1、万用卡,Respiratory Failure,The department of pathophysiology,SUN Huilan,O2,CO2,CO2,External respiration,circulation,Internal respiration,What is respiratory failure Respiratory failure is a pathological process In which the external respiratory dysfunction leads to an abnormal decrease of arterial part
2、ial pressure of oxygen with or without carbon dioxide retention.,How to Judge respiratory failure（1）PaO2 6.6 kpa（50mmHg）classification of RF：Hypoxemic(Group ）RF（1） Hypercapnic（ Group ）RF（1）（2）,Etiology and Pathogenesis of RF,Ventilatory disorders,Diffusion disorders,Ventilation-perfusion imbalance,A
3、natomic shunt,Etiology and Pathogenesis of RF (1),Ventilatory disorder,Restrictive Ventilatory disorders,Obstructive Ventilatory disorders,Restrictive Ventilatory disorders,Paralysis of the respiratoy muscles Decreased compliance of chest wall Decreased compliance of lungs Hydrothorax or pneumothora
4、x,Etiology and Pathogenesis of RF (1),大脑皮层调节呼吸肌作随意运动,脑桥、延髓不随意的自主节律呼吸调节,脊 髓,肋间神经,肋间肌,肋骨、胸骨,隔肌,胸膜及胸膜腔,胸 廓,外伤、中毒 出血、感染,脊髓灰质炎、高位截瘫,多发性神经炎,重症肌无力、多发性肌炎 大量腹水、上腹巨大肿物,外伤、骨折,气胸、大量胸腔积液,Etiology and Pathogenesis of RF (1),Central airway obstruction,Peripheral airway obstruction,Obstructive Ventilatory disorders
5、,O2,CO2,CO2,O2,口 鼻,喉头,肺泡,气管、支气管,肺泡膜,肺血管,意外 异物,水肿 炎症 异物,异物 肿瘤 哮喘,肺水肿 肺泡癌 炎症,纤维化间质 水肿,休克 栓塞,Central airway obstruction,Peripheral airway obstruction,Extrathoracic variable obstruction,expiration,inspiration,Intrathoracic variable obstruction,expiration,inspiration,nomal,Chronic bronchitis emphysema,20
6、 30 20,35,01020,0,10,20 20,2025,20 20,20 20,Peripheral airway obstruction,Blood gasLow PaO2 and High PaCO2,Ventilatory disorders,O2,CO2,CO2,O2,口 鼻,喉头,肺泡,气管、支气管,肺泡膜,肺血管,意外 异物,水肿 炎症 异物,异物 肿瘤 哮喘,肺水肿 肺泡癌 炎症,纤维化间质 水肿,休克 栓塞,Etiology and Pathogenesis of RF (2),Area of alveolar-capillary membrane,Diffusion
7、disorders,Thickness of alveolar-capillary membrane ,Exchenge time ,O2,CO2,alveolar-capillary membrane,surfactant,Alveolar epithelium,Capillary endotheliocyte,Blood gasLow PaO2 and nomal PaCO2,Diffusion disorders,Etiology and Pathogenesis of RF (3),Local hypoventilation VA/Q Functional shunt,Local hy
8、poperfusion VA/Q Dead space like ventilation,Ventilation- perfusion imbalance,Blood gasLow PaO2 and Nomal or low or high PaCO2,Ventilation-perfusion imbalance,Blood gas,Ventilation-perfusion imbalanceFunctional shunt,Blood gas,Ventilation-perfusion imbalance Dead space like ventilation,Etiology and
9、Pathogenesis of RF (4),Anatomic shunt,abnormal anatomical shunt,Be not ventilatedat all,Pulmonary arterio-venous fistulas,Pulmonary edema Atelectasis,Functional shunt and Anatomic shunt,Anatomic shuntNo blood gas exchangeApplying O2 cant increase PaO2,Functional shunt blood gas exchangedecreaseApply
10、ing O2 can increase PaO2,Blood gasLow PaO2,Anatomic shunt,ARDS adult/acute respiratory distress syndrome,What is ARDS? ARDS is a common form of acute respiratory failure in adult that is characterized by dyspnea,hypoxia.,Recognition of ARDS.,History:Systemic or pulnonary insult Chest radiograph:Diff
11、use pulnonary infiltrates Respiratorydistress:Labored breathing,tachypnea Severe hypoxemia:refractory to treatment with supplement of oxygen,Sequential development of ARDS,Trauma,Shock,Infection and other causative factor,Pulmonary hypoperfusion and hypoxemia,Damage to epithelium,Hypoxemia,Damage to
12、 endothelium,Platelet aggregation,Increased vascular permeability,Release of vasoactive substances,Mechamical obstruction,Stagnation of blood,Leakage of fluid and plasma into lungs,Noncardiogenic pulmonary edema or hemorrhage,Decreased surfactant,Alveolar filling,Atelectasis,Pathogenesis of ARDS,Sti
13、mulus,Complement activation,Pulmonary edema,Lysosomal proteinase,Active oxygen,Pulmonary vasoconstiction,Arachidonic acid metabolites,Epithelial and endothelial Cell damage,C5a,Sequestration of neutrophils in lungs,Increased pulmonary permeability,Pulmonary hypertension,Pathophysiology of ARDS,causa
14、tive factor,alveolar-capillary membrane damage inflammation,Pulmonary edema,Pulmonary vasoconstriction Microvascular thrombus,Diffusion disorders,Pulmonary shunt,Dead space ventilation,Atelectasis,Bronchia constriction,Hypoxemia,COPD Chronic obstructive pulmonary disease,What is COPD?COPD is a kind
15、of chronic obstructive ventilatory disorders caused by chronic bronchitis and emphysema,Pathophysiology of RF in COPD,COPD,Peripheral airway obstructed and convulsion,surfactant respiratory muscles failure,diffusion membrane,underventilated or Poor perfusion,Obstructive ventilatory disorders,Restric
16、tive ventilatory disorders,Diffusion disorders,Ventilation-Perfusion mismatching,Respiratory Failure,Functional and Metabolic Alterations in Respiratory Failure (1),1.Metabolic acidosis K 、Cl 2.respiratory acidosis K 、Clor normal 3.respiratory alkalosis K 、Cl ,Acid-base disturbance,Functional and Me
17、tabolic Alterations in Respiratory Failure (2),PaO2 30mmHg,PaCO2 80mmHg,Ventilation increase,Ventilation depression,60mmHg,50mmHg,20mmHg,90mmHg,medulla,carotid,Respiratory system 1,medulla,medulla,Functional and Metabolic Alterations in Respiratory Failure (2),Central depression,PaCO2,Cheyne-stokes
18、respiration,Central excitement,PaCO2,Respiratory system 2,Functional and Metabolic Alterations in Respiratory Failure (3),Pulmonary hypertension,Hypoxia、Hypercapnia 【H】 ,Pulmonary embolism、Pumonary ateriolitis,Pulmonary ateriolosclerosis,right ventricle Afterload ,polycythemia Blood viscidity,Hypoxi
19、a acidosis,Dyspnea,Heart extrusion,Cardiovascular system,chronical,Heart failure,R,Functional and Metabolic Alterations in Respiratory Failure (4),acidosis,Hypoxia,Cerebrovascular VasodilationDamage endothelium,ATP NaKbump,Activity of Glutamate decarboxylase Activity of phospholipase,Membrane potent
20、ial neurotransmitters ATP Intracellular Ca2 ,cerebrovascular,Neural cell,Nervous system,Principles of treatment of Respiratory failure,Correcting the causeRelieving the hypoxemia and hypercapnia,男,32岁, 有肺结核病史，咳血水样痰 ,伴胸闷、气短、乏力。 查体: 发热,体温 39.2,脉搏120次/分 ,呼吸38次/分, 急性病容 , 极度呼吸困难, 贫血外观,口唇末稍明显发绀, 双肺可闻及中、小水泡音, 用支气管解痉剂无效。 血气分析 Pa2 :42.3,Pa2 :28.2 胸片 :肺野出现磨玻璃状伴弥漫性斑点状阴影 ,比粟粒影大, 大小不等 ,边缘不清 ,有的融合成片状，肝功不全。,结合病史 ,临床表现 ,胸片 ,血气分析诊断为 “急性粟粒型肺结核合并ARDS” ,给予抗结核治 疗,间断吸40%浓度氧,以及激素、利尿剂、 保肝降黄治疗,1周后病情逐渐好转,呼吸平稳, 紫绀减轻。氧分压逐渐升高。胸片示粟粒状阴影。,讨论： 1.分析患者ARDS的发病机制 2.分析血气变化,
