Respiratory Failure

Respiratory failure:
Diagnosis and management

Dr Victor Duong
Respiratory Registrar
Slides provided by Dr Liam Hannan, Respiratory and

Sleep Physician
Overview
• Assessing respiratory failure
• Hypoxaemic respiratory failure
• Hypercapnic respiratory failure
• Bilevel PAP
• CPAP
• Cases and ABGs
Respiratory failure
Simplest method to differentiate – do
an ABG
Type I = hypoxaemic
Type II = hypercapnic = ventilatory
failure = respiratory acidosis
Respiratory failure – Type I
Hypoxaemic
Alveolus
• Differentials
– Alveolar problem – fluid, pus,
destruction, collapse
– Circulation problem – V/Q mismatch,
PE, shunt, destruction
– Interstitial problem – fibrosis,
infiltration
By definition there is no problem with ventilation
• Options:
– High flow oxygen
– CPAP – for pulmonary oedema +/- atelectasis
– Bi-level – immunocompromised with LRTI
(ICU)
– Invasive ventilation – where above fails (and
failure can occur very quickly!)
Evaluating ventilatory (type 2) failure
Excess load or reduced Reduced drive
capacity (=won’t breathe)
(=can’t breathe) •Drugs
• Lung problem •Central pathology
• Chest wall problem •Sleep problem
(usually have
• Muscle problem
load/capacity
problem too)
Ventilatory failure (T2RF)
PaCO2>45mmHg
– Exacerbation of COPD
– Obesity hypoventilation syndrome
– Chest wall/neuromuscular – respiratory
muscle weakness
– Progression of Type I cause (prior to
respiratory arrest)
– Central – CNS depression/trauma/medications
(opioid/BZDs)
Respiratory failure – Type II
• Ventilatory failure → needs ventilation
Exclude reversible causes (particularly
drugs, oxygen)
Ventilate – invasive vs non-invasive
(Bi-level)
Bi-level
Limited (proven) indications
– COPD
– Neuromuscular disease
– Obesity hypoventilation
– Type I respiratory failure in
immunocompromised patients with LRTI or
pulmonary oedema
• Other uses are not proven
Traps
Asthma
– Classic temptation – evidence is generally
lacking
– Elevated PaCO2 due to asthma precedes
death by only a short period
– CO2 should generally be low in asthma
exacerbation
Traps
Altered conscious state
– Chicken or egg scenario
– Contraindication to non-invasive
therapy (no airway protection provided
+ theoretical aspiration risk from FFM)
– Exclusion of reversible causes and
airway protection are the priority
Settings, what settings?
• EPAP (and CPAP) = 1cmH2O for every 10kg of
body weight
– 70kg male – 7cmH2O
– if over 100kg - start at 10cmH2O
• IPAP = start 4-6cmH2O above the EPAP
• Repeat the ABG (1-2hrs) and titrate settings:
– increase EPAP if oxygen requirements high
– increase PS (IPAP-EPAP) if CO2 high/pH low
What is CPAP?
• Continuous PAP
–Fixed pressure applied via face mask
–Provides a constant/continuous pressure
throughout the respiratory cycle
–Does not provide ventilatory support
–Doesn’t offload respiratory muscles or lower
PaCO2
How does CPAP work?
• OSA
–Splints the upper airway during sleep
• APO
– increased intrathoracic pressure –
decreased venous return
– decreased atelectasis and alveolar collapse
does not affect ventilation/CO2
How to get CPAP or bilevel for your
patient:
1. Do an arterial blood gas
2. Think carefully about the underlying
diagnosis
3. Speak to the respiratory registrar
ABGs vs VBGs
Why venous?
• Venous blood gases (VBG) have been
considered as an alternative to arterial
(ABG) to assess breathless patients
• Why?
• Safer?
• Better?
• Easier?
Safer?
For the patient
- Up-to-date data demonstrating harm from ABG just
doesn’t exist
- Complication rate from arterial catheters 2.5%
(which is why we do punctures)
For the clinician

- Similar needlestick injury rates (both comprised 1%
of all needlestick injuries in a 12 month period)
- Much safer than suturing (46% of injuries) or IM/SC
injections (24% of injuries)
Better?
Correlation between PaCO2 and PvCO2 is good
because they are physiologically linked
(strength of relationship between two variables)
Agreement between PaCO2 and PvCO2 is poor

(relationship between two tests that attempt to
measure the same thing)
Limits of agreement are wide (-17 to +24mmHg in

one review, more recent -10 to +3mmHg)
VBG
pH 7.32 95% confident that

arterial pH is 7.35-7.36
PvCO2
50 95% confident that PaCO2
PvO2 45 is between 40 and
53mmHg
PvHCO3
30
Easier?
Yes VBGs are easier
But that’s not really a justification for
performing them
• FiO2 0.21 Case 1
• pH 7.48 (7.35-7.45)
• pO2 45 (80-100)
• pCO2 37 (35-45)
• HCO3- 27.5 (22-32)
Case 2
• FiO2 0.21
• pH 7.20 (7.35-7.45)
• pO2 62 (80-100)
• pCO2 90 (35-45)
• HCO3- 28.2 (22-32)
Case 3
• FiO2 0.21
• pH 7.43 (7.35-7.45)
• pO2 49 (80-100)
• pCO2 54 (35-45)
• HCO3- 33.6 (22-32)
Case 4
• FiO2 0.21
• pH 7.41 (7.35-7.45)
• pO2 60 (80-100)
• pCO2 50 (35-45)
• HCO3- 28.8 (22-32)
Examples
Drunk patient, SpO2 92% but comes up with
oxygen
ABG pH 7.15 CO2 63
What is the respiratory rate likely to be?
Likely to be very low RR – 5-6bpm – and he may

not be drunk as something is likely to be
impairing his drive to breathe (drugs, CNS
pathology)
Examples
Young asthmatic patient – RR 34, SpO2 93%
ABG – PaCO2 47mmHg, pH 7.38
In trouble or doing OK?
In BIG trouble – probably close to maximal

respiratory effort but unable to keep CO2 down
Needs ventilatory support ASAP
Examples
Elderly male with COPD – RR 28, SpO2 88% on
oxygen therapy
ABG pH 7.30 CO2 50
What evidenced-based, life saving treatment

should he get?
Bilevel PAP
please don’t say CPAP!!
Examples
Elderly female, current smoker with clinically
moderate AECOPD – SpO2 91% on 2LNP, RR=24
VBG pH 7.27 PvCO2 49
What should you do next?
Do an ABG please!
Might be an excellent candidate for bilevel
Take home messages
• ABGs remain a vital component of the assessment of
a breathless patient and reliably monitoring their
response to therapy
• Differentiating hypoxaemic from hypercapnic
respiratory failure is useful both for diagnostic and
management purposes
• Evidence supports bilevel therapy predominantly for
hypercapnic respiratory failure – except in
immunocompromised and APO
• If you think your patient needs bilevel or CPAP, do an
ABG and speak to the Respiratory registrar
Questions?

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Respiratory failure:

Diagnosis and management

Slides provided by Dr Liam Hannan, Respiratory and

For the clinician

Agreement between PaCO2 and PvCO2 is poor

Limits of agreement are wide (-17 to +24mmHg in

pH 7.32 95% confident that

What is the respiratory rate likely to be?

Likely to be very low RR – 5-6bpm – and he may

In trouble or doing OK?

In BIG trouble – probably close to maximal

What evidenced-based, life saving treatment

What should you do next?

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