Respiratory Failure

Respiratory failure is a clinical condition that happens when the 

respiratory system fails to maintain its main function, which is
gas exchange, in which PaO2 is lower than 60 mmHg and/or
PaCO2 higher than 50 mmHg.
Respiratory failure is classified according to blood gases
abnormalities into type 1 and type 2.
Type 1 - (hypoxemic) respiratory failure has a PaO2 < 60
mmHg with normal or subnormal PaCO2. In this type, the gas
exchange is impaired at the level of aveolo-capillary membrane.
Examples of type I respiratory failures are carcinogenic or non-
cardiogenic pulmonary edemaa, ARDs, COVID-19 and severe 
pneumonia.
Type 2 - (hypercapnic) respiratory failure has a PaCO2 > 50
mmHg. Hypoxemia is common, and it is due to respiratory
pump failure.
•RF a major cause of mortality and morbidity and mortality
rates increase with age and presence of co-morbidities.
PATHOPHYSIOLOGY
Hypoventilation: in which PaCO2 and PaO2 and alveolar-arterial PO2 gradient (difference
between the calculated oxygen pressure available in the alveolus and the arterial oxygen tension,
measures the efficiency of gas exchange). are normal. Depression of CNS from drugs (eg 
opiod use disorder) is an example of this condition.
V/P mismatch: this is the most common cause of hypoxemia. Administration of 100% O2
eliminates hypoxemia.
In respiratory physiology, the ventilation/perfusion ratio (V̇/Q̇ ratio or V/Q ratio) is a ratio used to
assess the efficiency and adequacy of the matching of two variables:V (ventilation) the air that
reaches the alveoli; Q (perfusion) the blood that reaches the alveoli via the capillaries. V/Q ratio is
defined as the ratio of the amount of air reaching the alveoli per minute to the amount of blood
reaching the alveoli per minute. These two variables, V & Q, constitute the main determinants of the
blood oxygen (O2) and carbon dioxide (CO2) concentration.
1.Type I respiratory failure involves low oxygen, and normal or
low carbon dioxide levels. Occurs because of damage to lung
tissue eg including pulmonary oedema, pneumonia, acute
respiratory distress syndrome, and chronic pulmonary fibrosing
alveoloitis. This lung damage prevents adequate oxygenation of
the blood (hypoxaemia); however, the remaining normal lung is
still sufficient to excrete the carbon dioxide being produced by
tissue metabolism. This is possible because less functioning
lung tissue is required for carbon dioxide excretion than is
needed for oxygenation of the blood.
Type II respiratory failure involves low oxygen, with high carbon dioxide (pump
failure). It occurs when alveolar ventilation is insufficient to excrete the carbon
dioxide being produced. The most common cause is chronic obstructive pulmonary
disease (COPD). Others include chest-wall deformities, respiratory muscle weakness
(e.g. Guillain-Barre syndrome) and central depression of the respiratory centre (e.g.
heroin overdose) Inadequate ventilation is due to reduced ventilatory effort, or
inability to overcome increased resistance to ventilation – it affects the lung as a
whole, and thus carbon dioxide accumulates. Complications include: damage to vital
organs due to hypoxaemia, CNS depression due to increased carbon dioxide levels,
respiratory acidosis (carbon dioxide retention). This is ultimately fatal unless treated.
Complications due to treatment may also occur.
Epidemiology
Overall frequency of respiratory failure is not well known as
respiratory failure is a syndrome not a single disease process
Respiratory failure may be due to pulmonary or extra-
pulmonary causes which include:
1-CNS causes due to depression of the neural drive to breath as
in cases of overdose of a narcotic and sedative.
2-Disorders of the peripheral nervous system: Respiratory
muscle and chest wall weakness as in cases of Guillian-Barre
syndrome and myasthenia gravis.
3-Upper and lower airways obstruction: due to various
causes as in cases of exacerbation of 
chronic obstructive pulmonary diseases and acute severe
bronchial asthma
4-Abnormities of the alveoli that result in type 1 (hypoxemic)
respiratory failure as in cases of pulmonary edema and severe 
pneumonia
Clinical Presentation
Presentation of respiratory failure is dependent on the
underlying cause and associated hypoxemia or hypercapnia.
Common presentations include:
•Dyspnoea
•Tachypnoea
•Restlessness
•Confusion
•Anxiety
•Cyanosis- central
•Tachycardia
•Pulmonary hypertension
•Loss of consciousness
Signs and symptoms of RF Type I (Hypoxemia) include:
•Dyspnea, irritability
•Confusion, fits, somnolence
•Tachycardia, arrhythmia
•Tachypnea
•Cyanosis
Signs and symptoms of RF Type II (Hypercapnia) include
•Change of behavior
•headache
•Coma
•Warm extremities
•Astrexis
•Papilloedema
Symptoms and signs of the underlying disease:eg
•Fever, cough, sputum production, chest pain in cases of
pneumonia.
•History of sepsis, polytrauma, burn, or blood transfusions
before the onset of acute respiratory failure may point to 
acute respiratory distress syndrome
Evaluation:
Arterial blood gases- measures oxygen and carbon dioxide levels in the blood
Renal function tests and liver function tests- may indicate the etiology of respiratory failure or identify
complications associated with it.
Pulmonary Function Test- identifies obstruction, restriction, and gas diffusion abnormalities. Normal values
for forced expiratory volume in 1 second(FEV1) and forced vital capacity(FVC) suggest a disturbance in
respiratory control. Decrease in FEV1 to FVC ratio indicates airflow obstruction. A decrease in FEV1 and
FVC and maintenance of FEV1 to FVC ratio suggest restrictive lung disease.
Electrocardiography(ECG)
Chest radiography is needed as it can detect chest wall, pleural and lung parenchymal Lesions.
Other investigations needed for detecting the underlying cause of the respiratory failure may include:
Complete blood count (CBC)
Sputum, blood and urine culture
Blood electrolytes and thyroid function tests
Echocardiography
Bronchoscopy
Complications:
Pulmonary: pulmonary embolism, pulmonary fibrosis, complications secondary to the
use of mechanical ventilator
Cardiovascular: hypotension, reduced cardiac output, cor pulmonale, arrhythmias,
pericarditis and acute myocardial infarction
Gastrointestinal: haemorrhage, gastric distention, ileus, diarrhoea, pneumoperitoneum
and duodenal ulceration- caused by stress is common in patients with acute respiratory
failure
Infectious: noscomial- pneumonia, urinary tract infection and catheter-related sepsis.
Usually occurs with use of mechanical devices.
Renal: acute renal failure, abnormalities of electrolytes and acid-base balance.
Nutritional: malnutrition and complications relating to parenteral or enteral nutrition
and complications associated with NG tube- abdominal distention and diarrhea
MANAGEMENT
1-Correction of Hypoxemia
•The goal is to maintain adequate tissue oxygenation, generally
achieved with an arterial oxygen tension (PaO2) of 60 mm Hg
or arterial oxygen saturation (SaO2), about 90%.
•Un-controlled oxygen supplementation can result in oxygen
toxicity and CO2 (carbon dioxide) narcosis. Inspired oxygen
concentration should be adjusted at the lowest level, which is
sufficient for tissue oxygenation.
•Oxygen can be delivered by several routes depending on the
clinical situations in which we may use a nasal cannula, simple
face mask nonrebreathing mask, or high flow nasal cannula.
•Extracorporeal membrane oxygenation may be needed in
refractory cases
2-Correction of hypercapnia and respiratory acidosis
•This may be achieved by treating the underlying cause or
providing ventilatory support.
3. Ventilatory support for the patient with respiratory
failure
The goals of ventilatory support in respiratory failure are:
•Correct hypoxemia
•Correct acute respiratory acidosis
•Resting of ventilatory muscles.
Non-invasive respiratory support: is ventilatory support
without tracheal intubation/ via upper airway. 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, duration of
ICU stay and mortality(). It has been suggested that NIPPV is
more effective in preventing endotracheal intubation in acute
respiratory failure due to COPD than other causes. The etiology
of respiratory failure is an important predictor of NIPPV failure
Invasive respiratory support: indicated in persistent
hypoxemia despite receiving maximum oxygen therapy,
hypercapnia with impairment of conscious level. Intubation is
associated with complications such as aspiration of gastric
content, trauma to the teeth, barotraumas, trauma to the trachea
etc