DONE: BUTHAI NA AL- ZAABI

I D: 8591 2
Respiratory Failure
Objectives


Define and classify acute respiratory failure
Discuss the pathophysiology of acute respiratory failure
Outline the management of respiratory failure
Acute Respiratory Failure

Definition:

The loss of the ability to ventilate adequately or to provide
sufficient oxygen to the blood and systemic organs. The
pulmonary system is no longer able to meet the metabolic
demands of the body with respect to oxygenation of the blood
and/or CO
2
elimination.

http://www.mcgill.ca/criticalcare/teaching/files/acute
Classification
Type 1 (Hypoxemic)
Type 2 (Hypercapnic/ Ventilatory )

Type 3 (Peri-operative)
Type 4 (Shock)
Hypoxemic respiratory failure (type I)

Arterial oxygen tension (P
a
O
2
) lower than 60 mm Hg with a normal or low
arterial carbon dioxide tension (P
a
CO
2
).







The most common form of respiratory failure.



Pathophysiology of respiratory failure type 1 (Failure of oxygenation)
Low ambient oxygen (e.g. at high altitude)
Alveolar hypoventilation
Diffusion impairment
Ventilation/perfusion (V/Q) mismatch
Right-to-left shunt


Hypercapnic respiratory failure (type II)

Hypoxia with hypercapnia


Pathophysiology of respiratory failure type 2 (Failure of ventilation) :
Abnormalities of central respiratory drive
Neuromuscular dysfunction
Abnormalities of the chest wall
Abnormalities of the airways and the lungs
Clinical presentation of acute respiratory failure

Altered mental status (agitation, somnolence)
Peripheral or central cyanosis or decreased oxygen saturation on pulse
oximetry
Manifestations of a "stress response" including tachycardia,
hypertension, and diaphoresis
Evidence of increased respiratory work of breathing including
accessory muscle use, nasal flaring, intercostal indrawing, suprasternal
or supraclavicular retractions, tachypnea
Evidence of diaphragmatic fatigue (abdominal paradox)
Investigation


Pulse oximetry
Arterial blood gas test
CXR

Management of Acute Respiratory Failure
Management
Urgent
resuscitation
Ongoing care
Cont. Management


Urgent resuscitation
Oxygenation
Airway control
Ventilator management
Stabilization of the circulation
Bronchodilators/ Steroids



Ongoing care
Differential diagnosis and
investigations
Therapeutic plan tailored to
diagnosis

Oxygen therapy
Low flow devices
Simple face mask Max FiO2 30-50%
Nasal cannula Max FiO2 30-60%
Reservoir bag Max FiO2 60-80%
High flow devices
Venturi mask Max FiO2 24-60%
Low flow device give a variable amount of oxygen depending on the minute
volume .

High flow device give a precise concentration of oxygen depending on the
value used.
Case

A 65 year old man
Smoking for 50 yrs

Chronic cough with sputum production and chronic dyspnea on
exertion

Now admitted with several days of increased cough
(productive green sputum) and shortness of breath even at
rest.

On examination:
RR: 32/min
Reduce air entry with prolonged expiratory phase
Wheezes in expiration.

Investigation
ABG
pH=7.38
PCO2= 68 mmHg
PO2= 48 mmHg
SpO2 = 78%


Management:

Oxygen therapy via venturi mask
Bronchodilaters (ipratropium 0.5mg + salbutamol 5 mg)
Steroids
Antibiotic
Physiotherapy
Consider supported ventilation if:
Failure to respond
Decline in conscious level
Worsening respiratory acidosis