Diagnosis and Management of Acute Respiratory Failure

Albert L. Rafanan, MD, FCCP Pulmonary, Critical Care and Sleep Medicine

Objectives

Define and classify acute respiratory failure Describe pathophysiology of acute respiratory failure Discuss clinical manifestations Review oxygen supplementation strategies

Discuss noninvasive positive-pressure ventilation

Definition

Acute respiratory failure (ARF) exists when the patient's breathing apparatus fails in its ability to maintain arterial blood gases within the normal range.

Acute Respiratory Failure

Hypoxemic (Type I )

Room air PaO2 50 torr

Hypercapnic (Type II or ventilatory

respiratory failure) PaCO2 50 torr

Acute

vs chronic

Hypoxia
CNS - Uncooperative, confused, drunkenlike state CVS - Bradycardia, variable blood pressure, cyanosis

Hypercarbia
CNS - Tremor and overt flap CVS - Raised pulse rate, peripheral vasodilation with pink peripheries, blood pressure changes are variable

Causes of Respiratory Failure

The respiratory centre in the CNS The respiratory apparatus (e.g. chest wall and lungs) The respiratory muscles including the diaphragm, the main respiratory pump The gas exchanging units in the lung i.e. the respiratory bronchioles and the alveoli

Site

Examples

Respiratory centre (CNS)

Spinal cord and peripheral nerves Neuromuscular junction Muscle Pleura and thoracic cage

Depressant drugs, opiates; traumatic and ischaemic lesions Loss of respiratory sensitivity to CO2
Spinal injury, Guillain Barre, poliomyelitis Myasthenia, neuromuscular blocking drugs Myopathies, respiratory muscle fatigue in COPD Flail chest, pneumothorax, hemothorax, Deformities, trauma (e.g. rib fractures), loss of optimal shape due to chronic lung hyperinflation

Airways
Gaseous exchange

Extrathoracic: foreign bodies, croup Intrathoracic: asthma, bronchiolitis, bronchitis

Emphysema, pulmonary oedema, ARDS, pneumonia

Lung vasculature

Pulmonary embolus, ARDS

Pathophysiology of Hypoxemia
Ventilation/perfusion mismatch Shunt effect Decreased diffusion of O2 Alveolar hypoventilation High altitude

Pathophysiology of Hypercapnia

Decreased tidal volume and/or respiratory rate Inability to sense elevated PaCO2

Inability to signal effector mechanisms

Inability to effect a response from respiratory muscles

Increased Dead Space

Hypovolemia

Low cardiac output

Pulmonary embolus High airway pressures Short-term compensation by increasing tidal volume and/or respiratory rate

Manifestations of Respiratory Distress

Altered mental status Increased work of breathing

Tachypnea Accessory muscle use, retractions, paradoxical breathing pattern

Catecholamine release
Tachycardia, diaphoresis, hypertension

Abnormal arterial blood gas values

Treatment
Establish an airway Administer oxygen to ensure adequate tissue oxygenation Maintain alveolar ventilation Treat underlying cause

Patient Assessment
Level of consciousness Spontaneous efforts vs. apnea Airway and cervical spine injury Chest expansion Signs of airway obstruction Breath sounds Protective airway reflexes

Look, listen, and feel

Opening the Airway the Triple Airway Maneuver

Slightly extend neck (when cervical spine injury not suspected) Elevate mandible Open mouth Consider adjunctive devices

Reassessment

Adequate spontaneous breathing Provide oxygen supplementation Proceed to manual assisted ventilation Apneic patient Inadequate spontaneous tidal volumes Excessive work of breathing Hypoxemia with poor spontaneous ventilation

Manual Assisted Ventilation

Open the airway Apply face mask and obtain seal Deliver optimal minute ventilation from resuscitation bag Consider cricoid pressure Monitor with pulse oximetry

Single-Handed Method of Face Mask Application

Base of mask placed over chin and mouth opened Apex of mask over nose Mandible elevated, neck extended (if no cervical spine injury), and downward pressure by mask hand

Two-Handed Method of Face Mask Application

Helpful when mask seal difficult Fingers placed along mandible on each side Assistant provides ventilation

Inadequate Mask-to-Face Seal

Identify leak Reposition face mask Improve seal along cheek(s) Change mask inflation or size Slightly increase downward pressure over face Use two-handed technique

Acute Respiratory Failure Management

Oxygen supplementation
Increase FIO2 Match flow between delivery device and inspiratory demand High- vs. low-oxygen systems High- vs. low-flow systems

Nasal Cannula
100% oxygen delivered Low flow

<0.55.0 L/min

Low oxygen
FIO2 <0.40.5

Air-Entrainment Face Mask

100% O2 + entrainment device High flow Venturi Mask Variable oxygen

FIO2 0.240.5

Aerosol Face Mask

100% O2 + large-bore tubing

Nebulizer/O2 blender
Flow matching
If mist disappears in inspiration, air is entrained

Moderate-flow, variable FIO2 device

Reservoir Face Mask

Reservoir bag filled with 100% O2 High oxygen

High flow

Resuscitation Bag-Mask-Valve Device

100% O2 High flow (> 15 L/min) Emergency equipment Little to no air entrainment with firm fit

Noninvasive Positive-Pressure Ventilation (NPPV)

Ventilatory assistance with controlled FIO2 Unilevel or bilevel pressure support Nasal or face mask Volume or pressure-cycled ventilator Most effective with alert, oriented and cooperative patient Successful in hypoxemic and hypercapnic failure

Types of Ventilators

Negative Pressure Ventilators

Positive Pressure Ventilators

Positive pressure maintains airway patency When adequately titrated it is 100% effective against obstructive sleep apnea

CPAP treatment Continuous Positive Airway Pressure

CPAP therapy

What is BiPAP?
BiPAP is similar to CPAP in that it keeps the throat open during sleep The main difference is that the pressure is lower during exhalation (EPAP) and higher during inhalation (IPAP)

Makes it easier to breathe out

Some units have back up rates and also give a breath if no breath is detected in a preset time

Relative Contraindications for NPPV

Decreased level of consciousness Poor airway protective reflexes Copious secretions Cardiovascular instability Progressive pulmonary decompensation Upper gastrointestinal hemorrhage

Pharmacologic Adjuncts
Bronchodilators

2-agonists Anticholinergics (ipratropium)

Corticosteroids
Theophylline

Antibiotics

Thank You