Respiratory Failure

GROUP A5
Objectives and ILOs

1) introduction to respiratory system and its function

2) respiratory failure definition
3) respiratory failure types
4) etiology of each type of respiratory failure
5) clinical presentation of respiratory failure
6) investigations done
7) management of respiratory failure cases
1) introduction to respiratory system :

 Normal physiology of respiratory system :

 respiratory processes :
 Respiratory system function :

 The main function of respiratory system is gas exchange by mean of entering O2

to the body and getting rid of co2 so that maintain the functions of different
body parts
 And that can be done at the alveoli through :
1) ventilation
2) perfusion
3) diffusion
Firstly, ventilation :
 Definition : it is the flow of air in and out of the alveoli
 Factors affecting ventilation :
1) air ways diameter and alveoli compliance
2) pleural compliance
3) chest wall
4) nervous system
2) Perfusion :
 Definition : it is the flow of blood through the lung and it's distribution
 _ it is affected by pulmonary circulation including arterioles and capillaries

3) Diffusion :
 Definition : it is the exchange of O2 and co2 between blood capillaries and alveoli
 Factors affecting diffusion :
 1) ventilation perfusion matching
 2) surface area of alveolocapillary membrane
 3) thickening of alveolocapillary membrane
 Definition

• The term respiratory failure is used when pulmonary gas exchange fails to maintain normal
arterial oxygen and carbon dioxide levels.

• It’s classified into types 1 and 2 according to the absence or presence of hypercapnia
 Respiratory Failure Type 1

• Hypoxia, PaO2 < 60 mmhg

• Normo or hypocapnia, Paco2: 45 mmhg

 Pathophysiology

 Hypoxia:

• Due to diffusion defect, insult is usually in alveoli, impairment of gas exchange, usually because of decreased surface
area due to damage of the alveolar wall or consolidation, etc.

 Normo or hypocapnia

• Diseases causing RFT1 include those that impair ventilation locally with sparing of other regions
• Admixture of blood from the under ventilated and normal regions thus results in hypoxia with normo-capnia.
• Hypoxia is uncorrected as haemoglobin is already saturated
• Carbon dioxide is thirty times more diffusible than oxygen
• Hypoxia leads to increased ventilation, eventually washing of excess co2
 Etiology and causes:
Acute Chronic

H+ Normal Normal

Bicarbonate Normal Normal

Causes Pulmonary oedema emphysema

Pneumonia Lung fibrosis
Lobar collapse Right-to-left shunts
Pneumothorax
Pulmonary embolus
ARDS
Respiratory failure type 2

 Hypoxia,, PaO2 < 60 mmhg

 Hypercapnia , PaCO2 > 50 mmHg
 
Mainly due to disturbed ventilation

 Ventilatory failure is a rise in PaCO2 (hypercapnia) that occurs when the

respiratory load can no longer be supported by the strength or activity of
the system and that leads finally to hypoventilation and RF type 2
Aetiology and causes

RF type 2 occurred due to ventilation disorders (hypoventilation).

1. Airflow limitation .
2. CNS causes
3. Ventilatory pump limitations
  Airflow limitation.

 Upper airway obstruction

 Laryngeal oedema , tracheal obstruction , foreign body , or any tumor of
upper respiratory tract .
 
 Lower airway obstruction .
 COPD
 Bronchial asthma
 Bronchial tumours .
 CNS causes ( leads to respiratory centre depression )


 Cerebral stroke , Tumor , Trauma
 Drugs that depress the respiratory center. E.g. morphine , barbiturate
 Central sleep apnea syndrome
 Other neurological causes : gullian barie syndrome , polio

Ventilatory pump limitation .

 Neuromuscular : myopathy, neuropathy , myasthenia gravis .
 Chest wall deformity : kyphoscoliosis
 Pleural diseases :. Massive pleural effusion , pneumothorax ,
Clinical presentation of
Respiratory failure
 There are 2 picture of respiratory failure :
 picture of hypoxia
 Picture of hypercapnia
Picture of hypoxia

 4 C & 1 S.

• Central cyanosis.
• Chest manifestation :
 ** tachypnea with type 1 RF
 ** dyspnea
• CNS manifestations:
 ** Irritability
 ** Loss of concentration.
 ** Convulsion .
 ** Comma .
 CVS manifestation:
** core pulmonale
** cardiac arrest

 Secondary polycythemia
Clinical picture of hypercapnia

 CNS manifestation:

** co2 narcosis:
coma
confusion
** cerebral vessels dilatation so increase intracranial pressure which causes
headache, blurring of vision .

** sympathetic stimulation so pupillary dilatation.

 CVS manifestation:
• ** Vasodilation which causes :
• Hyperdynamic circulation
• Congested conjunctiva
How to diagnose respiratory failure?

 Respiratory failure is not a clinical syndrome.

 SO, Its diagnosis is classified into two categories:
1. Diagnosis of hypoxia and hypercapnia by:
 Clinical picture
 Arterial blood gases
2. Diagnosis of the causative disease. (The most common cause
COPD)
Diagnosis of hypoxia and hypercapnia

 Arterial blood gases (ABG) is mandatory to confirm the diagnosis of respiratory failure as
it measures oxygen and carbon dioxide levels in the blood and also gives information
about acid-base balance.
Arterial blood gases Type I Type II

PaO2 Very low Low

PaCO2 Normal or low High

PH Normal or low Low

HCO3 Normal Normal

 Pulse oximetry: is used in monitoring of respiratory failure

Pulse oximeter is attached to ear lobe or finger.

It shows arterial oxygen saturation.
However it may be inaccurate
in those patients with poor peripheral perfusion.
Investigations needed for detecting the underlying
cause of the respiratory failure these may include:

 Chest radiography is needed as it can detect chest wall, pleural and lung parenchymal Lesions
 Renal function tests and liver function tests- may indicate the etiology of respiratory failure or
identify complications associated with it.
 Pulmonary function tests- spirometry: it measures vital capacity (VC) and forced expiratory volume in
1 second (FEV1). This permits differentiation between restrictive and obstructive respiratory diseases. 
 Complete blood count (CBC): secondary polycythemia
 Sputum, blood and urine culture
 Blood electrolytes and thyroid function tests
 Electrocardiography (ECG) : p-pulmonale, RVE in cor pulmonale
 Echocardiography: to assess cardiac function
 Bronchoscopy
How to deal with
respiratory failure??!!
Managemen
t of
respiratory
failure :

• ABC’s assessment
• Airway maintenance and regular suction
• Breathing
• Circulation
•2. Treatment of underlying
causes:
• Bronchodilators
• Corticosteroids
• Broad spectrum
antibiotics
• Duritics
•2. Oxygen therapy:
• High concentration with type 1
respiratory failure > 35% . By
simple mask
• Low concentration oxygen (24-
28) % in type 2 respiratory
failure. By nasal cannula or
Venturi mask.
•Why????!!!!!!!
• High concentration of O2 with
hypercapnia can cause deterioration
because it reduces the drive to
breathing in patients whose central
response to CO2 is diminished or
absent.
•Oxygen is given to reduce hypoxia but it
should be administered in a low dose
that there should be no total correction
of hypoxia and no loss of hypoxic drive.
•Aim of therapy??!!!
•Is to raise the PO2 to 55 -60 mmHg ,
monitor by ABG , if still less than 55
mmHg increase the O2 flow and
measure ABG every 30 mins for the first
1-2 hours until PO2 at least is 55 mmHg
and CO2 narcosis is not developing.
Types of oxygen therapy
•4. Mechanical ventilation:
Whyyy??!
•When patients continue to deteriorating of
failure of improving with oxygen therapy
Aim:
• Respiratory support
• CO2 elimination
• Gives relief from exhaustion by giving rest to
respiratory muscles.
•Types:
• Non –invasive: supported by only face mask
without intubation. Patient should be:
• Conscious
• Cooperative
• Breath spontaneously
•Types of non invasive mechanical ventilation:
• CPAP to treat hypoxia.
• BiPAP to treat hypoxia and hypercapnia.
CPAP vs BiPAP
•5. Invasive mechanical ventilation:
•With endotracheal tube.
•Indications:
• No respiratory to the previous management.
• Severe cases as:
• Severe pulmonary edema.
• ARDS
• Massive hemoptysis
• Cardiac arrest
•Types:
• Full support :
• Not allowed spontaneous breathing.
• Patient is deeply sedative with short acting IV
anesthesia and muscle relaxers.
• Partial support:
• Patient owns breathing
• Doesn't require anesthesia
ANY QUESTIONS?
THANK YOU