Mild hypoxemia with a fully compensated respiratory acidosis

Mild hypoxemia with a fully compensated respiratory acidosis 92% 100%The following 5 ABG analyses were formulated using Pierces (2007) systematic analyses (p.55 60). Normal values according to Pierce are listed as follows: The systematic analysis is done by first looking at each number individually and labeling it. Second describing the adequacy of oxygenation by assessing PaO2 and SaO2. Pierce (2007) lists hypoxemia as mild ( ABG #1 FiO2 0.21 pH 7.40 Normal PaCO2 50 Acidemia PaO2 71 Hypoxemia HCO3 30.9 Alkalemia BE 5.0 Alkalemia SaO2 95.1 Normal Hb 12.9 Mr. Puffins PaO2 of 71 shows mild hypoxemia, with a SaO2 within normal limits. His pH of 7.40 is neutral and shows that his acid base status is within normal limits; however his PaCO2 of 50 demonstrates that he is acidotic and his elevated HCO3 indicates compensation is occurring. These results suggest Mr. Puffin has a mild hypoxemia with a fully compensated respiratory acidosis. His normal pH indicates full compensation is occurring, ABG#2 FiO2 0.50 pH 7.14 Acidemia PaCO2 127 Acidemia PaO2 44.2 Hypoxemia HCO3 41.6 Alkalemia BE 7.1 Alkalemia SaO2 69.2 Hypoxemia Hb 14.1 Mr. Puffins PaO2 and SaO2 show he has a severe hypoxemia. His pH of 7.14 is indicative that he is acidotic. His PaCO2 is elevated which shows the acidemia is respiratory in origin. The elevated HCO3 of 41.6 shows that metabolic compensation is occurring, therefore these results indicate Mr. Puffin has severe hypoxemia with a partially compensated respiratory acidosis. ABG #3 FiO2 0.40 pH 7.22 Acidemia PaCO2 99.6 Acidemia PaO2 45.3 Hypoxemia HCO3 39.9 Alkalemia BE 8.3 Alkalemia SaO2 Hb ABG #3 shows Mr. Puffins respiratory acidosis has improved due to BiPAP therapy. There is a slight increase in his PaO2 although it still shows severe hypoxemia. His pH has improved but still shows acidemia. PaCO2 has decreased due to BiPAP therapy but remains elevated and indicates respiratory remains his primary cause of acidosis. Mr. Puffins HCO3 is also still elevated indicative of partial compensation occurring. ABG #3 shows Mr. Puffin still remains severely hypoxic, with a partially compensated respiratory acidosis. ABG #4 FiO2 0.40 pH 7.32 Acidemia PaCO2 71.9 Acidemia PaO2 55.6 Hypoxemia HCO3 36.1 Alkalemia BE 8.0 Alkalemia SaO2 Hb ABG #4 shows further improvement in Mr. Puffins severe hypoxemia and respiratory acidosis. His PaO2 has increased further but still shows a severe hypoxemia. His pH although increased still suggests mild acidosis, as well as his PaCO2 of 71.9, although it has decreased, still indicates a respiratory origin. HCO3 remains elevated showing compensation is occurring; therefore Mr. Puffin still has severe hypoxemia with a partially compensated respiratory acidosis. ABG #5 FiO2 0.28 pH 7.00 Acidemia PaCO2 59.1 Acidemia PaO2 62.4 Hypoxemia HCO3 18 Acidemia BE -7.8 Acidemia SaO2 92% Hb 14.2 Mr. Puffins 5th ABG PaO2, indicates moderate hypoxemia. His pH is low and shows he is acidotic. An elevated PaCO2 suggests acidemia respiratory in nature. HCO3 is also low which also shows acidemia metabolic in nature. Mr. Puffin in ABG #5 has a moderate hypoxemia with a mixed respiratory and metabolic acidosis confirmed by the decreased BE. Question Two: What type of respiratory failure does Mr. Puffin have? Provide a rationale for your answer based on the clinical information supplied. Differentiate between Type 1 and Type 2 Respiratory failure. Respiratory failure as described by Pierce (2007) is the absence of the normal homeostatic state of ventilation as it relates to acid base status of the blood and the exchange of oxygen and carbon dioxide (p.181). Type 1 respiratory failure, Pierce (2007), describes as a failure to oxygenate or hypoxemic respiratory failure, categorized by a PaO2 of less than 60mm Hg on an FiO2 of more than 0.5, and Type 2 respiratory failure as failure to ventilate, also called ventilatory failure, hypercapnic respiratory failure, or respiratory pump failure, as a PaCO2 of greater than 50mm Hg, with a pH of 7.25 or less (p.181-182). In contrast to Pierces definition Hennessey Japp (2007) define respiratory failure as respiratory impairment. Hennessy Japp define type 1 respiratory impairment as low PaO2 with normal or low PaCO2 which implies defective oxygenation despite adequate ventilation and the PaCO2 is low due to compensatory hyperventilation (p.20). Hennessey Japp (2007), define type 2 respiratory impairment as a high PaCO2 (hypercapnia), and is due to inadequate alveolar ventilation, and since oxygenation also depends on ventilation, the PaO2 is usually low, but may be normal if the patient is on supplemental oxygen (p.22). Type 1 respiratory failure is most commonly caused by VQ mismatch, pneumonia, pulmonary embolism, pneumothorax, pulmonary edema, shunt and acute respiratory distress syndrome and initial treatment is aimed at achieving an adequate PaO2 and SaO2 with supplemental O2 while attempting to correct the underlying cause, Hennessey Japp (2007) p. 20. Type 2 respiratory failure is commonly caused by chronic obstructive pulmonary disease, exhaustion, flail chest injury, opiate/benzodiazepine toxicity, neuromuscular disorders and obstructive sleep apnea, with clinical signs that include confusion, drowsiness. Based on the case study information it is evident Mr. Puffin has Type 2 respiratory failure. The diagnosis of type 2 respiratory failure could be made through the interpretation of ABG #2 as he has a decreased pH and elevated PaCO2 with hypoxemia. His presentation of his difficulty breathing, productive green cough, drowsiness and confusion are consistent with the presentation of an acute exacerbation of chronic obstructive pulmonary disease due to his previous diagnosis made by his doctor of emphysema. Question Three: What is BiPAP? BiPAP (Bi Level Positive Airway Pressure) is a form of non invasive mechanical ventilation commonly administered to patients with exacerbations of type 2 respiratory failure, that delivers two airway pressures through inspiration, (IPAP), and expiration, (EPAP) measured in cm H20. IPAP is the abbreviation for Inspiratory Positive Airway Pressure and EPAP is the abbreviation for Expiratory Positive Airway Pressure. BiPAP is delivered to the patient through an appropriate bilevel ventilator eg Vision BiPAP, or Respironics BiPAP, through a nasal mask, full face mask, or total face mask. Describe the effects of BiPAP. In your answer consider its effects on airway pressures, the alveoli, the lung, and the cardiovascular and neurological systems. When BiPAP is administered to a patient with type 2 respiratory failure, during inspiration (IPAP) a higher level of positive airway pressure is delivered, increasing breath size, which helps to clear out carbon dioxide and assumes a fatigued patients work of breathing, and during expiration (EPAP) prevents atelectasis, recruits collapsed alveoli and enables gas exchange between breaths (Woodrow 2003). The difference between IPAP and EPAP is termed pressure support so for example if Mr. Puffin was commenced on 12 cm H20 IPAP and 6 cm H20 EPAP he would have 6 cm H20 being the being the difference between 12 and 6 of pressure support. Pressure support decreases the work of breathing by initiating breathing and increasing tidal volume. Question Four: Outline the clinical indications for the use of BiPAP in Mr Puffins case. Discuss the monitoring that would be required for the safe application of BiPAP. List the possible complications of BiPAP that may occur in Mr Puffins case.