Severe Atelectasis and Refractory Hyoxemia and Severe Systemic Hypotension

Severe Atelectasis with resultant Refractory Hypoxemia and Severe Systemic Hypotension … Mechanism of Action (MoA).

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What Is A Respiratory Therapist

Melissa Allen ,RRT, MS, CHES

What is a Respiratory Therapist? If you are one, you probably know, respiratory therapists are understaffed and overworked and few understand what we do. The patients and families confuse us with other disciplines while other professions have huge misconceptions about our duties. This does not stop us from being amazing and, in my not so humble opinion, more often than not being the heroes of the hospital. Like all heroes we don’t seek praise and tend to hide in the shadows until we are needed. Then we are there, front and center: saving lives, coming up with innovative ideas and solving problems no one else in the room is aware even exist.

Perhaps it says something about us that we are not a profession that seeks praise at every turn. What makes us amazing, is in fact that we are the tough ones, the ones who go days on end without time off, we were saying “winter is coming” long before any TV show. As RT’s we see patient after patient without calling for help because we know its not available. We are the ones who respond when everyone else is out of ideas; Time after time, we fix the patient and the problem quietly, humbly and then move on with our shift. We don’t ask for credits or pats on the back. Many times the families still don’t know we exist even after we help their loved ones. They do not know what a Respiratory Therapist is.

This is what I ask that we change. We are not seen on flashy television shows because some other discipline is seen doing our job. Respiratory Therapists should be promoted. Small children should want to grow up to be one of us because we are Respiratory and we are substantial. It is time we step out of the shadows, spread the word far and wide. We are Respiratory, we are every bit as breathtaking as with are breath giving. We are the heroes of healthcare, night after night , day after day all across this country and beyond.

It is time to let the world know, what a Respiratory Therapist is.

Severe Atelectasis

Mechanisms of Action (MoA)

Patient walked into hospital comfortably.

During surgery, blood pressure dropped. (Picture is not the patient).

Aggressive fluid resuscitative initiative undertaken.

Answer to be posted tomorrow.

Patient stabilized intra-operatively.

Pre-operatively : 100% alveoli are patent.

Aggressive fluid resuscitative initiative is swishing around the blood vascular system and starting to weep into the lun … specifically into the pulmonary interstium… and will eventually crush alveoli into an atelectatic state.

Alveoli progressively becoming atelectatic.

“Vt vs. time scalar” is trending upward …indicative that the lung is slowly regaining atelectatic alveoli … demonstrating that the applied PEEP and mean airway pressure is therapeutically efficacious.

“Vt vs. time scalar” is trending upward …indicative that the lung is EXONENTIALLY regaining atelectatic alveoli … demonstrating that the applied PEEP and mean airway pressure is therapeutically efficacious.

Pre-operative lung in great physiologic state.

Intra-operative aggressive fluid resuscitative initiative. Pulmonary capillaries now full of 20L of fluid …represented now as dark yellow.

Now, the 20L of fluid is seeping into the pulmonary interstium and the pulmonary interstitial is also demonstrated as dark yellow.

The pulmonary capillary pressure rose from capillary pressure=CVP=2 to 20.

The pulmonary interstitial tissue pressure rose from 0 to 20 cmH2O.

The alveoli with a PEEP=14 cmH2O is trying to avoid the crushing pulmonary interstial pressure=20.

Some alveoli are losing the fight of PEEP =14 vs. pulmonary interstitial and becoming atelectatc …seen in dark blue as an atelectatic alveolus.

Here, we see the “Vt vs. time” scalar, is demonstrating a decreasing trend line … we are losing alveoli per unit time.
The alveoli lack the PEEP or lack therapeutic mean airway pressure to negate whatever crushing forces are impinging the external alveolus.
It is very important to monitor and rectify progressive atelectasis.

Evoking Epiphany : What’s Your Opinion?

We are going to start posting questions or statements to start a significant discussion group.

Our goals are to :

  • Start a wide berth of discussions.
  • establish synergies of thought.
  • improve patient care.
  • improve interdisciplinary communications.
  • introduce varied approaches to healthcare.
  • decrease length of intubation.
  • decrease length of time to liberation from mechanical ventilation.
  • decrease length of hospital stay.
  • decrease the cost of health care.
  • introduce new or variant concepts of ICU care.

Here is the first 2 of many thought provoking statements.

Evoking Epipheny – 2019-05-001

Understanding ARDS

The understanding of ARDS starts with a solid foundation in histology … the study of tissue structure.

This is the pulmonary alveolar capillary functional unit.
The alveoli identified in pink.
The capillaries identified in red.
The pulmonary interstium identified in yellow. The pulmonary interstitial tissue is not functional structure… but rather tissue that holds functional tissue in place (ie the alveolus and the pulmonary capillary in place).
Here are the 3 major players in the lung … colorized.
We will see what happens when systemic hypotension requires aggressive fluid resuscitation in future slides.
Here are all components of the lung …colorized. When aggressive fluid resuscitation is initiated (ex. 20L of fluid) are administered (“hung”) 1L at a time over 8 hours, the fluid will start in the blood vessel and may end up in the pulmonary interstitial tissue making the interstitial very dense. Since the interstitial tissue is now dense and completely surrounding the alveolus, it acts to start compressing the alveolus with atelectasis soon to occur.
Aggressive fluid resuscitation with 20L of fluid over 8 hours will result in some of that fluid ending up in the pulmonary interstitium and become dense enough to cause atelectasis.
Soon the clinician will have problems of ubiquitous SEVERE ATELECTASIS.
Interstitial tissue dense with 20L of fluid surrounding the alveolus starting the atelectatic process.

As an analogy to normal vs. dense pulmonary interstitial tissue, angel food cake vs. rum cake is demonstrated.

Angel food cake : soft, compressible, rebounding cake.

Rum cake : dense, non re-bounding cake.

PEEP=3 alveolus soon to be crushed by pulmonary interstitial tissue pressure=5.
impending ATELE TASIS.
PEEP=5 alveolus wii maintain its integrity vs. pulmonary interstitial tissue pressure=5.
Alveolus to maintain itself…ok for now.
PEEP=9 alveolus soon to recruit other alveoli vs. pulmonary interstitial tissue pressure=5.
Alveolus in good shape with therapeutic PEEP applied.