, immobile with breathing;
• Auscultation: diminished vesicular murmur,
prolonged expiration and fine sibilant rallies,
expiration problems;
Predominantly emphysematous or
pink puffers (PP); COPD type A
• Paraclinical
• Low PaO2 (<70 mmHg); PaCO2 normal
/ low (polypneic);
• FVT: Increased TPC and RV; VC and
low FEVS1;
• The elastic properties of the lungs are
diminished;
• Low DLCO.
Predominantly emphysematous or
pink puffers (PP); COPD type A
• Lungs radiograph:
- hypertransparency of lung fields;
- flattening of the diaphragm;
-alveolar drawing in the periphery;
- Expansion of clear retrosternal space;
- small, verticalized cord.
• Hemoglobin and hematocrit: normal /
low (without poliglobulia);
Predominantly bronchial or
blue bloaters (BB); COPD
type B
Clinical
Subjective:
- Appears in a big smoker;
- with a long history of: chronic cough and
mucous / mucopurulent expectoration, which in
time become more frequent and prolonged;
- dyspnea appears late, initially as an effort
dyspnea, which progressively becomes
permanent dyspnea and whose severity is
appropriate to the degree of obstruction.
Predominantly bronchial or
blue bloaters (BB); COPD
type B
Objective:
General Inspection
• Overweight, cyanotic, polypneic patients who
do not use accessory respiratory muscles.
Respiratory system
• normally conformed thorax;
• normosonority / hipersonority;
• subcrepitant rales ± sibilant and ronflant rales
+- diminished vesicular whispering.
Predominantly bronchial or
blue bloaters (BB); COPD
type B
Cardiovascular:
• enlargement of the right ventricle
(Harzer sign present);
• Systolic bouts of tricuspid insufficiency
(TI);
• turgescent jugular ;
• peripheral edema and cyanosis
Predominantly bronchial or
blue bloaters (BB); COPD
type B
• Paraclinical
• Gasometry: PaCO2 increased (> 50
mmHg), low PaO2, low SaO2;
• FVT: Low FEVS1; TPC normal; RV
normally increased slightly;
• Alveolo-capillary membrane diffusion
capability: Normal DLCO.
Predominantly bronchial or
blue bloaters (BB); COPD
type B
• Pulmonary Radiography:
- emphasizing the peribronhovascular
drawing in the lower areas;
- cranial distribution of pulmonary
circulation;
- increase of the cardiac figure on the
right side;
Predominantly bronchial or
blue bloaters (BB); COPD
type B
• Differential diagnosis is done with:
1. Persistent bronchial asthma.
2. Congestive heart failure (CHF)
associated with stasis of chronic
bronchitis 3. bronchiectasis
4. Tuberculosis (TB)
5. Sarcoidosis