Acute Respiratory Failure

Tacla Sfeir,MD,FCCP
 Objectives
• Recognize different types of acute respiratory
failure
• Recognize the cause of hypoxia in different
clinical scenarios
• Interpret arterial blood gases in different
clinical scenarios
• Describe management of respiratory failure
 Acute respiratory failure
• Acute hypoxemic respiratory failure : Type I
(hypoxia and hypocapnea)

• Acute hypercapneic respiratory failure: Type 2

(hypoxia and hypercapnea)
V/Q mismatch or
diffusion
 Case 1
• A 65 year old lady has a fracture of the left femoral
neck after tripping and a falling at home. Her past
medical history is notable for breast cancer
diagnosed a year ago for which she is still treated.
While waiting for her surgery she develops an acute
onset of right sided chest pain associated with
shortness of breath. Lung exam is clear. An arterial
blood gas is drawn and shows the following:
• pH= 7.50 PCO2=30 PO2=45 HCO3 =23
Saturation=81%
• CXR is clear
 Case 1
• What is the acid-base disorder?
• A. Metabolic alkalosis
• B. Metabolic acidosis
• C. Respiratory alkalosis
• D. Respiratory acidosis
 Case 1
• What is the acid-base disorder?
• A. Metabolic alkalosis
• B. Metabolic acidosis
• C. Respiratory alkalosis
• D. Respiratory acidosis
 Case 1
• Please comment on the PaO2 in this patient
 Case 1
HYPOXIA AND HYPOCAPNEA
 Case 1
• What is the most likely diagnosis
• A. pneumothorax
• B. Pneumonia
• C. Pulmonary embolism
• D. Pleural effusion
• E. ARDS
 Case 1
• What is the most likely diagnosis
• A. pneumothorax
• B. Pneumonia
• C. Pulmonary embolism
• D. Pleural effusion
• E. ARDS
 Case 1
• You place the patient on 100% oxygen and the
saturation improves to 97%
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B. V/Q mismatch
• C. Hypoventilation
• D. Shunt
 Case 1
• You place the patient on 100% oxygen and the
saturation improves to 97%
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
 PHYSIOLOGY
• Initially dead space increases ( + ventilation, No
perfusion) which will produce hypercapnea and
hypoxemia (blood) and then you have release of
vasoactive mediators which will produce
ventilation-perfusion mismatching which will
produce further hypoxia.
• Then alveolar hyperventilation occurs due to
reflex stimulation of irritant receptors and also in
response to hypoxemia
• RESULT: HYPOXEMIA/HYPOCAPNEA on arterial
blood gas measurement
 Case 2
• You are the intern on call and you get called in
the middle of the night for an acute
desaturation down to 79% on this newly
admitted patient with history of a stroke.
• Patient has been in the hospital in a semi-
comatose state. He has been unable to bring
up secretions and has been requiring frequent
suctioning
 Case 2
• Suctioning has been very difficult
• The patient is on low molecular weight
heparin for DVT prophylaxis since admission
• On PE: the patient is very tachypneic,
RR=30/min, there is some use of accessory
muscles and there is absence of breath sound
on the right
 Case 2
• pH= 7.48 PCO2=33 PO2=44 HCO3 =24
Saturation=79%
You place the patient on 100% FiO2 and
saturation of oxygen increases to 83%
• You order a CXR :
Case 2
 Case 2
• What do you see?
 Case 2
• Almost a complete white out of the right lung
field
• Tracheal shift to the right

• Complete collapse of the right lung because of

a mucus plug in the right main stem bronchus
 Case 2
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
 Case 2
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
 Mechanism of hypoxia
• Perfusion to a whole right lung with no
ventilation = Shunt
• Shunt does not correct with oxygen because
the shunted blood is never exposed to the
higher PAO2 achieved by the high
concentration of Oxygen administered to the
patient
 Case 3
• A 40 year old man brought by EMS after being
found lying on the street at 10 pm at night.
• Low oxygen saturation was noted on the pulse
oximeter
• Room air ABG: pH= 7. 19, PCO2= 70, PO2= 55,
HCO3- = 26
 Case 3
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
• E.Hypoventilation and V/Q mismatch
 Case 3
• A-a gradient:

• (760-47)x 21% - PaCO2/0.8 – paO2=

• 150-(70/0.8)-55= 7.5
 Case 3
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
• E.Hypoventilation and V/Q mismatch
 Case 4
• A 65 year old patient with significant smoking
history presents to the ED with dyspnea, fever
up to 39C cough and sputum production. On
PE, he has rales and increased tactile fremitus
over the RLL and diffuse wheezing. Upon
questioning he reports daily sputum
production and wheezing. CXR reveals a right
lower lobe pneumonia.
 Case 4
• In the next hour, the patient becomes more
and more obtunded and develops
desaturation.
• Room air ABG reveals: pH= 7. 32, PCO2= 55,
PO2= 45, HCO3- = 28, Sat= 79%
 Case 4
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
• E.Hypoventilation and V/Q mismatch
 Case 4
• A-a gradient: 150-(55/0.8)- 45= 37
 Case 4
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
• E.Hypoventilation and V/Q mismatch
 Case 5
• A 60 year old lady presents to your office
because of dyspnea on exertion that has been
getting worse over the past 4 months . She
reports cough. She is a non smoker. Her past
medical history is significant for Hodgkin
lymphoma. She completed her chemotherapy
around 2 months ago with a regimen that
included bleiomycin
 Case 5
• Her physical exam reveals an anxious lady with
crackles over both lung fields
• ABG at rest : pH= 7. 43, PCO2= 34, PO2= 67
HCO3- = 22, SaO2= 94%
SpO2 at rest: 94%
SpO2 on exercise: 87%
 Case 5
• CXR reveals Bilateral reticular infiltrates
• What is the diagnosis?
 Case 5
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
• E.Hypoventilation and V/Q mismatch
• F.Hypoventilation and diffusion
 Case 5
• What is the mechanism of this patient’s
hypoxia?
• A. Diffusion
• B.V/Q mismatch
• C.Hypoventilation
• D.Shunt
• E.Hypoventilation and V/Q mismatch
• F.Hypoventilation and diffusion
 Case 6
• Your neighbor has been involved in a fire. He was
found unconscious by EMS on the scene. You are
worried about CO toxicity
All of the following is true EXCEPT
A. PaO2 is decreased
B. Arterial content of blood is decreased
C. Oxygen dissociation curve shifted to the left
D. Oxygen saturation by pulse oximetry is normal
 All of the following is true EXCEPT

A. PaO2 is decreased
B. Arterial content of blood is decreased
C. Oxygen dissociation curve shifted to the left
D. Oxygen saturation by pulse oximetry is
normal
 REMEMBER
ALWAYS LOOK AT THE PaCO2 and A-a gradient
to determine the etiology of the hypoxia
 Treatement
• For type I ARF you administer supplemental oxygen
• In severe cases you can start mechanical ventilation
• Adjust FiO2 to increase oxygenation
• Patients with type II ARF : Non invasive ventilation (ventilation via a
mask which provided Positive Pressure Ventilation and will help to
decrease PaCO2) may be tried
Bi level mode of ventilation BiPAP
Inspiratory positive airway pressure (IPAP) and Expiratory positive
airway pressure (EPAP) and the difference between the two pressures
will determine tidal volume
• If not successful , you perform intubation and mechanical
ventilation
For the increase in CO2 you can increase either tidal volume and or
respiratory rate on the ventilator (increase minute ventilation)
 4 types of perturbation of acid-base
LOOK at the pH
disturbances
Acidosis primary compensation
Respiratory PCO2 HCO3-
Metabolic HCO3- PCO2

Alkalosis primary compensation

Respiratory PCO2 HCO3-
Metabolic HCO3- PCO2
 Match the arterial blood gas with the
appropriate patient
• PH HCO3- PCO2 PO2
(mEq/L) (mm Hg) (mm Hg)
• A. 7.32 31 60 55
• B. 7.65 48 45 70
• C. 7.29 14 31 70
• D. 7.55 23 27 95

• ----A patient with a history of vomiting for the past 5 days

• ---- A COPD patient with worsening mental status

• ----A 28 year old lady presenting with panic attack to the ER

• ----A patient with uncontrolled diabetes presenting semi comatose to the ER