Respiratory Failure

 Respiratory failure is not a disease per se

but a consequence of the problems that
interfere with the ability to breathe.
 Theterm refers to the inability to perform
adequately the fundamental functions of
respiration: to deliver oxygen to the blood
and to eliminate carbon dioxide from it
Respiratory failure is “inability to maintain either
normal delivery of O2 to the tissues or the
normal removal of CO2 from the tissues”
(Egan’s- 9th edition)

or
Failure of gas exchange due to inadequate
function of one or more essential components
of respiratory system
(Harrison’s principles of internal medicine- 16th edition)

The condition results from imbalance between

respiratory workload and ventilatory strength or
endurance
Respiration

Respiration is gas exchange between

the organism and its environment.
Function of respiratory system is to
transfer O2 from atmosphere to blood
and remove CO2 from blood.
Physiology

Normal respiration requires five separate components

 Nervous system- dorsal and ventral nuclei of

respiratory control group, their afferent and
efferent nuclei
 Musculature- diaphragm, accessory muscles and
chest wall
 Airways- up to the terminal bronchiole
 Alveolar units
 Vasculature
Oxyhemoglobin Dissociation
Respiratory Failure

“inability of the lung to meet the

metabolic demands of the body. This
can be from failure of tissue
oxygenation and/or failure of CO2
homeostasis.”
Respiratory Failure

 Clinically:
Respiratory failure is defined as PaO2 <60 mmHg
while breathing air, or a PaCO2 >50 mmHg.
 RESPIRATORY FAILURE

Hypoxemic Hypercapnic
(Oxygenation Failure) (Ventilatory Failure)
PaO2 < 60 mmHg on 60% PaCO2 > 45 mmHg and
oxygen pH < 7.35

Inhaling Exhaling
Affects PaO2 Affects PCO2

Airway Protection Failure*

*Be aware in trauma patient
Airway Protection Failure
What to do?
What to do?
What to do?
Hypoxemic

Oxygenation Failure
Causes of Oxygenation Failure

 Pneumonia syndromes
 Acute lung injury / ARDS
 Pulmonary edema, alveolar hemorrhage
 Shock syndromes
Nasal Cannula
 A plastic disposable
device consisting of two
tips or prongs 1 cm long,
connected to oxygen
tubing
 Inserted into the vestibule
of the nose
 FiO2 – 24-40%
 Flow – ¼ - 8L/min (adult)
< 2 L/min(child)
Nasal Cannula

Merits Demerits
 Easy to fix  Unstable
 Keeps hands free  Easily dislodged
 Not much interference  High flow uncomfortable
with further airway care  Nasal trauma
 Low cost  Mucosal irritation
 Compliant  FiO2 can be inaccurate
and inconsistent
 Estimation of FiO2 provided by nasal
cannula

O2 Flowrate (L/min Fi O2
1 0.24
2 0.28
3 0.32
4 0.36
5 0.40
6 0.44

Patient of normal ventilatory pattern - each liter/min of nasal O2

increases the FiO2 approximately 4%.
E.g. A patient using nasal cannula at 4 L/min, has an estimated FiO2 of
37% (21 + 16)
Reservoir Mask

 Commonly used reservoir system

 Three types
1. Simple face mask
2. Partial rebreathing masks
3. Non rebreathing masks
Simple face mask

 Reservoir - 100-200 ml
 Variable performance
device
 FiO2 varies with
 O2 input flow,
 mask volume,
 extent of air leakage
 patient’s breathing pattern
 FiO2: 40 – 60%
 Input flow range is 5-8 L/min
 Minimum flow – 5L/min to
prevent CO2 rebreathing
Face mask
Merits
 Moderate but variable FiO2.
O2 Flowrate FiO2
 Good for patients with blocked nasal
passages and mouth breathers (L/min)
 Easy to apply 5-6 0.4
6-7 0.5
Demerits
7-8 0.6
 Uncomfortable
 Interfere with further airway care
 Proper fitting is required
 Risk of aspiration in unconscious pt
 Rebreathing (if input flow is less than 5
L/min)
Reservoir masks

Partial rebreathing mask Nonrebreathing mask

Partial rebreathing mask
 No valves
 Mechanics –
Exhalation Exp: O2 + first 1/3 of
ports exhaled gas (anatomic
+ dead space) enters the
bag and last 2/3 of
exhalation escapes out
through ports
Insp: the first exhaled gas
and O2 are inhaled
O2  FiO2 - 60-80%
 FGF > 8L/min
 The bag should remain
inflated to ensure the
highest FiO2 and to
prevent CO2 rebreathing
Reservoir
Non-rebreathing mask

One-way valves  Has 3 unidirectional valves

 Expiratory valves prevents
air entrainment
 Inspiratory valve prevents
exhaled gas flow into
reservoir bag
 FiO2 - 0.80 – 0.90
 FGF – 10 – 15L/min
O2  To deliver ~100% O2, bag
should remain inflated
 Factors affecting FiO2
 air leakage and
 pt’s breathing pattern
Reservoir
Hypercapnic

Ventilation Failure
Causes of Ventilatory Failure

 Depressed MS
 COPD; UAO
 Weakness, NMS
 Obesity / OSAS
Guidelines for Standards of Care for Patients with
Acute Respiratory Failure On
Mechanical Ventilatory Support

Task Force on Guidelines

Society of Critical Care Medicine

Crit Care Med 1991 Feb; 19(2):275-278

Treatment

 Airway management – ETT if required

 Correction of hypoxemia- goal is to achieve a SaO2 of

>90%, and a PaO2 of >60 mm Hg
- supplemental oxygen
- Non-Invasive Positive Pressure Ventilation (NIPPV)
- intubation and mechanical vent
Treatment

 Correction of coexistent hypercapnia and respiratory

acidosis

 Ventilator management

- non invasive

- invasive
Non-invasive ventilatory support
The application of ventilatory support through a nasal
prong or full face mask in lieu of ETT is being used
increasingly for patients with
 Acute or chronic mild to moderate respiratory failure

 Conscious

 Intact airway

 Intact airway reflexes

The various modes by which NIPPV can be provided

include volume assist control, pressure assist control,
BiPAP, CPAP, etc
Non-invasive ventilatory support

Has proven beneficial in

 acute exacerbations of COPD and asthma,

 decompensated CHF with mild-to-moderate pulmonary
edema,
 pulmonary edema from hypervolemia
 obesity hypoventilation syndrome

Guidelines for noninvasive ventilation in acute respiratory failure. Indian J Crit Care Med 2006;10:117-47
Invasive ventilatory support

 Useful when patient does not respond to non invasive

methods of ventilation

 Indications for IPPV based on specific threshold values

for PCO2 and pH or arterial oxygenation have not been
validated by clinical evidence
Invasive ventilatory support
Indications
 Apnea or bradypnea
 ALI & ARDS
 Severe cardiogenic shock
 Traumatic brain injury
 Brain injury

Indications for Invasive Mechanical Ventilation in Adults with Acute Respiratory Failure
Conference proceedings- Respiratory Care 2002, 47(3)
Non-invasive vs invasive ventilatory
support

 Guidelines for noninvasive ventilation in acute respiratory

failure. Indian J Crit Care Med 2006;10:117-47

 Indications for Invasive Mechanical Ventilation in Adults

with Acute Respiratory Failure Conference proceedings-
Respiratory Care 2002, 47(3)
Non-invasive vs invasive ventilatory
support
 NIV has been shown to be an effective treatment for acute
hypercapnic respiratory failure (AHRF), particularly in chronic obstructive
pulmonary disease (COPD). Facilities for NIV should be available 24 hours
per day in all hospitals likely to admit such patients

 NIV should not be used as a substitute for tracheal intubation and

invasive ventilation when the latter is clearly more appropriate

Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:192–211 (British Thoracic

Society Standards of Care Committee)
Follow up

Complications

 Pulmonary – embolism, barotrauma, fibrosis, cx

secondary to use of mechanical devices, VILI, oxygen
toxicity

 Cardiovascular- hypotension, reduced cardiac output,

arrhythmia, pericarditis, and acute myocardial
infarction.
 Gastrointestinal- hemorrhage, gastric distention,
ileus, diarrhea, and pneumoperitoneum.

 Infectious- pneumonia, urinary tract infections, and

catheter-related sepsis

 Renal - Acute renal failure and abnormalities of

electrolytes and acid-base homeostasis

 Nutritional – malnutrition, hypoglycemia, abd

distension, etc
Tengkyu