Respiratory Failure


Article Author:
Eman Shebl


Article Editor:
Bracken Burns


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/6/2019 12:32:58 AM

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 PaCO2.In 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 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
    • 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 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 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].


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Respiratory Failure - Questions

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Which condition is least likely to cause hypercapnic respiratory failure?



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Which of the following indicates respiratory failure?



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A 17-year-old male hospitalized for treatment of bacterial endocarditis is found to be cyanotic with bradypnea and pinpoint pupils. What is the most likely cause of these symptoms?



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A patient is admitted to the intensive care unit following a thoracotomy for a gunshot wound. He requires significant inotropic support. Two days later, he is transferred to the floor and has minimal chest pain. A week later, he suddenly becomes short of breath and tachycardic. Examination reveals that he has ventilatory failure. Which of the following is best equated with ventilatory failure?



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A 53-year-old is admitted after a fall from a 2-story building. He is anxious, restless, and cyanotic. The left side of his chest does not appear to move and he complains of chest pain. Breath sounds are present bilaterally and the trachea is midline. Blood pressure is 110/80 mm Hg, respiration rate is 40 breaths per minute, and heart rate is 105 beats per minute. What is the highest priority in the management of this patient?



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Which of the following is not an accepted indication for mechanical ventilation in an adult?



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An unrestrained driver involved in a high speed motor vehicle accident is transported by paramedics with cervical spine precautions. Glasgow Coma Scale score is 7, but there is no obvious trauma. Respirations are shallow, and bag-valve mask is not providing adequate ventilation. Extremities are cool, and the pulses are thready. Prior to rapid sequence intubation, what should be done?



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A patient is agitated, hypoventilating, and has a partial pressure of carbon dioxide of 60 millimeters of mercury. Which of the following should be performed next?



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Which of the following may be an early sign of respiratory distress?



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Patients in respiratory distress due to hypoventilation should not undergo which of the following?



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Which arterial blood gas finding is most suggestive of hypoxemic respiratory failure?



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A 60-year-old female is brought to the emergency department with sudden onset of substernal chest pain and shortness of breath. Vital signs show a blood pressure of 95/65 mmHg, heart rate of 125 bpm, respiratory rate of 38, and oxygen saturation of 84 percent on room air. The patient has jugular venous distension and rales more than half way up bilaterally. ECG shows an acute anterior wall myocardial infarction. The patient is given intravenous morphine, furosemide, and nitroglycerin. Pressure support ventilation is started by mask, and the oxygen saturation increases to 92 percent. While the patient is waiting for percutaneous transluminal cardiac intervention she becomes anxious, restless, and diaphoretic. Select appropriate management.



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Which of the following is not a sign of impending respiratory failure in patients with croup?



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Which of the following is a late sign of impending respiratory failure?



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Which of the following measures does not help prevent acute respiratory failure?



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What is the best position for a hospitalized patient experiencing difficulty breathing?



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What is the term for retraction of neck tissues when breathing?



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A patient with a "Do Not Resuscitate (DNR)" order is in respiratory distress secondary to acute pulmonary edema. What is the best management option?



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Which of the following is most consistent with ventilatory failure due to asthma?



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What is true regarding acute respiratory failure?



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Which of the following is not seen after an episode of acute hypoxic respiratory failure?



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A patient has an acute asthma attack and treatment is delayed. What will be seen with a late arterial blood gas?



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A 65-year-old male with chronic, type 2 respiratory failure due to chronic obstructive pulmonary disease (COPD) presents to the emergency department due to COPD exacerbation. The patient is fully conscious. Arterial blood gases show hypoxemia and compensated hypercapnia with no respiratory acidosis. Which of the following is not part of the management of this patient?



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Respiratory Failure - References

References

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Fazekas AS,Aboulghaith M,Kriz RC,Urban M,Breyer MK,Breyer-Kohansal R,Burghuber OC,Hartl S,Funk GC, Long-term outcomes after acute hypercapnic COPD exacerbation : First-ever episode of non-invasive ventilation. Wiener klinische Wochenschrift. 2018 Jul 31     [PubMed]
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Radovanović NN,Pavlović SU,Milašinović G,Kirćanski B,Platiša MM, Bidirectional Cardio-Respiratory Interactions in Heart Failure. Frontiers in physiology. 2018     [PubMed]
Avendaño-Reyes JM,Jaramillo-Ramírez H, [Prophylaxis for stress ulcer bleeding in the intensive care unit]. Revista de gastroenterologia de Mexico. 2014 Jan-Mar     [PubMed]
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