M.A.

Lung/BMSN2202/Respiration/15-16

RESPIRATORY FAILURE

Respiratory failure occurs when the lungs are unable to maintain arterial blood gases at normal
levels when the subject breathes air at rest. There is no absolute definition of the levels of arterial
PO2 and PCO2 that indicate respiratory failure. However, as a general guide, for subjects at sea-
level a PO2 of <60 mm Hg or a PCO2 >50 mm Hg are numbers often quoted.

A. Physiological causes of respiratory failure

1. Hypoventilation (impaired alveolar ventilation)

e.g. upper airway obstruction, weakness/paralysis of respiratory muscles, chestwall
injury etc..
arterial blood gas - PO2 and PCO2

2. Alveolar ventilation perfusion mismatching

e.g. chronic obstructive lung disease, restritive lung disease, pneumonia etc.
arterial blood gas - PO2 and PCO2 or normal PCO2

3. Impaired diffusion
e.g. lung edema, adult respiratory distress syndrome etc.
arterial blood gas - PO2 and normal PCO2 or PCO2

B. Types of respiratory failure

1. Type I respiratory failure gas exchange failure

PO2 < 60 mm Hg
PCO2 < 50 mm Hg

2. Type II respiratory failure ventilatory failure Shunt refers to the portion of

PO2 < 60 mm Hg mixed venous blood that is
related to pumping action added directly to the systemic
PCO2 > 50 mm Hg of respiratory system circulation (i.e. these blood is
not exposed to O2 and gas
C. Hypoxemia exchange didn't occur)

Hypoventilation, diffusion impairment, shunt, and VA/Q mismatching can contribute to
severe hypoxemia of respiratory failure. Severe hypoxemia causes cyanosis. Measurement of
arterial PO2 is essential in determining the degree of hypoxemia in patients. Hypoxemia is
dangerous because it causes tissue hypoxia. Tissues vary considerably in their vulnerability to
hypoxia. Those at greatest risk include the CNS and myocardium. Mild hypoxemia produces
a slight impairment of mental performance, visual acuity, and mild hyperventilation. Profound
acute hypoxemia may cause convulsion, retinal hemorrhages and permanent brain damage.

D. Hypercapnia

Hypoventilation and VA/Q mismatching contribute to CO2 retention of respiratory failure.
Injudicious use of O2 therapy may also be an important cause of CO2 retention. Raised levels
of PCO2 in the blood cause headache. High levels of PCO2 are narcotic and cause clouding
of consciousness.

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 M.A. Lung/BMSN2202/Respiration/15-16

E. Acidosis
The CO2 retention causes respiratory acidosis especially following injudicious use of oxygen.
Metabolic acidosis caused by liberation of lactic acid from hypoxic tissues frequently co-
exists with respiratory acidosis and complicates the acid-base abnormality.

E. Management of respiratory failure

1. treatment for underlying disease.
2. treatment for airway obstruction.
3. treatment for hypoxemia.
4. treatment for hypercapnia.

Learning objectives:

You should now be able to:

1. state a general definition for respiratory failure.
2. understand the pathophysiological changes of type I and type II respiratory failure.
3. state the causes and consequences of hypoxemia, hypercapnia and acidosis in respiratory
failure.
4. understand the principles underlying the management of respiratory failure.

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Physiological causes of respiratory failure

Hypoventilation (impaired alveolar ventilation)

Upper airway obstruction, PO2
Weakness/paralysis of respiratory muscles, PCO2
Chest wall injury etc Xintoenough energy to bring air
and out of the lungs,
i.e.: X active respiration

Alveolar ventilation/perfusion mismatching

uneven blockage of airways, uneven flow of air/blood will lead to perfusion mismatching

Chronic obstructive lung disease, PO2

Restrictive disease, PCO2 or n PCO2
Pneumonia etc
inflammation: alveolar filled with lots of fluids

Impaired Diffusion only oxygen diffusion will be affected usually becoz

PO2 diffusion of CO2 is much easier than that of O2
Lung edema, lungs under trauma n PCO2 or PCO2
Adult respiratory distress syndrome (shock lung) ARDS
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Types of Respiratory Failure

Type I gas exchange failure

PO2 < 60 mm Hg
PCO2 < 50 mm Hg

Type II ventilatory failure related to pumping

action of respiratory
system

PO2 < 60 mm Hg
PCO2 > 50 mm Hg

- Bypass vessel, a pathway linking 2 types of blood vessels

- if too much shunt in body, hypoxia

(most common sign)

rapid HR (via chemoreceptors)
- confusion
test the systemic arterial blood

more lactic acid production

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 CO2 level drops

more blood to fill up the heart, higher stroke volume

under organ damage level

damage of the glomerulas, renal problems

high PCO2 level in the body

remove CO2 at a lower rate

in order to control and direct the

blood into regions those are in need
(V/Q mismatching)

skull with fixed capacity,

increased blood supply lead to
an increase in ICP

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 High CO2 value indicates respiratory failure

eg. humidify air for breathing

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 reasofor using 25-30%:
similar to room air

Artificial machine to help breathing

(Positive end-expiratory pressure)

- use pressure to pump the air into patient's
(ARDS) lung
- in expiratory phase: intermittent pumping of air

Learning objectives:

You should now be able to:

1. state a general definition for respiratory failure.

2. understand the pathophysiological changes of

type I and type II respiratory failure.

3. state the causes and consequences of

hypoxemia, hypercapnia and acidosis in
respiratory failure.

4. understand the principles underlying the

management of respiratory failure.
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 Review Questions

Functional residual capacity is the volume at

which
A. The elastic recoil of the lungs vanishes
B. The chest-wall tends neither to contract or
recoil
C. Chest-wall and the lung recoil forces are
equal and opposite
D. Collapse of small airways occurs
E. Chestwall and the lungs are recoiling
inwards
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Which of the following conditions will increase

functional residual capacity?

A. Changing the body position from standing

to supine won't be changed, becoz lung recoil and elasticity are the same
B. Pulmonary fibrosis should be decreased in this case
C. Obesity
D. Emphysema loss of tissue elasticity, recoil presssure of the lung is weaker,
tend to pull the system outward

E. Decreased pulmonary surfactant decrease surface tension,

harder to distend the lungs

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What is the most likely action of surfactant on
the respiratory system?

A. Stimulates the medullary respiratory

centres
B. Increases the strength of the respiratory
muscles
C. Decreases the tissue elasticity of the lungs
D. Decreases the surface tension at the air-
liquid interface of the lungs
E. Decreases the bronchomotor tone of the
airways

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An infant born prematurely is found to have

infant respiratory distress syndrome. Which of
the following would NOT be expected in this
infant?

A. Cyanosis
B. Alveolar collapse high surface tension, easier to collapse
C. Increased lung compliance easy to distend
D. Difficulty in breathing
E. Alveolar edema

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Which of the following is the site of lowest
airway resistance?

A. Nose
B. Mouth
C. Trachea
D. Medium sized bronchi
E. Bronchioles highese total cross-sectional area

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Which of the following will increase airway

resistance?
dilate the vessel, decrease airway resistance

A. Stimulation of the sympathetic nerves to

the bronchial and bronchiolar smooth
muscle
B. Breathing through the mouth instead of the
nose
C. Large lung volume larger lung, larger recoil, increase pull of airway, airway dilated
D. Airway mucosal edema mucosal layer thicker, smaller airway, increase resistance
E. Pulmonary fibrosis

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Which of the following best describes
hypoventilation?

A. Increased arterial PCO2 and decreased

arterial PO2
B. Increased arterial PO2 and decreased
arterial PCO2
C. Increased arterial O2 content
D. Decreased arterial CO2 content
E. Dizziness

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All the following will impair oxygen transfer

across the alveolocapillary membrane EXCEPT

A. Thickening of the membrane by disease

B. Destruction of alveolar membrane by
disease
C. Alveolar edema
D. Pulmonary embolism can impair all gas transfer
E. Exercise

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If an area of the lung is NOT ventilated because
of bronchial obstruction, the pulmonary
capillary blood serving that area will have a PO2
that is

A. Equal to atmospheric PO2

B. Equal to systemic mixed venous PO2
C. Equal to normal systemic arterial PO2
D. Higher than inspired PO2
E. Less than systemic mixed venous PO2

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All of the following cause hypoxemia EXCEPT

A. Hypoventilation
B. Alveolar edema
C. Pulmonary fibrosis
D. Asthmatic attack
E. Anemia will not have hypoxemia, because there is oxygen in blood, but cannot bound with Hb
deficiency of red cells

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Which of the following is a most likely
mechanism for Type I respiratory failure?
Gas exchange failure

A. Deformation of chest wall

B. Respiratory muscle weakness
C. Depression of central drive for respiration.
D. Pulmonary edema
E. Severe airway obstruction

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Spirometry is a useful tool in helping to

distinguish various types of lung disorders.
Airway obstruction is defined by which of the
following?

A. A normal FEV1.0/FVC ratio

B. A FEV1.0 of 45 % of predicted value
C. A supranormal FEV1.0/FVC ratio
D. A decrease in the FEV1.0/FVC ratio
E. A FVC less than 75 % of the predicted value

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