Hypercapnic Respiratory

Failure
Mark J. Rosen, MD, FCCP
Director, Global Education and Strategic Development,
ACCP
Past President 2006-2007
Professor of Medicine, Hofstra North Shore-LIJ School
of Medicine
D|sc|osures
no conlcL of lnLeresL wlLh Lhe Loplcs l wlll dlscuss
Wh|ch of the fo||ow|ng |s most ||ke|y to be
assoc|ated w|th hypercapn|a?
1. lncreased dead space venulauon (hlgh venulauon
relauve Lo perfuslon)
2. lncreased perfuslon relauve Lo venulauon
3. ArLerlovenous shunL
4. 8educed cardlac ouLpuL
PaCO
2
= K VCO
2

V
A


V
A
=V
E
-V
D

PaCO
2
= K VCO
2

V
E
(1-V
D
/V
T
)




Increased CC
2
roducnon
lncreased meLabollc raLe
hyslcal acuvlLy
Sepsls
1hyroLoxlcosls
CarbohydraLe meLabollsm
Decreased A|veo|ar Venn|anon
uecreased mlnuLe venulauon
v
u
/v
1
lncreases, wlLh consLanL mlnuLe venulauon
8apld, shallow breaLhlng
v/C mlsmaLch
Respiratory center
Spinal cord
Motor neurons
Neuromuscular junction
Respiratory muscles
Work of breathing
Lungs
Causes of ulaphragmauc uysfuncuon, Accordlng Lo Level of lmpalrmenL.
McCool FD, Tzelepis GE. N
Engl J Med
2012;366:932-942.
D|sorders of the "Centra| Contro||er
CongenlLal cenLral hypovenulauon syndrome:
PCx28
CenLral sleep apnea
urug eecL
ulsease of medulla
PypoLhyroldlsm
MeLabollc alkalosls
D|sorders of the Sp|na| Cord
Cervlcal cord ln[ury (C3)
1eLanus
8eLrograde LransporL of exoLoxln
8locks lnhlblLory neuroLransmluers
5posuc paralysls, especlally laryngeal and
resplraLory muscles
1reaL wlLh LeLanus lmmune globulln, supporL,
muscle relaxanLs
Anter|or norn Ce|| D|sorders
AmyoLrophlc laLeral sclerosls
uysarLhrla
1ongue aLrophy and fasclculauon
Muscle aLrophy, weakness and fasclculauon
nypettefexlo
ollomyellus: osLpollo syndrome
D|sorders of er|phera| Nerves
Culllaln-8arre syndrome
ulphLherla
orphyrla
1lck paralysls
llsh Loxlns
Crlucal lllness polymyoneuropaLhy
Gu|||a|n-8arr syndrome |s
character|zed by:
A. Spasuc paralysls
8. LMC shows slowed conducuon of moLor neurons
C. CSl lymphocyLosls
u. AceLylchollne lnhlblLors ln Lhe serum
2
Gu|||a|n-8arr Syndrome
MosL common form ls acuLe lnammaLory
demyellnaung polyneuropaLhy
Areexlc weakness due Lo demyellnauon or axonal
degenerauon
AberranL 1-cell response Lo prlor lnfecuon
AssoclaLed wlLh compyloboctet (2/3),
cyLomegalovlrus lnfecuon (1/3)
lnuenza vacclne 1-3 excess cases/mlllloo
8x: lasma exchange, lvlC (noL boLh)
CPC. NEJM 1999;341:1996-2001
Cr|nca| I||ness o|yneuropathy
arL of MCuS ln sepsls
usually overlaps wlLh crlucal lllness myopaLhy
ulmculLy weanlng from venulaLor
8educed deep Lendon reexes
Cbvlous llmb weakness, preserved cranlal
muscles
8esoluuon aer weeks or monLhs
Cr|nca| I||ness o|yneuropathy
CSl: mlld lncrease ln proLeln
LMC: axonal degenerauon of moLor and
sensory nerves
PlsLology: axonal degenerauon,
denervauon aLrophy (lncludlng
dlaphragm)
Fugu
D|sorders of the Neuromuscu|ar
Iuncnon
MyasLhenla gravls
LaLon-LamberL syndrome
CrganophosphaLe polsonlng
8oLullsm
urugs: amlnoglycosldes, anuarrhyLhmlcs, phenyLoln
Myasthen|a grav|s |s character|zed by:
A. LMC shows lncremenLal response Lo repeuuve
sumull
8. Cllnlcal response Lo anuchollnerglc agenLs
C. Anubodles Lo aceLylchollne recepLors
u. AssoclaLed wlLh small cell carclnoma of Lhe lung
4
Myasthen|a Grav|s
Anubodles Lo aceLylchollne recepLors
uecremenLal response Lo repeLeuve sumulauon
Cllnlcal response Lo cbolloetqlc agenLs
1reaLmenLs
Chollnerglc agenLs
CorucosLerolds for mlld-moderaLe
lasmapheresls or lvlC for exacerbauons
1hymecLomy beLween puberLy and age 60
Botulism
Sam AH, Beynon HL.
N Engl J Med 2010;363:2444-2444.
Wound 8otu||sm
8otu||sm
1oxln lrreverslbly blocks Ach release
CculomoLor and faclal and bulbar weakness
promlnenL
oLenually leLhal, descendlng symmeLrlc accld
paralysls
ulagnose by ldenufylng Lhe Loxln or organlsm ln
serum, sLool, wound
1reaLmenL: debrlde wounds, anuLoxln, supporL
kesp|ratory Musc|e Weakness
gects
vC
8v (explraLory muscles- jL8v)
vC ln Lhe suplne posluon (severe dlaphragm
weakness or paralysls)
maxlmal explraLory and lnsplraLory peak ows
Pypercapnla when sLrengLh <40 predlcLed
uesaLurauon and hypercapnla durlng 8LM sleep.
ATS/ERS. AJRCCM 2002;518-624
Date of download:
7/14/2013
From: Narrative Review: Ventilator-Induced Respiratory Muscle Weakness
Ann Intern Med. 2010;153(4):240-245. doi:10.7326/0003-4819-153-4-201008170-00006
\
Max|ma| ressures
Normo/ Predicted vo/ues
Male MIP = 143 - 0.55 x age
MEP = 268 - 1.03 x age

Female MIP = 104 - 0.51 x age
MEP = 170 - 0.53 x age
8lack, Pyau: A88u 1989:99,898
kesp|ratory Musc|e Weakness
couses
uenervauon
MyopaLhy
Lndocrlne
PyperLhyroldlsm
Pypercorusollsm
MeLabollc
k

Mg
MalnuLrluon
Pyperlnauon
Mechanlcal
venulauon!
Mechanisms
Muscle
Weakness
Laghi F, Tobin MJ.
AJRCCM
2003;168:10-48
Date of download:
7/14/2013
From: Narrative Review: Ventilator-Induced Respiratory Muscle Weakness
Ann Intern Med. 2010;153(4):240-245. doi:10.7326/0003-4819-153-4-201008170-00006
kesp|ratory Musc|e Iangue
P breath/MIP x Ti/Tt
is excessive
kesp|ratory Musc|e Iangue
nerqy uemonds
Work of breaLhlng
MlnuLe venulauon
Compllance, reslsLance
Lmclency
Lung volume
neuromuscular dlsease
nuLrluonal sLaLus
8ody posluon
kesp|ratory Musc|e Iangue
nerqy 5upp/y
Cxygen LransporL
C
2
conLenL
8lood ow
SubsLraLe avallablllLy
SubsLraLe sLores
D|sorders of the Chest Wa||
kyphosco/iosis
Cbes|ty nypovenn|anon

Cbes|ty-nypovenn|anon Syndrome
CbeslLy, dayume hypovenulauon, sleep-dlsordered
breaLhlng
Can'L breaLhe"
Low l8C, lLv1, chesL wall compllance
3x lncrease ln work of breaLhlng
Cbes|ty-nypovenn|anon Syndrome
Won'L breaLhe"
8lunLed CC
2
drlve

Lepun reslsLance?
D|sorders of Chest Wa||
Mechonisms of nypercopnio
chesL wall compllance
8educed v
1
and v
u
/v
1

8educed venulaLory drlve
Muscle weakness or faugue