Objectives

Define and classify acute respiratory failure

Describe pathophysiology and

manifestations of acute respiratory failure

Review oxygen supplementation strategies

Case Study 1
70 yo M with COPD presents c/o increasing
dyspnea and cough for past several days. He
is on home O2 at 3LNC and has been using
his home nebulizer Q2H for past day without
relief.
Vital Signs
T: 36 (96.8), P: 125, RR 28-30, BP: 155/90
SpO2 92% on 5LNC
Breathing with accessory muscles and is only
able to speak 1-2 word answers before
becoming acutely SOB.

Case Study 1

What findings suggest respiratory failure?

What evaluation is needed to determine if

acute respiratory failure exists?

What findings suggest

respiratory failure?
Tachypnea
Use of accessory muscles
Distress
ALSO
Altered mental status agitation/lethargy
Increased Work of breathing intercostal,
suprasternal or supraclavicular retractions,
paradoxical WOB
Altered RR
Cyanosis
Catecholamine release hypertension/diaphoresis

Forms of Respiratory
Failure
Hypoxemic
Room air PaO2
50-60 mm Hg
(6.7-8 kPa)
Abnormal
PaO2:FIO2 ratio

ARDS, PNA, CHF, ILD, PE

Forms of Respiratory
Failure

Hypercapnic
PaCO2 50 mm Hg
(6.7kPa) with pH 7.36

COPD, TBI, Drugs, Narcosis, sleep

apnea neuromuscular dz,
metaboilic abnormalities

Case Study 1

ABG:

pH: 7.23
PaCO2: 75 mmHg
PaO2: 65 mmhg on RA
HC03: 30

Chest Radiograph:
Hyperinflation, increased interstitial markings in
lower lobes

ABG Interpretation
Normal Ranges
pH: 7.35-7.45
CO2 35-45
HCO3 22-26
Every blood gas has a First and Last name
First name choices: Metabolic, Mixed, Respiratory
Last name Choices: Acidosis, Alkalosis

Approach to Blood gases

FIRST GIVE IT A LAST NAME: LOOK AT pH

Choose which one matches
7.23 = acidosis

NEXT GIVE IT A FIRST NAME: LOOK AT CO2 AND HCO3

Look at CO2 and Bicarb and choose which one matches
He is acidotic PaCO2 58
If both CO2 and Bicarb match (i.e. both acidotic) then mixed

IS IT COMPENSATED?
If pH is not within normal range then it is NOT FULLY
COMPENSATED
If factor not used in naming is out of range and in the OPPOSITE
direction then it is either partially or fully compensated
depending on pH
HCO3 30 = partially compensated

Types of Non-Invasive Positive

Pressure Ventilation

CPAP
Gives constant pressure
Best for treating OSA

BiPap
Gives a baseline constant pressure and provides
an inhalatory assist
Best for CHF, COPD, Mild Narcosis

Hi Flow nasal cannula

Increases intrinsic PEEP
Best for mild/moderate hypoxic respiratory failure

Indications for NPPV

Potentially reversible respiratory process
Respiratory muscle fatigue
Neuromuscular disease
Refractory hypoxemia
Hypercarbia
Need for PEEP
Excessive work of breathing

Contraindications to NPPV
Severe encephalopathy
Significant agitation
Hemodynamic instability
Myocardial ischemia or arrhythmias
Inability to protect airway
High risk for aspiration
Active upper GI bleeding
Vomiting
Severe hypoxemia
Facial trauma/recent facial surgery

Is the patient in CASE 1

appropriate for NPPV?

YES
He is awake and cooperative
He is hemodynamically stable tachycardia, but
BP 155/90
He has a potentially reversible process
He has excessive work of breathing accessory
muscle use
NPPV offers time to allow other interventions such
as steroids and bronchodilators time to work

Why not just intubate?

NPPV avoids many of the complications
associated with intubation and mechanical
ventilation such as upper airway trauma
and ventilator associated pneumonia
It also avoids the need for sedation and
improves mortality

How would you initiate NPPV in

this patient?

Type of Ventilator?
ICU ventilator with NPPV capabilities or NPPV
ventilator

Type of interface?
Face Mask

Initial settings?
IPAP Inspiratory Positive Airway Pressure
EPAP- Expiratory Positive Airway Pressure
10/5 titrate O2

Trouble Shooting
Titrate IPAP and EPAP to achieve appropriate Minute
Ventilation
The further apart the IPAP and EPAP are, the larger
the breath. i.e. 12/6 is a larger breath than 13/8.
Limit oral intake
IPAP should not exceed 20 as this represents
esophageal opening pressure
HOB 45 degrees
Check for airleak most machines can compensate
for an airleak of 35%
Big head does not equal big face choose the
appropriate mask.

Minute Ventilation

Minute ventilation is TV X RR

Target minute ventilation is generally

BSX X 3 for women
BSA X 4 for men

Sicker patients may need more.

CASE STUDY 1
NPPV is initiated via full face mask with IPAP
10 cm H2O, and EPAP 5 cm H2O, and FIO2
40%. What parameters should be monitored
to assess patients response to NPPV?
Tidal volume
Minute ventilation
Respiratory Rate
Pulse oxemitry
Mental status

Fine tuning Bipap

What adjustments would you make if TV or

MV was too low?
You would either decrease EPAP or increase IPAP

What adjustments would you make if

oxygen saturation was too low?
EPAP can be increased to improve oxygenation
FIO2 can be increased.

Patient coaching improves

success
Teaching and coaching the patient can result in
improved acceptance. The patient should
understand the reasons for the device and, before
mask placement, should be told what to expect
with regards to air pressure and coverage of the
mouth/nose. One technique, which can be of
great value, is asking the patient to lightly place
the mask on his/her face for familiarization before
strapping the mask in place. Patients must also
be taught how to remove the mask in the event of
intolerance or emesis

CASE STUDY 1
The patient now appears more comfortable
and his ABG shows
pH 7.31, PaCO2 75, PaO2 65, HCO3 30
Is the patients acid base status better or
worse?
What information do you need to fully
evaluate his respiratory status?

CASE STUDY 1
How would you determine that NPPV failed
and intubation and Mechanical Ventilation is
required?
Failure to significantly improve in 1-2 hrs
Inability to achieve therapeutic goals in 4-6
hrs
Intolerance of NPPV
Worsening vital signs

Case Scenario 2
A 55 yo homeless man presents with fever and
cough productive of thick green secretions. He is
confused and resists attempts of care.
Vital signs on admission are:
T: 39.2 (102)
Pulse: 140
BP: 90/45
RR: 40
SpO2: 95% on HFNC
CXR: Multi-lobular PNA

CASE STUDY 2
ABG:
pH: 7.32
PaCO2: 38
PaO2: 70
HCO3: 19
Interpret this ABG

CASE STUDY 2

pH 7.32 - indicates acidosis

HCO3 at 19 is decreased this indicates metabolic
acidosis
PaCO2 38 is near normal
Is this gas compensated?

WINTERS FORMULA
Expected PCO2 = 1.5 X HCO3 + 8 (+/- 2)
This gas is partially compensated to be fully
compensated the pH would need to be between 7.357.39

Is this patient a candidate for

NPPV?
NO
Confusion and resistance of attempts at
care
His respiratory status is unlikely to improve
quickly
He is hemodynamically unstable BP 90/45
Presence of metabolic acidosis is a
concerning finding and suggestive of sepsis
this weighs against using NPPV