Acute Respiratory Failure

Matthew Karulf, MD
Pulmonary & Critical Care Medicine

Michigan State University College of Human Medicine
Spectrum Health Medical Group
Hypoxemic Respiratory Failure
Type I Respiratory Failure
Definition
Impairment of respiratory function characterized by
the presence of hypoxemia as diagnosed by a reduced
partial pressure of oxygen in arterial blood.
PaO2 <= 60 mmHg
Acute vs. Chronic
Acute hypoxemia occurs over period of hours to days.
Chronic hypoxemia occurs over a period of weeks to
months.
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)

PaO2 <= 60 is chosen because below
this Hgb saturation falls rapidly.
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)
Anatomic Differential
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)
(A-a) gradient
Normal (A-a) gradient increases with age.

= Approx 10-20 (depending on age of patient)
Alveolar gas equation


100 = 0.21 X [760 47] [40/0.8]
= 150 - 50
(A-a) gradient = PAO
2
PaO
2

Differential of a Normal (A-a) gradient
Normal
Pure Hypoventilation
Low FIO
2
Common Causes
with an abnormal (A-a) gradient
Cardiogenic pulmonary edema
Pneumonia
Sepsis
Aspiration
Trauma
Multiple transfusions
TRALI/TACO
Case #1
48 yo woman complains of 3 days of dyspnea,
cough, fevers, malaise and left-sided pleuritic
chest pain.
Vital Signs
Temp 39.2 Celsius HR 95 BP 100/60 RR 35
Room Air O2 saturation 82%
What is your differential diagnosis for this
patient?
Differential Diagnosis
Pneumonia
Pericarditis
Influenza
Infective Endocarditis with septic emboli
Empyema
Venous Thromboembolic Disease


What are your initial diagnostic and therapeutic
steps?
HPI
Symptoms began 3 days prior with cough, fevers
and malaise.
Progressively worsening
No hemoptysis
No syncope, trauma
No significant past medical or surgical history
Works as a grade school teacher without recent
sick contacts aside from students with colds.
Non-smoker, No EtOH or illicit drug use

What risk factors identify a patient who may
have multidrug resistant pathogens?

Initial Evaluation
ABCs!
Supplemental Oxygen is placed
O2 saturation improves to 90% on NRBM
Physical Exam
Appears in acute distress
Lung auscultation reveals rhonchi over left base
IV access, fluid challenge, labs and CXR

Interpret the following labs
Na 136 Cl 100 BUN 30
K 3.8 HCO3 18 Cr 1.4

WBC 4.2 (36% Bands)
Lactate 2.7

Room Air ABG
7.36/28/47
PAO
2
= 0.21 x [760 47] [28/0.8] = 115
= 150 - 35
(A-a) gradient = PAO
2
PaO
2
= 115 47 = 68
Normal (A-a) gradient for this patient = 2.5 + (0.21 * Age) = 13
Case #1 Working Diagnosis
Previously healthy 48 yo woman with
Community Acquired Pneumonia
Severe Sepsis
Acute Respiratory Failure with Hypoxemia
Acute Kidney Injury
Lactic Acidosis
Elevated Anion Gap Metabolic Acidosis
Respiratory Alkalosis


Why is this patient hypoxemic?

Why does pneumonia cause hypoxemia?
Five Mechanisms of Hypoxemic
Respiratory Failure
Normal (A-a) gradient
Decreased Inspired Oxygen Pressure
Hypoventilation

Abnormal (A-a) gradient
Impaired Diffusion
Right-to-Left Shunt
Ventilation-Perfusion Mismatch
Five Mechanisms of Hypoxemic
Respiratory Failure
Decreased Inspired Oxygen Pressure

Reduction in FIO
2
(suffocation)
Altitude
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)
Five Mechanisms of Hypoxemic
Respiratory Failure
Decreased Inspired Oxygen Pressure

Hypoventilation

As alveolar CO2 increases Alveolar O2 decreases
Opioid Overdose
Will see a normal (A-a) gradient
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)
Five Mechanisms of Hypoxemic
Respiratory Failure
Decreased Inspired Oxygen Pressure

Hypoventilation

Impaired Diffusion
Unlikely to be sole cause of respiratory failure
Often coexists with other mechanisms
Pulmonary Edema
Cardiogenic
Non-Cardiogenic
Significant reserve overcomes many
diffusion impairments
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)
Five Mechanisms of Hypoxemic
Respiratory Failure
Decreased Inspired Oxygen Pressure

Hypoventilation

Impaired Diffusion
Right-to-Left Shunt
Intrapulmonary
Atelectasis or Consolidation with loss of hypoxic vasoconstriction
Pulmonary arteriovenous malformation
Intracardiac
ASD with eisenmeingers physiology
Five Mechanisms of Hypoxemic
Respiratory Failure
Decreased Inspired Oxygen Pressure

Hypoventilation

Impaired Diffusion
Right-to-Left Shunt
Ventilation-Perfusion Mismatch
A Small V/Q mismatch is normal and explains the normal
(A-a) gradient.
Pulmonary Embolus

The two most common mechanisms of
acute hypoxemic respiratory failure.
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)
Clinical Approach
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)
Case #1 Working Diagnosis
Previously healthy 48 yo woman with
Community Acquired Pneumonia
Severe Sepsis
Acute Respiratory Failure with Hypoxemia
Acute Kidney Injury
Lactic Acidosis
Elevated Anion Gap Metabolic Acidosis
Respiratory Alkalosis



Case #1(cont.)
Pt. remains distressed, complaining of
dyspnea, despite the non-rebreather mask.
Temp 39.2 Celsius HR 112 BP 100/60 RR 38
90% Non-Rebreather Mask

What additional management steps should be
implemented now?
Intubation
Empiric antibiotics for CAP in the ICU
Early Sepsis Resuscitation

What clinical syndrome of respiratory
failure does this patient have?
Acute Respiratory Distress Syndrome (ARDS)
Berlin Criteria 2012
Acute onset (within 7 days of insult)
PaO2/FiO2 < 300 (with a minimum PEEP of 5)
Mild 200-300
Moderate 100-200
Severe <100
Bilateral opacities consistent with pulmonary edema
(on either CXR or CT)
Not fully explained by cardiac failure or volume
overload

When should mechanical ventilation be
initiated?

When hypoxemic or hypercapneic respiratory
failure cannot be treated by less aggressive
methods.

Non-Invasive Positive Pressure Ventilation
(NIPPV) or Invasive.



What is the mechanical ventilation strategy in
ARDS?

Low Tidal Volume Ventilation.
(6ml/kg PBW)


861 patients w/ ALI randomized
4-6ml/kg PBW vs. 12ml/kg PBW
Goal Pplat <30 cm H2O
Main Outcomes
Mortality
The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301-1308
What information is needed in order to
determine the appropriate tidal volume?
Gender and Height
Not the measured weight!

FIO
2
/PEEP titration
Why do patients with ARDS benefit from a low
tidal volume and PEEP strategy?

Limits ventilator associated lung injury.
Decreases biomechanical factors contributing
to multisystem organ failure and death.
Slutsky AS, Ranieri VM. N Engl J Med 2013;369:2126-2136.
Slutsky AS, Ranieri VM. N Engl J Med 2013;369:2126-2136.
Protective Ventilation
Malhotra A. N Engl J Med 2007;357:1113-1120
Lung Protective Ventilation
Slutsky AS, Ranieri VM. N Engl J Med 2013;369:2126-2136.
Lung Protective Ventilation
Slutsky AS, Ranieri VM. N Engl J Med 2013;369:2126-2136.

Case #2
68 yo man presents with 5 days of progressive
dyspnea and increased cough productive of
purulent sputum.
Vital Signs
Temp 37.9 Celsius HR 95 BP 100/60 RR 35
Room Air O
2
saturation 82%

What is your differential diagnosis?
Differential Diagnosis
Acute Exacerbation of Chronic Bronchitis
Pneumonia
Venous Thromboembolic Disease
Acute Myocardial Infarction
HPI (cont.)
History of COPD, FEV
1
47% predicted.
Ongoing 50 pack year history of Tobacco
Abuse.
Two pneumonias in the past year treated
with prednisone and azithromycin.
Objective Findings
Oxygen saturation improves to 89% on 3L
Appears distressed, speaks in 4 word sentences.
Intercostal retractions, pursed lip breathing
Lung auscultation reveals diffuse expiratory
wheezes.

ABG on 3L 7.24/80/78

Na 139 Cl 99 BUN 25
K 3.8 HCO3 34 Cr 1.2

What is your patient suffering from?

Acute on Chronic Hypercarbic Respiratory
Failure
Acute Exacerbation of Chronic Bronchitis
Acute Hypercarbic Respiratory Failure
PaCO
2
is elevated.



Total minute ventilation is the sum of alveolar ventilation
and dead space ventilation.
A decrease in total minute ventilation or an increase in dead
space ventilation can reduce alveolar ventilation.
Any decrease in or increase in with
constant results in increased PaCO
2
.

= CO
2
production
= Alveolar ventilation
Acute Hypercarbic Respiratory Failure
The absolute PaCO
2
level is not diagnostic.
Many conditions result in chronic hypercapnia.
Acute implies that PaCO
2
rises faster than
the kidneys are able to retain bicarbonate,
resulting in acute respiratory acidosis.
The diagnosis requires an arterial blood gas!
Physiologic mechanisms of acute
ventilatory failure
Murray & Nadels Textbook of Respiratory Medicine (5
th
ed.)
Wont Breathe Cant Breathe
Reduced Ventilatory Drive
Wont Breathe
Pharmacologic disruption
Drug overdose
Consider reversal agents (naloxone for opioids and
flumazenil for benzodiazepines)
Acquired Defect
Stroke
Neoplasm
Obesity-Hypoventilation syndrome
Myxedema
Inadequate Ventilation despite effort
Cant Breathe
Neuromuscular weakness
Cervical spinal cord injury
Myasthenia gravis (Monitor Vital Capacity)
Restrictive Chest Wall disease
Kyphoscoliosis
Airway Obstruction
Upper foreign body, vocal cord paralysis
Lower COPD, Status Asthmaticus
Increased Dead-space ventilation
High V/Q COPD (Emphysema)
Generalized pulmonary hypoperfusion shock
Increased CO2 production (unable to compensate)
Fever, sepsis, burns, trauma, seizures
Case #2 (cont.)
What is your next step in the management of
your patient with an acute exacerbation of
COPD?
ABCs
Bronchodilators
Systemic Glucocorticoids
Antibiotics
NiPPV
Noninvasive Mechanical Ventilation
Invasive mechanical ventilation for COPD (i.e.
Intubation) exacerbations is associated with high
morbidity and mortality.
Noninvasive Positive Pressure Ventilation (NIPPV
e.g. BiPAP or CPAP) reduces intubation rates and in-
hospital mortality for COPD exacerbations
Plant et al. Lancet, 2000.
NIPPV vs. standard therapy
reduced intubation rates (15% vs. 27%, P = .02)
Reduced mortality (10% vs. 20%, P = .05)
What are the indications for NIPPV?
Hypoxemic respiratory failure
Cardiogenic pulmonary edema
Immunocompromised patients
Hypercapnic respiratory failure
Acute exacerbation of COPD
Acute Asthma exacerbation
What are the contraindications to
NIPPV?
Uncooperative patient
Inability to protect airway
High risk for aspiration
Cardiac or respiratory arrest
Hemodynamic instability
Myocardial ischemia
Facial trauma, surgery, burns
Is post-extubation NIPPV beneficial in
preventing reintubation?
NIPPV for patients who develop respiratory
distress within 48 hours of extubation may not
prevent reintubation and may be harmful.
Preemptive use of NIPPV (extubating to BiPAP)
may prevent reintubation.

Review on Liberation from mechanical
ventilation:
McConville JF, Kress JP. N Engl J Med 2012;367:2233-2239
.