type of respiratory...
TRANSCRIPT
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
[email protected] 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
