COLLEGE OF ALLIED MEDICAL PROFESSIONS

Department of Pharmacy
CLINICAL PHARMACY

ILARDE, Kryzzle Princess V.

ClinPhar 5A

ACUTE RESPIRATORY FAILURE

I.INTRODUCTION
The respiratory system primarily functions to provide adequate oxygenation and carbon dioxide
elimination for the purposes of sustaining aerobic metabolism and pH homeostasis.

GAS EXCHANGE PROCESS

-is performed automatically by the lungs and respiratory system. How it works:
1 the air, containing oxygen and other gases, comes into the body through the lungs.
2 in the lungs, the oxygen is moved into the bloodstream and carried through the body (PULMONARY
VEIN)
3 Red blood cells collect the carbon dioxide and transport it back to the lungs, where it leaves the body
when we exhale. (PULMONARY ARTERY)

***ALVEOLI- facilitate the exchange of oxygen and carbon dioxide

ACUTE RESPIRATORY FAILURE (ARF)

-is characterized by an acute lack of oxygen transfer to the blood by the respiratory system or acute
failure of the respiratory system to remove carbon dioxide (CO2) from the blood.
- occurs within minutes and hours and is usually an emergency.

CLASSIFICATION of ARF:
1. Type 1 (Hypoxemic) - PaO2 < 60 mmHg while breathing in room air
and the PaCO2 is normal or low
2. Type 2 (Hypercapnic) - PaCO2 > 50 mmHg accompanied by a low PaO2
and usually with pH <7.35

II. PATHOPHYSIOLOGY (HYPOXEMIA)

 Ventilation/ Perfusion Mismatch (V/Q)
V: amount of gas that reaches the alveoli
Q: Volume of blood perfusing the lungs
When your lungs are functioning properly, 4 liters/min of air enter your respiratory tract (V)
while 5 liters/min of blood go through your capillaries (Q) every minute for a V/Q ratio of 0.8. A
number that’s higher or lower is called a V/Q mismatch.
E.g.
LOW VENTILATION
 Pneumonia- alveoli are filled with exudate, limiting the ability to maintain
ventilation.
LOW PERFUSION
  Pulmonary Embolism- can result in reduced perfusion of the lungs. Areas of
the pulmonary circulation are obstructed, limiting blood flow to alveoli.
 Intrapulmonary Shunting
-persistent hypoxemia despite 100% O2 inhalation. In cases of intrapulmonary shunt, the
deoxygenated blood bypasses the alveoli without being oxygenated and mixes with oxygenated
blood that has flowed through the ventilated alveoli, and this leads to hypoxemia

***V/Q mismatch & Intrapulmonary Shunting

Example:
Acute Respiratory Distress Syndrome (ARDS)
-commonly encountered in intensive care units (ICU). It can be caused by several
triggers, including pneumonia or trauma.
-ARDS results in severe hypoxemia, which is refractory to oxygen treatment and
requires assisted ventilation.

PATHOPHYSIOLOGY (HYPERCAPNIA)
-usually results from alveolar hypoventilation, which may or may not be accompanied by V/Q
mismatching and intrapulmonary shunting.

 Alveolar Hypoventilation
- Insufficient ventilation of the alveoli, resulting in both an increase in Paco2  and a decrease
in  Pao2 and any increase in the PaCO 2, if not accompanied by an increase in [HCO3−], leads to a
measurable drop in the pH.
III. ETIOLOGY

HYPOXEMIA HYPERCAPNIA
Pneumonia COPD
Pulmonary Edema Asthma
Pulmonary Embolism Brain: Drug overdose (narcotic and sedative)
ARDS Spinal Cord: Guillain-Barré syndrome
Neuromuscular system: Myasthenia gravis
Pleura: Pleural effusion
Upper airway obstruction: Sleep apnea

IV. RISK FACTORS

 Family history of respiratory disease
 Tobacco smoking
 Injury to the spine, brain, or chest
 Compromised immune system
 Chronic respiratory problems, such as cancer of the lungs, chronic obstructive pulmonary
disease (COPD), or asthma
 Pulmonary infections (influenza and pneumonia)

V. SIGNS AND SYMPTOMS

Parameter Hypoxemia Hypercapnia

Sensorium Restlessness Headache
Confusion Altered Level Of Consciousness
Poor judgement Coma
Coma
Respiration Dyspnea Dyspnea
Skin Cyanosis Flushed
Pale skin & nail beds Warm
Moist
Cardiovascular Slight hypertension & Tachycardia Hypertension & Tachycardia
or
Hypotension & Bradycardia

VI. DIAGNOSIS
 FIRST TESTS TO ORDER:
Pulse oximetry- provides noninvasive measurements of capillary oxygen saturation (SpO2) using
transmitted and absorbed light sources. Low SpO2 or temporarily decreasing SpO2 of <80% are
associated with respiratory failure.

Arterial Blood gas analysis- should be obtained as soon as possible after an ABCDE assessment has been
made.
-Analysis provides sensitive measures of pulmonary function.
NORMAL VALUES:
pH: 7.35-7.45
Partial Pressure of oxygen (PaO2): 75-100 mmHg
Partial Pressure of carbon dioxide (PaCO2): 35-45 mmHg

OTHER TESTS TO CONSIDER:

Capnography – it measures expired CO2 and reflects arterial CO2. Measurements are dependent on
pulmonary perfusion status (cardiac output and alveolar blood flow patterns).

Chest-Xray Findings

 Clear CXR with hypoxemia and normocapnia - Pulmonary embolus

 Diffusely white (opacified) CXR with hypoxemia and normocapnia - ARDS, CHF, pulmonary
fibrosis
 Localized infiltrate - pneumonia, atelectasis
 Clear CXR with hypercapnia - Drug overdose (narcotic, sedative), neuromuscular weakness
V/Q lung scan- is a type of medical imaging using scintigraphy and medical isotopes to evaluate the
circulation of air and blood within a patient's lungs, in order to determine the ventilation/perfusion
ratio.
VII. MANAGEMENT
Management of ARF focuses on:
 Optimizing oxygen delivery to tissues by ensuring airway management, oxygenation and
ventilation (if indicated).
 Appropriate management of the underlying cause
NON-PHARMACOLOGIC
Airway, Breathing, Circulation, Disability, Exposure (ABCDE) assessment
-is the first step of management for all patients, and these should be reassessed regularly
throughout treatment.
***Rapid deterioration, vital organ compromise, and/or loss of the airway/gag reflex indicates
the need for endotracheal intubation.

Mechanical ventilation
Non - invasive (if patient can protect airway and is hemodynamically stable)
-is a ventilatory support without tracheal intubation
-Considered in patients with mild to moderate respiratory failure.
-Patients should be conscious, have an intact airway and airway protective reflexes.
-Noninvasive positive pressure ventilation (NIPPV) has been shown to reduce
complications and duration of ICU stay and mortality.
-Mechanical Ventilation with Positive end-expiratory pressure (PEEP) - is widely used
to improve oxygenation and prevent alveolar collapse in mechanically ventilated
patients with the acute respiratory distress syndrome (ARDS).

Invasive - indicated in persistent hypoxemia despite receiving maximum oxygen therapy &
hypercapnia with impairment of conscious level.

 Endotracheal tube
 Tracheostomy – if upper airway is obstructed
-involves surgically creating a hole in the front of your neck and
into your windpipe. A tube called a tracheostomy is put into the
hole to improve your breathing. You may also receive oxygen
therapy through a tracheostomy

Supplemental Oxygen
- Should be administered as part of, or immediately after, the initial ABCDE assessment.
- Patients (conscious or unconscious) with spontaneous respiration and intact airways can be
maintained on supplemental oxygen providing there is no vital organ compromise and the
airway/gag reflex remains intact.
 - COPD and chronically elevated carbon dioxide partial pressure- Care is required when
providing supplemental oxygen as these individuals are dependent on central oxygen receptors
detecting hypoxemia to drive ventilation. Acutely increasing blood oxygen levels in these
patients can lead to respiratory depression.
PHARMACOLOGIC
Treatment of underlying condition when possible
Infection
-Antimicrobials
Airway obstruction
- Mucolytic- NAC
-Bronchodilators:
B-2 agonist  Salbutamol
Anticholinergics Ipratropium
Xanthine Derivatives  Theophylline
-Corticosteroids: Methylprednisolone
Pulmonary Edema
-Diuretics: Furosemide, Bumetanide
Pulmonary Embolism
-Anticoagulants
-Thrombolytics

VIII. PATIENT COUNSELING

 Monitoring and continued medical management of patients with relevant chronic lung disease
(e.g., asthma) helps to limit acute exacerbations and reduces the risk of respiratory failure.
 Maintaining influenza and pneumococcal vaccinations is also extremely important for those with
conditions that predispose to respiratory disease or disorders.
 Smoking cessation for all patients with lung disease limits the progression of pulmonary
dysfunction.

REFERENCES
Epocrates: Acute Respiratory Failure Retrieved: February 11, 2019
https://online.epocrates.com/diseases/85311/Acute-respiratory-failure/Key-Highlights
BMJ Best Practice: Acute Respiratory Failure Retrieved: February 11, 2019
https://bestpractice.bmj.com/topics/en-gb/853/aetiology#referencePop1
https://emedicine.medscape.com/article/167981-medication#3
https://www.mcgill.ca/criticalcare/teaching/files/acute
https://www.ncbi.nlm.nih.gov/books/NBK526127/
https://journals.lww.com/ajnonline/Citation/2003/07000/Inhaled_Epoprostenol__An_approach_to_the
_treatment.48.aspx?trendmd-shared=0
https://www.youtube.com/watch?v=HqHH_N02yNo
https://www.youtube.com/watch?v=3uc12D1Q8N4
https://www.uspharmacist.com/article/treatment-considerations-for-acute-respiratory-distress-
syndrome