respiratory failure of lungs

1. Respiratory Failure (RF)
Prof. Omer Alamoudi, MD, FRCP,
FCCP,FACP

2. Respiratory Failure (RF)
 Normal ABG
 Definition
 Classification of RF
 Distinction between Acute and Chronic RF
 Pathophysiologic causes of Acute RF
 Diagnosis of RF
 Causes
 Clinical presentation
 Investigations
 Management of RF

3. Arterial Blood Gases (ABG)
Normal values at sea level
 pH 7.35-7.45
 PaO2 >70 mmHg
 PaCO2 35-45 mmHg
 HCO3 22-28 mmol/l
 Minute ventilation = Tidal
volume X Respiratory rate
 ↓pH Acidosis
 ↑pH Alkalosis
 ↓ PaO2 Hypoxemia
 ↑PaCO2 Hypercapnia
 ↓pH+ ↑PaCO2 R. acidosis
 ↑HCO3
 ↑pH+↓PaCO2 R.Alkalosis
 ↓HCO3

4. Respiratory Failure (RF)
 Definitions
 Clinical conditions in
which PaO2 < 60 mmHg
while breathing room air
or a PaCO2 > 50 mmHg
 Failure of oxygenation
and carbon dioxide
elimination
 Acute and chronic
 Type 1 or 2

5. Classification of RF
 Type 1
 Hypoxemic RF **
 PaO2 < 60 mmHg with
normal or ↓ PaCO2
 Associated with acute
diseases of the lung
 Pulmonary edema
(Cardiogenic,
noncardiogenic (ARDS),
pneumonia, pulmonary
hemorrhage, and collapse
 Type 2
 Hypercapnic RF
 PaCO2 > 50 mmHg
 Hypoxemia is common
 Drug overdose,
neuromuscular disease,
chest wall deformity,
COPD, and Bronchial
asthma

6. Distinction between Acute and Chronic RF
 Acute RF
 Develops over minutes to
hours
 ↓ pH quickly to <7.2
 Example; Pneumonia
 Chronic RF
 Develops over days
 ↑ in HCO3
 ↓ pH slightly
 Polycythemia, Corpulmonale
 Example; COPD

7. Pathophysiologic causes of Acute RF
●Hypoventilation
●V/P mismatch
●Shunt
●Diffusion
abnormality

8. Pathophysiologic causes of Acute RF
1 - Hypoventilation
 Occurs when ventilation ↓
4-6 l/min
 Causes
 Depression of CNS
from drugs
 Neuromuscular disease
of respiratory ms
 ↑PaCO2 and ↓PaO2
 Alveolar –arterial PO2
gradient is normal
 COPD

9. Pathophysiologic causes of Acute RF
●Hypoventilation
●V/P mismatch
●Shunt
●Diffusion
abnormality

10. Pathophysiologic causes of Acute RF
2 -V/Q mismatch
 Most common cause of
hypoxemia
 Low V/Q ratio, may occur
either from
 Decrease of ventilation 2ry
to airway or interstitial lung
disease
 Overperfusion in the
presence of normal
ventilation e.g. PE
 Admin. of 100% O2 eliminate
hypoxemia

11. Pathophysiologic causes of Acute RF
●Hypoventilation
●V/P mismatch
●Shunt
●Diffusion
abnormality

12. Pathophysiologic causes of Acute RF
3 -Shunt
 The deoxygenated blood
bypasses the ventilated
alveoli and mixes with
oxygenated blood →
hypoxemia
 Persistent of hypoxemia
despite 100% O2 inhalation
 Hypercapnia occur when
shunt is excessive > 60%

13. Pathophysiologic causes of Acute RF
3 – Causes of Shunt
 Intracardiac
 Right to left shunt
 Fallot’s tetralogy
 Eisenmenger’s
syndrome
 Pulmonary
 A/V malformation
 Pneumonia
 Pulmonary edema
 Atelectasis/collapse
 Pulmonary Hge
 Pulmonary contusion

14. Pathophysiologic causes of Acute RF
●Hypoventilation
●V/P mismatch
●Shunt
●Diffusion
abnormality

15. Pathophysiologic causes of Acute RF
4 - Diffusion abnormality
 Less common
 Due to
 abnormality of the
alveolar membrane
 ↓ the number of the
alveoli
 Causes
 ARDS
 Fibrotic lung disease

16. Diagnosis of RF
1 – Clinical (symptoms, signs)
 Hypoxemia
 Dyspnea, Cyanosis
 Confusion, somnolence, fits
 Tachycardia, arrhythmia
 Tachypnea (good sign)
 Use of accessory ms
 Nasal flaring
 Recession of intercostal ms
 Polycythemia
 Pulmonary HTN,
Corpulmonale, Rt. HF
 Hypercapnia
 ↑Cerebral blood flow, and
CSF Pressure
 Headache
 Asterixis
 Papilloedema
 Warm extremities,
collapsing pulse
 Acidosis (respiratory, and
metabolic)
 ↓pH, ↑ lactic acid

17. Diagnosis of RF
2 – Causes
 1 – CNS
 Depression of the neural
drive to breath
 Brain stem tumors or vascular
abnormality
 Overdose of a narcotic, sedative
Myxedema, chronic metabolic
alkalosis
 Acute or chronic hypoventilation
and hypercapnia

18. Diagnosis of RF
2 – Causes
 2 - Disorders of peripheral
nervous system, Respiratory
ms, and Chest wall
 Inability to maintain a level
of minute ventilation
appropriate for the rate of
CO2 production
 Guillian-Barre syndrome,
muscular dystrophy,
myasthenia gravis, KS,
morbid obesity
 Hypoxemia and hypercapnia

19. Diagnosis of RF
2 – Causes
 3 - Abnormities of the
airways
 Upper airways
 Acute epiglotitis
 Tracheal tumors
 Lower airway
 COPD, Asthma, cystic
fibrosis
 Acute and chronic
hypercapnia

20. Diagnosis of RF
2 – Causes
 4 - Abnormities of the
alveoli
 Diffuse alveolar filling
 hypoxemic RF
 Cardiogenic and
noncardiogenic
pulmonary edema
 Aspiration pneumonia
 Pulmonary hemorrhage
 Associate with
Intrapulmonary shunt and
increase work of breathing

21. Diagnosis of RF
3 – Common causes
Hypoxemic RF
Chronic bronchitis, emphysema
Pneumonia, pulmonary edema
Pulmonary fibrosis
Asthma, pneumothorax
Pulmonary embolism,
Pulmonary hypertension
Bronchiectasis, ARDS
Fat embolism, KS, Obesity
Cyanotic congenital heart disease
Granulomatous lung disease
Hypercapnic RF
Chronic bronchitis,emphysema
Severe asthma, drug overdose
Poisonings, Myasthenia gravis
Polyneuropathy, Poliomyelitis
Primary ms disorders
1ry alveolar hypoventilation
Obesity hypoventilation synd.
Pulmonary edema, ARDS
Myxedema, head and cervical
cord injury

22. Diagnosis of RF
3 - Investigations
 ABG
 CBC, Hb
 Anemia → tissue hypoxemia
 Polycythemia → chronic RF
 Urea, Creatinine
 LFT → clues to RF or
its complications
 Electrolytes (K, Mg, Ph) → Aggravate RF
 ↑ CPK, ↑ Troponin 1 → MI
 ↑CPK, normal Troponin 1 → Myositis
 TSH → Hypothyroidism

23. Diagnosis of RF
3 - Investigations
 Chest x ray → Pulmonary edema
→ ARDS
 Echocardiography → Cardiogenic pulmonary
edema
→ ARDS
→ PAP, Rt ventricular
hypertrophy in CRF
■ PFT- (FEV1/ FVC ratio)
Decrease → Airflow obstruction
Increase → Restrictive lung disease

24. Diagnosis of RF
3 - Investigations
 ECG → cardiac cause of RF
→ Arrhythmia due to hypoxemia and
severe acidosis
■ Right heart catheterization to measure
●Pulmonary capillary wedge pressure (PCWP)
● Normal → ARDS (<18 mmHg)
● Increased → Cardiogenic pulmonary
edema

25. Distinction between Noncardiogenic (ARDS)
and Cardiogenic pulmonary edema
ARDS
Pulmonary edema

26. Distinction between Noncardiogenic (ARDS) and
Cardiogenic pulmonary edema
 ARDS
 Tachypnea, dyspnea,
crackles
 Aspiration, sepsis
 3 to 4 quadrant of alveolar
flooding with normal heart
size, systolic, diastolic
function
 Decreased compliance
 Severe hypoxemia
refractory to O2 therapy
 PCWP is normal <18 mm
Hg
 Cardiogenic edema
 Tachypnea, dyspnea,
crackles
 Lt ventricular dysfunction,
valvular disease, IHD
 Cardiomegaly, vascular
redistribution, pleural
effusion, perihilar bat-
wing distribution of
infiltrate
 Hypoxemia improved on
high flow O2
 PCWP is High >18 mmHg

27. Management of ARF

28. Management of ARF
 ICU admition
 1 -Airway management
 Endotracheal intubation:
 Indications
 Severe Hypoxemia
 Altered mental status
 Importance
 precise O2 delivery to the lungs
 remove secretion
 ensures adequate ventilation

29. Management of ARF
 2 -Correction of hypoxemia
 O2 administration via
nasal prongs, face mask,
intubation and Mechanical
ventilation
 Goal: Adequate O2
delivery to tissues
 PaO2 = > 60 mmHg
 Arterial O2 saturation
>90%

30. Management of ARF
 3- Correction of hypercapnia
 Control the underlying cause
 Controlled O2 supply
 1 -3 lit/min, titrate according
O2 saturation
 O2 supply to keep the O2
saturation >90% but <93 to
avoid inducing hypercapnia
 COPD-chronic bronchitis,
emphysema

31. Management of ARF
 Oxyhemoglobin
dissociations curve
60mmHg

32. Management of ARF
 4 – Mechanical
ventilation
 Indications
 Persistence hypoxemia
despite O2supply
 Decreased level of
consciousness
 Hypercapnia with severe
acidosis (pH< 7.2)

33. Management of ARF
 4 - Mechanical ventilation
 Increase PaO2
 Lower PaCO2
 Rest respiratory ms
(respiratory ms fatigue)
 Ventilator
 Assists or controls the
patient breathing
 The lowest FIO2 that
produces SaO2 >90% and
PO2 >60 mmHg should be
given to avoid O2 toxicity

34. Management of ARF
 5 -PEEP (positive End-
Expiratory pressure
 Used with mechanical ventilation
 Increase intrathoracic pressure
 Keeps the alveoli open
 Decrease shunting
 Improve gas exchange
 Hypoxemic RF (type 1)
 ARDS
 Pneumonias

35. Management of ARF
 6 - Noninvasive
Ventilatory support
(IPPV)
 Mild to moderate RF
 Patient should have
 Intact airway,
 Alert, normal airway
protective reflexes
 Nasal or full face mask
 Improve oxygenation,
 Reduce work of
breathing
 Increase cardiac output
 AECOPD, asthma, CHF

36. Management of ARF
 7 - Treatment of the
underlying causes
 After correction of hypoxemia,
hemodynamic stability
 Antibiotics
 Pneumonia
 Infection
 Bronchodilators (COPD, BA)
 Salbutamol
 reduce bronchospasm
 airway resistance

37.  7 - Treatment of the
underlying causes
 Anticholinergics (COPD,BA)
 Ibratropium bromide
 inhibit vagal tone
 relax smooth ms
 Theophylline (COPD, BA)
 improve diaphragmatic
contraction
 relax smooth ms
 Diuretics (pulmonary edema)
 Frusemide, Metalzone
Management of ARF

38. Management of ARF
 7 - Treatment of the
underlying causes
 Methyl prednisone (COPD,
BA, acute esinophilic pn)
 Reverse bronchospasm,
inflammation
 Fluids and electrolytes
 Maintain fluid balance and
avoid fluid overload
 IV nutritional support
 To restore strength, loss of
ms mass
 Fat, carbohydrate, protein

39. Management of ARF
 7 - Treatment of the
underlying causes
 Physiotherapy
 Chest percussion to
loosen secretion
 Suction of airways
 Help to drain secretion
 Maintain alveolar
inflation
 Prevent atelectasis, help
lung expansion

40. Management of ARF
 8 - Weaning from mechanical ventilation
 Stable underlying respiratory status
 Adequate oxygenation
 Intact respiratory drive
 Stable cardiovascular status
 Patient is a wake, has good nutrition, able to cough and
breath deeply

41. Complications of ARF
 Pulmonary
 Pulmonary embolism
 barotrauma
 pulmonary fibrosis (ARDS)
 Nosocomial pneumonia
 Cardiovascular
 Hypotension, ↓COP
 Arrhythmia
 MI, pericarditis
 GIT
 Stress ulcer, ileus, diarrhea,
hemorrhage
 Infections
 Nosocomial infection
 Pneumonia, UTI,
catheter related sepsis
 Renal
 ARF (hypoperfusion,
nephrotoxic drugs)
 Poor prognosis
 Nutritional
 Malnutrition, diarrhea
hypoglycemia,
electrolyte disturbances

42. Prognosis of ARF
 Mortality rate for ARDS → 40%
 Younger patient <60 has better survival rate
 75% of patient survive ARDS have impairment of
pulmonary function one or more years after recovery
 Mortality rate for COPD →10%
 Mortality rate increase in the presence of hepatic,
cardiovascular, renal, and neurological disease

43. Quiz

44. Thank you

45.  Suggested text book to read
 Davidson’s principle of internal medicine