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==Overview==
==Overview==

Revision as of 21:35, 20 March 2018

Respiratory failure Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vellayat Ali M.B.B.S[2] Karina Zavaleta, MD [3]

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Differentiating Respiratory Failure from other Diseases

  • [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
  • [Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
  • As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].


Type of respiratory failure Causes/Etiology Onset Clinical manifestations Investigations Gold standard Other features
Symptoms Physical exam
Dyspnea Cough Fever Others findings Imaging Labs
Hypoxic respiratory failure (Type 1 respiratory failure) Cardiogenic pulmonary edema Acute decompensated heart failure[1][2] [3]
  • Acute
+ + with frothy expectoration +/-
  • nausea and anorexia
  • confusion
  • headaches
  • Pulse oximetry
  • Assays for BNP (B-type natriuretic peptide) and NT-proBNP (N-terminal pro-B-type natriuretic peptide)
  • Cardiac troponin levels
  • ST and T waves abnormalities in ECG
  • Clinical diagnosis
  • History of heart disease, hypertension
Non cardiogenic pulmonary edema Adult respiratory distress syndrome (ARDS) [4]
  • Acute
+ +/- +/-
  • Diffuse, bilateral, alveolar infiltrates without cardiomegaly in chest radiograph
  • Bilateral opacities in CT
  • Clinical diagnosis with supportive test

According to Berlin definition:

  • One week of new or worse respiratory symptoms or clinical insult
  • Symptoms can not be explained by cardiac disease
  • Bilateral opacities in chest X-Ray or CT
  • Compromised oxygenation
High-Altitude Pulmonary edema (HAPE) [5]
  • Acute
+ + with frothy expectoration +
  • Chest X-ray may show patchy alveolar infiltrates, predominantly in the right central hemithorax, which become more confluent and bilateral as the illness progresses
  • Clinical diagnosis with supportive test
  • Occurrs over 2500 m
  • Descent is mandatory in >4000 m
Neurogenic pulmonary edema [6] [7]
  • Acute
+ +/- with frothy expectoration +/-
  • Diagnosis of exclusion
  • A proposed criteria is as follows
    • Bilateral infiltrates
    • PaO2/FiO2 ratio < 200
    • No evidence of left atrial hypertension
    • Presence of CNS injury
    • Absence of other common causes of acute respiratory distress or ARDS
Pulmonary embolism [8] [9]
  • Acute
  • Sub-acute
  • Chronic
+ + +/-
  • Hamptom and Westermark sign may be seen in chest X-Ray
Pneumonia[10] [11]
  • Acute
+ + with sputum production +
  • Pleuritic chest pain
  • Clinical manifestations and infiltration chest X-Ray with or without microbiological test
Idiopatic chronic lung fibrosis[12] [13] [14] [15]
  • Chronic
+ + without any sputum production +/-
  • symptoms suggestive of rheumatic diseases may be present
  • Reticular or nodular pattern in chest X-Ray
  • HRCT may show reticular opacities, including honeycomb changes and traction bronchiectasis
  • Serological tests e.g. ANA, RF for underlying rheumatological diseases
  • Clinical presentation in combinations with HRCT findings
  • Lung biopsy when lab, imaging and PFT do not yield enough evidence
  • History of cigarette smoking
Hypercapnic respiratory failure (Type 2 respiratory failure) COPD [16] [17]
  • Acute
  • Chronic
  • Acute-on-chronic
+ + +/-
  • Exercise intolerance
  • Acute exacerbation may affect CNS, ranging from irritability to decreased responsiveness
  • Clubbing
  • Tachypnea
  • Barrel shaped chest
  • Decreased breath sounds with prolonged expiration
  • Rhonchi and Wheeze
  • Use of accessory respiratory muscles
  • Increased JVP, peripheral edema may manifest with right ventricular overload during an acute exacerbation
  • Chest X-ray may show hyperinflation, flattened diaphragm, rapid tapering of vascular markings 
  • CT scan helps to correlate with COPD prognosis
 
  • PFTs: (FEV1/FVC) <70% of predicted   
  • Clinical diagnosis with supportive test
  • CNS symptoms may be the only manifestation in elderly with baseline hypercapnia
Severe Asthma/Status Asthmaticus [18] [19]
  • Acute
+ + -
  • Chest tightness
  • Audible wheeze
  • Chest X-ray not required in acute conditions, may show hyperinflation
  • PEF <40 percent predicted or personal best
  • Clinical diagnosis
Drug Overdose (opioid toxicity) [20] [21] [22]
  • Acute
+ - -
  • Nausea and vomiting
  • Constipation
  • Seizures
  • Classic triad suggesting opioid toxicity consist of respiratory depression, pinpoint pupils, and altered mental state 
  • Conjunctival injection,
  • Decreased bowel sounds
  • Euphoria
  • Urine toxicology screen: may reveal polysubstance abuse
  • Clinical diagnosis with supportive test
Myasthenic crisis [23] [24] [25] [26] [27]
  • Acute
+ +/- +/-
  • Inability to cough
  • Bulbar weakness: dysphagia, nasal regurgitation, a nasal quality to speech, staccato speech, jaw weakness, bi-facial paresis, and tongue weakness
  • Pulse Oximetry
  • ABGs
  • CBC: Infective cause precipitating the crisis may be observed
  • Tensilon (edorphonium) test
  • Clinical diagnosis with supportive test
Guillain-Barré syndrome [28] [29] [30] [31] [32] [33]
  • Acute
+ - +/-
  • Difficulty walking (ascending symmetric muscular weakness)
  • Back pain
  • Pain in extremities
  • Diminished or absent deep tendon reflexes
  • Limb weakness (first lower then upper limbs)
  • Facial droop (Facial nerve palsy)
  • Ophthalmoparesis (3rd & 6th nerve palsies)
  • Decreased breath sounds
  • Decreased bowel sounds
  • CSF analysis: Albuminocytologic dissociation
  • Nerve conduction studies may show conduction block, slowed motor conduction velocities and delayed latencies
  • PFTs: Vital Capacity, maximum inspiratory pressure (PImax) and maximum expiratory pressure (PEmax) should be followed to determine appropriate timing of intubation and mechanical ventilation
  • Clinical diagnosis with supportive test
 
  • Signs depicting respiratory failure occur late, early manifestations are tachypnea, tachycardia, air hunger, broken sentences, and a need to pause between sentences
  • Use of the accessory respiratory muscles, paradoxical breathing, and orthopnea indicate severe diaphragmatic weakness
Perioperative respiratory failure (Type 3 respiratory failure) Post-operative atelectasis [34] [35] [36] [37] [38]
  • Acute
+ +/- +/-
  • Tachypnea
  • Tachycardia
  • Decreased movement in the affected lung area
  • Dullness percussion note
  • Absent breath sounds Tracheal deviation to affected side
  • Chest X-ray may show increased density and reduced volume
  • CT chest accurately shows the involved segment
  • Pulse oximetry
  • ABGs
  • Clinical diagnosis with support of radiographic findings
  • History of abdominal or thoracic surgery
Type 4 respiratory failure Shock[39] [40]
  • Acute
+ - +/-
  • Clinical diagnosis with supportive test

References

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