M.A.

Lung/BMSN2202/Respiration/15-16

RESPIRATORY FAILURE

Respiratory failure occurs when the lungs are unable to maintain arterial blood gases at normal
levels when the subject breathes air at rest. There is no absolute definition of the levels of arterial
PO2 and PCO2 that indicate respiratory failure. However, as a general guide, for subjects at sea-
level a PO2 of <60 mm Hg or a PCO2 >50 mm Hg are numbers often quoted.

A. Physiological causes of respiratory failure

1. Hypoventilation (impaired alveolar ventilation)

e.g. upper airway obstruction, weakness/paralysis of respiratory muscles, chestwall
injury etc..
arterial blood gas - PO2 and PCO2

2. Alveolar ventilation perfusion mismatching

e.g. chronic obstructive lung disease, restritive lung disease, pneumonia etc.
arterial blood gas - PO2 and PCO2 or normal PCO2

3. Impaired diffusion
e.g. lung edema, adult respiratory distress syndrome etc.
arterial blood gas - PO2 and normal PCO2 or PCO2
Shunt refers to the portion of mixed
B. Types of respiratory failure
venous blood that is added directly to
1. Type I respiratory failure gas exchange failure the systemic circulation (i.e. these
PO2 < 60 mm Hg blood is not exposed to O2 and gas
PCO2 < 50 mm Hg exchange didn't occur)

2. Type II respiratory failure ventilatory failure

PO2 < 60 mm Hg related to pumping action of respiratory system
PCO2 > 50 mm Hg

C. Hypoxemia

Hypoventilation, diffusion impairment, shunt, and VA/Q mismatching can contribute to
severe hypoxemia of respiratory failure. Severe hypoxemia causes cyanosis. Measurement of
arterial PO2 is essential in determining the degree of hypoxemia in patients. Hypoxemia is
dangerous because it causes tissue hypoxia. Tissues vary considerably in their vulnerability to
hypoxia. Those at greatest risk include the CNS and myocardium. Mild hypoxemia produces
a slight impairment of mental performance, visual acuity, and mild hyperventilation. Profound
acute hypoxemia may cause convulsion, retinal hemorrhages and permanent brain damage.

D. Hypercapnia

Hypoventilation and VA/Q mismatching contribute to CO2 retention of respiratory failure.
Injudicious use of O2 therapy may also be an important cause of CO2 retention. Raised levels
of PCO2 in the blood cause headache. High levels of PCO2 are narcotic and cause clouding
of consciousness.

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 M.A. Lung/BMSN2202/Respiration/15-16

E. Acidosis
The CO2 retention causes respiratory acidosis especially following injudicious use of oxygen.
Metabolic acidosis caused by liberation of lactic acid from hypoxic tissues frequently co-
exists with respiratory acidosis and complicates the acid-base abnormality.

E. Management of respiratory failure

1. treatment for underlying disease.
2. treatment for airway obstruction.
3. treatment for hypoxemia.
4. treatment for hypercapnia.

Learning objectives:

You should now be able to:

1. state a general definition for respiratory failure.
2. understand the pathophysiological changes of type I and type II respiratory failure.
3. state the causes and consequences of hypoxemia, hypercapnia and acidosis in respiratory
failure.
4. understand the principles underlying the management of respiratory failure.

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Physiological causes of respiratory failure

Hypoventilation (impaired alveolar ventilation)

Upper airway obstruction, PO2
Weakness/paralysis of respiratory muscles, PCO2
Chest wall injury etc

Alveolar ventilation/perfusion mismatching

Chronic obstructive lung disease, PO2
Restrictive disease, PCO2 or n PCO2
Pneumonia etc

Impaired Diffusion PO2

Lung edema, n PCO2 or PCO2
Adult respiratory distress syndrome (shock lung)
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Types of Respiratory Failure

Type I gas exchange failure

PO2 < 60 mm Hg
PCO2 < 50 mm Hg

Type II ventilatory failure

PO2 < 60 mm Hg
PCO2 > 50 mm Hg

(most common sign)

(via chemoreceptors)

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 (Positive end-expiratory pressure)
(ARDS)

Learning objectives:

You should now be able to:

1. state a general definition for respiratory failure.

2. understand the pathophysiological changes of

type I and type II respiratory failure.

3. state the causes and consequences of

hypoxemia, hypercapnia and acidosis in
respiratory failure.

4. understand the principles underlying the

management of respiratory failure.
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 Review Questions

Functional residual capacity is the volume at

which
A. The elastic recoil of the lungs vanishes
B. The chest-wall tends neither to contract or
recoil
C. Chest-wall and the lung recoil forces are
equal and opposite
D. Collapse of small airways occurs
E. Chestwall and the lungs are recoiling
inwards
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Which of the following conditions will increase

functional residual capacity?

A. Changing the body position from standing

to supine
B. Pulmonary fibrosis
C. Obesity
D. Emphysema
E. Decreased pulmonary surfactant

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What is the most likely action of surfactant on
the respiratory system?

A. Stimulates the medullary respiratory

centres
B. Increases the strength of the respiratory
muscles
C. Decreases the tissue elasticity of the lungs
D. Decreases the surface tension at the air-
liquid interface of the lungs
E. Decreases the bronchomotor tone of the
airways

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An infant born prematurely is found to have

infant respiratory distress syndrome. Which of
the following would NOT be expected in this
infant?

A. Cyanosis
B. Alveolar collapse
C. Increased lung compliance
D. Difficulty in breathing
E. Alveolar edema

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Which of the following is the site of lowest
airway resistance?

A. Nose
B. Mouth
C. Trachea
D. Medium sized bronchi
E. Bronchioles

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Which of the following will increase airway

resistance?

A. Stimulation of the sympathetic nerves to

the bronchial and bronchiolar smooth
muscle
B. Breathing through the mouth instead of the
nose
C. Large lung volume
D. Airway mucosal edema
E. Pulmonary fibrosis

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Which of the following best describes
hypoventilation?

A. Increased arterial PCO2 and decreased

arterial PO2
B. Increased arterial PO2 and decreased
arterial PCO2
C. Increased arterial O2 content
D. Decreased arterial CO2 content
E. Dizziness

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All the following will impair oxygen transfer

across the alveolocapillary membrane EXCEPT

A. Thickening of the membrane by disease

B. Destruction of alveolar membrane by
disease
C. Alveolar edema
D. Pulmonary embolism
E. Exercise

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If an area of the lung is NOT ventilated because
of bronchial obstruction, the pulmonary
capillary blood serving that area will have a PO2
that is

A. Equal to atmospheric PO2

B. Equal to systemic mixed venous PO2
C. Equal to normal systemic arterial PO2
D. Higher than inspired PO2
E. Less than systemic mixed venous PO2

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All of the following cause hypoxemia EXCEPT

A. Hypoventilation
B. Alveolar edema
C. Pulmonary fibrosis
D. Asthmatic attack
E. Anemia

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Which of the following is a most likely
mechanism for Type I respiratory failure?

A. Deformation of chest wall

B. Respiratory muscle weakness
C. Depression of central drive for respiration.
D. Pulmonary edema gas exchange
E. Severe airway obstruction

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Spirometry is a useful tool in helping to

distinguish various types of lung disorders.
Airway obstruction is defined by which of the
following?

A. A normal FEV1.0/FVC ratio

B. A FEV1.0 of 45 % of predicted value
C. A supranormal FEV1.0/FVC ratio
D. A decrease in the FEV1.0/FVC ratio
E. A FVC less than 75 % of the predicted value

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