respiratory failure

1. PHYSIOTHERAPY IN CARDIOPULMONARY CONDITION (402)
RESPIRATORY FAILURE
Submitted by – ANHA ALI BPT 4th yr
Submitted to – DR. JAMAL MOIZ
Date of presentation – 29-12-2020

2. RESPIRATORY FAILURE DEFINATION -
• It is a clinical condition which occur when respiratory system fails to maintain its normal gaseous
exchange function
• In respiratory failure PaO2 lower then 60 mmHg (normal 75-100 mmHg) and PaCo2 higher than 50
mmHg (normal 35- 45)
Respiratory failure may be Acute or Chronic
ACUTE RF - short term condition occur suddenly and treated as medical emergency show symptoms like
loss of consciousness, rapid and shallow breathing. racing heart, irregular heartbeats (arrhythmias) e.g. ARDS
CHRONIC RF – ongoing condition worsen over time , shows symptoms like coughing of mucus, wheezing,
dyspnea, bluish skin, lip or fingernails
Condition causing chronic RF – COPD, Cystic fibrosis, drug or alcohol misuse, muscular dystrophy
CONDITION CAUSING RESPIRATORY FAILURE
1. Conditions that affects the flow of blood into the lungs:
Pulmonary embolism
2. Conditions that affects the muscles and nerves that control breathing
• Muscular dystrophy – inherited non inflammatory progressive muscular disorders cause
progressive weakness of muscles
• Amyotrophic lateral sclerosis (ALS) is a progressive neurological disease that affect nerve
cells responsible for controlling muscles movement
• SCI

3. 3. Conditions that affect the area of brain that control breathing (Medulla oblongata)
Stroke
4. Conditions that affect the flow of air in and out of the lungs
COPD
5. Conditions that affects gas exchange in the alveoli (air sacs)
6. ARDS (acute respiratory distress syndrome) caused by increase in permeability of alveolar capillary barrier,
leading to an influx into alveoli.
7. Pneumonia
CLASSIFICATION
Respiratory failure is classified according to blood gases abnormalities into type 1 and type 2.
• Type 1 – (hypoxemic) respiratory failure is failed oxygenation and has a PaO2 < 60 mmHg with normal or
subnormal PaCO2. It caused by failure of gas exchanging function of respiratory system can be acute
(pneumonia) or chronic (COPD)
• Type 2 – (hypoxemic and hypercapnic) RF is a failed ventilation, represented by PaCO2 > 50 mmHg as
well as hypoxemia. It is caused by failure of respiratory pump and can be acute (e.g. severe acute asthma )
or chronic (blue bloater type of COPD, severe restrictive disease, Pick- wickian syndrome).
Type 2 RF also known as ventilatory failure and is a clinical manifestation of impaired central
respiratory drive, muscles weakness or fatigue (respiratory muscles strength falling below 30% of normal)
MORTALITY RATE
• Mortality rates increase with age and presence of co-morbidities.

4. Pathophysiology
Respiratory failure can arise from an abnormality in any of the components of the respiratory system, including
the airways, alveoli, central nervous system (CNS), peripheral nervous system, respiratory muscles, and
chest wall.
1. Hypoxemic respiratory failure
The pathophysiologic mechanisms that account for the hypoxemic RF includes V/Q mismatch and Shunt
 V/Q (ventilation-to-perfusion ratio) MISMATCH –
• Most common cause of hypoxemia
• The low-V/Q units contribute to hypoxemia and hypercapnia
• The low V/Q ratio may occur either from a decrease in ventilation secondary to airway or interstitial lung
disease or from over perfusion in a case of pulmonary embolism
 SHUNT
• Pathological condition in which the alveoli are perfused but not ventilated
• In cases of a shunt, the deoxygenated blood (mixed venous blood) bypasses the alveoli without being
oxygenated and mixes with oxygenated blood that has flowed through the ventilated alveoli, and this leads to
hypoxemia as in cases of pulmonary edema, pneumonia and atelectasis
• There is persistent hypoxemia despite 100% O2 inhalation.
2. Hypercapnic respiratory failure
• At a constant rate of carbon dioxide production, PaCO2 is determined by the level of alveolar ventilation
according to the following equation
• PaCO2 = VCO2 × K/VA, where K is a constant (0.863)
• The relation between PaCO2 and alveolar ventilation is hyperbolic., as ventilation decreases below 4-6
L/min, PaCO2 rises precipitously.

5. • Alveolar ventilation decreases due to reduction in overall (minute) ventilation or an increase in the
proportion of dead space ventilation.
• Decrease minute ventilation results of neuromuscular disorders and CNS depression.
• Severe airway obstruction is a common cause of acute and chronic hypercapnia.
Etiology
• Drug overdose - CNS causes due to depression of the neural drive to breath as in cases of overdose of
a narcotic and sedative.
• Peripheral nerve disorders - Respiratory muscles and chest wall weakness
• COPD and acute sever bronchial asthma
• Pulmonary edema and severs pneumonia
Clinical Presentation
Common presentation include:
• Dyspnea
• Tachypnoea
• Confusion
• Restlessness
• Anxiety
• Cyanosis- central
• Pulmonary hypotension

6. Signs and symptoms of RF Type I (Hypoxemia) include
• Dyspnea, irritability
• Confusion
• Tachycardia, arrhythmia
• Tachypnea
• Central Cyanosis
Signs and symptoms of RF Type II (Hypercapnia) include:
• Change of behavior
• Papilloedema
• Astrexis – tremors of hand when wrist extended
Pneumonia show symptoms of fever, cough, sputum production, chest pain
ARDS show symptoms of shortness of breath, sepsis, tachycardia, low BP etc.
DIAGNOSTIC ASSESMENT
• History – Dyspnea, fatigue, anxiety
• Physical examination - cyanosis, JVP
• ABG – PaCo2 > 50mmHg , pO2 < 60 mmHg (acute RF), Pulse oximetry
• PFT – FEV1/FVC > 70- 75%, pH < 7.35
• Renal function tests – increase in serum ceratinine or urine output decrease per hour or anuria for > 12hr
• Liver function test, ECG
• Sputum – yellowish to brownish (due to bacterial growth in moderate to severe COPD)
• Chest X ray

7. TREATMENT AND MANAGEMENT
1.ACUTE RF
GOALS:
• Correct acute respiratory acidosis
• Correct hypoxemia
• Correction of hypercapnia
• Resting of ventilatory muscles
• Early ambulation that helps ventilate atelectatic areas of the lung.
ASSESSMENT OF PATIENT
• See the patient is well conscious or not
• Note temperature and type of mode of ventilator
Examination of the chest in mechanically ventilated patients
• 1) INSPECTION – Chest movement, Cyanosis
• 2) PALPATION - Confirm all inspectory findings, tenderness, JVP (jugular venous pulse)
• 3) AUSCULTATION - Breath sounds-Vesicular Bronchial , Wheeze
Neuromuscular assessment – Evaluation of proprioception reflexes, muscles function and strength , MRC
(muscles power scale) cum score
TREATMENT
Correction of Hypoxemia, Hypercapnia and acidosis
• High flow oxygen therapy via Nasal cannula
• In high flow nasal cannula FiO2 remains relatively constant and gas is generally warmed to 37 C and
completely humidified , muco cilliary function remain good, thus prevent acidosis.

8. • Rates up to 8 L/min in infants and up to 40L/min in children and adults
• High flow washes out CO2 in anatomical dead space prevents from hypercapnia
Non-invasive respiratory support:
• Ventilatory support without tracheal intubation/ via upper airway
• NIPPV has been shown to reduce complications, duration of ICU stay and mortality
• NIPPV is more effective in preventing endo tracheal intubation in acute respiratory failure due to
COPD than other causes
VENTILATORY MANAGEMENT (Invasive respiratory support)
• Intrinsic positive end-expiratory pressure (auto-PEEP) is a common occurrence in patients with acute
respiratory failure requiring mechanical ventilation, protective lungs from barotraumas

9. • Auto PEEP can be manage by reduction of minute ventilation, use of small tidal volumes (4-6ml/kg) and
prolongation of the time available for exhalation
PHYSIOTHERAPY MANAGEMENT
GOALS
 In mechanically ventilated patients, early physiotherapy goals is to :
• To prevent ICU associated complications like de-conditioning, ventilatory dependency and respiratory
conditions
• Weaning from mechanical ventilators and restoration to maximal functional level of activity
 SPECIFIC GOALS
• Maintaining and improve muscles strength, endurance, joint ROM and secretion clearance
 OTHER GOALS
• Psychological support and education to patient and family
HANDLING A VENTILATORY PATIENT
• For Positioning 2-3 therapist are needed to turn a patient
• Ensure sufficient slack in lines and tubes
• Inform the patient
• If possible disconnect the patient from ventilator/tracheal manually
• Turn the patient smoothly & check the lines, patient comfort and observe monitors
MOBILISATION
• It help to maintain or restore normal fluid distribution in the body
• It reduces the effect of immobility & bed rest
• It includes ankle pump, Moving/Turning in bed , Sitting in the edge of the bed

10. • ICU Management
 Early ICU (Stage I)
• MMT if participatory
 Late ICU (Stage II)
• Evaluate strength – MMT, hand grip
• Assess highest level of activity – FSS ICU scale or IMS
 After ICU (Stage III)
• Evaluate strength - MMT, hand grip
• Test endurance – 6MWT
• Return to baseline
EXERCISES
As patient weaning from mechanical ventilator
1.)Breathing Control
• Treatment should start with breathing control
• It is a normal tidal breathing to promote relaxation & prevent hyperventilation
• While teaching BC avoid full expiration , it should be controlled but not forceful
• Position- Side lying, head elevated, leaning forward
• EFFECT- Relief of dyspnea, improve vital capacity, improve V/Q
2.) Breathing retraining exercises – diaphragmatic breathing (DB), It is often used with pursed lip breathing
• Stage 1 – continue diaphragmatic breathing in semi- Fowler’s position / side lying (anti-gravity)

11. • Stage 2 – patient advance to sitting position with shoulder and hand in relaxed position
• Stage 3 – DB in standing and entire body must be supported
• Stage 4 – Walking is the fourth stage of retraining, patient encourage to relax , control his breathing, take
longer step and slow down
• Stage 5 – stairs climbing, instruct to pause slightly as he breathes in and to exhale as he climbs one or
two stairs .
3) 6 MWT in noninvasive mechanical ventilated patients depends upon BORG score is beneficial to lung
functioning
2.CHRONIC RF
GOALS -
• Prevent dyspnea
• Respiratory muscles training
• Correct hypoxemia, hypercapnia
• Improve ADLs
TREATMENT
Correction of Hypoxemia and Hypercapnia
• AEM ( venturi mask 0.24- 0.28) , Spo 2 of 85%- 92%) (PaO2 50-70 mmHg) or low flow nasal cannula
• Noninvasive positive pressure ventilation (NIPPV) is a ventilatory support without tracheal intubation/
via upper airway, in patients with mild to moderate respiratory failure.
BRONCODIALATORS – helps in dilating airways thus decreasing airflow resistance, in COPD this drugs
provide symptomatic relief but do not alter disease progression or mortality

12. PHYSIOTHERAPY MANAGEMENT
GOALS
• Secretion clearance
• Inspiratory muscles training
• Prevent dyspnea and improve ADLs
1. SECREATION CLEARANCE
 Positioning: the use of specific body position aimed at improving ventilation/perfusion(V/Q) matching,
promoting mucocilliary clearance, improving aeration via increased lung volumes and reducing the work
of breathing.
• Prone: helps to improve V/Q matching, redistribute edema and increase functional residual
capacity(FRC) in patients with acute respiratory distress syndrome. It has been shown to result in
oxygenation for 52-92% of patients with severe acute respiratory failure
• Side-lying: with affected lungs uppermost to improve aeration through increased lung volumes in
patients with unilateral lung disease.
• Upright: helps to improve lung volumes and decrease work of breathing in patients that are being
weaned from mechanical ventilator.
• Semi fowler position - prevent the risk of gastro esophageal reflux and aspiration.
 Postural drainage and percussion - uses gravitational effects to facilitate mucocilliary clearance
 Suction - used for clearing secretions when the patient cannot do so independently

13. 2. INSPIRATORY MUSCLES TRAINING (IMT)–
Two technique used for inspiratory muscles training
• ISOCAPNIC HYPERVENTILATION - controlled hyperventilation can be
achieved using this device, which consist of gas mask connected
to a of supply of oxygen and carbon dioxide, so that body adjust the
breathing pattern without causing the patient to lose consciousness.
• INSPIRATORY RESISTIVE BREATHING – IMT devices that incorporate
both isometric and isotonic exercises , patient inspire with a control rate
of breathing through narrow tube offer non-linear resistance
ACSM GUIDELINES OF IMT –
• Frequency – a minimum of 4-5 d/week
• Intensity – 30% of maximal inspiratory pressure measured at FRC
• Time – 30 min/ day or two 15 min sessions/day
• Type – IMT devices or normocapnic hyperpnea
3. IMPROVE ADLs
• Aerobic exercises
• Flexibility and resistance exercises
• Perceptions of dyspnea should be measured during exercise using BORG CR 10 scale.
FITT RECOMMENDATION (AEROBIC EXERCISES)
• FREQUENCY – at least 3-5 d/wk
• INTENSITY – light intensity ( 30-<40 % of peak work rate ) training results in improvement in symptoms,
health related quality of life, performance of ADL
• Intensity based on dyspnea rating of between 4 to 6

14. • TIME – exercise only at a specific intensity for few min. at a start of training programme
• Intermittent exercise may also used for the initial training sessions until individual tolerates exercise at
higher intensity and duration of activity
• TYPE – walking / or ergometers cycling
FITT RECOMMENDATION ( RESISTANCE EXERCISES)
• FREQUENCY – 2-3 d/week with at least 48h separating the exercise training sessions for the same
muscles group ( muscles group of chest, shoulder, upper and lower back, abdomen, hip, legs)
• Split weight training routine entails 4d/week
• INTENSITY – 60-70% 0f 1RM (minimum) with 8-12 rep , 2-4 sets intermediate exercises to improve
strength
• TIME – no specific duration of training , rest interval of 2-3 min. between each set of rep.
• TYPE – free weights, resistance band, weight machines multi joint exercises that targeting agonist and
antagonist muscles group
• single joint exercises targeted major muscles group
COMPLICATIONS –
• Pulmonary: pulmonary embolism, pulmonary fibrosis complications secondary to the use of mechanical
ventilator
• Cardiovascular: hypotension, reduced cardiac output, arrhythmias, pericarditis and acute MI
• Gastrointestinal: haemorrhage, gastric distention
• Infectious: 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.

15. SUMMARY
• Respiratory failure is a condition respiratory system fails to maintain its normal gaseous exchange
function, may be acute or chronic
• RF cause by pulmonary embolism, SCI, ARDS, muscular dystrophy, COPD, Stroke, Pneumonia
• RF are of two types TYPE I Hypoxemic and TYPE II Hypoxemic and Hypercapnic
• TYPE I show symptoms like Dyspnea, irritability, Confusion, Tachycardia, arrhythmia, Tachypnea,
Cyanosis
• TYPE II show symptoms like Change of behavior, Papilloedema, Astrexis
• Acute respiratory failure hypoxemia should be treated by high oxygen flow therapy via nasal cannula or
via Non Invasive Positive Pressure Ventilation
• Ventilatory management via AUTO PEEP, ICU management, early mobilization should done while
patient is on ventilator
• As patient weaning from mechanical ventilator control breathing techniques, breathing retraining
exercises, 6MWT should taught
• Chronic RF hypoxemia should treated with NIPPV, AEM (venturi mask), Bronchodilators
• Secretion clearance via positioning postural drainage percussion and suction
• Inspiratory muscles training via isocapnic hyperventilation and inspiratory resistive breathing device
(IMT) device
• ACSM guidelines of inspiratory muscles training, Aerobic and resistive exercises for Chronic (ongoing
conditions worsen over time) RF patients

16. REFERENCES
• Principle and practice of Cardiopulmonary physical therapy (3rd edition) by Donna
Frownfelter and Elizabteh Dean
• www.physio-pedia.com > Respiratory failure
• ASCMs guidelines for exercise testing and prescription (9th edition) by Wolters Kulwers
• Laghi F, Goyal A. Auto-PEEP in respiratory failure. Minerva Anestesiol. 2012
Feb;78(2):201-21. Epub 2011 Nov 18. PMID: 21971439.
• Medlineplus.gov/respiratoryfailure.html