Respiratory Failure

Handoko T, MD

Respiratory and Sleep Medicine

SubDepartment of Pulmonology and Allergy
Dr. Ramelan Navy Hospital, Surabaya

Definition
Impairment in gas exchange to a level that
causes
a significant potential for
morbidity & mortality
Rule of fifty
PaO2

< 50 mmHg (breathing room

air)
PaCO2 > 50 mmHg
Manifestation
Acute respiratory failure (ARF)
Chronic Respiratory Failure (CRF)

Clinical presentations
Hypoxic-hypo/normocapnic RF
PaO2 < 55-60 mmHg, normal/low
PaCO2
V/Q missmatch, Physiologic R-L shunt
Without prior underlying lung disease
Eg. ALI, ARDS, P. carinii pneumonia

Hypoxic-hypercapnic RF
PaO2 < 55-60 mmHg, PaCO2 > 50
mmHg
Alveolar hypoventilation, V/Q
missmatch
Chronic underlying lung disease

Etiology
1. Alveolar hypoventilation
Hypoxia secondary to inadequate
ventilation
P(A-a)DO2 > 20 mmHg
2. V/Q missmatch
Inhomogeneity in the distribution of V &
Q
Hypoxia from underventilated area of
the lung
3. Shunt
Passage of blood from venous to arterial
system
without traveling through any
ventilated area

Common causes of ARF

Airflow obstruction

Pulmonary Vascular Disease

Status asthmaticus
AECOPD
Foreign body aspiration
Upper-airway obstruction
Acute epiglottitis
Laryngeal edema
Alveolar-Filling processes
Pneumonia
Pulmonary edema
Cardiogenic
syndrome
Non-cardiogenic
Intra-alveolar hemorrhage
Aspiration
Interstial Lung disease

Pulmonary thromboembolism
Fat embolism
Amniotic fluid embolism
Pulmonary vasculitis
Neuromuscular Disease
Narcotics/sedative drug overdose
GBS, ALS
Phrenic nerve, spinal cord injury
Stroke
Obesity/hypoventilation
Chest wall/pleural disease
Pneumothorax, Flail Chest
Large pleural effusion, Hemothorax
Miscellaneous

Pulmonary fibrosis
Toxic inhalation injury
Sarcoidosis
Smoke inhalation, CO poisoning
Collagen Vascular lung disease
Metabolic dearrangement
Hypersensitivity pneumonitis
Hypophosphatemia, Severe

Clinical Evaluation
History
1. Assessment of the rapidity of symptom
onset
2. Assessment of the presence of
underlying lung,
cardiovascular,
neuromuscular disorders
3. Information about past episodes of RF
4. Current medications
5. Potential toxic exposures
6. Recent illnesses
7. Recent trauma

Symptoms
1. Dyspnea, more common in hypoxic RF
2. Hypoxic-hypercapnic RF Somnolence &
lethargy in the absent of dyspnea
3. Confusion & disorientation in severely
hypoxic pts
4. Headache in hypercapnic pts due to
cerebral blood vessel dilatation 2nd to
PaCO2
5. Chest pain, nausea, diaphoresis in
LVH dysfunction
6. Pleuritic chest pain in pneumothorax / PE
7. Fever, malaise, purulent sputum in

Signs
1. Vital signs
2. Skin: cyanosis, diaphoresis
3. Nasal flaring, dry mucous membrane
4. Neck: accessory muscle, JVP
5. Lung: wheezing, breath sounds,
bronchial BS
6. Heart: S3 Gallop, murmur,
7. Abdomen: hepatomegaly, ascites, HJR,
paradoxical movement of abdominal
muscle
8. Extremities: Clubbing, peripheral
edema

Laboratory studies
1. Arterial blood gas analysis
2. Chest Rontgenogram
3. Other laboratory tests
* Electrocardiogram
* Complete Blood Count
* Electrolyte panel
* Sputum gram stain
* V/Q scan
* Carboxyhemoglobin level

Treatment
Initial priorities
1. Airway
2. Ventilation
3. Oxygenation
4. Circulation
General measures
VS, SaO2, Cardiac monitor, IV access,
ECG,
Laboratory analysis (ABG, CBC, RF,

Treatment
Therapy directed at specific causes of ARF
1. Airflow obstruction
2. Left ventricular failure
3. Pneumonia
4. Pulmonary embolism
5. Pneumothorax
6. Large pleural effusion
7. Acute toxic inhalation injury

Disposition
Nearly all patients with evidence of ARF by
ABGs in the ED should be admitted to the
hospital for further evaluation and
treatment
Pts should be admitted to the ICU if:
a. Intubated
b. Clinically unstable requiring close
supervision/ continuous SaO2 /ECG
monitoring
c. High FiO2 requirements (> 0.5 to
maintain
SaO2 > 90%
d. Persistent respiratory acidosis (pH<7.30