Acute Respiratory Failure

Aka: Acute Respiratory Failure, Respiratory Failure

II. Types: Hypoventilatory Respiratory Failure or Hypercapnic Respiratory Failure (Bellows Failure)

  1. Defining features
    1. High PaCO2 >50 mmHg (not due to respiratory compensation for Metabolic Alkalosis)
    2. Normal A-a Gradient
  2. Causes: Compromised lung mechanics
    1. Upper airway obstruction
      1. Infection (Epiglottitis, Bacterial Tracheitis, croup)
      2. Adenotonsillar Hypertrophy
      3. Neck Mass
      4. ThyroidGoiter
      5. Obstructive Sleep Apnea
      6. Vocal Cord Paralysis (bilateral)
      7. Laryngeal Foreign Body
    2. Pulmonary muscle Fatigue (Skeletal muscle Fatigues at >40% of maximum load)
      1. Obesity
      2. Ascites
      3. Pleural Effusion
      4. Supine position
      5. Kyphoscoliosis
      6. Ankylosing Spondylitis
      7. Hypercarbia (fever, Sepsis, burns)
      8. Inefficient breathing (flat diaphragm, high Residual Volume)
        1. Asthma
        2. Emphysema
    3. Unstable chest wall
      1. Pneumothorax
      2. Flail Chest or multiple Rib Fractures
      3. Diaphragmatic Rupture
  3. Causes: Neuromuscular
    1. Drug Overdose or depressant drugs
      1. Opioids
      2. Benzodiazepines
      3. Barbiturates
      4. Procedural Anesthesia (e.g. Propofol)
      5. Phencyclidine (PCP)
    2. Toxins (or other medication adverse effects)
      1. Aminoglycosides
      2. Arsenic
      3. Strychnine
      4. Botulism
    3. Electrolyte and endocrine abnormalities
      1. Hyponatremia
      2. Hypocalcemia
      3. Hypokalemia
      4. Hyperkalemia
      5. Hypomagnesemia
      6. Severe Hypophosphatemia
      7. Hypothyoidism
    4. Brainstem injury
    5. Severe global CNS injury
      1. Head Trauma
      2. Intracranial Hemorrhage
      3. CNS Infection (Meningitis, Encephalitis, Brain Abscess, West Nile Encephalitis, Poliomyelitis)
      4. Central Sleep Apnea
      5. Central Alveolar Hypoventilation Syndrome (CHS)
    6. Nerve dysfunction
      1. Spinal cord injury
      2. Polyneuritis (e.g. Guillain-Barre Syndrome)
      3. Amyotrophic Lateral Sclerosis
      4. Multiple Sclerosis
      5. Nerve Agent Exposure (e.g. Organophosphates)
      6. Phrenic nerve injury
        1. Example: Phrenic Nerve Injury from Birth Trauma
    7. Muscular dysfunction
      1. Muscular Dystrophy
      2. Myasthenia Gravis
      3. Polymyositis
      4. Tetanus

III. Types: Ventilation-perfusion mismatch (venous admixture)

  1. Defining features
    1. High PaCO2
    2. Increased A-a Gradient
    3. Often improves with Supplemental Oxygen
  2. Causes
    1. Asthma
    2. Chronic Obstructive Pulmonary Disease (COPD)
    3. Pneumonia
    4. Pneumothorax
    5. Pulmonary Embolism
    6. Interstitial Lung Disease

IV. Types: Hypoxemic Respiratory Failure (or physiologic right to left shunting)

  1. Defining features
    1. Low PaCO2
    2. Low PaO2 <50-60 mmHg on room air
    3. A-a Gradient may be increased
    4. May not improve with Supplemental Oxygen
  2. Causes
    1. Cardiac pulmonary edema (high pressure edema)
      1. Left Ventricular Failure
      2. Acute Myocardial Ischemia (left ventricle)
      3. Malignant Hypertension
      4. Mitral Regurgitation or stenosis
    2. Lung Conditions
      1. Lobar Pneumonia
      2. Atelectasis
      3. Pulmonary Contusion
      4. Alveolar Hemorrhage
      5. Bronchospasm
      6. Cystic Fibrosis
      7. Acute Respiratory Distress Syndrome (ARDS)
        1. Increased permeability (low pressure edema)

V. Signs

  1. General appearance
    1. Altered Mental Status
    2. Diaphoresis
  2. Increased work of breathing
    1. Accessory muscle use
    2. Intercostal retractions
    3. Tachypnea
    4. Paradoxical breathing patterns
      1. Abdominal wall moves inward with inspiration as respiratory Fatigue occurs
  3. Cardiovascular changes
    1. Mucous membrane and nail bed Cyanosis
    2. Tachycardia
    3. Hypertension

VI. Differential Diagnosis

  1. See Causes above
  2. See Dyspnea Causes
  3. See Tachypnea Causes
  4. See Hypoxia

VII. Management: General

  1. See Emergency Breathing Management
  2. See Advanced Airway
  3. See Non-Invasive Positive Pressure Ventilation
  4. Specific Approaches
    1. Emergency Management of Asthma Exacerbation (or Status Asthmaticus)
    2. Emergency Management of COPD Exacerbation
    3. Congestive Heart Failure Exacerbation Management
    4. Acute Respiratory Distress Syndrome

VIII. Management: Approach to Non-Invasive Positive Pressure Ventilation Selection

  1. Hypoxemic Respiratory Failure (Inadequate oxygenation)
    1. Reflected by Arterial Blood GasPaO2 and Oxygen Saturation
    2. Concepts
      1. Increase oxygen delivered to the lung (esp. FIO2) or
      2. Increase mean airway pressure (or Positive End-Expiratory Pressure)
    3. Interventions
      1. Continuous Positive Airways Pressure (CPAP)
  2. Hypercarbic Respiratory Failure (Inadequate ventilation)
    1. Reflected by Arterial Blood GasPaCO2 and pH
    2. Concepts (increase minute ventilation)
      1. Increase Tidal Volume (TV) or
      2. Increase Respiratory Rate (RR)
    3. Interventions
      1. Bilevel Positive Airway Pressure (BiPap)
  3. References
    1. Mallemat and Runde in Herbert (2015) EM:Rap 15(2): 7-8

IX. References

  1. (2016) Fundamental Critical Care Support, p. 46-60
  2. Davies (1986) Acute Respiratory Failure, Cyberlog
  3. Presberg in Noble (2001) Primary Care, p. 705-16

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Related Studies

Ontology: Acute respiratory failure (C0264490)

Definition (NCI) Life-threatening respiratory failure that develops rapidly. Causes include injury, sepsis, drug overdose, and pancreatitis. It manifests with dyspnea and cyanosis and may lead to cardiovascular shock.
Concepts Disease or Syndrome (T047)
ICD9 518.81
ICD10 J96.0
SnomedCT 65710008
English Acute respiratory failure, ARF - Acute respirat failure, ARF, acute respiratory failure (diagnosis), acute respiratory failure, Acute respiratry failure, acute failure respiratory, arf, ARF - Acute respiratory failure, Acute respiratory failure (disorder), Acute Respiratory Failure
Italian Insufficienza respiratoria acuta, Insufficienza renale acuta
Dutch ANF, Acute respiratoire insufficiëntie, acuut ademhalingstekort
French IRA, Défaillance respiratoire aiguë
German ARF, Akute respiratorische Insuffizienz, anderenorts nicht klassifiziert, akute respiratorische Insuffizienz
Portuguese Insuficiência renal aguda, Insuficiência respiratória aguda
Spanish FRA, fallo respiratorio agudo, falla respiratoria aguda (trastorno), falla respiratoria aguda, difucultad respiratoria aguda, dificultad respiratoria aguda (trastorno), dificultad respiratoria aguda, fallo respiratorio agudo (trastorno), Insuficiencia respiratoria aguda
Japanese 急性腎不全, 急性呼吸不全, ｷｭｳｾｲｼﾞﾝﾌｾﾞﾝ, ｷｭｳｾｲｺｷｭｳﾌｾﾞﾝ
Czech Akutní respirační selhání, Akutní renální selhání
Korean 급성 호흡기능상실
Hungarian Heveny légzési elégtelenség, ARF
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Respiratory Failure (C1145670)

Definition (MEDLINEPLUS)

Respiratory failure happens when not enough oxygen passes from your lungs into your blood. Your body's organs, such as your heart and brain, need oxygen-rich blood to work well. Respiratory failure also can happen if your lungs can't remove carbon dioxide (a waste gas) from your blood. Too much carbon dioxide in your blood can harm your body's organs.

Diseases and conditions that affect your breathing can cause respiratory failure. Examples include

  • Lung diseases such as COPD (chronic obstructive pulmonary disease), pneumonia, pulmonary embolism, and cystic fibrosis
  • Conditions that affect the nerves and muscles that control breathing, such as spinal cord injuries, muscular dystrophy and stroke
  • Damage to the tissues and ribs around the lungs. An injury to the chest can cause this damage.
  • Drug or alcohol overdose
  • Injuries from inhaling smoke or harmful fumes

Treatment for respiratory failure depends on whether the condition is acute (short-term) or chronic (ongoing) and how severe it is. It also depends on the underlying cause. You may receive oxygen therapy and other treatment to help you breathe.

NIH: National Heart, Lung, and Blood Institute
Definition (NCI) The significant impairment of gas exchange within the lungs resulting in hypoxia, hypercarbia, or both, to the extent that organ tissue perfusion is severely compromised. Causes include chronic obstructive pulmonary disease, asthma, emphysema, acute respiratory distress syndrome, pneumonia, pulmonary edema, pneumothorax, and congestive heart failure. Treatment requires intubation and mechanical ventilation until the time the lungs recover sufficient function.
Definition (NCI_CTCAE) A disorder characterized by impaired gas exchange by the respiratory system resulting in hypoxemia and a decrease in oxygenation of the tissues that may be associated with an increase in arterial levels of carbon dioxide.
Definition (CSP) respiratory function fails to maintain adequate oxygen supply and carbon dioxide removal.
Concepts Disease or Syndrome (T047)
MSH D012131
ICD10 J96.9
SnomedCT 207552005, 207555007, 51395007, 196165003, 158731006, 158734003, 409622000
English Respiratory Failure, Respiratory failure, unspecified, [D]Respiratory failure (context-dependent category), [D]Respiratory failure NOS (context-dependent category), [D]Respiratory failure, [D]Respiratory failure NOS, respiratory failure (diagnosis), respiratory failure, Respiration failure, Failure respiratory, Failure;respiratory, respiratory insufficiency, respiratory insufficiency/failure, [D]Respiratory failure NOS (situation), [D]Respiratory failure (situation), RESPIRATORY FAILURE, FAILURE, RESPIRATORY, Respiratory failure, NOS, Respiratory failure, Respiratory failure (disorder), Respiratory failure NOS
Italian Insufficienza respiratoria, Crisi respiratoria
German Atemversagen, Versagen Atmung, Respiratorische Insuffizienz, ATEMVERSAGEN, Respiratorische Insuffizienz, nicht naeher bezeichnet, respiratorische Insuffizienz
Spanish Fallo de la respiración, [D]falla respiratoria (categoría dependiente del contexto), Paro Respiratoria, [D]falla respiratoria (situación), [D]falla respiratoria, Insuficiencia respiratoria, falla respiratoria (trastorno), falla respiratoria
Japanese 呼吸不全, ｺｷｭｳﾌｾﾞﾝ
Portuguese Falência Respiratória, FALENCIA RESPIRATORIA, Insuficiência respiratória
French Défaillance respiratoire, DEFAILLANCE RESPIRATOIRE
Czech Respirační selhání, Selhání respirační, respirační selhání
Korean 상세불명의 호흡기능상실
Hungarian Respiratiós insufficientia, Légzési elégtelenség, Légzési insufficientia
Norwegian Respirasjonssvikt
Dutch Respiratoire insufficiëntie, niet gespecificeerd, respiratoir falen, Ademhalingsinsufficiëntie
Derived from the NIH UMLS (Unified Medical Language System)

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