Respiratory Failure

Esam H. Alhamad, M.D

Assistant Professor of Medicine
Consultant Pulmonary and Critical Care
Medicine.
Definitions

• acute respiratory failure occurs when:

– pulmonary system is no longer able to meet
the metabolic demands of the body
• hypoxaemic respiratory failure:
– PaO2  50 mm Hg when breathing room air
• hypercapnic respiratory failure:
– PaCO2  50 mm Hg.
Basic respiratory physiology
CO2 O2
Oxygen in

• Depends on
– PAO2
– Diffusing capacity
– Perfusion
– Ventilation-perfusion matching
 Oxygen

Carbon
dioxide

Water
vapour

Nitrogen

Alveolarpressure PAO2  PACO2  PAH2O  PAN2

Oxygen in

• Depends on
– PAO2
• FIO2
• PACO2
• Alveolar pressure
• Ventilation
– Diffusing capacity
– Perfusion
– Ventilation-perfusion matching
Carbon dioxide out

• Largely dependent on alveolar ventilation

Alveolar ventilation  RR x (V - V )
T D

• Anatomical deadspace constant but

physiological deadspace depends on
ventilation-perfusion matching
Carbon dioxide out

• Respiratory rate
• Tidal volume
• Ventilation-perfusion matching
Pathophysiology
 FIO2

Ventilation
without
perfusion Hypoventilation
(deadspace
ventilation)

Diffusion
abnormality
Normal

Perfusion
without
ventilation
(shunting)
 FIO2

Ventilation
without
perfusion Hypoventilation
(deadspace
ventilation)

Diffusion
abnormality
Normal

Perfusion
without
ventilation
(shunting)
75% 75%

100% 75%
87.5%
Perfusion without
ventilation (Shunting)
• Intra-cardiac
– Any cause of right to left shunt
• eg Fallot’s, Eisenmenger
• Intra-pulmonary
– Pneumonia
– Pulmonary oedema
– Atelectasis
– Collapse
– Pulmonary haemorrhage or contusion
Perfusion without
ventilation (shunting)
Intra-pulmonary
• Small airways occluded ( e.g asthma, chronic
bronchitis)

• Alveoli are filled with fluid ( e.g pulm edema,

pneumonia)

• Alveolar collapse ( e.g atelectasis)

 FIO2

Ventilation
without
perfusion Hypoventilation
(deadspace
ventilation)

Diffusion
abnormality
Normal

Perfusion
without
ventilation
(shunting)
V/Q mismatch:
Dead space ventilation

Alveoli that are normally ventilated but poorly perfused

Anatomic dead space

Gas in the large conducting airways that does not come in

contact with the capillaries e.g pharynx
V/Q mismatch:

Dead space ventilation

Physiologic dead space

Alveolar gas that does not equilibrate fully with

capillary blood
Dead space vantilation

• DSV increase:
• Alveolar-capillary interface
destroyed e.g emphysema
• Blood flow is reduced e.g CHF, PE
• Overdistended alveoli e.g positive-
pressure ventilation
 FIO2

Ventilation
without
perfusion Hypoventilation
(deadspace
ventilation)

Diffusion
abnormality
Normal

Perfusion
without
ventilation
(shunting)
Diffusion abnormality:

• Less common

• Abnormality of the alveolar membrane or a

reduction in the number of capillaries resulting
in a reduction in alveolar surface area

• Causes include:
– Acute Respiratory Distress Syndrome
– Fibrotic lung disease
 FIO2

Ventilation
without
perfusion Hypoventilation
(deadspace
ventilation)

Diffusion
abnormality
Normal

Perfusion
without
ventilation
(shunting)
 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 Brainstem

Spinal cord
Airway Nerve root

Lung Nerve

Pleura

Neuromuscular
Chest wall junction

Respiratory
muscle

Sites at which disease may cause ventilatory disturbance

 Respiratory Failure
Symptoms
CNS:
Headache
Visual Disturbances
Anxiety
Confusion
Memory Loss
Weakness
Decreased Functional Performance
 Respiratory Failure
Symptoms
Pulmonary:
Cough
Chest pains
Sputum production
Stridor
Dyspnea
 Respiratory Failure
Symptoms
Cardiac:
Orthopnea
Peripheral edema
Chest pain

Other:
Fever, Abdominal pain, Anemia, Bleeding
Clinical

• Respiratory compensation
• Sympathetic stimulation
• Tissue hypoxia
• Haemoglobin desaturation
Clinical

• Respiratory compensation
– Tachypnoea RR > 35 Breath /min
– Accessory muscles
– Recesssion
– Nasal flaring
• Sympathetic stimulation
• Tissue hypoxia
• Haemoglobin desaturation
Clinical

• Respiratory compensation
• Sympathetic stimulation
– HR
– BP
– sweating
• Tissue hypoxia
• Haemoglobin desaturation
Clinical

• Respiratory compensation
• Sympathetic stimulation
• Tissue hypoxia
– Altered mental state
– HR and BP (late)
• Haemoglobin desaturation
Clinical

Altered mental state

⇓PaO2 +⇑PaCO2 ⇨ acidosis ⇨
dilatation of cerebral resistance
vesseles ⇨ ⇑ICP

Disorientation Headache
coma asterixis
personality changes
Clinical

• Respiratory
compensation
• Sympathetic
stimulation
• Tissue hypoxia
• Haemoglobin
desaturation
– cyanosis
 Respiratory Failure
Laboratory Testing
Arterial blood gas
PaO2
PaCO2
PH
Chest imaging
Chest x-ray
CT sacn
Ultrasound
Ventilation–perfusion scan
 Respiratory Failure
Laboratory Testing
Respiratory mechanics
Spirometry (FVC, FEV1, Peak flow)

Respiratory muscle pressures

MIP ( maximum inspiratory pressure)
MEP ( maximum expiratory pressure)
 Respiratory Failure
Laboratory Testing
Other tests
Hemoglobin
Electrolytes, blood urea nitrogen, creatinine
Creatinine phosphokinase, aldolase
EKG, echocardiogram
Electromyography (EMG)
Nerve conduction study
 True or False

•Diffusion abnormality is
considered the most
common cause of
hypoxia.
 True or False

•Dead space ventilation

decreases when blood
flow is reduced
 True or False

•Shunt occurs when areas

of lung are perfused but
not ventilated
 True or False

•In myasthenia gravis

mechanism of hypoxia
may be due to alveoli
being perfused but not
ventilated
 True or False

•Arterial hypoxemia may

be caused by alveolar
hypoventilation alone
 True or False
• The distinction between
ventilation/perfusion mismatch
and intrapulmonary shunting
can be made by measuring the
response to the administration
of 100% oxygen
 True or False
• There is a good relationship
between dyspnea and arterial
hypoxemia but a poor
relationship between dyspnea
and arterial carbon dioxide
retention
Which of the following statements
regarding the physical examination
for patients with acute respiratory
failure are true or false?

• Central nervous examination is important

• Breath sounds are commonly diminished
• Supraclavicular and intercostal space
muscle retractions do not correlate with
increased work of breathing
QUESTIONS
?
?
?
?
Pulse oximetry
90
Hb saturation (%)

PaO2 (kPa)
Sources of error

• Poor peripheral perfusion

• Dark skin
• False nails or nail varnish
• Lipaemia
• Bright ambient light
• Poorly adherent probe
• Excessive motion
• Carboxyhaemoglobin or methaemoglobin
Sources of error

• Poor peripheral perfusion

• Dark skin
• False nails or nail varnish
• Lipaemia
• Bright ambient light
• Poorly adherent probe
• Excessive motion
• Carboxyhaemoglobin or methaemoglobin
Sources of error

• Poor peripheral perfusion

• Dark skin
• False nails or nail varnish
• Lipaemia
• Bright ambient light
• Poorly adherent probe
• Excessive motion
• Carboxyhaemoglobin or methaemoglobin
Sources of error

• Poor peripheral perfusion

• Dark skin
• False nails or nail varnish
• Lipaemia
• Bright ambient light
• Poorly adherent probe
• Excessive motion
• Carboxyhaemoglobin or methaemoglobin
Sources of error

• Poor peripheral perfusion

• Dark skin
• False nails or nail varnish
• Lipaemia
• Bright ambient light
• Poorly adherent probe
• Excessive motion
• Carboxyhaemoglobin or methaemoglobin
Sources of error

• Poor peripheral perfusion

• Dark skin
• False nails or nail varnish
• Lipaemia
• Bright ambient light
• Poorly adherent probe
• Excessive motion
• Carboxyhaemoglobin or methaemoglobin
Sources of error

• Poor peripheral perfusion

• Dark skin
• False nails or nail varnish
• Lipaemia
• Bright ambient light
• Poorly adherent probe
• Excessive motion
• Carboxyhaemoglobin or methaemoglobin
Sources of error

• Poor peripheral perfusion

• Dark skin
• False nails or nail varnish
• Lipaemia
• Bright ambient light
• Poorly adherent probe
• Excessive motion
• Carboxyhaemoglobin or methaemoglobin
Arterial blood gases

• See “Arterial blood gases” lecture