Respiratory Failure

Symptoms and signs of hypoxemia

• Dyspnea,irritability
• Confusion, somnolence, fits
• Tachycardia, arrhythmia
• Tachypnea
• Cyanosis

Symptoms and signs of hypercapnia

• Headache
• Change of behavior
• Coma
• Asterixis
• Papilloedema
• Warm extremities

Symptoms and signs of the underlying disease

Examples:

Fever, cough, sputum production, chest pain in cases of pneumonia.

History of sepsis, polytrauma, burn, or blood transfusions before the onset of acute respiratory failure may point to acute respiratory distress syndrome[2].

The following investigations are needed:

• Arterial blood gases (ABG) is mandatory to confirm the diagnosis of respiratory failure.
• Chest radiography is needed as it can detect chest wall, pleural and lung parenchymal Lesions.
• Investigations needed for detecting the underlying cause of the respiratory failure these may include:
• Complete blood count (CBC)
• Sputum, blood and urine culture
• Blood electrolytes and thyroid function tests
• Pulmonary function tests
• Electrocardiography (ECG)
• Echocardiography
• Bronchoscopy

This includes supportive measures and treatment of the underlying cause.

Supportive measures which depend on depending on airways management to maintain adequate ventilation and correction of the blood gases abnormalities

Correction of Hypoxemia

The goal is to maintain adequate tissue oxygenation, generally achieved with an arterial oxygen tension (PaO2) of 60 mm Hg or arterial oxygen saturation (SaO2), about 90%.

Un-controlled oxygen supplementation can result in oxygen toxicity and CO2 (carbon dioxide) narcosis. So the inspired oxygen concentration should be adjusted at the lowest level, which is sufficient for tissue oxygenation.

Oxygen can be delivered by several routes depending on the clinical situations in which we may use a nasal cannula, simple face mask nonrebreathing mask, or high flow nasal cannula.

Extracorporeal membrane oxygenation may be needed in refractory cases[3]. 

Correction of hypercapnia and respiratory acidosis 

This may be achieved by treating the underlying cause or providing ventilatory support.[4]

Ventilatory support for the patient with respiratory failure

The goals of ventilatory support in respiratory failure are:

• Correct hypoxemia
• Correct acute respiratory acidosis
• Resting of ventilatory muscles 

Common indications for mechanical ventilation include the following:

• Apnea with respiratory arrest 
• Tachypnea with respiratory rate >30 breaths per minute
• Disturbed conscious level or coma
• Respiratory muscle fatigue
• Hemodynamic instability
• Failure of supplemental oxygen to increase PaO2 to 55-60  mm Hg
• Hypercapnea with arterial pH less than 7.25[5].

The choice of invasive or noninvasive ventilatory support depends on the clinical situation, whether the condition is acute or chronic, and how severe it is. It also depends on the underlying cause. If there are no absolute indications for invasive mechanical ventilation or intubations and if there are no contraindications for noninvasive ventilation non- invasive ventilation is preferred particularly in cases of chronic obstructive pulmonary disease (COPD) exacerbation[6][7], Cardiogenic pulmonary edema[6] [8]and obesity hypoventilation syndrome[9].

• Cardiogenic shock

• Cor pulmonale 

• Cyanosis

• Diaphragmatic Paralysis

• Dilated Cardiomyopathy

• Emphysema

• Myocardial Infarction 

• Noninvasive Ventilation

• Obstructive Sleep Apnea

• Pulmonary Embolism

Complications from respiratory failure may be a result of blood gases disturbances or from the therapeutic approach itself

Example of these complications:

Lung complications: for example, pulmonary embolism irreversible scarring of the lungs, pneumothorax, and dependence on a ventilator.

Cardiac complications: for example, heart failure arrhythmias and acute myocardial infarction[10].

Neurological complications: a prolonged period of brain hypoxia can lead to irreversible brain damage and brain death.

Renal:  acute renal failure may occur due to hypoperfusion and/or nephrotoxic drugs.

Gastro-intestinal: stress ulcer, ileus, and hemorrhage[11]

Nutritional: malnutrition, diarrhea hypoglycemia, electrolyte disturbances[12]

During the management of respiratory failure consultation for other specialties may be indicated like cardiac and neurological consultation.

• Liberal oxygen supplementation beyond the required level for adequate tissue oxygenation may be hazardous and may lead to deterioration of the patient's condition as in cases of acute on top of chronic type 2 respiratory failure in patients with chronic obstructive pulmonary disease[13].
• During mechanical ventilation, carbon dioxide over-wash should be avoided in patients with acute on top of chronic type 2 respiratory failure by adjusting the ventilatory parameters to maintain carbon dioxide to its basal level.
• Lung protective strategy is mandatory during mechanical ventilation in especially in cases of acute respiratory distress syndrome[2].

The diagnosis of the underlying cause of respiratory failure and its treatment is challenging as respiratory failure may result from numerous pulmonary and extrapulmonary causes, so consultation for other specialties, for example, neurological and cardiac consultation, may be mandatory. As complications from respiratory failure may be due to improper patient positioning and poor adherence to infection control policies, so the nurses are vital members of the interprofessional group, assuring that appropriate position is rendered. Also, complications can be the result of drug toxicities or drug interactions, so a pharmacist should be incorporated in the management team for respiratory failure cases. The job of the nurse carries a far more important role if the patient is on a mechanical ventilator. The nurse has to monitor the patient 24/7 and assess each organ system several times a day. The nurse also is responsible for suctioning, positioning, and feeding of the patient. Because the patient with respiratory failure is usually on multiple medications, the pharmacist is responsible for ensuring the most appropriate drug is administered without causing drug interactions or severe adverse reactions. Finally, a patient in respiratory failure is also looked after respiratory therapists for chest therapy or administration of oxygen. [14][15][16](Level 5)

Outcomes

The prognosis of respiratory failure varies according to underlying causes and other factors like the age of the patients and the associated comorbidities [17].