ACUTE RESPIRATORY FAILURE

INTRODUCTION
Respiratory failure is a syndrome in which the respiratory system fails in one or both of
its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, respiratory
failure is defined as a PaO2 value of less than 60 mm Hg while breathing air or a PaCO2 of more
than 50 mm Hg. Furthermore, respiratory failure may be acute or chronic. While acute
respiratory failure is characterized by life-threatening derangements in arterial blood gases and
acid-base status, the manifestations of chronic respiratory failure are less dramatic and may not
be as readily apparent.
Respiratory failure may be classified as hypoxemic or hypercapnic. Hypoxemic
respiratory failure (type I) is characterized by a PaO2 of less than 60 mm Hg with a normal or
low PaCO2. This is the most common form of respiratory failure, and it can be associated with
virtually all acute diseases of the lung, which generally involve fluid filling or collapse of
alveolar units. Some examples of type I respiratory failures are cardiogenic or non cardiogenic
pulmonary edema, pneumonia, and pulmonary hemorrhage.
Hypercapnic respiratory failure (type II) is characterized by a PaCO2 of more than 50
mm Hg. Hypoxemia is common in patients with hypercapnic respiratory failure who are
breathing room air. The pH depends on the level of bicarbonate, which, in turn, is dependent on
the duration of hypercapnia. Common etiologies include drug overdose, neuromuscular disease,
chest wall abnormalities, and severe airway disorders (e.g., asthma, chronic obstructive
pulmonary disease [COPD]).
1. CAUSES AND RISK FACTORS
Respiratory failure can be caused by:
 Conditions that make it difficult to breathe in and get air into your lungs. Examples
include weakness following a stroke, collapsed airways, and food getting stuck in and
blocking your windpipe.
 Conditions that make it difficult for you to breathe out. Asthma causes your airways to
narrow, while COPD can cause mucus to buildup and narrow your airways, which can
make it hard for you to breathe out.
 Lung collapse. When no air is able to enter your lungs, one or both lobes may collapse
and cause a condition called atelectasis. This collapsing of the lung can happen in certain
situations, such as when the lungs become extremely weak, mucus blocks one of the large
airways, a rib is broken or fractured, or severe pain in the lung makes it difficult to take a
deep breath. Chest trauma or lung injury can also cause air to leak from the lung, filling
the space around the lung within the chest. This air could cause the lung to collapse,
called a pneumothorax.
 Fluid in your lungs. This makes it harder for oxygen to pass from the air sacs into your
blood and for carbon dioxide in your blood to pass into the air sacs to be breathed
out. Pneumonia, acute respiratory distress syndrome (ARDS), drowning, and other lung
diseases can cause this fluid buildup. It can also be caused by the inability of the heart to
pump enough blood to the lungs (called heart failure). Severe head injury or trauma can
also cause sudden fluid buildup in the lungs.
 A problem with your breathing muscles. Such problems can occur after a spinal cord
injury or when you have a nerve and muscle condition such as muscular dystrophy. It can
also happen when your diaphragm and other breathing muscles do not get enough
oxygen-rich blood, when the heart is not pumping well enough (cardiogenic shock), or
when you get a severe infection called sepsis.
 Conditions that affect the brain’s control over breathing. In opioid overdose, for example,
the brain may not detect high levels of carbon dioxide in the blood. Normally, the brain
would signal to you to deepen your breathing so that you breathe out the carbon dioxide.
Instead, carbon dioxide builds up in the body, while oxygen levels fall, leading to
respiratory failure.

You may have an increased risk of respiratory failure because of your age, environment or
occupation, lifestyle habits, and other medical conditions or medicines and procedures.
Age - Premature babies who have neonatal respiratory distress due to an under-developed
lung, pulmonary hypertension, or certain lung birth defects have a higher risk of respiratory
failure. Older adults have more risk factors for respiratory failure. It is more likely that food will
accidentally go down the windpipe instead of the food pipe or that a cold will lead to a severe
chest infection. Older adults are also more likely to have muscle weakness that can affect
breathing.
Environment or occupation - Breathing in lung irritants can lead to lung damage over the long
term and put you at risk of serious lung diseases. You may breathe in these irritants from the air
where you live or work.
Lung irritants include air pollution, chemical fumes, asbestos, aniline dyes and paints, dust, and
secondhand smoke (smoke in the air from other people smoking).
Other medical conditions
You may have a greater risk of respiratory failure if you have certain medical conditions or
injuries.
 Nerve and muscle disorders such as amyotrophic lateral sclerosis, Guillain-Barre
syndrome, and myasthenia gravis. A stroke can also affect the area of the brain that
controls breathing.
 Lung and airways diseases, such as asthma, cystic fibrosis, COPD, and interstitial lung
diseases. Fluid buildup in the lungs or pulmonary embolism (a blood clot in your lungs)
can also lead to respiratory failure.
 Infections in your brain or spinal cord (such as meningitisexternal link), lungs (such
as pneumonia), or airways (such as bronchiolitis). Watch this video to learn how
infection with SARS-CoV-2, the virus responsible for COVID-19, can affect the
lungsexternal link. 
 Airway blockages, such as when food or another object gets stuck in your airways or
your epiglottis swells. Your epiglottis is the flap at the back of your throat that prevents
food or drink from getting into your airways when you swallow. During obstructive sleep
apnea, your upper airway becomes blocked repeatedly during sleep, reducing or
completely stopping airflow.
 Chest or back injuries that damage your ribs or lungs.
 Severe scoliosis, a condition in which the spine is curved from side-to-side.
 Severe allergies to food or medicine can cause your throat to swell up.
Many other serious health conditions can also raise your risk. This includes coronary heart
disease, kidney or liver disease, or a weakened immune system.
Lifestyle habits -Smoking can cause lung diseases that raise your risk of respiratory failure.
Using drugs or alcohol raises your risk of an overdose. A drug or alcohol overdose affects the
area of the brain that controls breathing. During an overdose, breathing becomes slow and
shallow, and this can cause acute respiratory failure. This can happen from using illegal drugs or
misusing prescription opioid painkillers.
Medicines or medical procedures - Certain sedatives used during surgery affect your breathing.
This can put you at risk of respiratory failure, especially if you have other risk factors.
Complications from major surgery can also raise your risk of respiratory failure.

2. PATHOPHYSIOLOGY (Diagram Form)

3. DIAGNOSIS
Your doctor will check your medical history, perform a physical exam, and do tests and
procedures to diagnose respiratory failure.
Medical history
Your doctor will ask you or your family members about your medical history and risk factors,
especially any medical conditions that may affect your lungs and breathing. Your doctor will
also ask if you have any symptoms  of respiratory failure such as shortness of breath, rapid
breathing, and confusion.
Physical exam
During a physical exam your doctor may do the following:
 Check for a bluish color on your lips, fingers, or toes.
 Listen to your heart with a stethoscope to check for a fast or irregular heartbeat.
 Listen to your lungs with a stethoscope for rapid breathing or any unusual sounds when
you breathe. He or she will also see if your chest moves unevenly while you breathe.
 Measure your blood oxygen level with a clip on a finger, called pulse oximetry.
 Measure your blood pressure to check if it is too high or low.
 Measure your temperature to check for a fever and ask if you have recently had a
fever.
Diagnostic tests and procedures
To diagnose respiratory failure, your doctor may order some of the following tests and
procedures.
 Arterial blood gas tests to measure levels of oxygen, carbon dioxide, pH, and
bicarbonate. A sample of your blood will be taken from your arteries. These tests help
determine whether you have respiratory failure and what type it is.
 Blood tests to help find the cause of your respiratory failure. Blood tests can also help
your doctor see how well your other organs are working.
 Bacterial cultures using samples of your blood, urine, or phlegm (a slimy substance that
you cough out) to check for a bacterial infection.
 Bronchoscopy to check for blockages, tumors, or other possible causes of respiratory
failure.
 Chest X-ray to identify any lung or heart conditions that may be causing respiratory
failure.
  Chest computed tomography (CT) scan to image the lungs and look
for inflammation or damage.
 Electrocardiogram (EKG or ECG) to check your heart rhythm and how well your heart
is working.
 Echocardiography to check how well your heart is working.
 Lung ultrasound to check for lung conditions such as pleural effusion.
 Lung biopsy to collect samples of your lung tissue.
 Pulmonary function tests to measure how well your lungs are working

4. MEDICAL MANAGEMENT
The medical management of patients with acute respiratory failure will vary depending
on the cause and type of failure. Treatment should be targeted at the cause. Therapeutic goals
should focus on preventing cellular damage from hypoxia, preventing acidosis from
hypercapnoea and relieving patients’ symptoms and distress.
Airway obstruction is a clinical emergency. If this is the cause of respiratory failure it should be
treated and a safe airway maintained as a priority. This may require simple clearance such as the
removal of a foreign body, or secretions using suction. Patient positioning and manipulation of
the airway will be required to open it if obstructed. Artificial airway adjuncts such as
oropharyngeal airways may be required. Airway obstruction may occur for many reasons and the
cause should be identified as soon as possible. Acute soft tissue swelling of the upper airway, as
seen in anaphylactic shock, will require treatment in line with European Resuscitation Council
guidelines (Resuscitation Council UK, 2008).

Oxygen therapy - Regardless of the aetiology of respiratory failure, virtually all patients with
acute hypoxia will require oxygen supplementation. Oxygen therapy aims to supplement the
inspired oxygen concentration to prevent tissue hypoxia and resultant cellular dysfunction.
However, cellular oxygen delivery not only depends on inspired oxygen but also relies on
haemoglobin concentration, its ability to saturate with oxygen, and cardiac output as a
mechanism to deliver oxygen to the cells (Higgins, 2005).
Various devices are available to deliver oxygen including fixed and variable rate performance
devices. The method of delivery depends on the concentration of oxygen required, patients’
compliance with therapy and the underlying pathophysiology (Jevon and Ewens, 2001).
In certain patients, such as those with chronic hypercapnoea, titration of oxygen therapy will
require specialist advice and serial arterial blood gas analysis as high concentrations may be
contraindicated. Oxygen therapy may require humidification, particularly at high flow rates.
Humidification moistens the oxygen during administration, preventing dehydration of the
mucous membranes and pulmonary secretions (Bennett, 2003).
Drug therapy - Bronchodilatory drugs cause relaxation of the smooth muscles in the airways,
improving airway calibre. They may be administered using a variety of routes, in particular
inhaled in the form of aerosol sprays or nebulisers.
Inhaled bronchodilators are an essential component in the treatment of asthma and obstructive
airways disease. Peak expiratory flow rate measurements taken pre and post dose are usually
recorded to assess effectiveness. Other medications – particularly anti-inflammatory drugs such
as steroids – may be required.
Antimicrobial, antiviral or antifungal therapy is usually initiated if the cause of respiratory failure
is considered to be of infective origin. Again, these drugs may be administered using a variety of
routes and time periods.
Ventilatory support - Ventilatory support may be required in type 1 or type 2 respiratory failure.
This may take the form of continuous positive airway pressure, non-invasive ventilation or
invasive ventilation. Non-invasive ventilation has been shown to be a particularly effective
treatment for COPD-related respiratory failure (British Thoracic Society Standards of Care
Committee, 2002).
Other issues - All patients with acute respiratory failure should be assessed regularly by a
physiotherapist to provide treatment and advice on sputum clearance and optimising gaseous
exchange. Other medical management of acute respiratory failure includes serial blood gas
analysis, electrocardiography and chest X-ray, in conjunction with management of potentially
related disease processes or conditions. Further pulmonary function testing and investigative
procedures may be required.

5. NURSING INTERVENTION
Patients with acute respiratory failure should be closely observed for potential deterioration.
Respiratory assessment should occur on a frequent/continual basis. Monitoring may involve
intermittent/continual pulse oximetry and regular peak expiratory flow rate measurement but
should always include basic respiratory rate monitoring and general assessment. Physiological
track and trigger warning systems are widely used to identify patients on general wards at risk of
clinical deterioration (NICE, 2007). These systems provide a framework to access higher levels
of care. Patients at risk of developing acute respiratory failure are an ideal group for these
systems and their use should be encouraged. Any changes in physiological signs should be
reported promptly to the senior practitioner.
Anxiety - Patients will most likely be frightened and anxious as a result of dyspnoea. While
undertaking assessments and during subsequent care it is very important to try to alleviate these
anxieties and provide reassurance. Simple techniques, such as patient positioning, may reduce
symptoms by maximising lung expansion. Patients may advise which position they feel offers
some relief. Communication skills, such as asking closed questions during assessment, may be
used if patients are breathless to a point where they cannot answer in sentences.

Pulmonary secretion - Many processes leading to acute respiratory failure are associated with
an increase in pulmonary secretions. Tissues or receptacles for sputum should be provided to
assist patients to void secretions independently. If their ability to void is limited, assistance may
be required in the form of oropharyngeal/nasopharyngeal suction. These procedures should not
be undertaken without appropriate training. Sputum and other samples may be required for
microbiological screening – this should be performed according to local guidelines.

Pain management - Pain, particularly associated with abdominal or thoracic surgery or injury,
can limit chest expansion. If patients are experiencing pain, relief should be provided and future
control optimised. Expert advice may be necessary because of the respiratory depressant effects
of some analgesics. Liaison with multidisciplinary specialists such as acute or chronic pain
specialists may be required.

Oxygen therapy -The majority of patients in acute respiratory failure will need oxygen
supplementation. Before starting oxygen therapy, it is important to explain the reasons for this to
them, their relatives and carers, and check their understanding (Jevon and Ewens, 2001). Unless
in a medical emergency situation, the oxygen flow rate or percentage and duration of therapy
should be prescribed. Nurses are best placed to select the most appropriate delivery system for a
particular patient.

The system chosen should aim to deliver therapy with maximum effectiveness and optimise
patient independence. The detrimental effects of oxygen therapy, such as the dehydration of
mucosa, should be observed for and appropriate therapies such as gas humidification introduced
where necessary. Tissue damage from a delivery device may occur – in particular, oxygen masks
cause soreness behind the ears after longer-term use and nasal cannulas cause irritation to the
nostrils. Small adaptations to the device, such as adding gauze padding, may prevent or alleviate
this.
Other medication - If aerosol-inhaled medications are prescribed, effective delivery will only
occur through patient compliance. Therapeutic effectiveness can be improved by providing
education on inhaler technique. It is imperative that appropriate devices are chosen and patients’
technique is adequate (Bennett, 2003). When administering nebulisers, patients should be sat
upright (as tolerated), be encouraged to take normal breaths and avoid talking in order to
maximise drug delivery (Bennett, 2003). Nebulised medication may be administered using air
flow or oxygen and nurses should ensure the type of gas used to deliver the drug is prescribed.
Certain concentrations of oxygen may be contraindicated in certain patients. Practitioners should
also bear in mind that patients may be dependent on a certain oxygen flow before nebulisation
and interrupting this may be contraindicated.
Attempts should be made to minimise oxygen consumption (Smyth, 2005). This can be achieved
by minimising patient exertion. They should be assisted with activities of daily living such as
meeting hygiene needs, and all essential items, such as sputum pots, drinks and nurse call bells,
should be within easy reach. Patients will also require time to ‘catch their breath’ following
exertion, so activities should be planned with this in mind.

6. COMPLICATIONS
Complications of acute respiratory failure may be pulmonary, cardiovascular, gastrointestinal
(GI), infectious, renal, or nutritional.

Common pulmonary complications of acute respiratory failure include pulmonary embolism,

barotrauma, pulmonary fibrosis, and complications secondary to the use of mechanical devices.
Patients are also prone to develop nosocomial pneumonia. Regular assessment should be
performed by periodic radiographic chest monitoring. Pulmonary fibrosis may follow acute lung
injury associated with ARDS. High oxygen concentrations and the use of large tidal volumes
may worsen acute lung injury.

Common cardiovascular complications in patients with acute respiratory failure include

hypotension, reduced cardiac output, arrhythmia, endocarditis, and acute myocardial infarction.
These complications may be related to the underlying disease process, mechanical ventilation, or
the use of pulmonary artery catheters.

The major GI complications associated with acute respiratory failure are hemorrhage, gastric
distention, ileus, diarrhea, and pneumoperitoneum. Stress ulceration is common in patients with
acute respiratory failure; the incidence can be reduced by routine use of antisecretory agents or
mucosal protectants.

Nosocomial infections, such as pneumonia, urinary tract infections, and catheter-related sepsis,

are frequent complications of acute respiratory failure. These usually occur with the use of
mechanical devices. The incidence of nosocomial pneumonia is high and associated with
significant mortality.
Regarding renal complications, acute renal failure and abnormalities of electrolytes and acid-
base homeostasis are common in critically ill patients with respiratory failure. The development
of acute renal failure in a patient with acute respiratory failure carries a poor prognosis and high
mortality. The most common mechanisms of renal failure in this setting are renal hypoperfusion
and the use of nephrotoxic drugs (including radiographic contrast material).

Nutritional complications include malnutrition and its effects on respiratory performance and

complications related to administration of enteral or parenteral nutrition. Complications
associated with nasogastric tubes, such as abdominal distention and diarrhea, also may occur.
Complications of parenteral nutrition may be mechanical (resulting from catheter insertion),
infectious, or metabolic (eg, hypoglycemia, electrolyte imbalance).