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Definition
Pulmonary gas exchange fails to maintain normal arterial O2 & CO2 levels.
Classified into types I and II.
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Pathophysiology
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Management of Acute Respiratory Failure
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Chronic & "Acute on Chronic" Type II Respiratory Failure
Most common cause of chronic type II respiratory failure: severe COPD.
Although PaCO2 may be persistently , there is no persisting acidaemia because the kidneys
retain bicarbonate, correcting arterial pH to normal.
This compensated pattern, which may also occur in chronic neuromuscular disease or
kyphoscoliosis, is maintained until there is a further acute illness, such as an exacerbation of
COPD which precipitates an episode of acute on chronic respiratory failure, with acidaemia and
initial respiratory distress followed by drowsiness and eventually coma.
These patients have lost their chemosensitivity to PaCO2, and so they may paradoxically
depend on hypoxia for respiratory drive, and are at risk of respiratory depression if given high
concentrations of oxygen.
Patients may not be distressed, despite being critically ill with severe hypoxaemia, hypercapnia
and acidaemia.
While the physical signs of CO2 retention (confusion, flapping tremor, bounding pulses) can be
helpful if present, they may not be, so arterial blood gases are mandatory in the assessment of
initial severity and response to treatment.
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HOME VENTILATION FOR CHRONIC RESPIRATORY FAILURE
Non-invasive ventilation (NIV) is of great value in the long-term treatment of respiratory failure
due to spinal deformity, neuromuscular disease and central alveolar hypoventilation.
Some patients with advanced lung disease (cystic fibrosis) also benefit from NIV.
In these conditions, the onset of type II respiratory failure can be very gradual.
Morning headache (due to PaCO2) & fatigue are common symptoms but, in many cases, the
diagnosis is only revealed by sleep studies or morning blood gas analysis.
In the initial stages, ventilation is insufficient for metabolic needs only during sleep, when there is
a physiological decline in ventilatory drive.
Over time, CO2 retention becomes chronic + renal compensation of acidosis.
Home-based NIV overnight is sufficient to restore the daytime PCO2 to normal, and to relieve
fatigue and headache.
In advanced disease (muscular dystrophies or cystic fibrosis), daytime NIV may also be required.
LUNG TRANSPLANTATION
Single lung
Advanced emphysema, lung fibrosis
transplantation
Cystic fibrosis, bronchiectasis
Bilateral Lungs (Transplanted lung is vulnerable to cross-infection in the context of post-
transplantation transplant immunosuppression, thus single lung transplantation is
contraindicated.)
Combined heart-
Advanced congenital heart disease: Eisenmengers syndrome.
lung
Primary pulmonary hypertension unresponsive to medical therapy.
transplantation
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PULMONARY EOSINOPHILIA
Definition
Association of radiographic (usually pneumonic) abnormalities & peripheral blood eosinophilia.
Eosinophils are the predominant cell recovered in sputum or BAL.
Eosinophil products are likely to be the prime mediators of tissue damage.
Etiology
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Acute Eosinophilic Pneumonia
An acute illness (<5 days) characterized by diffuse pulmonary infiltrates &
Definition
hypoxic respiratory failure.
Rx Diethycarbamazine.
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