1. Acute respiratory failure Type I: „acute hypoxaemic” PaO 2 < 60 mmHg, PaCO 2 normal or low due to diseases that damage lung tissue (right-to-left shunts or V/Q mismatch): pulmonary oedema, pneumonia, ARDS, pulmonary fibrosing alveolitis (chronic) Type II: „ventilatory failure” PaO 2 55 mmHg due to insufficient alveolar ventilation (diminished carbon dioxide excretion): chronic bronchitis and emphysema (COPD), chest-wall deformities, respiratory muscle weakness (e.g. Guillain-Barre syndrome), depression of the respiratory centre.

2. Clinical assessment of respiratory distress The use of accessory muscles of respiration Tachypnoe Tachycardia Sweating Pulsus paradoxus Inability to speak Signs of CO 2 retention (peripheral vasodilation, a bounding pulse, a coarse flapping tremor, confusion, progressive drowsiness, coma, papilloedema) Asonchronous respiration Paradoxical respiration

3. Gas blood analysis pH 7.35-7.45 PaO 2 75-100 mmHg PaCO 2 35-45 mmHg HCO 3 - 21-28 mmHg HCO 3 - pCO 2 Saturation vs. oxygenation SaO 2 PaO2 pulse oximetry

4. Management of respiratory failure – I.C.U. Oxygen therapy Respiratory support (e.g. IPPV, CPAP, IMV, HFJV). Control of secretions Treatment of pulmonary infection Control of airways obstruction Limitation of pulmonary oedema

5. ARDS = adult respiratory distress syndrome Syndrome of severe dyspnoea, tachypnoea, cyanosis refractory to oxygen therapy, a reduction in lung compliance (stiff lungs), diffuse alveolar infiltrates on the chest X-ray Causes: sepsis, shock, fat embolism, trauma, burns, acute pancreatitis, inhalation of smoke and toxic gases, amniotic fluid aspiration... usu. a part of MOF Mortality: > 50% overall

6. Chronic respiratory failure COPD = chronic obstructive pulmonary disease, a condition of chronic obstruction to airflow due to: 1.Chronic bronchitis (cough with expectoration for at least 3 months of the year for more than 2 consecutive years). 2.Emphysema (permanent, abnormal distension of the air spaces distal to the terminal brochiole with destruction of alveolar septa). Clinical picture: „blue bloater” vs. „pink puffer”

7. Pleural disease Dry pleurisy Pleural effusion Chylothorax Empyema – complication of pneumonia Pneumothorax Malignancy

8. Exsudate vs. transsudate - causes TransudateExudate Heart failure Hypoproteinaemia (e.g.nephrotic syndrome, liver cirrhosis) Hypothyroidism Meig’s syndrome Constrictive pericarditis Bacterial pneumonia Lung cancer Pulmonary infarction Tuberculosis Connective tissue disease Post-myocardial infarction syndrome (Dressler’s syndrome) Acute pancreatitis Mesothelioma

9. Exsudate vs. transsudate – laboratory features TransudateExudate Protein < 30 g/L LDH < 200 IU/l Protein > 30 g/L LDH > 200 IU/l Light’s criteria: exsudate when  1 criterion is present: 1.fluid protein/serum protein > 0.5 2.fluid LDH/serum LDH > 0.6 3.fluid LDH > 2/3 of upper normal value in serum

10. Pleural fluid examination appearance protein and LDH content cellular content (lymphocytosis  malignancy, TBC) pH (if  7.2 drainage of infected fluid is necessary) glucose (< 3.3 mmol/l: RA, empyema) amylase cytology bacterial culture TBC

11. Pneumothorax Trauma Chronic bronchitis, emphysema Spontaneous: tall and thin young males, M:F = 6:1, both lungs are effected with equal frequency Lung carcinoma Bronchial asthma

12. Pneumothorax - management Chest X-ray on expiration Small pneumothorax: < 20% of radiographic volume: observe, avoidance of strenous exercise Medium (20-50%): aspiration, intercostal drainage with underwater seal Large (> 50%, shift of trachea and mediastinum): as above Tension pneumothorax Recurrent pneumothorax (more than twice): surgery (pleurectomy), talc pleurodesis.

13. Physical signs: pleural effusion, pneumothorax Pathological process Chest wall movement Mediastinal displacement Percussion note Breath sounds Vocal resonace Added sounds Pleural effusion (>500 mL) Reduced on affected side Away from lesion (in massive effusion) Stony dullVesicular reduced or absent Reduced or absent None Pneumo- thorax (large) Reduced on affected side Away from the lesion Normal or hyper- resonant Reduced or absent None