Respiratory conditions in Critically ill Surgical patient

Respiratory
Conditions
Unwell Surgical Patient

Case
• 63 year-old male, 2 days after emergency
perforated DU repair with omental patch via upper
midline incision.
• Smoker with COPD, not cardiac, not diabetic
• You have been called by relatives
• He is blue and breathless
What will you do for him?

Immediate
Management
• A
• B
• C
• D
• E
Full
Assessment
• Chart
• Sheet / History
and Examination
• Investigations /
Blood results
Plan
• Unstable/Unsure
• Stable
• Diagnosis required
• Definitive treatment
• Medical / high level care
• Surgical
• Radiological
• Daily management plan
• S
• O
• A
• P

Immediate management
• ABCs
• O2 mask
• Pulse Oximeter
• Set up the patient
• Help??
What next??

Clinical Assessment
• RR / Pattern (Tachypnea early sign of many disease processes)
• Patient (able to talk in complete sentences - cough)
• Inspection (Symmetry - Accessory ms. of respiration - NECK -
FiO2 - SO2 - Chest Tube patency and content? - Sputum?)
• Palpation / Percussion
• Auscultation (Equality - Additional Sounds)
• Adjuncts (X-ray - ABGs - Pulse Oximeter)
• Consultations?

Chart Review
• Absolute values vs. trends
• Chart review
• vitals (RR, P, T & BP)
• fluids (Urine output, Fluid balance, Chest drains
function and drainage)
• drugs (analgesia)
• labs (ABGs, SaO2)

Available results
• Results:
• Biochemistry / Haematology / Pathology
• Microbiology (C&S)
• Physiology (Pulmonary function test)
• ABGs
• Radiology (Reports and films)
• Return to chart when in need

The Case
• Breathless at rest, RR 32
• Cyanotic
• Cough, Sputum
• Expiratory wheeze
• Percussion and sounds are less on left base
• P 90 regular, BP 150/80, T 38
What next?

Management Plan
• Respiratory Failure?
• Need for ventilation?
• Need for immediate intervention? (e.g Needle
decompression)

Management Plan
• Humidified O2 (need for HDU for CPAP?)
• Physiotherapy
• Nebuliser
• Sputum C&S / Blood C&S
• Antibiotics??
• ABGs and SaO2
Set Parameters - Set time for review

the Case after 2 hours
• Condition is deteriorating
• RR 44, SaO2 87%, FiO2 0.6
• T 38.5, P 104 regular, BP 150/70
• GCS 13 confused
• pH 7.23
• pCO2 7.4 kPa (*7.5 = 55.5 mmHg),
• pO2 7.8 kPa (*7.5 = 58.5 mmHg)
• BE -1

Respiratory Failure
An arterial pO2 (at sea level, breathing air, at rest)
< 8 kPa (*7.5 = 60 mmHg)

Respiratory Failure - Type
1
• Hypoxaemic respiratory failure:
• Usually due to V/Q mismatch
• Often associated with low PaCO2 due to hyperventilation as a response to
hypoxaemia
• Caused by
• Chest infection / Aspiration pneumonitis
• PE
• Asthma
• Pulmonary oedema / Contusion /ARDS

Respiratory Failure - Type
2
• Hypercapnic respiratory failure/ventilatory failure
• Hypoxaemia with arterial PCO2 exceeding 6.5 kPa (*7.5 = 50 mmHg)
• Caused by Hypoventilation
• Cerebral lesion:(e.g., Opioids, anaesthetic agents, intracranial pathology, sleep apnoea)
• Spinal lesion: high cervical trauma, poliomyelitis
• Peripheral nerve lesion: motorneurone disease, Guillan–Barre syndrome
• Neuromuscular junction lesion: myasthenia gravis
• Muscular lesion: exhaustion, e.g. late acute severe asthma (Pain)
• Thoracic cage lesion: flail chest injury with inefficient ventilation (Pain)
• Lung parenchymal lesion: COPD with CO2 retention,
• Peripheral: (e.g., airway obstruction, restriction due to Pain / obesity / ascites)
• Decreased central drive Impaired Can also occur when patient with type 1 respiratory failure is exhausted by
compensatory hyperventilation—a very bad sign

Respiratory Failure - Risk Factors
• Patient factors:
• Pre-existing respiratory disease
• Smoking
• Obesity
• Immunosuppression
• Surgical factors:
• Emergency surgery
• Thoracic/upper abdominal surgery

Respiratory Failure - Management
The basic principles are
• Ensure adequate oxygenation: preferably humidified
• Ensure adequate ventilation: may need intubation and Invasive
respiratory support or CPAP
• Management of underlying causes, e.g. bronchodilators Antibiotics
if the underlying process is infective, analgesics
• Others: airway suction

Back to your Patient
• Condition is deteriorating
• RR 44, SaO2 87%, FiO2 0.6
• T 38.5, P 104 regular, BP 150/70
• GCS 13 confused
• pH 7.23
• pCO2 7.4 kPa (*7.5 = 55.5 mmHg),
• pO2 7.8 kPa (*7.5 = 58.5 mmHg)
• BE -1
Is this patient in Respiratory Failure? Why?

Your Patient
Has been taken to the ICU for further management
and higher level of care
How would you assess him?

ICU Chart review
• R: Respiratory: Rate, FiO2, SaO2, PaO2
• C: Circulation: Pulse rate, Rhythm, BP, CVP,
Urinary output, IV lines, fluid balance
• S: Surgical: Temperature, Drains (nature & volume),
TLC

Patient in ICU day 4
• Intubated, sedated and ventilated
• FiO2 0.6, PEEP +10, PCV, f14, Vt 550
• Sputum production, temperature 38
• TLC 16, C: S.aureus on Broncho-Alveolar lavage
• pH 7.34, pCO2 6.9 (52 mmHg), pO2 10 (75 mmHg), BE +2
• CXR bilateral diffuse pulmonary infiltrates
What happened to this patient?

ARDS
• Acute respiratory failure with noncardiogenic pulmonary
oedema leading to decreased lung compliance and
hypoxaemia refractory to oxygen therapy
• Characterised by:
• Diffuse pulmonary infiltrates on CXR
• A normal pulmonary artery wedge pressure (PAWP < 18 mmHg)
Excludes pulmonary oedema secondary to elevated left atrial pressure
• PaO2 /FiO2 ratio < 26.6 kPa (*7.5 = 200 mmHg)

remember - Your Patient
• Intubated, sedated and ventilated
• FiO2 0.6, PEEP +10, PCV, f14, Vt 550
• Sputum production, temperature 38
• TLC 16, C: S.aureus on Broncho-Alveolar lavage
• pH 7.34, pCO2 6.9 (52 mmHg), pO2 10 (75 mmHg),
BE +2
• CXR bilateral diffuse pulmonary infiltrates

ALI vs. ARDS
The severity of the hypoxic insult can be quantified
into acute lung injury (ALI) or ARDS depending on the
fraction of inspired oxygen that the patient is
breathing:
• In ALI the PaO2 /FiO2 ratio is <40 kPa (300 mmHg).
• In ARDS the PaO2 /FiO2 ratio is <26.6 kPa (200 mmHg).

ARDS - Clinical Picture
• There must be a known precipitating cause and the onset of symptoms is
acute.
• Dyspnoea / Tachypnoea
• Hypoxia refractory to oxygen therapy
• New bilateral diffuse infiltrates on chest radiograph: May lag behind clinical picture by 12–
24 hr
• No clinical evidence of a raised left atrial pressure
• Associated clinical findings (but are not included as diagnostic criteria):
• Need for mechanical ventilation
• Low lung compliance
• High airway pressures during positive pressure ventilation

ARDS - Causes
• Direct/pulmonary causes:
• Infection, Contusion from blunt trauma, Aspiration of gastric
contents, Near drowning and Smoke inhalation
• Indirect or nonpulmonary causes:
• Sepsis, Major trauma, Severe hypotension and prolonged
haemorrhage, Fat/amniotic fluid/thrombotic embolism, Burns,
Pancreatitis, Massive blood transfusion, DIC and
Cardiopulmonary bypass

ARDS - Pathology
• Inflammatory phase
• Neutrophils & Macrophages (Mediators) / activation of Complement and
Coagulation cascades
• Endothelial Injury (increased capillary permeability, Edema, Atelectasis)
• Peumocytes Type-II injury (less surfactant & Atelectasis)
• Proliferative phase (5-10 days later)
• Proliferation of Type-II pneumocytes
• Increase in the local fibroblast
• Progressive interstitial fibrosis

ARDS - Pathology
Pathological changes result in:
• Decreased lung compliance
• Increased atelectasis and reduced FRC
• Increased shunt and V/Q mismatch
• Increased pulmonary vascular resistance and pulmonary
hypertension

ARDS - Treatment
• Most patients will need to be managed in ITU / Identify and treat the cause (if known).
• Nutritional support.
• Mechanical ventilation (aid oxygenation, decrease the work of breathing, improve clearance of CO2)
• Avoid ventilator-induced lung injury:
• Limit mean airway pressures (<30 cmH2O) and tidal volume (6–8 ml/kg ideal body weight).
• Use PEEP to aid alveolar recruitment.
• Strict fluid management and ensure that patient does not develop cardiogenic pulmonary oedema
• Prone ventilation: usually for 4–8 hr at a time; redistributes secretions
• Minimises basal atelectasis with regular turning
• Improves V/Q mismatch, thereby improving oxygenation
• Inhaled prostacyclins, ECMO (extracorporeal membrane oxygenator), high frequency oscillatory
ventilation, nitric oxide and steroids may also help.

ARDS - Prognosis
• Outcome usually poor
• 50%–60% mortality rate overall
• 90% mortality rate if associated with sepsis
• Death of most patients due to sepsis and multiorgan
failure, not hypoxaemia
• Considerable morbidity with progressive interstitial
fibrosis and pulmonary hypertension

Your Patient - ICU day
11
• Tracheotomy
• Spontaneous breathing RR 24
• CPAP 2.5cm, FiO2 0.35
• Suction required 2 hourly
• 4 hourly nebuliser, IV Dalacin C.
• pO2 11, pCO2 5.8

Questions?
other than ABGs and Ventilation :)

Conclusion
• Anticipate problems
• Institute Preventive measures routinely
• Regular reassessment
• Detect deterioration and failure to respond
• Early consultation and transfer to HDU/ICU
• Treat the underlying cause of respiratory failure

Summery
• Systematic CCrISP approach
• Respiratory Failure
• ARDS

Respiratory conditions in Critically ill Surgical patient

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