Respiratory Failure (RF)

Respiratory system includes:

CNS (medulla)
Peripheral nervous system (phrenic
nerve)
Respiratory muscles
Chest wall
Lung
Upper airway
Bronchial tree
Alveoli
Pulmonary
vasculature

Potential causes of Respiratory Failure

Arterial Blood Gases (ABG)

Normal values at sea level
pH
PaO2
PaCO2
HCO3

7.35-7.45
>70 mmHg
35-45 mmHg
22-28 mmol/l

pH
pH

Acidosis
Alkalosis
PaO2
Hypoxemia
PaCO2
Hypercapnia
pH+ PaCO2 R. acidosis

HCO3

pH+PaCO2 R.Alkalosis

HCO3

Respiratory Failure (RF)

Definitions

Clinical conditions in
which PaO2 < 60 mmHg
while breathing room air
or a PaCO2 > 50 mmHg
Failure of oxygenation
and carbon dioxide
elimination
Acute and chronic
Type 1 or 2

Classification of RF
Type

Type

Hypoxemic RF
PaO2 < 60 mmHg with

Hypercapnic RF
PaCO2 > 50 mmHg

normal or PaCO2
Associated with acute
diseases of the lung
Pulmonary edema
(Cardiogenic,
noncardiogenic (ARDS),
pneumonia, pulmonary
hemorrhage

Hypoxemia is present
Drug overdose,

neuromuscular disease,
chest wall deformity,
COPD, and Bronchial
asthma

Distinction between Acute and Chronic RF

Acute RF
Develops over minutes to

Chronic RF
Develops over days

hours
pH quickly to <7.2
Example; Pneumonia

in HCO3
pH slightly
Example; COPD

Pathophysiologic causes of RF
Hypoventilation
V/P mismatch
Shunt
Diffusion
abnormality

Assesment
History
Ask if there is a
1. respiratory symptoms related to any underlying
diseases ( SOB, cough (productive/nonproductive),
pleuritic chest pain, fever, PND, orthopnea etc
2. symptoms of CNS involvement (muscle weakness,
head injury, headache) and Cardiovasvular ( chest
pain, palpitation)
3. Medical history
4. Drug history beta blockers (asthma), CNS
depression drug
5. Social history

Physical examination
General inspection

Posture, skin colour (peripheral or central

cyanosis), clubbing finger, pitting oedema,
temperature, pulse
Chest chest shape, chest movement
(symmetrically or unilaterally), work of
breathing (any use of accessory muscle),
respiration rate, type of breathing pattern
(Kussmaul, Cheyne-stokes)

 Palpation chest expansion, any tenderness,

any mass for lung cancer

Percussion hyper resonant, stony dull, dull
related to underlying diseases
Auscultation check for any additional sounds
related to underlying diseases
CNS examination if there is CNS involvement in
the underlying disease

Clinical (symptoms, signs)

Hypoxemia
Dyspnea, Cyanosis
Confusion, somnolence, fits
Tachycardia, arrhythmia
Tachypnea (good sign)
Use of accessory ms
Nasal flaring
Recession of intercostal ms
Polycythemia
Pulmonary Hypertension,
Corpulmonale,

Hypercapnia
Cerebral blood flow, and

CSF Pressure
Headache
Asterixis
Papilloedema
Warm extremities,
collapsing pulse
Acidosis (respiratory, and
metabolic)
pH, lactic acid

Causes
1 CNS
Depression of the neural
Brain stem tumors or vascular

abnormality
Overdose of a narcotic, sedative
Myxedema, chronic metabolic
alkalosis
Acute or chronic hypoventilation
and hypercapnia

 2 - Disorders of peripheral

nervous system, Respiratory

muscle, and Chest wall
Inability to maintain a level
of minute ventilation
appropriate for the rate of
CO2 production
Guillian-Barre syndrome,
muscular dystrophy,
Hypoxemia and hypercapnia

 3 - Abnormities of the

airways
Upper airways
Acute epiglotitis
Tracheal tumors
Lower airway
COPD, Asthma, cystic
fibrosis
Acute and chronic
hypercapnia

 4 - Abnormities of the

alveoli
Diffuse alveolar filling
hypoxemic RF
Cardiogenic and
noncardiogenic
pulmonary edema
Aspiration pneumonia
Pulmonary hemorrhage
Associate with
Intrapulmonary shunt and
increase work of breathing

Investigations
ABG
CBC, Hb

Anemia
Polycythemia
Urea, Creatinine
LFT

Electrolytes (K, Mg, Ph)

CPK, Troponin 1
CPK, normal Troponin 1
TSH

tissue hypoxemia
chronic RF
clues to RF or
its complications
Aggravate RF
MI
Myositis
Hypothyroidism

 Chest x ray Pulmonary edema

ARDS
Echocardiography
Cardiogenic pulmonary

edema
ARDS
PFT- (FEV1/ FVC ratio)
Decrease Airflow obstruction
Increase
Restrictive lung disease
ECG
cardiac cause of RF
Arrhythmia due to hypoxemia and
severe acidosis

Management of RF
ICU admition
1 -Airway management

Endotracheal intubation:

Indications
Severe Hypoxemia
Altered mental status
Importance
precise O2 delivery to the lungs
remove secretion
ensures adequate ventilation

 2 -Correction of hypoxemia

O2 administration via
nasal prongs, face mask,
intubation and Mechanical
ventilation
Goal: Adequate O2
delivery to tissues
PaO2 = > 60 mmHg
Arterial O2 saturation
>90%

 3- Correction of hypercapnia
Control the underlying cause
Controlled O2 supply
1 -3 lit/min, titrate according

O2 saturation
O2 supply to keep the O2
saturation >90%

 4 - Mechanical ventilation
Increase PaO2
Lower PaCO2
Rest respiratory ms
(respiratory ms fatigue)
Ventilator
Assists or controls the
patient breathing
The lowest FIO2 that
produces SaO2 >90% and
PO2 >60 mmHg should be
given to avoid O2 toxicity

 6 - Noninvasive

Ventilatory support
Mild to moderate RF
Patient should have

Intact airway,
Alert, normal airway
protective reflexes

Nasal or full face mask

Improve oxygenation,
Reduce work of
breathing
Increase cardiac output
COPD, asthma, CHF

 7 - Treatment of the

underlying causes

After correction of hypoxemia,

hemodynamic stability
Antibiotics
Pneumonia
Infection
Bronchodilators (COPD, BA)
Salbutamol
reduce bronchospasm
airway resistance

 7 - Treatment of the

underlying causes
Anticholinergics (COPD,BA)

Ibratropium bromide
inhibit vagal tone
relax smooth ms
Theophylline (COPD, BA)
improve diaphragmatic
contraction
relax smooth ms
Diuretics (pulmonary edema)
Frusemide, Metalzone

 7 - Treatment of the

underlying causes

Methyl prednisone (COPD,

BA)

Reverse bronchospasm,
inflammation

Fluids and electrolytes

Maintain fluid balance and
avoid fluid overload
IV nutritional support

To restore strength, loss of

ms mass
Fat, carbohydrate, protein

 7 - Treatment

of the
underlying causes

Physiotherapy

Chest percussion to
loosen secretion
Suction of airways
Help to drain secretion
Maintain alveolar
inflation
Prevent atelectasis, help
lung expansion

 8 - Weaning from mechanical ventilation

Stable underlying respiratory status
Adequate oxygenation
Intact respiratory drive
Stable cardiovascular status
Patient is a wake, has good nutrition, able to cough and
breath deeply

Thank you