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Diagnosis and Diagnosis and Management of Acute Management of Acute
Respiratory FailureRespiratory Failure
Diagnosis and Diagnosis and Management of Acute Management of Acute
Respiratory FailureRespiratory Failure
ARF 1 ARF 1 ®
ObjectivesObjectivesObjectivesObjectives
• Define and classify acute respiratory failureDefine and classify acute respiratory failure
• Describe pathophysiology of acute Describe pathophysiology of acute respiratory failurerespiratory failure
• Discuss clinical manifestations Discuss clinical manifestations
• Review oxygen supplementation strategiesReview oxygen supplementation strategies
• Discuss noninvasive positive-pressure Discuss noninvasive positive-pressure ventilationventilation
• Define and classify acute respiratory failureDefine and classify acute respiratory failure
• Describe pathophysiology of acute Describe pathophysiology of acute respiratory failurerespiratory failure
• Discuss clinical manifestations Discuss clinical manifestations
• Review oxygen supplementation strategiesReview oxygen supplementation strategies
• Discuss noninvasive positive-pressure Discuss noninvasive positive-pressure ventilationventilation
ARF 2
ARF 2 ®
Acute Respiratory FailureAcute Respiratory FailureAcute Respiratory FailureAcute Respiratory Failure
• HypoxemicHypoxemic
–Room air PaORoom air PaO22 50 torr (6.7 kPa) 50 torr (6.7 kPa)
• HypercapnicHypercapnic
–PaCOPaCO22 50 torr (6.7 kPa) 50 torr (6.7 kPa)
• Acute vs chronic Acute vs chronic
• HypoxemicHypoxemic
–Room air PaORoom air PaO22 50 torr (6.7 kPa) 50 torr (6.7 kPa)
• HypercapnicHypercapnic
–PaCOPaCO22 50 torr (6.7 kPa) 50 torr (6.7 kPa)
• Acute vs chronic Acute vs chronic
––
Pathophysiology of Pathophysiology of HypoxemiaHypoxemia
Pathophysiology of Pathophysiology of HypoxemiaHypoxemia
• Ventilation/perfusion mismatchVentilation/perfusion mismatch• Shunt effectShunt effect
• Decreased diffusion of ODecreased diffusion of O22 • Alveolar hypoventilationAlveolar hypoventilation• High altitudeHigh altitude
• Ventilation/perfusion mismatchVentilation/perfusion mismatch• Shunt effectShunt effect
• Decreased diffusion of ODecreased diffusion of O22 • Alveolar hypoventilationAlveolar hypoventilation• High altitudeHigh altitude
Pathophysiology of Pathophysiology of HypercapniaHypercapnia
• Decreased tidal volume and/or Decreased tidal volume and/or respiratory rate respiratory rate
• Inability to sense elevated PaCOInability to sense elevated PaCO2 2
• Inability to signal effector Inability to signal effector mechanisms mechanisms
• Inability to effect a response from Inability to effect a response from respiratory musclesrespiratory muscles
• Decreased tidal volume and/or Decreased tidal volume and/or respiratory rate respiratory rate
• Inability to sense elevated PaCOInability to sense elevated PaCO2 2
• Inability to signal effector Inability to signal effector mechanisms mechanisms
• Inability to effect a response from Inability to effect a response from respiratory musclesrespiratory muscles
Increased Dead SpaceIncreased Dead SpaceIncreased Dead SpaceIncreased Dead Space
• HypovolemiaHypovolemia
• Low cardiac outputLow cardiac output
• Pulmonary embolusPulmonary embolus
• High airway pressuresHigh airway pressures
• Short-term compensation by increasing Short-term compensation by increasing tidal volume and/or respiratory ratetidal volume and/or respiratory rate
• HypovolemiaHypovolemia
• Low cardiac outputLow cardiac output
• Pulmonary embolusPulmonary embolus
• High airway pressuresHigh airway pressures
• Short-term compensation by increasing Short-term compensation by increasing tidal volume and/or respiratory ratetidal volume and/or respiratory rate
Manifestations of Manifestations of Respiratory DistressRespiratory DistressManifestations of Manifestations of Respiratory DistressRespiratory Distress
• Altered mental statusAltered mental status
• Increased work of breathingIncreased work of breathing
– TachypneaTachypnea
– Accessory muscle use, retractions, Accessory muscle use, retractions, paradoxical breathing pattern paradoxical breathing pattern
• Catecholamine releaseCatecholamine release
– Tachycardia, diaphoresis, hypertensionTachycardia, diaphoresis, hypertension
• Abnormal arterial blood gas valuesAbnormal arterial blood gas values
• Altered mental statusAltered mental status
• Increased work of breathingIncreased work of breathing
– TachypneaTachypnea
– Accessory muscle use, retractions, Accessory muscle use, retractions, paradoxical breathing pattern paradoxical breathing pattern
• Catecholamine releaseCatecholamine release
– Tachycardia, diaphoresis, hypertensionTachycardia, diaphoresis, hypertension
• Abnormal arterial blood gas valuesAbnormal arterial blood gas values
ARF 7ARF 7®
Acute Respiratory Failure Acute Respiratory Failure ManagementManagement
Acute Respiratory Failure Acute Respiratory Failure ManagementManagement
• Oxygen supplementationOxygen supplementation
– Increase FIncrease FIOIO22
–Match flow between delivery Match flow between delivery device and inspiratory demanddevice and inspiratory demand
–High- vs. low-oxygen systemsHigh- vs. low-oxygen systems
–High- vs. low-flow systemsHigh- vs. low-flow systems
• Oxygen supplementationOxygen supplementation
– Increase FIncrease FIOIO22
–Match flow between delivery Match flow between delivery device and inspiratory demanddevice and inspiratory demand
–High- vs. low-oxygen systemsHigh- vs. low-oxygen systems
–High- vs. low-flow systemsHigh- vs. low-flow systems
ARF 8ARF 8®
Nasal CannulaNasal Cannula
• 100% oxygen 100% oxygen delivereddelivered
• Low flow Low flow
–<0.5–5.0 L/min<0.5–5.0 L/min
• Low oxygen Low oxygen
–FFIOIO22 <0.4–0.5 <0.4–0.5
Air-Entrainment Face MaskAir-Entrainment Face MaskAir-Entrainment Face MaskAir-Entrainment Face Mask
• 100% O100% O22 + entrainment + entrainment
devicedevice
• High flowHigh flow
• Variable oxygenVariable oxygen
–FFIOIO22 0.24–0.5 0.24–0.5
• 100% O100% O22 + entrainment + entrainment
devicedevice
• High flowHigh flow
• Variable oxygenVariable oxygen
–FFIOIO22 0.24–0.5 0.24–0.5
Aerosol Face MaskAerosol Face Mask
• 100% O100% O22 + large-bore tubing + large-bore tubing
• Nebulizer/ONebulizer/O22 blender blender
• Flow matchingFlow matching
– If mist disappears in If mist disappears in inspiration, air is entrainedinspiration, air is entrained
• Moderate-flow, variable FModerate-flow, variable FIOIO22
devicedevice
• 100% O100% O22 + large-bore tubing + large-bore tubing
• Nebulizer/ONebulizer/O22 blender blender
• Flow matchingFlow matching
– If mist disappears in If mist disappears in inspiration, air is entrainedinspiration, air is entrained
• Moderate-flow, variable FModerate-flow, variable FIOIO22
devicedevice
Reservoir Face MaskReservoir Face MaskReservoir Face MaskReservoir Face Mask
• Reservoir bag filled Reservoir bag filled with 100% Owith 100% O22
• High oxygen High oxygen
• High flow High flow
• Reservoir bag filled Reservoir bag filled with 100% Owith 100% O22
• High oxygen High oxygen
• High flow High flow
Resuscitation Bag-Mask-Resuscitation Bag-Mask-Valve DeviceValve Device
Resuscitation Bag-Mask-Resuscitation Bag-Mask-Valve DeviceValve Device
• 100% O100% O2 2
• High flow (> 15 L/min)High flow (> 15 L/min)
• Emergency equipmentEmergency equipment
• Little to no air entrainment Little to no air entrainment with firm fit with firm fit
• 100% O100% O2 2
• High flow (> 15 L/min)High flow (> 15 L/min)
• Emergency equipmentEmergency equipment
• Little to no air entrainment Little to no air entrainment with firm fit with firm fit
Noninvasive Positive-Noninvasive Positive-Pressure Ventilation (NPPV)Pressure Ventilation (NPPV)
Noninvasive Positive-Noninvasive Positive-Pressure Ventilation (NPPV)Pressure Ventilation (NPPV)• Ventilatory assistance with controlled FVentilatory assistance with controlled FIOIO22
• Unilevel or bilevel pressure supportUnilevel or bilevel pressure support
• Nasal or face maskNasal or face mask
• Volume or pressure-cycled ventilatorVolume or pressure-cycled ventilator
• Most effective with alert, oriented and Most effective with alert, oriented and cooperative patientcooperative patient
• Successful in hypoxemic and hypercapnic Successful in hypoxemic and hypercapnic failure failure
• Ventilatory assistance with controlled FVentilatory assistance with controlled FIOIO22
• Unilevel or bilevel pressure supportUnilevel or bilevel pressure support
• Nasal or face maskNasal or face mask
• Volume or pressure-cycled ventilatorVolume or pressure-cycled ventilator
• Most effective with alert, oriented and Most effective with alert, oriented and cooperative patientcooperative patient
• Successful in hypoxemic and hypercapnic Successful in hypoxemic and hypercapnic failure failure
ARF 14 ARF 14 ®
Relative Contraindications Relative Contraindications for NPPVfor NPPV
Relative Contraindications Relative Contraindications for NPPVfor NPPV
• Decreased level of consciousnessDecreased level of consciousness
• Poor airway protective reflexesPoor airway protective reflexes
• Copious secretionsCopious secretions
• Cardiovascular instabilityCardiovascular instability
• Progressive pulmonary decompensationProgressive pulmonary decompensation
• Upper gastrointestinal hemorrhageUpper gastrointestinal hemorrhage
• Decreased level of consciousnessDecreased level of consciousness
• Poor airway protective reflexesPoor airway protective reflexes
• Copious secretionsCopious secretions
• Cardiovascular instabilityCardiovascular instability
• Progressive pulmonary decompensationProgressive pulmonary decompensation
• Upper gastrointestinal hemorrhageUpper gastrointestinal hemorrhage
ARF 15 ARF 15 ®
Initiation of NPPVInitiation of NPPV
• Set FSet FIOIO2 2 at 1.00at 1.00
• Hypoxemic failureHypoxemic failure
– Inspiratory pressure (IPAP) 10 cm HInspiratory pressure (IPAP) 10 cm H22OO
– Expiratory pressure (EPAP) 5 cm HExpiratory pressure (EPAP) 5 cm H22OO
– Titrate EPAP in 2 cm HTitrate EPAP in 2 cm H22O incrementsO increments
• Ventilatory failureVentilatory failure
– IPAP 10 and EPAP 2 cm HIPAP 10 and EPAP 2 cm H22OO
– Titrate IPAP in 2 cm HTitrate IPAP in 2 cm H22O incrementsO increments
Initiation of NPPVInitiation of NPPV
• Make changes every 15-30 minutesMake changes every 15-30 minutes
• Monitor vital signs, appearance, Monitor vital signs, appearance, pulse oximetry and blood gasespulse oximetry and blood gases
• Head of bed at 45Head of bed at 45 angle angle
• Consider gastric decompressionConsider gastric decompression
• Intubation if patient deterioratesIntubation if patient deteriorates
Pharmacologic AdjunctsPharmacologic Adjuncts Pharmacologic AdjunctsPharmacologic Adjuncts
• BronchodilatorsBronchodilators
22-agonists-agonists
–Anticholinergics Anticholinergics (ipratropium)(ipratropium)
• CorticosteroidsCorticosteroids
• TheophyllineTheophylline
• AntibioticsAntibiotics
• BronchodilatorsBronchodilators
22-agonists-agonists
–Anticholinergics Anticholinergics (ipratropium)(ipratropium)
• CorticosteroidsCorticosteroids
• TheophyllineTheophylline
• AntibioticsAntibiotics
Key PointsKey PointsKey PointsKey Points