OM VERMA ASSISTANT PROFESSOR GRACIOUS COLLEGE OF NURSING( C.G)

1. RESPIRATORY FAILURE AND
INSUFFICIENCY
PRESENTED : MR.OM VERMA
ASSISTANT PROFESSOR
RELIANCE INSTITUTE OF NURSING

3. INTRODUCTION
RESPIRATORY FAILURE ( AREEST) results from
inadequate gas exchange by the respiratory system,
meaning that the arterial oxygen, carbon dioxide or both
cannot be kept at normal levels. A drop in the oxygen
carried in blood is known as hypoxemia; a rise in arterial
carbon dioxide levels is called hypercapnia.
INSUFFICIENCY the quality or state of not being sufficient: as.
a : lack of adequate supply of something an insufficiency of
vitamins. b : lack of physical power or capacity especially
inability of an organ or bodily part to function normally
renal insufficiency pulmonary insufficiency

4. .

5. Definition
A syndrome in which the respiratory system
fails in one or both of its gas exchange functions
i.e. oxygenation and/or carbon dioxide
elimination, such that the levels of arterial
oxygen (PaO₂) and carbon dioxide (PaCO₂)
partial pressures cannot be maintained within
their normal ranges.
According to Lewis's

6. Respiratory failure is a condition in which your
blood doesn't have enough oxygen or has too
much carbon dioxide. Sometimes can have both
problems. When you breathe, lungs take in
oxygen. ... Your organs, such as heart ,lungs and
brain, need this oxygen-rich blood to work well.
According to Thomas Luckmann

7. Respiratory arrest should be distinguished
from respiratory failure. The former refers to the
complete cessation of breathing, while respiratory
failure is the inability to provide adequate
ventilation for the body's requirements
According to Brunner & Suddarth's

8. Respiratory arrest and
insufficiency: The condition in which
the lungs cannot take in sufficient oxygen or
expell sufficient carbon dioxide to meet the
needs of the cells of the body. Also
called pulmonary insufficiency.
According to Lippincott Williams & Wilkins

9. The inability of the cardiac and pulmonary
systems to maintain an adequate
exchange of oxygen and CO2 in the Lungs.
According to American nurses
Dictionary

10. Components of the respiratory system
Gas-exchange (Interface)organ
• Lungs (parenchyma)
• Blood vessels (pulmonary and
bronchial)
Ventilatory pump
• Thoracic wall
• Respiratory muscles
• Brainstem and cortex
• Anterior horn cells
• Phrenic nerves and other
nerves

11. TYPES

12. TYPES
1. Acute respiratory failure occurs when fluid
builds up in the air sacs in lungs. When that
happens, your lungs can't release oxygen into your
blood. In turn, your organs can't get enough
oxygen-rich blood to function.
2.Chronic respiratory failure
is a condition that results in the inability to
effectively exchange carbon dioxide and oxygen,
and induces chronically low oxygen levels
or chronically high carbon dioxide levels.
Symptoms: Shortness of breath

13. 1.ACUTE RESPIRATORY FAILURE:

14. 1.ACUTE RESPIRATORY FAILURE:
Results from inadequate gas exchange
for a short
period.
Insufficient O2 transferred to the blood
Hypoxemia (type I) Hypoxemia refers to the
low level of oxygen in blood,
• Inadequate CO2 removal
Hypercapnia (Type II Hypercapnia is a buildup of carbon dioxide in your
bloodstream

15. Acute Respiratory Failure:
CLASSIFICATION
• HYPOXEMIC RESPIRATORY
FAILURE(TYPE I)
An arterial oxygen tension lower than 60
mm Hg with a normal or low arterial
carbon dioxide tension.
• HYPERCAPNIC RESPIRATORY
FAILURE(TYPE II)
CO2 higher than 50 mm Hg.

16. HYPOXEMIC RESPIRATORY
FAILURE (TYPE I)
CAUSES
1. Ventilation-perfusion (V/Q)
mismatch
2. Shunt
3. Diffusion Limitation
4. Alveolar hypoventilation

17. 1. VENTILATION-PERFUSION (V/Q)
MISMATCH:
"V" – ventilation – the air that reaches the
alveoli
"Q" – perfusion – the blood that reaches the
alveoli
o COPD
o Pneumonia
o Asthma
o Atelectasis
o Pulmonary embolus

18. COPD:
COPD stands for Chronic Obstructive Pulmonary
Disease. It is a progressive disease that makes it hard
to breathe. In COPD, less air flows in and out of the
AIRWAYS BECAUSE OF ONE OR MORE OF THE
FOLLOWING:
•The airways and air sacs lose their
elastic quality.
•The walls between many of the air sacs
are destroyed.
•The walls of the airways become thick
and inflamed.
•The airways make more mucus than
usual, which can clog them

19. PNEUMONIA:
Pneumonia is an inflammatory condition of
the lung. It is usually caused by infection
with viruses or bacteria.
ATELECTASIS:
Partial collapse or incomplete inflation of
the lung.

20. PULMONARY EMBOLISM
is the sudden blockage of a major
blood vessel (artery) in the lung,
usually by a blood clot.

21. 2. SHUNT
o Anatomic shunt
o Intrapulmonary shunt

22. ANATOMIC SHUNT:
Passes through an anatomic channel of the
heart and does not pass through the lungs.
INTRAPULMONARY SHUNT:
Blood flows through pulmonary capillaries
without participating in gas exchange.

23. 3. DIFFUSION LIMITATION:
o Severe emphysema
o Recurrent pulmonary emboli
o Pulmonary fibrosis
o Hypoxemia present during exercise

24. Severe Emphysema:
Emphysema gradually damages the air sacs
(alveoli) in your lungs, making you
progressively more short of breath. Smoking
is the leading cause of emphysema.
Recurrent pulmonary emboli:
Pulmonary embolism (PE) occurs when a
blood clot dislodges from a vein, travels
through the veins of the body, and lodges in
the lung.

25. Pulmonary fibrosis:
Pulmonary fibrosis occurs when lung tissue becomes
damaged. This thickened, stiff tissue makes it more
difficult for your lungs to work properly.
Hypoxemia present during exercise:
An abnormally low concentration of oxygen in the blood
Recurrent Pulmonary embolism (PE) is a blockage of an artery in
the lungs by a substance that has moved from elsewhere in the
body through the bloodstream (embolism). Symptoms of a PE may
include shortness of breath, chest pain particularly upon breathing
in, and coughing up blood.

26. 4. ALVEOLAR HYPOVENTILATION:
o Restrictive lung disease
o CNS disease
o Chest wall dysfunction
o Neuromuscular disease

27. HYPERCAPNIAC RESPIRATORY

28. • HYPERCAPNIAC RESPIRATORY
Failure (Type II)
Causes :
1. Airways and alveoli.
2. Central Nervous System.
3. Chest Wall.
4. Neuromuscular Conditions

29. 1. AIRWAYS AND ALVEOLI:
o Asthma.
o Emphysema.
o Bronchitis.
o Cystic fibrosis.

30. . ASTHMA:
A respiratory condition marked by
attacks of spasm in the bronchi of the
lungs, causing difficulty in breathing. It is
usually connected to allergic reaction or
other forms of hypersensitivity
Emphysema:
Emphysema gradually damages the air
sacs (alveoli) in your lungs,

31. BRONCHITIS:
Bronchitis is an inflammation of the
bronchial tubes.
CYSTIC FIBROSIS:
A heriditary disorder causes the
production of abnormally thick
mucus, leading to the blockage of
brunch.

32. 2. CENTRAL NERVOUS SYSTEM:
o Drug overdose.
o Brainstem infarction.
o Spinal cord injuries
1. RESPIRATORY FAILURE is a common complication
of drug abuse. ... Drugs may acutely precipitate respiratory
failure by compromising respiratory pump function and/or
by causing pulmonary pathology.
Polysubstance overdoses are common, and clinicians should
anticipate complications related to multiple drugs.

33. 2. BRAINSTEM INFARCTION (BSI) is a stroke that
happens when blood cannot flow to your brainstem.
When oxygen cannot get to an area of the brain, tissue in
that area may be damaged. Your brainstem allows you to
speak, hear, and swallow
3. SPINAL CORD INJURY (SCI) is damage to the spinal
cord that causes temporary or permanent changes in its
function. Symptoms may include loss of muscle function,
sensation, or autonomic function in the parts of the body
served by the spinal cord below the level of the injury.

34. 3. CHEST WALL:
o Flail chest.
o sternal fractures.
o Muscle spasm
1. FLAIL CHEST is a life-threatening medical
condition that occurs when a segment of the
rib cage breaks due to trauma and becomes
detached from the rest of the chest wall. Two
of the symptoms of flail chest are chest pain
and shortness of breath.

35. 2.STERNAL FRACTURE is a fracture of the
sternum (the breastbone), located in the
center of the chest. The injury, which
occurs in 5–8% of people who experience
significant blunt chest trauma, may occur
in vehicle accidents, when the still-
moving chest strikes a steering wheel or
dashboard or is injured by a seatbelt.

36. 3. MUSCLE SPASM is a sudden,
involuntary contraction of one or
more muscles. A spasm results from an
abnormally sustained muscle contraction
and is often painful. Various muscles may
develop spasms,

37. 4. NEUROMUSCULAR CONDITIONS:
o Muscular Dystrophy.
o Multiple Sclerosis.
MUSCULAR DYSTROPHY is a group of
diseases that cause progressive weakness and
loss of muscle mass. In muscular dystrophy,
abnormal genes (mutations) interfere with
the production of proteins needed to form
healthy muscle. .

38. MULTIPLE SCLEROSIS:
Multiple sclerosis (MS) is a disease in
which your immune system
attacks the protective sheath (myelin)
that covers your nerves. Myelin
damage disrupts communication
between your brain and the rest of your
body. Ultimately, leading to respiratory
failure and other diseases

39. CHRONIC RESPIRATORY FAILURE

40. CHRONIC RESPIRATORY FAILURE:
The respiratory failure which passes
the acute stage. All of the disorders are
same, just the duration is lengthened.

41. CHRONIC RESPIRATORY FAILURE:
Chronic respiratory failure is a condition
that results in the inability to effectively
exchange carbon dioxide and oxygen, and
induces chronically low oxygen levels
or chronically high carbon dioxide levels.

42. . •Tissue Organ Needs:
Major threat is the inability of the lungs
to meet the
oxygen demands of the tissues.
• Clinical Manifestations:
A sudden decrease in O2 or rapid
increase in CO2 indicates a
serious condition

43. CLASSIFICATION
HYPOXAEMIC (TYPE I)
• Failure of oxygenation
↓
HYPOXEMIA without
HYPERCAPNIA
VENTILATORY (TYPE II)
• Respiratory “PUMP” FAILURE
↓
HYPOXEMIA and
HYPERCAPNIA

44. ETIOLOGY

45. 1. OBSTRUCTION
When something lodges in your throat, you may have trouble getting
enough oxygen into your lungs. Obstruction can also occur in people
with chronic obstructive pulmonary disease (COPD) or asthma when
an exacerbation causes the airways to become narrow.
2.INJURY
An injury that impairs or compromises your respiratory system can
adversely affect the amount of oxygen in your blood. For instance, an
injury to the spinal cord or brain can immediately affect your
breathing. The brain tells the lungs to breathe. If the brain can’t relay
messages due to injury or damage, the lungs can’t continue to
function properly.
An injury to the ribs or chest can also hamper the breathing process.
These injuries can impair your ability to inhale enough oxygen into
your lungs.

46. 3. ACUTE RESPIRATORY DISTRESS SYNDROME
Acute respiratory distress syndrome (ARDS) is a serious condition
characterized by low oxygen in the blood. ARDS affects you if you
already have an underlying health problem such as:
pneumonia
pancreatitis (inflammation of the pancreas)
severe trauma
Sepsis
4. SEVERE BRAIN INJURIES
lung injuries caused by inhalation of smoke or chemical products
It can occur while you’re in the hospital being treated for your
underlying condition
5. DRUG OR ALCOHOL ABUSE
If you overdose on drugs or drink too much alcohol, you can
impair brain function and hinder your ability to breathe in or
exhale.

47. 6.CHEMICAL INHALATION
Inhaling toxic chemicals, smoke, or fumes can also cause acute
respiratory failure. These chemicals may injure or damage the
tissues of your lungs, including the air sacs and capillaries.
7.STROKE
A stroke occurs when your brain experiences tissue death or
damage on one or both sides of the brain. Often, it affects only one
side. Although stroke does present some warning signs, such as
slurred speech or confusion, it typically occurs quickly. If you have a
stroke, you may lose your ability to breathe properly.
8. INFECTION
Infections are a common cause of respiratory
distress. Pneumonia in particular, may cause respiratory failure,
even in the absence of ARDS. According to the Mayo Clinic, in some
cases pneumonia affects all five lobes of the lungs.

48. PATHOPHYSIOLOGY

49. Hypoxaemic (Type I)
• Pneumonia
• ARDS
• Pulmonary fibrosis
• Asthma
• COPD
• Pnemothorax
• PE
• Obesity
• Pulmonary Hypertension
Hypercapnic (Type II)
• COPD / Severe Asthma
• Drug Overdose (Opiates
benzodiazepines,)
• CNS Injury (SCI, CVA)
• Primary muscle disorders
(Duchenne muscular dystrophy)
• Neuromuscular junction disorders
(eg. Myasthenia gravis)
• Anatomical chest deformities
(eg. Kyphoscoliosis, Flail chest)
• Obesity Hypo-ventilatory
(Pickwickian) syndrome
DUE TO ETIOLOGICAL FACTORS SUCH AS

50. Failure of one and both gas exchange
abnormal function oxygenation and co2

51. CLINICAL PRESENTATION
RF may be preceded by signs of respiratory distress:
• Tachypnoea (>25/min)
• Breathlessness
• Gasping or pursed lip
breathingह ांफते हुए स ांस लेन
• Tight chest
• Sweating,
• Agitation =a state of
anxiety or nervous
felling.
• Sitting or hunched
(swelling )posture
• Sense of impending
doom feeling fear
• Inability to complete a
sentences
• Cyanosis
• HYPOXAEMIA Sats
• HYPERCAPNEA

52. PRE TERMINAL SIGN
Signs of the pre-active dying phase include
increased restlessness, being uncomfortable in one
position, increased tiredness and periods of sleep,
decreased food and liquid intake and oedema.
• Bradycardia,
• (dysrhythmias Cardiac dysrhythmias are a problem with the rate or rhythm
of your heartbeat caused by changes in your heart's normal sequence of electrical
impulses. heart may beat too quickly, called tachycardia; too slowly, bradycardia; or
with an irregular heart pattern.), hypotension
• Bradypnoea or silent chest
• Decreased L.O.C ( level of consciousness )

53. PHYSICAL EXAMINATION
1) VITAL SIGNS AND INSPECTION
• Fever, tachycardia, tachypnea → Infection
• Fever, lethargy → CNS infection /septic encephalopathy
• ↑Pulsus paradoxus (>10 mmHg) → Asthma or COPD

54. DIAGNOSTICS
2) NEUROLOGICAL EXAMINATION
• Depressed mental status (lethargy or coma) → Central drive failure
• Pupillary constriction (miosis) excessive constriction of the pupil of
the eye.
• “pinpoint pupils” → Opiate overdose
(Severe hypercarbia causes miosis as well)
• Sensory deficits → Polyneuropathy (e.g. GBS)
• Muscle fasciculations → Motor neuron diseases (e.g. ALS)

55. DIAGNOSTICS
3) Head and Neck
• Stridor, drooling → upper airway obstruction
4) Chest
• Pattern of respiratory muscle contraction, chest diameter and
intergrity (Flail chest), presence of abnormal breath sounds
5) Abdomen
• Normal abdominal wall movement during inspiration is
outward, inward movement with inspiration is paradoxical and
suggests diaphragmatic fatigue.

56. DIAGNOSTICS
Laboratory Testing
1. Arterial Blood Gas (ABG)
An arterial blood gas (ABG) test measures
oxygen and carbon dioxide levels in blood.

57. DIAGNOSTICS
Normal values of arterial blood gases
(at R.A., sea level, 37°C)

58. DIAGNOSTICS
Interpretative remarks:
• PaO₂ < 60mmHg(8kPa) →HYPOXEMIA
• PaCO₂ > 50 mmHg(6.7 kPa) →HYPERCAPNIA
• pH < 7.35 → ACIDOSIS
• pH >7.45 → ALKALOSIS

59. DIAGNOSTICS
1. Complete Blood Count (CBC)
• Leukocytosis → infection
• Anemia (dyspnea,↓O₂ transport to tissues, but in isolation
will not cause ventilatory failure.
2. Lumbar Puncture (LP) A lumbar puncture (spinal tap) is
performed in lower back, in the lumbar region. During a lumbar
puncture, a needle is inserted between two lumbar bones (vertebrae)
to remove a sample of cerebrospinal fluid. This is the fluid that
surrounds your brain and spinal cord to protect them from injury
• (essential in cases of suspected CNS infection or GBS)
3. Serum Chemistries
• (↓Ca,Mg,PO⁻ may contribute to respiratory muscle fatigue)

60. 4. TOXICOLOGY
A toxicology screen is a test that determines the
approximate amount and type of legal or illegal
drugs that any person taken. It may be used to
screen for drug abuse, to monitor a substance
abuse problem, or to evaluate drug intoxication
or overdose. Toxicology screening can be done
fairly quickly.

61. 5.PULMONARY FUNCTION TESTS (PFTs) are
noninvasive tests that show how well the lungs
are working. The tests measure lung volume,
capacity, rates of flow, and gas exchange. This
information can help your healthcare provider
diagnose and decide the treatment of certain
lung disorders

62. DIAGNOSTICS
Imaging and Other Tests
• XRAY
• (Pneumonia, atelectasis, pulmonary oedema, evidence of chronic
lung disease, tumours, chest wall and pleural abnormalities)
• CT Scan
• (tumours, parenchymal lung disease, pleural and chest wall
disease)
• MRI
• (encephalitis, brain stem pathology, and spinal cord injury)
• ECG
• (evidence of chronic lung disease, left ventricular failure or valve
disease)
• Last hai

63. MANAGEMENT
Medical management
Pharmacological
management
Surgical intervention
Nursing management

64. MEDICAL MANAGEMENT
Treatments for respiratory failure include the
following:
1. Identification of causative agent
2. To give oxygen therapy
3. To maintain nutritional diet
4. Inhaled medications: Medicines administered
either through an inhaler device or through a nebulizer
machine can also open up airways, allowing lungs to
pick up oxygen and remove carbon dioxide more
effectively.

65. OXYGEN THERAPY:
Face mask. Nasal canula.

66. 2. Drug Therapy:
Use of Bronchodilators, Anti-biotics
• DRUGS:
• Respiratory stimulants (eg. Doxapram) Doxapram is an analeptic agent
(a stimulant of the central nervous system). The respiratory stimulant
action is manifested by an increase in tidal volume associated with a
slight increase in respiratory rate.(rarely used)
• Antidote for sedative overdose
» Opioids → naloxone
» Benzodiazepines → Flumazenil
3. Nutritional Therapy:
•Maintain protein and energy stores

67. Principles of treatment
• Emergency treatment should follow principles of
cardiopulmonary resuscitation (C-A-B);
• Ensure patent airway
• Administer oxygen to maintain sats >90%
• Correct hypoperfusion/anaemia
followed by treatment of underlying (reversible)
causes:
• Acidosis/Alkalosis
• Hypovolemia
• Hypoxia
• Pneumothorax
• Pulmonary embolism

68. Principles of treatment (Cont…)
• All patients with acute VF not responding to simple
measures in an emergency room, clinic, or hospital ward
setting should be monitored in an
intensive/intermediate care unit.
• Inhaled bronchodilators should be administered to all
patients with bronchospasm.
• Fever reduction with acetaminophen will decrease CO₂
production.
• Avoid excessive caloric intake (which increases CO₂
production)

69. The main goal of treating respiratory failure
is to get enough oxygen to your lungs and
organs and remove carbon dioxide.
Treatments for respiratory failure include
the following:
Inhaled medications: Medicines
administered either through an inhaler
device or through a nebulizer machine can
also open up airways, allowing your lungs
to pick up oxygen and remove carbon
dioxide more effectively.

70. Con…
The underlying cause may also require treatment
- for example, steroids and antibiotics.
For some patients there may not be any further
treatment options and their respiratory failure
may be terminal. They may benefit from the
palliative care team, which deals with managing
patients with terminal illnesses.

71. Surgical
intervention

72. Principles of treatment (Cont…)
• Consider non-invasive ventilatory support:
• CPAP: continous positive airway pressure
• BiPAP: Biphasic positive airway pressure
• Evaluate patient for the need of Endotracheal
intubation and mechanical ventilation (e.g. in
cases of severe respiratory failure with PaO2 Partial pressure of
oxygen (PaO2). less than 50 mmHg).

73. Tracheostomy: involves surgically creating a hole in the front of cleint
neck and into windpipe. A tube called a tracheostomy is put into the hole
to improve your breathing. You may also receive oxygen therapy through
a tracheostomy
Ventilator: is used when blood oxygen levels do not increase with oxygen
therapy or tracheostomy alone. A ventilator is a machine that helps you
breathe. It blows air into your airways and lungs.
Non-invasive Positive Pressure Ventilation (NPPV): is a noninvasive
treatment that helps to keep airways open while you sleep. NPPV
involves wearing a mask that creates mild air pressure to keep the
airways open.
Fluids: Having the correct amount of fluid in the body supports proper
blood flow and transportation of nutrition throughout the body, without
causing fluid to build up in the lungs. You may be given fluids
intravenously to ensure have just the right amount. This is usually done if
are in the hospital.

74. Oxygen - high levels will be given through a mask
(although lower levels may be needed in patients
with chronic respiratory failure who have
adapted to high carbon dioxide levels).
Artificial ventilation:
MECHANICAL VENTILATION:
This involves the patient being put into a coma, using
medication and paralyzing their breathing.
A tube is inserted into the trachea and an artificial
ventilator then does the work of breathing.
Once the underlying cause is treated, patients will be
'weaned' off the ventilator so that their lungs start to do
the work of breathing.
This is a form of 'invasive' ventilation.

75. COMPLICATION

76. As a result of respiratory failure various
complications can occur, including:
Lung complications: for example, a blood clot on
the lung (pulmonary embolism), irreversible
scarring of the lungs (pulmonary fibrosis), a
collection of air between the lung and chest wall
(pneumothorax) which can further compromise
breathing, chronic respiratory failure and
dependence on a ventilaton

77. CON…….
Heart complications: for
example, heart failure, fluid
around the heart (pericarditis)
and acute heart attack

78. Increase in blood count (called polycythaemia):
the increased level of red cells occurs from low
blood oxygen levels but can lead to blood clots,
due to sluggish flow in the blood vessels.
Neurological complications: a prolonged period
of low blood oxygen levels can deprive the brain
of oxygen, which may be irreversible and may
present as coma, fits (seizures) and even brain
death.

79. Prolonged hospital admissions can lead to the
following complications:
Hospital-acquired infections: for example, pneumonia and
diarrhoea. A pneumonia is likely to put further strain on the
respiratory function and can require a need for further
ventilation.
Complications from being bed bound for long periods: wasting
of limbs with associated weakness, pressure sores, deep vein
thrombosis and mental depression

80. Prolonged hospital admissions can lead to the
following complications:
Hospital-acquired infections: for example, pneumonia and
diarrhoea. A pneumonia is likely to put further strain on the
respiratory function and can require a need for further
ventilation.
Malnutrition which may require assisted feeding methods,
such as a tube being inserted down the nose into the stomach
(nasogastric feeding), or providing nutrition through a needle
straight into the bloodstream. Both of these methods have
complications of their own.
Complications from being bed bound for long periods: wasting
of limbs with associated weakness, pressure sores, deep vein
thrombosis and mental depression

81. ***************The End***************
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