Pemicu 7

KURNIA F PANGARIBUAN
405120090
RESPIRATORY FAILURE
 RESPIRATORY FAILURE
• Inadequate blood oxygenation or cabon
dioxide removal
• Classified as
– Hypercapnic Respiratory Failure
– Hypoxemic Respiratory Failure

Fishman’s Pulmonary Diseases & Disorders 4th Ed

 ETIOLOGY
• Central nervous system
– Sedative/narcotic overdose
– Meningoencephalitis
– Tumirs or vascular
abnormalities of medulla
– Strokes
– Severe myxedema
– Hepatic failure
– Advanced Uremia
– Obesity-hypoventilation
syndrome
• Perpipheral Nervous
system or Chest Wall
– GBS
– Mysathenia Gravis
– Polymiositis
– Muscular dystrophies
– Acute Poliomyelitis
– Traumatic Spinal Cord
Injury
– Severe kyphoscoliosis
– Flail chest, morbid obesity
Fishman’s Pulmonary Diseases & Disorders 4th Ed
 ETIOLOGY
• Airways • Alveoli
– Epiglotitis – Pulmonary edema
– Foreign body aspiration – Diffuse pneumonia
– Tracheal tumor – Pulmonary hemmorhage
– COPD – Aspiration of stomach
– Asthma contents
– Advanced cystic fibrosis – Near-drowning

Fishman’s Pulmonary Diseases & Disorders 4th Ed

CLASSIFICATION

Fishman’s Pulmonary Diseases & Disorders 4th Ed

PATHOPHYSIOLOGY

Fishman’s Pulmonary Diseases & Disorders 4th Ed

PATHOPHYSIOLOGY

Fishman’s Pulmonary Diseases & Disorders 4th Ed

Fishman’s Pulmonary Diseases & Disorders 4th Ed
Fishman’s Pulmonary Diseases & Disorders 4th Ed
 MANAGEMENT
• Blood gas analysis for confirmation
• Triage, based on
– Acuity of the respiratory failure
– Degree of hypoxemia, hypercapnia, acidemia
– Presence of co-morbidities (cardiac/renal disease)
• Airway Management
– Emergency intubation or ventilator depends on
clinical condition and arterial blood gas test

Fishman’s Pulmonary Diseases & Disorders 4th Ed

 MANAGEMENT
• Correction of Hypoxemia and Hypercapnia
– Hypoxemia  correction to PaO2 60mmHg,
higher in patients with coronary or CVD
– May use face mask or Venturi Mask (high flow O2)
– May require intubation or ventilator
• Search for underlying cause

Fishman’s Pulmonary Diseases & Disorders 4th Ed

 MANAGEMENT
• Monitoring
– Acute : RR, tidal volume, use of accessory muscles,
paradoxical breathing movement
– Mechanical ventilation  related complications
– Status asthmaticus  hypotension due to intrinsic
PEEP  alter ventilator, implement sedation or
paralytic agents

Fishman’s Pulmonary Diseases & Disorders 4th Ed

Fishman’s Pulmonary Diseases & Disorders 4th Ed
COMPLICATIONS

Fishman’s Pulmonary Diseases & Disorders 4th Ed

Fishman’s Pulmonary Diseases & Disorders 4th Ed
 PROGNOSIS
• Acute hypoxemic respiratory failure
– Survival rate 60%
– Worse outcomes in old patients and patients with
pre-existing lung disease
– 2/3 survivors  impaired pulmonary function

Fishman’s Pulmonary Diseases & Disorders 4th Ed

 PROGNOSIS
• Acute hypercapnic respiratory failure
– Mortality depends on
• Patient physiological reserve (cardiac, renal, hepatic
status, patient’s age)
• Underlying causes
• Severity of respiratory failure (pH and PCO2)
• Complications after onset (sepsis, pneumonia, GI bleed)
• Cachexia and hime confinement  poor outcome

Fishman’s Pulmonary Diseases & Disorders 4th Ed

PNEUMOTHORAX
 PNEUMOTHORAX
• Accumulation of air in the pleural space
• Reported to be present in 15-50% traumatic
patients
• Classified as :
– Simple
– Communicating
– Tension

Simple Pneumothorax

Rosen’s Emergency Medicine 7th Ed

COMMUNICATING PNEUMOTHORAX

Rosen’s Emergency Medicine 7th Ed

 TENSION PNEUMOTHORAX

Tension Pneumothorax After Tube Throacostomy

Rosen’s Emergency Medicine 7th Ed

 CLINICAL FEATURES
• Signs : dyspneic, agitated, restless, cyanotic,
tachycardic, hypotensive, decreased mental
activity, jugular vein distension
• Symptoms : Shortness of breath, Chest pain
• PE : decreased/absent breath sound,
hyperresonance

Rosen’s Emergency Medicine 7th Ed

 DIAGNOSIS
• Initial chest radiography while full inspiration
• Focused Assesment with Sonography for
Trauma (FAST) examination
• CT-Scan
Occult Pneumothorax
• PTX that is absent on initial CXR but present i
subsequent chest or abdominal CT-Scan

Rosen’s Emergency Medicine 7th Ed

OCCULT PNEUMOTHORAX

Rosen’s Emergency Medicine 7th Ed

 MANAGEMENT
• Asymptomatic & Negative CXR  observe for
3 hours, or 6hours for blunt trauma
• Simple Pneumothorax  chest tube in 4th or
5th intercostal space at the anterior or
midaxilarry site (36-40F adults, 16-32F child)
• Complications of chest tube : hemothorax,
pulmonary edema, bronchopleural fistula,
pleural leaks, empyema, infection, etc

Rosen’s Emergency Medicine 7th Ed

 MANAGEMENT
• Communicating Pneumothorax  defect
should be covered. In ED  ETT & Chest Tube
+ Surgical repair
• Tension Pneumothorax  needle
thoracostomy throung 2nd or 3rd interspace
anterior or 4th or 5th interspace lateral

Rosen’s Emergency Medicine 7th Ed

TUBE THORACOSTOMY

Rosen’s Emergency Medicine 7th Ed

HEMOTHORAX
 HEMOTHORAX
• Accumulation of blood in pleural space from
injured lung parenchyma after blunt or
penetrating trauma
• May be self-limited, unless major laceration
• Leaks from intercostal and internal mammary
arteries, great vessels, hilar
• May cause hypovolemic shock, tactile fremitus
↓, absent breath sound

Rosen’s Emergency Medicine 7th Ed

 HEMOTHORAX
• Diagnosis
– Chest Radiography
– CT-Scan
• Delayed hemothorax  residual blood serve as
nidus for empyema or fibrothorax
• Management
– Tube thoracostomy at 5th interspace at anterior
axilarry line
– Thoracotomy
– Autotransfusion

Rosen’s Emergency Medicine 7th Ed

THORACOTOMY

Rosen’s Emergency Medicine 7th Ed

Rosen’s Emergency Medicine 7th Ed
 REFERENCES
• Fishman AP, Elias JA, Fishman JA, Grippi MA,
editors. Fishman’s Pulmonary Diseases and
Disorders. 4th Ed. New York : McGraw-Hill,
2008
• Marx JA, Hockberger RS, Walls RM, Adams JG,
editors. Rosen’s Emergency Medicine
Concepts and Clinical Practice. 7th Ed.
Philadelpia : Mosby Elsevier, 2010