Acuut respiratoir falen

Diagnose en management van acuut respiratoir falen

A. doelstellingen
    A. respiratoir falen definieren en kunnen indelen
    B. de kenmerken en pathofysiologie van acuut respiratoir falen beschrijven
    C. strategieën voor zuurstoftoedieningen bekijken

B. welke bevindingen suggereren respiratoir falen?
    1. tachypnee
    2. gebruik van accesoire ademhalingsspieren
    3. matige distress
    4. eventueel ook
        bewustzijnsveranderingen
            agitatie
            verwardheid
        paradoxale ademhaling
        tachycardie
        cyanose
        hypertensie
        diaferese

C. welke evaluatie is nodig om vast te stellen of respiratoir falen bestaat?

    1. Wat is de rol van onze ademhaling?
        verwijderen van overtollig CO2
        oxygeneren van het bloed
    2. de vormen van respiratoir falen
        A. hypoxemie
            1. kamerlucht PaO2: </= 50-60 mmHg
            2. abnormale pO2: FIO2 ratio
            3. voorbeelden van klinische oorzaken
                ARDS
                pneumonie
                congestief hartfalen
                interstitiele longziekte
            4. Op Rx thorax: frequent infiltraten

            5. oorzaken van hypoxemie
                A. mismatch ventilatie/perfusie (meest frequent)
                    1. shunt: ventilatie naar de alveoli is geblokkeerd
                        pneumonie
                        atelectase
                    2. dode ruimte: wel voldoende zuurtsof in de alveoli maar problemen in het capillair bed zodat er geen uitwisseling plaats kan vinden
                        wat veroorzaakt toegenomen dode ruimte?
                            1. hypovolemie
                            2. verlaagde cardiac output
                            3. pulmonaire embolen
                            4. hoge druk in de luchtwegen: Bijvoorbeeld hoge beademingsdrukken van een beademde patiënt

                B. verminderde diffusie
                    1. interstitiele fibrose
                    2. amyloidose
                C. alveolaire hypoventilatie
                    1. hypercapnie
                    2. sedativa
                    3. alcohol
                    4. hersenletsel
                    5. neuromusculaire ziekte
                D. hoogte

        B. hypercapnie
            1. PaCO2 >/= 50mmHg met pH<7.36
            2. voorbeelden van klinische oorzaken
                traumatisch hersenletsel
                sedative medicatie
                neuromusculaire ziekte (bijv myastenia gravis, Giant Barré syndroom)
                slaapapnee
                metabole stoornissen
            3. Op Rx thorax eerder beeld van hyperinflatie
            4. Hoe kunnen we weten of hypoxemie enkel veroorzaakt is door hypoventilatie (en stijging van de PCO2)?
                Wat moeten we hiervoor weten? De alveolaire-arteriele O2 gradient
                Hiervoor moeten we exact weten hoeveel zuurstof de patiënt krijgt. Dat is vaak niet mogelijk en varieert in functie van het middel waarmee de patient zuurstof krijgt
                Een normale gradient is <20 mm Hg.  Indien deze gestegen is weten we dat enkel hypoventilatie niet verantwoordelijk kan zijn voor de hypoxemie. Er is dan ook een lokaal proces aanwezig.

        C. mixed: voorbeelden
            1. COPD
            2. ernstig congestief hartfalen
            3. multifactorieel bij kritische patient

Behandeling van acuut respiratoir falen:

                A. behandeling van de onderliggende oorzaak van hypoxemie
                    1. vochttherapie
                    2. verbetern van de cardiac output
                    3. verminderen van de beademingsdruk
                    4. oplossen van de vaatobstructie (embolen)

                B. zuurstoftoediening
                    Welke hulpmiddelen bestaan er om extra zuurstof toe te dienen? Hoe deel je ze in?
                        A. naar zuurstofconcentratie
                            1. laag: neusbril
                            2. gecontroleerd: venturi masker
                            3. hoog: masker met nonrebreathing zakje
                        B. naar flow
                            1. hoog
                            2. gemiddeld
                            3. laag

                C. Welke geneesmiddelen kunnen we gebruiken?

                      - beta2 agonist inhalatiemiddelen: werken sneller dan  ipratroprium
                            1. aerosol (vernevelaar of nebuliser)
                            2. dosisingestelde inhalator (puffer):  
                    - inhalatie van ipratroprium:  werken langer dan  beta2 agonist inhalatiemiddelen
                            1. aerosol (vernevelaar of nebuliser)
                            2. dosisingestelde inhalator (puffer)
                       - steroiden
                        - antibiotica
                    - antagonisten voor een eventuele intoxicatie toedienen

                D. intubatie en mechanische ventilatie (overweeg ook CPAP (Continues Positive Airway Pressure) voor hypoxemie en NIV (Niet invasieve ventilatie) voor hypercapnie.

D. Samenvatting
    A. Acuut respiratoir falen kan worden ingedeeld in
        1. hypoxie
        2. hypercapnie
        3. mixed
    B. Ventilatie/perfusie mismatch is de meest frequente oorzaak van hypooxisch acuut respiratoir falen
    C. Hypercapnisch acuut respiratoir falen wordt veroorzaakt door een verminderd minuutvolume
    D. Zuurstoftoediening wordt gebruikt om hypoxemie te behandelen
    E. Medicatieaanpassingen kunnen nodig zijn in acuut respiratoir falen

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