ACUTE RESPIRATORY FAILURE

Rupii
ICU Panti Wilasa Semarang
 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.
 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.”

• Clinically :
Respiratory failure is defined as PaO2 <60 mmHg
while breathing air, or a PaCO2 >50 mmHg.
CAUSES of RESPIRATORY FAILURE
FORMS of ACUTE RESPIRATORY FAILURE

1. Hypoxemic (type I)
– Room air PaO2  50–60 mm Hg (6.7-8 kPa).
– Abnormal PaO2: FiO2 (P/F ratio).
2. Hypercapnic (type II).
– PaCO2  50 mm Hg (6.7 kPa) with pH <7.36
3. Mixed.
HYPOXEMIC RESPIRATORY FAILURE
1. FiO2 <
– eg . High altitude
2. Hypoventilation.
3. V/Q mismatch
4. Impaired gas diffusion
FiO2 <

PAO2 < 80 (104 mmHg)

PACO2=40 mmHg

75% 100%
YPOVENTILATION

PAO2=77 mmHg

PACO2=80 mmHg

75%
89%
 V/Q mismatch

Atelectasis ARDS
Intraalveolar filling Interstitial lung dz
Pneumonia Pulmonary contusion
SHUNT Pulmonary edema DEAD SPACE
V/Q = 0 V/Q = ∞
Pulmonary embolus
Intracardiac shunt
Pulmonary vascular dz
Vascular shunt in lungs
Airway dz
(COPD, asthma)
SHUNTING

75% 75%
EAD SPACE

PAO2=104 mmHg
PACO2=0 mmHg
IMPAIRED GAS
DIFFUSION

PAO2=104 mmHg

PACO2=40 mmHg

75% 90%
 HYPERCAPNIC RESPIRATORY FAILURE

• Acute :
– Arterial pH is low

• Acute on chronic:
– This occurs in patients with chronic CO2 retention
who worsen and have rising CO2 and low pH.
– Mechanism: respiratory muscle fatigue
 CAUSES of HYPERCAPNIC RF
• Respiratory centre (medulla) dysfunction
• Drug over dose, CVA, tumor, hypothyroidism, central
hypoventilation
• Neuromuscular disease
– Guillain-Barre, Myasthenia Gravis, Polio M, Spinal injuries
• Chest wall/Pleural diseases
– kyphoscoliosis, pneumothorax, massive pleural effusion
• Upper airways obstruction
– tumor, foreign body, laryngeal edema
• Peripheral airway disorder
– asthma, COPD
 CLINICAL MANIFESTATION of ARF
• Confusion, somnolence and coma
• Dyspnea
– secondary to hypercapnia and hypoxemia
• Cyanosis
– bluish color of mucous membranes/skin indicate
hypoxemia
– unoxygenated hemoglobin 5 g%
– not a sensitive indicator
• Respiratory distress
• Convulsions
Clinical Manifestation…… (cont’d)

• Circulatory changes
- tachycardia, hypertension, hypotension

• Polycythemia
- chronic hypoxemia - erythropoietin synthesis

• Pulmonary hypertension

• Cor-pulmonale or right ventricular failure

 ASSESSMENT OF PATIENT
• Careful history
• Physical Examination
• BG analysis :
classify RF and help with cause
• Lung function test
• Chest radiograph
• EKG
 Hypoxemic Respiratory Failure
Is PaCO2 ↑
Yes No

Hypoventilation Is (PAO2 - PaO2) 

(PAO2 - PaO2) Yes No

Hypovent plus Is low PO2 Inspired PO2

Hypoventilation correctable
alone another •High altitude
mechanism with O2?
•FIO2
Respiratory drive
Neuromuscular dz No Yes

Shunt V/Q
mismatch
 Hypercapnic Respiratory Failure
PaCO2 >46mmHg
Not compensation for metabolic alkalosis
(PAO2 - PaO2)

normal increased

Alveolar V/Q abnormality

Hypoventilation

Central Neuromuscular V/Q •Hypermetabolism

Hypoventilation Disorder Abnormality •Overfeeding
 Alveolar-Arterial O2 gradient
• Normal P(A-a)O2 gradient: 5-10 mm of Hg
• A sensitive indicator of disturbance of gas
exchange.
• Useful in differentiating extrapulmonary and
pulmonary causes of respiratory failure.
• For any age, an A-a gradient > 20 mm of Hg is
always abnormal.
Management of Respiratory Failure Principles

• Treat the cause

• Supportive treatment
– Improve oxygenation & manage PaCO2
• Oxygen therapy
• Mechanical ventilation
 Ventilate?
• Severity of respiratory failure
• Cardiopulmonary reserve
• Adequacy of compensation
– Ventilatory requirement
• Expected speed of response
– Underlying disease
– Treatment already given
• Risks of mechanical ventilation
• Non-respiratory indication for intubation
 Mechanical Ventilation: Indications
1. PaO2< 55 mm Hg or PaCO2 > 60 mm Hg
despite 100% oxygen therapy.
2. Deteriorating respiratory status despite
oxygen and nebulization therapy
3. Anxious, sweaty lethargic child with
deteriorating mental status.
4. Respiratory fatigue: for relief of metabolic
stress of the work of breathing
 Mechanical Ventilation
Ventilators deliver gas to the lungs
using positive pressure at a certain
rate. The amount of gas delivered
can be limited by time, pressure or
volume. The duration can be cycled
by time, pressure or flow.
Thank you