Respiratory Failure - StatPearls - NCBI Bookshelf [Link]
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Respiratory Failure
Authors
Eman Shebl1; Bracken Burns2.
Affiliations
1 Zagazig University Faculty of Medicine
2
East Tennessee State University (ETSU)
Last Update: February 28, 2019.
Introduction
Respiratory failure is a clinical condition that happens when the respiratory system fails to maintain its main function
which is gas exchange, in which PaO2 lower than 60 mmHg and/or PaCO2 higher than 50 mmHg.
Respiratory failure is classified according to blood gases abnormalities into type 1 and type 2.
Type 1(hypoxemic) respiratory failure: in which PaO2 < 60 mmHg with normal or subnormal [Link] this type the
gas exchange is impaired at the level of aveolo-capillary membrane. Examples of type I respiratory failure is
carcinogenic or non-cardiogenic pulmonary edema and severe pneumonia.
Type 2 (hypercapnic) respiratory failure: in which PaCO2 > 50 mmHg. Hypoxemia is common and it is due to
respiratory pump failure.
Also respiratory failure is classified according to its onset, course and duration into acute, chronic and acute on top of
chronic respiratory failure.
Etiology
Respiratory failure may be due to pulmonary or extra-pulmonary causes which include:
CNS causes due to depression of the neural drive to breath as in cases of overdose of a narcotic and sedative.
Disorders of peripheral nervous system: Respiratory muscle, and chest wall weakness as in cases of Guillian-Barre
syndrome and myasthenia gravis.
Upper and lower airways obstruction: due to various causes as in cases of exacerbation of chronic obstructive
pulmonary diseases and acute severe bronchial asthma
Abnormities of the alveoli that result in type 1 (hypoxemic) respiratory failure as in cases of pulmonary edema and
severe pneumonia.[1].
Epidemiology
The overall frequency of respiratory failure is not well known as respiratory failure is a syndrome rather than a single
disease process.
Pathophysiology
The main path physiologic mechanisms of respiratory failure are:
Hypoventilation: in which PaCO2 and PaO2 and alveolar –arterial PO2 gradient is normal. Depression of CNS from
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Respiratory Failure - StatPearls - NCBI Bookshelf [Link]
drugs is an example of this condition.
V/P mismatch: this is the most common cause of hypoxemia. Administration. Of 100% O2 eliminate hypoxemia.
Shunt: in which there is persistent hypoxemia despite 100% O2 inhalation. In cases of shunt the deoxygenated blood
(mixed venous blood) bypasses the alveoli without being oxygenated and mixes with oxygenated blood that has
flowed through the ventilated alveoli, and this leads to hypoxemia as in cases of pulmonary edema (cardiogenic or
noncardiogenic), pneumonia and atelectasis
History and Physical
Symptoms and signs of hypoxemia
Dyspnea,irritability
Confusion, somnolence, fits
Tachycardia, arrhythmia
Tachypnea
Cyanosis
Symptoms and signs of hypercapnia
Headache
Change of behavior
Coma
Asterixis
Papilloedema
Warm extremities
Symptoms and signs of the underlying disease
Examples:
Fever, cough, sputum production, chest pain in cases of pneumonia.
History of sepsis, polytrauma, burn, or blood transfusions before the onset of acute respiratory failure may point to
acute respiratory distress syndrome[2].
Evaluation
The following investigations are needed:
Arterial blood gases (ABG) is mandatory to confirm the diagnosis of respiratory failure.
Chest radiography is needed as it can detect chest wall, pleural and lung parenchymal Lesions.
Investigations needed for detecting the underlying cause of the respiratory failure these may include:
Complete blood count (CBC)
Sputum, blood and urine culture
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Respiratory Failure - StatPearls - NCBI Bookshelf [Link]
Blood electrolytes and thyroid function tests
Pulmonary function tests
Electrocardiography (ECG)
Echocardiography
Bronchoscopy
Treatment / Management
This includes supportive measures and treatment of the underlying cause.
Supportive measures which depend on depending on airways management to maintain adequate ventilation and
correction of the blood gases abnormalities
Correction of Hypoxemia
The goal is to maintain adequate tissues oxygenation, generally achieved with an arterial oxygen tension (PaO2) of 60
mm Hg or arterial oxygen saturation (SaO2) about 90%.
Un-controlled oxygen supplementation can result in oxygen toxicity and CO2 (carbon dioxide) narcosis. So the
inspired oxygen concentration should be adjusted at the lowest level which is sufficient for tissue oxygenation.
Oxygen can be delivered by several routes depending on the clinical situations in which we may use nasal canula,
simple face mask nonrebreathing mask or high flow nasal canula.
Extracorporeal membrane oxygenation may be needed in refractory cases[3].
Correction of hypercapnia and respiratory acidosis
This may be achieved by treating the underlying cause or providing ventilatory support.[4]
Ventilatory support for the patient with respiratory failure
The goals of ventilator support in respiratory failure are:
Correct hypoxemia
Correct acute respiratory acidosis
Resting of ventilatory muscles
Common indications for mechanical ventilation include the following:
Apnea with respiratory arrest
Tachypnea with respiratory rate >30 breaths per minute
Disturbed conscious level or coma
Respiratory muscle fatigue
Hemodynamic instability
Failure of supplemental oxygen to increase PaO2 to 55-60 mm Hg
Hypercapnea with arterial pH less than 7.25[5].
The choice of invasive or noninvasive ventilatory support depends on the clinical situation whether the condition is
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acute or chronic and how severe it is. It also depends on the underlying cause. If there is no absolute indications for
invasive mechanical ventilation or intubations and if there is no contraindications for noninvasive ventilation non-
invasive ventilation is preferred particularly in cases of COPD exacerbation[6][7], Cardiogenic pulmonary edema[6]
[8]and Obesity hypoventilation syndrome[9].
Complications
Complications from respiratory failure may be a result of blood gases disturbances or from the therapeutic approach
itself
Example of these complications:
Lung complications: for example, pulmonary embolism irreversible scarring of the lungs, pneumothorax and
dependence on a ventilator.
Cardiac complications: for example, heart failure arrhythmias and acute myocarial infarction[10].
Neurological complications: a prolonged period of brain hypoxia can lead to irreversible brain damage and brain
death.
Renal: acute renal failure may occur due to hypoperfusionand and/or nephrotoxic drugs.
Gastro-intestinal: stress ulcer, ileus, and hemorrhage[11]
Nutritional: malnutrition, diarrhea hypoglycemia, electrolyte disturbances[12]
Consultations
During management of respiratory failure consultation for other specialties may be indicated like cardiac and
neurological consultation.
Pearls and Other Issues
Liberal oxygen supplementation beyond the required level for adequate tissue oxygenation may be hazardous
and may lead to deterioration of the patient condition as in cases of acute on top of chronic type 2 respiratory
failure in patients with chronic obstructive pulmonary disease[13].
During mechanical ventilation carbon dioxide over-wash should be avoided in patients with acute on top of
chronic type 2 respiratory failure by adjusting the ventilatory parameters to maintain carbon dioxide to its basal
level.
Lung protective strategy is mandatory during mechanical ventilation in especially in cases of acute respiratory
distress syndrome[2].
Enhancing Healthcare Team Outcomes
The diagnosis of the underlying cause of respiratory failure and its treatment is challenging as respiratory failure may
result from numerous pulmonary and extrapulmonary causes, so consultation for other specialties, for example,
neurological and cardiac consultation may be mandatory. As complications from respiratory failure may be due to
improper patient positioning and poor adherence to infection control policies, so the nurses are vital members of the
interprofessional group assuring that appropriate position is rendered. Also, complications can be the result of drug
toxicities or drug interactions so a pharmacist should be incorporated in the management team for respiratory failure
cases. The job of the nurse carries a far more important role if the patient is on the mechanical ventilator. The nurse
has to monitor the patient 24/7 and assess each organ system several times a day. The nurse also is responsible for
suctioning, positioning and feeding of the patient. Because the patient with respiratory failure is usually on multiple
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medications, the pharmacist is responsible for ensuring the most appropriate drug is administered without causing drug
interactions or severe adverse reactions. Finally, patient in respiratory failure is also looked after respiratory therapists
for chest therapy or administration of oxygen. [14][15][16](Level V)
Outcomes
The prognosis of respiratory failure varies according to underlying causes and other factors like the age of the patients
and the associated co morbidities [17].
Questions
To access free multiple choice questions on this topic, click here.
References
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