Respiratory Failure

Sa’ad Lahri
Registrar
Dept Of Emergency Medicine
UCT / University of Stellenbosch
 Introduction
• Most common reason for admission to ICU is to provide
airway and ventilator care to critically ill patients.
• Primary functions of lung and thorax is to oxygenate
arterial blood and to eliminate CO2.
• Dysfunction may occur in oxygenation (intrapulmonary
gas exchange by which mixed venous blood releases
CO2 and becomes oxygenated) or in ventilation (the
movement of gases between the environment and the
lungs)
 Clinical Recognition
The patient with resp failure may be recognised
early if they are:

• Dyspnoeic/tachypnoeic
• Unable to speak in complete sentences
• Using accessory muscles of respiration
• Centrally cyanosed
• Sweaty and tachycardic
• Showing a decrease in level of consciousness.
 Mechanisms of respiratory failure
• Acute respiratory failure can be divided
into two broad types:

• Ventilation perfusion mismatch (type I)

• and ventilation failure (type II)
 Ventilation – perfusion mismatch
• Overall ventilation is adequate but blood passing through
the lungs is not fully oxygenated.

• Caused by parenchymal lung disease:

lung contusion
pneumonia
Pulmonary oedema
ARDS
Atelectasis
Pulmonary embolism
• Blood gases are:
• PCO2
• PO2 decreased (<8KPa). (Compensatory
hyperventilation reduces or maintains PCO2 but is less
effective at increasing PO2)
 Detecting failure of simple oxygen
therapy
• You must be alert!
• May be indicated by:
• Increasing respiratory rate
• Increasing distress/dyspnoea/confusion
• Oxygen sats of 80% or less (late sign)
• PaO2 less than 8kPa
• PaCO2 greater than 7kPa
 Management
• Depends on the cause: Treat it!
• Increase inspired oxygen
• Use CPAP or mechanical ventilation with
PEEP
 What is PEEP?
• Positive pressure applied during expiration.
• Prevents collapse of alveoli at end-expiration
leading to an increased FRC.
• End –result is improved ventilation perfusion
mismatching in the pulmonary circulation
improving circulation.
• On the Flip-side: can induce barotrauma,
diminish venous return to the heart and raise
Intracranial pressure.
 CPAP
• Employed in patients with acute resp failure to correct hypoxamia.
Permits higher inspired oxygen concentration, increases mean
airway pressure and improves ventilation to collapsed areas of lung.
• Main indication is to correct hypoxaemia!!!!!!
• A tight – fitting mask with a range of expiratory valves that do not
open until a pressure of 2.5 to 10cm H2O is applied to the patient
with a high flow source of oxygen enriched air

• As patient expires against the valve or gas flows into the patient
during inspiration the pressure in the airways should not drop to
below that of the valve. This opens up any alveoli that may be
closed and prevents their collapse on expiration
 Ventilation failure (type II)
• Lungs are normal but not enough air is
moving in and out.
• Carbon dioxide accumulates and Oxygen
decreases in alveoli but there is normal
gas exchange across the alveolar capillary
interface.
• “hypoxia (PaO2 <8KPa) with hypercapnia
(PaCO2 >6KPa)”
• Caused by an interference with respiratory
mechanics, partial airway obstruction,
depression of resp centre.
• Blood Gases: PCO2
PO2
 Management
• Remove the cause
• Mechanical ventilation
• (be careful: only increasing the inspired O2
may mask the rising PCO2.
Non – invasive ventilation by mask
• If type II resp failure develops, This mode should
be considered.
• The level of CPAP is alternated between a high
and a low level at a fixed frequency. This may be
termed BiPAP mask ventilation.
• The higher CPAP level is set around 20 at
inspiration and the lower level at 5 during
expiration.
• This pressure difference will generate gas flow
into the lungs during inspiration
• Not effective in all patients.
• Inappropriate for :
• Cardiovascular unstable
• Decreased LOC
• Severe metabolic acidosis
• Must be in control of their own airway and be co-
operative
• NIV should not be used as a substitute for tracheal
intubation and invasive ventilation when the latter is
clearly more appropriate.
 Conclusions:

• Routine Assessment is predominately

clinical and aims to identify the patient who
is deteriorating.
• Treat the cause of the failure as well as
the hypoxia/hypercarbia.
• Continously reassess your clinical signs,
pulse oximetry and most importantly
ABG’s.
 References:
• Emergency Medicine Secrets 4th Edition
• Oxford Handbook of Trauma for Southern
Africa.
• Care of the Critically ill surgical Patient –
Ian Anderson.