Acute Respiratory Failure

Type 1 Respiratory Failure Type 2 Respiratory Failure

1. Failure of oxygenation 1. Failure of Ventilation
2. PaO2 < 60mmHg 2. PaO2 < 60mmHg, PaCO2 > 50mmHg
3. Hypoxemia w/o hypercapnia 3. Hypoxemia with Hypercapnia
4. Common causes: 4. Common causes:
 Low ambient O2  Increase airway resistance
 V/Q mismatch (COPD, asthma)
 Alveolar hypotension  Reduced WOB
 Diffusion problems  Decreased area of the lung for
 Shunt gas exchange (Bronchitis)
 Neuromuscular problems
 Depressed CNS
Clinical Manifestations
Early Signs:
1. Restlessness
2. Fatigue
3. Headache
4. Increased BP
5. Tachycardia
6. Tachypnoea
7. Dyspnoea
8. Use of respiratory muscles
9. Nasal flaring
10. Paradoxical breathing
Late Signs:
1. Confusion
2. Central cyanosis
3. Tachycardia
4. Tachypnea
5. Diaphoresis
6. Respiratory arrest
Goals for treatment of ARF
1. Maintain adequate airway patency
2. Correct underlying cause/issues
3. Optimise oxygen delivery
4. Minimize oxygen demand
5. Prevent complications
Maintain Airway Patency
1. Perform chest physiotherapy to remove trapped secretions
2. Administer bronchodilators to increase airway patency
3. Non-invasive Mechanical Ventilation  Face Mask
4. Invasive Mechanical Ventilation  ETT, if patient is unable to maintain airway
Correct Underlying Cause
1. Investigations & medical interventions is necessary to identify cause of ARF
Optimise Oxygen Delivery
1. Monitor for respiratory distress & auscultate for adventitious lung sounds
2. Provide supplement oxygen
3. Positioning for comfort & to enhance V/Q matching
Acute Respiratory Failure

4. Blood transfusion to ensure optimal Hb for oxygen transportation

Minimize Oxygen Demand
1. Provide adequate bed rest
2. Timing of ADLs
3. To address sepsis, restlessness & patient-ventilator desynchrony
Prevent Complication
Monitor for complications of ARF:
1. Immobility-related complications
2. Fluid & electrolytes imbalance
3. Nutritional imbalances
4. Medication side effects
5. Ventilator associated complications  pneumonia, infection
Acute Respiratory Distress Syndrome
1. Subset of Acute Lung Injury (ALI)
2. 3 Criteria to differentiate ARDS from ALI
 PaO2/FiO2 ratio <200 (ARDS), <300 (ALI)
 Chest x-ray  bilateral infiltrates
 Pulmonary Artery Occlusion Pressure (PAOP) <18 mmHg OR
 No evidence of left atrial hypertension
Stages of ARDS
Stage 1: Injury Stage 1. Increased Dyspnea & RR
(within 24 hours) 2. Coarse bilateral crackles
3. CXR – Patchy bilateral infiltrates
Stage 2: Exudative Stage (1 1. Marked by mediator-induced interstitial & alveola edema
– 7 days) 2. Increase permeability to proteins
3. Hypoxia resistant to supplement O2  Mechanical
Ventilation
Stage 3: Proliferative Stage 1. Characterised by hemodynamic instability
(1-2 weeks after initial 2. Evidence of SIRS (Temp >38 or <35, RR > 20, HR > 90, PaCO2
injury) <32 mmHg)
3. Thickened alveolar membrane
4. Generalised edema – lungs is become more dense
Stage 4: Fibrotic Stage 1. Lung is completely remodelled by fibrous tissues
(2-3 weeks after injury) 2. Increase dead space  Poor ventilation
Treatment of ARDS
Mainly supportive while waiting for the lungs to heal
1. Oxygenation
2. Sedation/Comfort
3. Prone positioning
4. Fluids & Electrolytes + Nutrition
5. Pharmacological