Diagnosis and Management of Acute Respiratory Failure

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Objectives
Define and classify acute respiratory failure Describe the pathophysiology and manifestations of acute respiratory failure Review oxygen supplementation strategies

Copyright 2008 Society of Critical Care Medicine

Case Study
Elderly man with chronic lung disease is brought to ED with progressive dyspnea Respiratory rate 30/min, moderate distress Using accessory muscles, wheezing What findings suggest respiratory failure? What evaluation is needed to determine if acute respiratory failure exists?
Copyright 2008 Society of Critical Care Medicine

Case Study
Elderly man with chronic lung disease is brought to ED with progressive dyspnea Respiratory rate 30/min, moderate distress Using accessory muscles, wheezing
The patient is likely to have what form of respiratory failure?

Copyright 2008 Society of Critical Care Medicine

Forms of Respiratory Failure

Hypoxemic Room air PaO2 5060 mm Hg (6.7-8 kPa) Abnormal PaO2:FiO2 ratio Hypercapnic PaCO2 50 mm Hg (6.7 kPa) with pH <7.36 Mixed
Copyright 2008 Society of Critical Care Medicine

Case Study
Arterial blood gas: pH 7.32, PaCO2 58 mm Hg (7.7 kPa), PaO2 50 mm Hg (6.7 kPa) on room air Chest radiograph: hyperinflation, increased interstitial markings in the lower lobes Why is this patient hypoxemic?

Copyright 2008 Society of Critical Care Medicine

Causes of Hypoxemia
Ventilation/perfusion mismatch Impaired gas diffusion Alveolar hypoventilation High altitude

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Causes of Hypoxemia
Ventilation/perfusion mismatch
O2 CO2

Shunt

Normal

V/Q Mismatch

Copyright 2008 Society of Critical Care Medicine

Causes of Hypoxemia
Impaired gas diffusion Alveolar hypoventilation High altitude

O2 CO2 Alveolar hypoventilation Impaired diffusion

Copyright 2008 Society of Critical Care Medicine

High altitude

Case Study
Arterial blood gas: pH 7.32, PaCO2 58 (7.7 kPa) mm Hg, PaO2 50 mm Hg (6.7 kPa) on room air Is the hypoxemia due to hypoventilation and PaCO2 ? Alveolar-arterial O2 gradient
PAO2 =[FIO2 x (Pb 47)] [1.25 x PaCO2] PAO2 =[0.21 x (760 47)] [1.25 x 58] = 78 Gradient = 78-50 = 28 mm Hg (3.7 kPa)
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Case Study
Elderly man with chronic lung disease with dyspnea, tachypnea, and wheezing Arterial blood gas: pH 7.32, PaCO2 58 mm Hg (7.7 kPa), PaO2 50 mm Hg (6.7 kPa) on room air
Why is this patient hypercapnic?

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Hypercapnia
Alveolar minute ventilation VA= (VT-VD) f
What causes increased dead space (VD)? Hypovolemia Low cardiac output Pulmonary embolus High airway pressures
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Case Study
Elderly man with chronic lung disease with dyspnea, tachypnea and wheezing Arterial blood gas: pH 7.32, PaCO2 58 mm Hg (7.7 kPa), PaO2 50 mm Hg (6.7 kPa) on room air How would you treat the hypoxemia? Treat the underlying condition Supplemental oxygen
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O2 Supplementation Devices
O2 concentration High Controlled Low Flow High Moderate Low

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Pharmacologic Adjuncts
Inhaled 2-agonists Metered-dose inhaler Nebulizer Inhaled ipratropium Metered-dose inhaler Nebulizer Corticosteroids Antibiotics

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Case Study
Young woman overdosed on antidepressants and alcohol Respiratory rate 8 breaths/min Arterial blood gas: pH 7.15, PaCO2 71 mm Hg (9.5 kPa), PaO2 56 mm Hg (7.5 kPa) on room air Why is this patient hypoxemic? PAO2 =[0.21 x (760 47)] [1.25 x 71] = 61
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Case Study
Young woman overdosed on antidepressants and alcohol Respiratory rate 8 breaths/min Arterial blood gas: pH 7.15, PaCO2 71 mm Hg (9.5 kPa), PaO2 56 mm Hg (7.5 kPa) on room air
Why is this patient hypercapnic? How would you treat the hypoxemia?

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Questions

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Key Points
Acute respiratory failure is classified as hypoxic, hypercapnic or mixed Ventilation/perfusion mismatching is the most common cause of hypoxic ARF Hypercapnic ARF is due to decreased minute ventilation O2 supplementation is used to treat hypoxemia Pharmacologic adjuncts may be needed in ARF
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