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Respiratory Failure
Respiratory failure occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen
levels (hypoxia) or increased blood carbon dioxide levels (hypercapnia). [1]
Hypoxaemic respiratory failure is characterised by an arterial oxygen tension (PaO2) of <8 kPa (60
mm Hg) with normal or low arterial carbon dioxide tension (PaCO2).
Hypercapnic respiratory failure is the presence of a PaCO2 >6 kPa (45 mm Hg) and PaO2 <8 kPa.
Respiratory failure can be acute (develops within minutes or hours in patients with no or minor evidence of preexisting respiratory disease), acute on chronic (an acute deterioration in an individual with pre-existing respiratory
failure) or chronic (develops over several days or longer in patients with existing respiratory disease). [1]

Aetiology
Common causes of type I respiratory failure
Chronic obstructive pulmonary disease (COPD).
Pneumonia.
Pulmonary oedema.
Pulmonary fibrosis.
Asthma.
Pneumothorax.
Pulmonary embolism.
Pulmonary hypertension.
Cyanotic congenital heart disease.
Bronchiectasis.
Acute respiratory distress syndrome.
Respiratory illness associated with HIV infection. [2]
Kyphoscoliosis.
Obesity. [3]

Common causes of type II respiratory failure

COPD.
Severe asthma.
Drug overdose, poisoning.
Myasthenia gravis.
Polyneuropathy.
Poliomyelitis.
Muscle disorders.
Head injuries and neck injuries.
Obesity.
Pulmonary oedema.
Adult respiratory distress syndrome.
Hypothyroidism.

Presentation
The cause of respiratory failure is often clear from a thorough history and physical examination. See also the
separate Respiratory System History and Examination article.

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Symptoms
The history may indicate the underlying cause - eg, paroxysmal nocturnal dyspnoea, and orthopnoea
in pulmonary oedema.
Both confusion and reduced consciousness may occur.

Signs
Localised pulmonary findings are determined by the underlying cause.
Neurological features may include restlessness, anxiety, confusion, seizures or coma.
Tachycardia and cardiac arrhythmias may result from hypoxaemia and acidosis.
Cyanosis.
Polycythaemia is a complication of long-standing hypoxaemia.
Cor pulmonale: pulmonary hypertension is frequently present and may induce right ventricular failure,
leading to hepatomegaly and peripheral oedema.

Investigations
Investigations will depend on the individual cause and severity of respiratory failure and comorbidity. Investigations
may include:
Arterial blood gas analysis: confirmation of the diagnosis.
CXR: often identifies the cause of respiratory failure.
FBC: anaemia can contribute to tissue hypoxia; polycythaemia may indicate chronic hypoxaemic
respiratory failure.
Renal function tests and liver function tests: may provide clues to the aetiology or identify
complications associated with respiratory failure. Abnormalities in electrolytes such as potassium,
magnesium and phosphate may aggravate respiratory failure and other organ dysfunction.
Serum creatine kinase and troponin I: to help exclude recent myocardial infarction. Elevated creatine
kinase may also indicate myositis.
TFTs (hypothyroidism may cause chronic hypercapnic respiratory failure).
Spirometry: useful in the evaluation of chronic respiratory failure.
Echocardiography: if a cardiac cause of acute respiratory failure is suspected.
Pulmonary function tests are useful in the evaluation of chronic respiratory failure.
ECG: to evaluate a cardiovascular cause; it may also detect dysrhythmias resulting from severe
hypoxaemia or acidosis.
Right heart catheterisation: should be considered if there is uncertainty about cardiac function,
adequacy of volume replacement and systemic oxygen delivery.
Pulmonary capillary wedge pressure may be helpful in distinguishing cardiogenic from noncardiogenic oedema.

Management
A patient with acute respiratory failure generally needs prompt hospital admission in an intensive care unit. Many
patients with chronic respiratory failure can be treated at home, depending on the severity of respiratory failure,
underlying cause, comorbidities and social circumstances.
Immediate resuscitation may be required.
Appropriate management of the underlying cause.
The management will depend on the individual patient and treatment may be within the context of palliative care.

Hypoxaemia
Ensure adequate oxygen delivery to tissues, generally achieved with a PaO2 of 60 mm Hg or an
arterial oxygen saturation (SaO2) of greater than 90%.
Beware the prolonged use of high-concentration oxygen in chronic sufferers who have become reliant
on their hypoxic drive to maintain an adequate ventilation rate. Elevating the PaO2 too much may
reduce the respiratory rate so that the PaCO2 may rise to dangerously high levels.

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reduce the respiratory rate so that the PaCO2 may rise to dangerously high levels.
Assisted ventilation:
Mechanical ventilation:
The goal of mechanical ventilation in acute hypoxaemic respiratory failure is to
support adequate gas exchange without harming the lungs. [4]
It is used to increase PaO2 and to lower PaCO2.
It also rests the respiratory muscles and is an appropriate therapy for respiratory
muscle fatigue.
Weaning patients with chronic respiratory failure off of mechanical ventilation
may be very difficult. [5]
Non-invasive ventilation (NIV):
Has been increasingly used as an alternative to invasive ventilation. [6] [7]
Improves survival and reduces complications for selected patients with acute
respiratory failure. [8]
The main indications are exacerbation of COPD, cardiogenic pulmonary
oedema, pulmonary infiltrates in immunocompromised patients. [9]
When used for weaning patients off mechanical ventilation, reduces rates of
death and pneumonia without increasing the risk of weaning failure or reintubation. [5]
Extracorporeal membrane oxygenation (ECMO):
Is a mainstay of therapy in neonatal and paediatric patients with life-threatening
respiratory and/or cardiac failure. It has also been used for adults with severe
respiratory failure. [10]
The National Institute for Health and Care Excellence (NICE) recommends that
the evidence on the safety of ECMO for severe acute respiratory failure in adults
is adequate but shows that there is a risk of serious side-effects. [11]
Strategies to support oxygenation can cause substantial harm through lung stretch injury, oxygen toxicity,
transfusion risks and cardiac over-stimulation. [12]

Hypercapnia and respiratory acidosis

Correct the underlying cause and/or provide assisted ventilation.

Complications
Pulmonary: for example, pulmonary embolism, pulmonary fibrosis and complications secondary to the
use of mechanical ventilation.
Cardiovascular: for example, cor pulmonale, hypotension, reduced cardiac output, arrhythmias,
pericarditis and acute myocardial infarction.
Gastrointestinal: for example, haemorrhage, gastric distention, ileus, diarrhoea and
pneumoperitoneum. Duodenal ulceration caused by stress is common in patients with acute
respiratory failure.
Polycythaemia.
Hospital-acquired infection: for example, pneumonia, urinary tract infections and catheter-related
sepsis are frequent complications of acute respiratory failure.
Renal: acute kidney injury and abnormalities of electrolytes and acid-base balance are common in
critically ill patients with respiratory failure.
Nutritional: including malnutrition and complications related to administration of enteral or parenteral
nutrition. Complications associated with nasogastric tubes - eg, abdominal distention and diarrhoea.

Prognosis
The mortality rate associated with respiratory failure depends on the underlying cause as well as the speed of
diagnosis and efficacy of management.

Further reading & references

1. Pandor A, Thokala P, Goodacre S, et al; Pre-hospital non-invasive ventilation for acute respiratory failure: a systematic
review and cost-effectiveness evaluation. Health Technol Assess. 2015 Jun;19(42):1-102. doi: 10.3310/hta19420.

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2. Sarkar P, Rasheed HF; Clinical review: Respiratory failure in HIV-infected patients--a changing picture. Crit Care. 2013 Jun
14;17(3):228. doi: 10.1186/cc12552.
3. Bahammam AS, Al-Jawder SE; Managing acute respiratory decompensation in the morbidly obese. Respirology. 2012
Jul;17(5):759-71. doi: 10.1111/j.1440-1843.2011.02099.x.
4. Wilson JG, Matthay MA; Mechanical ventilation in acute hypoxemic respiratory failure: a review of new strategies for the
practicing hospitalist. J Hosp Med. 2014 Jul;9(7):469-75. doi: 10.1002/jhm.2192. Epub 2014 Apr 15.
5. Burns KE, Meade MO, Premji A, et al; Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with
respiratory failure: a Cochrane systematic review. CMAJ. 2014 Feb 18;186(3):E112-22. doi: 10.1503/cmaj.130974. Epub
2013 Dec 9.
6. Mas A, Masip J; Noninvasive ventilation in acute respiratory failure. Int J Chron Obstruct Pulmon Dis. 2014 Aug 11;9:837-52.
doi: 10.2147/COPD.S42664. eCollection 2014.
7. Singh G, Pitoyo CW; Non-invasive ventilation in acute respiratory failure. Acta Med Indones. 2014 Jan;46(1):74-80.
8. Hess DR; Noninvasive ventilation for acute respiratory failure. Respir Care. 2013 Jun;58(6):950-72. doi:
10.4187/respcare.02319.
9. Nava S, Hill N; Non-invasive ventilation in acute respiratory failure. Lancet. 2009 Jul 18;374(9685):250-9.
10. Turner DA, Cheifetz IM; Extracorporeal membrane oxygenation for adult respiratory failure. Respir Care. 2013
Jun;58(6):1038-52. doi: 10.4187/respcare.02255.
11. Extracorporeal membrane oxygenation for severe acute respiratory failure in adults, NICE Interventional Procedure
Guidance (April 2011)
12. MacIntyre NR; Supporting oxygenation in acute respiratory failure. Respir Care. 2013 Jan;58(1):142-50. doi:
10.4187/respcare.02087.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its
accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
For details see our conditions.
Original Author:
Dr Colin Tidy

Current Version:
Dr Colin Tidy

Peer Reviewer:
Prof Cathy Jackson

Document ID:
2723 (v24)

Last Checked:
26/08/2015

Next Review:
24/08/2020

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