Respiratory Failure

Lack of respiratory success

Richard Costello
Themes of this talk
Basic types of respiratory failure
Hypoxic Respiratory Failure (RF)
Hypoxic Hypercapnic Respiratory Failure
(HRF)

Terms: Arterial blood gas, hypercapnia,
airflow, drive to breathe, dead space V/Q
mismatch, compliance
Three important definitions
Respiratory failure occurs when:
pulmonary system is no longer able to meet the
metabolic demands of the body

Hypoxaemic respiratory failure:
PaO
2
8 kPa when breathing room air

Hypercapnic respiratory failure:
PaCO
2
6 kPa.
What you are going to need to
diagnose Respiratory Failure
History and physical exam
Arterial blood gasses
Radiology
Pulmonary function tests

Normal Arterial blood gas
Ph 7.34 - 7.45
PaCO2 4.5 5.5 Kpa
PaO2 10- 12 Kpa
HCO
3
24-26 mmol/l
Base Excess 0-2
Oxygen saturation 92-99%
Carboxy-haemoglobin (due smoke)
Meth-haemoglobin (iron on hemoglobin stays
reduced and so cannot bind oxygen- caused
by drugs such as lignocaine and cocaine)
Breathless on
walking across
the room


Heavy smoker
Blood Gases
Ph = 7.40 (7.35-7.45)

PaCO
2
= 4.5 kPa (4.5-6)

PaO
2
= 7.1 kPa (>9)

HCO
3
= 24 (24 -28)
Why is his Oxygen low?
To get oxygen into the circulation

Breathe in oxygen

Diffusing through the airways into and across the
alveoli

Perfusion

Ventilation-perfusion matching

Physiological tests
Actual %Predicted
FVC 2.3 85
FEV1 1.4 70
FEV1/FVC 61%
RV 1.6 120%
DLCO 58
Why is his Oxygen low?
To get oxygen into the circulation

Breathe in oxygen

Diffusing capacity (he has less
surface area)

Perfusion (blood is going through
his lungs)

Ventilation-perfusion matching (the
blood is not mixing with his oxygen

Treatment of Hypoxic RF
Establish and treat the underlying cause.
Hypoxia is a threat to all cellular systems and so
administer oxygen supplementation, how much is
determined by two principles.
(1) There is little value in the administration of too much
oxygen (although there may be some exceptions), due to
the shape of the oxygen association/dissociation curve.
(2) There is a risk of inducing carbon dioxide retention in
some patients with COPD.

Oxygen delivery systems
Nasal cannula Venturi Face Masks
Comes into the Hospital as
an emergency.

He is very ill, with extreme
breathlessness, cough and
fever
Emergency blood gases
Ph = 7.5 (7.35-7.45)

PaCO
2
= 4.1 kPa (4.5-
6)

PaO
2
= 7.1 kPa (>9)

HCO
3
= 24 (24 -28)

Ph = 7.5 (7.35-7.45)

PaCO
2
= 4.1 kPa (4.5-
6)

PaO
2
= 9.1 kPa (>9)

HCO
3
= 24 (24 -28)

On Room air On 100% oxygen

75% 75%
100% 75%
81.5%
V/Q mismatch -
shunt
Perfusion without ventilation
(shunting)
Intra-pulmonary
Small airways occluded ( e.g asthma, chronic bronchitis)

Alveoli are filled with fluid ( e.g pulm edema, pneumonia)

Alveolar collapse ( e.g atelectasis)


Intracardiac defect giving shunt
Perfusion without ventilation
(Shunting)
Intra-cardiac
Any cause of right to left shunt
eg Fallots, Eisenmenger
Intra-pulmonary
Pneumonia
Pulmonary oedema
Atelectasis
Collapse
Pulmonary haemorrhage or contusion
O2 CO2
Carbon dioxide out







) V - (V x RR entilation alveolar v
1
PaCO2
D T

Another case
30 year old (who should
know better!) is brought
into the AandE
unconscious
He has needle marks
from heroin use in his
arms and legs

Emergency blood gases
Ph = 7.25 (7.35-7.45)

PaCO
2
= 14.1 kPa (4.5-6)

PaO
2
= 7.1 kPa (>9)

HCO
3
= 24 (24 -28)

) V - (V x RR n ventilatio Alveolar D T
Brainstem
Spinal cord
Nerve root
Nerve
Neuromuscular
junction
Respiratory
muscle
Opiate cause ventilatory
disturbance by inhibiting
respiratory centres
Hypoventilation
V/Q mismatch: Physiologic dead space,
the other reason CO2 is increased

Physiologic dead space

All alveolar gas does not equilibrate fully with
capillary blood
) V - (V x RR entilation alveolar v
1
PaCO2
D T

This man is listless and breathless

He has a cough and phlegm
Hypoxic hypercapnic respiratory
failure: wont breathe
Problem with the
muscles of ventilation
Problems with the chest
wall/obesity
Ph = 7.25 (7.35-7.45)

PaCO
2
= 7.1 kPa (4.5-6)

PaO
2
= 7.1 kPa (>9)

HCO
3
= 24 (24 -28)

Normal gas exchange during respiration
Inspiration Expiration
CO
2
0 Kpa
O
2
20 Kpa
CO
2
3.5 Kpa
O
2
12 Kpa
CO
2
5 Kpa CO
2
4 Kpa
O
2
5 Kpa O
2
11 Kpa
Ph 7.35 Ph 7.40
CO
2
3.5 Kpa
O
2
12 Kpa
Inspiration Expiration
CO
2
0 Kpa
O
2
20 Kpa
CO
2
6 Kpa
O
2
8 Kpa
CO
2
5 Kpa CO
2
5 Kpa
O
2
5 Kpa O
2
8 Kpa
CO
2
5 Kpa
O
2
8 Kpa
Narrowed airways in asthma and COPD
slow expiration leading to higher alveolar
CO
2

Inspiration Expiration
CO
2
3 Kpa
O
2
20 Kpa
CO
2
5.5 Kpa
O
2
8 Kpa
CO
2
5.5 Kpa CO
2
5.5 Kpa
O
2
5 Kpa O
2
8 Kpa
CO
2
5.5 Kpa
O
2
8 Kpa
Progressive rise in CO
2
occurs in these
narrowed airways
Inspiration Expiration
CO
2
5 Kpa
O
2
15 Kpa
CO
2
3.5 Kpa
O
2
8 Kpa
CO
2
6.5 Kpa CO
2
6.5 Kpa
O
2
5 Kpa O
2
7 Kpa
CO
2
6.5 Kpa
O
2
7 Kpa
Non invasive ventilation with BiPaP
True or False
Diffusion abnormality is
considered the most common
cause of hypoxia.
True or False
Dead space ventilation
decreases when blood flow is
reduced
True or False
Shunt occurs when areas of
lung are perfused but not
ventilated
True or False
Arterial hypoxemia may be
caused by alveolar
hypoventilation alone
True or False
The distinction between
ventilation/perfusion mismatch and
intrapulmonary shunting can be made
by measuring the response to the
administration of 100% oxygen
True or False
There is a good relationship between
dyspnea and arterial hypoxemia