type of respiratory...

Type of

Respiratory

Failure

Andreas Infianto

WS 5 : Respiratory Critical Care

Work Conference XVI 2019

Indonesian Society Of Respirology

Andreas Infianto DKI Jakarta, 07 Nopember

degondreh@yahoo.com phone : +62 813 3327 3993

Pendidikan dan Pelatihan Dokter Umum Universitas Kristen Maranatha Bandung 2002

Magister Manajemen Pemasaran Universitas Bandar Lampung 2005

Spesialis Paru & Kedokteran Respirasi Universitas Brawijaya Malang 2011

Bronchoscopy Course for Trainee NUH Singapore 2014

Spirometry Course MTS Selayang University Malaysia 2015

Paediatric Flexible Bronchoscopy Course NUH Singapore 2016

Role of Interventional Pulmonologist in Lung Cancer Diagnostic and Therapeutics, NUH Singapore

2017

Pulmonary Funcyion & CPET Masterclass, University Kebangsaan Malaysia Medical Centre 2018

Interstitial Lung Disease Masterclass, Institut Perubatan Respiratori Malaysia 2018

Education Thematic Series Lung Cancer – The Ins and Outs, Singapore General Hospital 2019

Curriculum Vitae

Definisi

Gagal Nafas

Gagal Nafas adalah suatu sindrom dimana sistem

pernafasan mengalami kegagagalan pada

salah satu atau kedua duanya dari fungsi

pertukaran gas : oksigenasi dan

pembuangan karbondioksida.

Gagal Napas bukan merupakan

penyakit melainkan DAMPAK

dari beberapa penyakit akibat

disfungsi pernapasan.

Kondisi klinis dimana PaO2 <60

mmHg saat bernapas di udara

ruangan atau PaCO2 >50 mmHg.

•Insiden sekitar 360.000 kasu per tahun di US.

•Sekitar 36% meninggal selama perawatan.

•Angka morbiditas dan mortalitas meningkat

sesuai dengan usia dan adanya komorbid.

Epidemiologi

VENTILATION PERFUSION MISMATCH

• Setiap unit alveoli mengandung kapiler-kapiler

untuk fungsi perfusi.

• Pertukaran udara membutuhkan suatu rasio

ventilasi dan perfusi yang optimal —› V/Q unit.

VENTILATION PERFUSION MISMATCH

1. Alveolus is ventilated but underperfused

—› high V/Q unit

2. Alveolus is underventilated but perfused

—› low V/Q unit

VENTILATION PERFUSION MISMATCH

3. Alveolus is ventilated but

unperfused

—› dead space

VENTILATION PERFUSION MISMATCH

4. Alveolus is unventilated but perfused

— › shunt unit

RESPIRATORY PHYSIOLOGY

• Ventilatory capacity : ventilasi spontan

maksimal yang dapat dipertahankan tanpa

adanya kelelahan otot pernafasan

• Ventilatory demand : ventilasi spontan per menit

yang mempertahankan CO₂ yang stabil.

• Normalnya, ventilatory capacity lebih besar

daripada ventilatory demand.

PRINCIPAL OF RESPIRATORY FAILURE

• Respiratory failure may result from :

1. Reduction in ventilatory capacity or

2. Increase in ventilatory demand or

3. Decrease ventilatory capacity and

increase ventilatory demand.

OXYGENATION & VENTILATION

Gagal nafas dapat dibedakan menjadi :

• Akut

• Kronis

• Akut dalam kronis (Acute on chronic)

Contoh pada eksaserbasi akut pada

Klasifikasi

• Acute RF

✓Dalam beberapa menit hingga jam

✓↓ pH secara cepat ke <7.2

✓Contoh :Pneumonia

• Chronic RF

✓Dalam beberapa hari

✓↑ HCO3

✓↓ pH sedikit demi sedikit

✓Polycythemia, Cor pulmonale

✓Contoh :COPD

Klasifikasi

berdasarkan

onset

Tipe I atau Hipoksemia (PaO2 <60 di atas ketinggian laut):

Failure of oxygen exchange

• Peningkatan shunt fraction (Q S /QT )

• Akibat dari alveolar flooding

• Hipoksemia menetap dengan supplemental oxygen

Tipe II atau Hiperkapnia (PaCO2 >45):

Failure to exchange or remove carbon dioxide

• Penurunan alveolar minute ventilation (V A )

• Kadang disertai hipoksema yang dapat dikoreksi dengan supplemental oxygen.

Klasifikasi

Tipe III : Perioperative respiratory failure

• Increased atelectasis due to low functional residual capacity(FRC) in the setting of abnormal abdominal wall mechanics

• Often results in type I or type II respiratory failure

• Can be ameliorated by anesthetic or operative technique, posture, incentive spirometry, post-operative analgesia, attempts to lower intra- abdominal pressure

Tipe IV : Shock

• Type IV describes patients who are intubated and ventilatedin the process of resuscitation for shock

• Goal of ventilation is to stabilize gas exchange and to unload the respiratory muscles, lowering their oxygen consumption

Klasifikasi

Penyebab Gagal Nafas Tipe I

•Pneumonia

•Cardiogenic pulmonary edema Pulmonary edema due to increased hydrostatic pressure

•Non-cardiogenic pulmonary edema Pulmonary edema due to increased permeability

Acute lung injury (ALI)

Acute respiratory distress syndrome (ARDS)

•Pulmonary embolism (see also type IV respiratory failure)

•Atelectasis (see also type III respiratory failure)

•Pulmonary fibrosis

Hypoxemic repiratory failure (type I)

1. PaO₂ value is less than 60 mm Hg.

2. PaCO₂ value is normal or low.

3. The most common form of respiratory failure

PATHOPHYSIOLOGY

• Hypoxemic respiratory failure is caused by :

1. Ventilatory perfusion mismatch

(imbalance ratio of ventilation and perfusion) : pulmonary embolism.

2. Shunt

(persistence of hypoxemia despite 100% oxygen inhalation) : pneumonia, atelectasis.

Penyebab Gagal Nafas Tipe II

Central hypoventilation

Asthma

Chronic obstructive pulmonary disease (COPD) Hypoxemia and hypercapnia often occur together

*Neuromuscular and chest wall disorders •Myopathies

•Neuropathies

•Kyphoscoliosis

•Myasthenia gravis

Obesity Hypoventilation Syndrome

Hypercapnic respiratory failure (type II)

1. Hypoxemic is common when patients breath in room air.

2. PaCO₂ value of more than 50 mmHg.

3. Blood pH is usually slightly decrease.

PATHOPHYSIOLOGY

• Hypercapnic respiratory failure dapat disebabkan oleh :

1. Decrease minute ventilation :

a. CNS depression

b. Neuromuscular disorders

2. Increase dead space ventilation :

- COPD

Penyebab Gagal Nafas Tipe III Inadequate post- operative analgesia, upper abdominal incision

Obesity, ascites

Pre- operative tobacco smoking

Excessive airway secretions

Penyebab Gagal NafasTipe IV Cardiogenic shock

Septic shock

Hypovolemic shock

Tanda Klinis

Tanda tanda gagal nafas dapat berupa :

1. Respiratory compensation :

- tachypnea (respiratory rate > 35X/m)

- retraksi dari intercostal, suprasternal atau supraclavicular

- nasal flaring

TANDA KLINIS

2. Peningkatan sympathetic tone :

- tachycardia, hypertension & sweating

3. End organ hypoxia :

- altered mental status : agitation —›

decreasing of consciousness

- bradycardi & hypotension (late sign)

TANDA KLINIS

4. Desaturasi hemoglobin - sianosis

Saturasi 90% : critical threshold

Saturasi kurang dari 90% sama dengan PaO₂ < 60 mm Hg.

PENATALAKSANAAN

• Prinsip terapi :

1. Mengembalikan oksigenasi dan mencegah hipoksia

2. Mencegah asidosis karena hiperkapnia.

3. Perawatan di ICU untuk respiratory support.

4. Menangani underlying disease.

MEDICAL CARE

1. Manajemen gagal nafas

- Assure an adequate airway —› perform an endotracheal

intubation

2. Koreksi hipoksemia

- Lakukan support oksigenasi dan ventilasi untk mencapai PaO₂

> 60 mm Hg atau saturasi oksigen > 90

MEDICAL CARE

3. Koreksi hiperkapna:

Menggunakan penunjang ventilasi untuk menormalkan kembali

PaCO₂ dan mengistirahatkan otot otot pernafasan.

4. Penggunaan mechanical ventilation untuk ventilatory support :

a. Invasive

b. Non invasive

a. Invasive mechanical ventilation :

- endotracheal tube

- tracheostomi, if upper airway is obstructed

b. Noninvasive mechanical ventilation (if patient

can protect airway & hemodynamic is stable) :

- face mask

- nasal mask

MEDICAL CARE

5. Mengoptimalkan sistem kardiovaskulair :

- inotropic, vasodilator, diuretic and revascularization

6. Treatment penyebab spesifik ( dimuai ketika hipoksemia terkoreksi

dan hemodinamik stabil):

- Infection : antimicrobial & source control

- Airway obstruction : bronchodilator and

glucocorticoids

AKTIVITAS

• Pasien diminta bed rest pada fase awal manajemen gagal nafas.

• Ketika hemodinamik stabil maka segera lakukan ambulasi dini

untuk membantu area atelektasis di paru bisa mngembang>

LABORATORY WORKUP

• Darah lengkap dan analisa gas darah

• Cardiac serologic markers :

1. Troponin

2. Creatinine kinase - MB fraction (CKMB)

3. B – type natriuretic peptide (BNP)

• Mikrobiologi : :

1. Kutur dari sputum/bronchoalveolar lavage

2. Kultur darah

DIAGNOSTIC INVESTIGATION

1. Electrocardiogram

2. Chest radiography

3. Echocardiography

4. Pulmonary function test (tidak dianjurkan pada pasien kritis)

5. Bronchoscopy

INTERPRETASI

• Polisitemia dapat mengarah kepada hipoksemia kronis.

• Chest radiograph :

- peningkatan ukuran jantung

- vascular redistribution

- perihilar bat-wing

mengarah kepada hydrostatic pulmonary edema

• ECG : disritmia, dapat menandakan terjadinya hipoksemia berat atau

asidosis berat.

KOMPLIKASI

• Paru-paru :

- barotrauma

- nosochomial pneumonia

- pulmonary fibrosis

• Kardiovaskular :

- hypotension, arrhytmia

- acute myocardial infarction

Komplikasi

• Ginjal :

- acute renal failure

- abnormalities of electrolyte

• Gastro intestinal :

- gastric distention, stress ulcer

- gastrointestinal bleeding

• Nutrisi :

- malnutrition, hypoglycemia

Simpulan

• Gagal nafas adalah suatu kondisi yang mengancam jiwa yang

memerlukan diagnosis yang akurat, penilaian yang cepat dan

penatalaksanaan yang tepat.

• Respon waktu untuk resusitasi menentukan hasil pengobatan dan

prognosis.

LAST BUT NOT LEAST

• In a few irreversible pathologic process, respiratory failure needs a

life time ventilatory support :

- Prof. Stephen Hawking

† Christopher Reeve

( Actor of Superman the movie )

Terimo Kasihh