Respiratory Failure

Respiration
 external respiration （ pulmonary ventilation and
gas exchange in lung ）
 transport of gas
 internal respiration
 Respiratory failure
concept and classification

1. respiratory insufficiency
The condition in which the lungs can not take in
sufficient oxygen or expel sufficient carbon dioxide to
meet the needs of the cells of the body. Also called
pulmonary insufficiency.
 2. respiratory failure

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.

normal reference values ：

PaO2 < 60mmHg （ 8kPa ）
with or without PaCO2 > 50mmHg （ 6.67kPa ）
RFI = PaO2/FiO2 ≤ 300
3 ． classification
（ 1 ） according to PaCO2
■ hypoxemic (Group Ⅰ) respiratory failure
a PaO2 of less than 60 mm Hg with a normal or low PaCO2.
Cause of: Edema, Vascular disease, Chest Wall.

■ hypercapnic (Group Ⅱ ) respiratory failure

a PaO2 low 60 mm Hg and PaCO2 of more than 50 mm Hg.

Cause of: Airway obstruction, Neuromuscular disease.

 （ 2 ） according to pathogenic mechanism

■ ventilatory disorders

■ gas exchange disorders

（ 3 ） according to primary site

■ central respiratory failure

■ peripheral respiratory failure

（ 4 ） according to duration

■ acute respiratory failure

■ chronic respiratory failure

 etiology and pathogenesis
【 classification of respiration failure mechanism 】
respiratory failure

ventilatory gas exchange

disorders disorders
obstructive ventilatory

ventilation-perfusion
restrictive ventilatory

diffusion disorders

mismatching
disorders

disorders
Ⅰ. ventilatory disorders
1. restrictive ventilatory disorders
Restrictive hypoventilation is caused by the diseases that affect
the distensibility of the alveolar.
Respiratory movement

forced breathing
 ▲ Disorders of the respiratory muscles

damage of CNS
Depression of CNS Respiratory movement ↓
drug overdose
neuro-muscular disorders
Respiratory
decreased strength,
myasthenia gravis movement
hypoxia, acidosis
disorder

alveolar distensibility

Restrictive
ventilatory
respiratory failure
disorders
▲ decreased lung compliance

● decrease of pulmonary surfactants and increase of

surface tension force

● diffuse interstitial fibrosis

▲ decreased thoracic compliance of lung

deformity of thorax , fracture of several ribs,
tension
pneumothorax, thickened constrictive pleural layer.
 原因和机制

2. obstructive ventilatory disorders

■ obstructive ventilatory disorders are caused by the diseases which

share the common characterestic of causing enough narrowing within
the tracheobronchial tree to increase resistance to the flow of air.

■ etiology
asthma, emphysema, chronic bronchitis, and bronchiectasis.
1 ） central airway obstruction
defined as airway obstruction between the glottis and the carina

■Obstruction is located in the +

airway outside the thorax ：
inspiratory dysnea

■Obstruction is located in the

airway inside the thorax ：

expiratory dysnea
three depression sign
expire inspire
 2 ） peripheral airway obstruction

smaller airways less than 2 mm in diameter.

Determinants of airway closure are the intrinsic caliber of peripheral

airways.
Smooth muscle tone, thickness of the wall,
mechanical properties of the surface film,
and secretions in the lumen ,bingding
effect of attachments of the surrounding
lung parenchyma.

equal pressure point

(EPP)
In forced expiration, the point where
intrapleural pressure and alveolar
pressure are equal.
Peripheral airway obstruction may be
caused by: specific chemical mediators
(such as histamine, leukotrienes,
prostaglandins ), other substances released
during inflammatory and allergic responses.

forced expiration

EPP moves distally as expiration progresses

because as air leaves the alveolar unit, the
pressure in the alveolar decreases hence
the pressure in the airway decreases as
well.
 3. The alteration of blood gas

1 ） Low PaO2 ： PaO2 < 60mmHg

2 ） PaCO2 change ：
A. hypoventilation ： high PaCO2.
R=40/50 mmHg=0.8 ；
B. part hypoventilation: Low PaO2 and normal or low PaCO2.
Ⅱ . gas-exchanging dysfunction
1. diffusion disorders
The diffusion impairment is characterized by
a disruption in the exchange of O2 or CO2 or
both across the alveolar-capillary membrane.
Causes:
reduction and/or thicken of alveolar-capillary
membrane or reduction of the diffuse time.
1 ） etiology of diffusion disorders

■ reduction of diffusion membrane area

Abnormalities of diffusion may not cause arterial hypoxia in

persons at rest unless they are extremely severe.

(total: 80 mm2; at rest: 30~40 mm2)

Causes: emphysema, pneumonia, lobectomy

■ increase of diffusion membrane thickness

edema, fibrosis, capillary vessel dilatation
■ decreased time of blood contacts with alveolar
 2. ventilation/perfusion imbalance

The dysfunction of gas exchange can arise secondary to ventilation

/perfusion mismatching.

·
V Q· V·A/ Q·
A

Top 1.2L/min 0.4L/min 3.0

Middle 1.8L/min 2.0L/min 0.9

Bottom 2.1L/min 3.4L/min 0.6

1) type and cause of ventilation-perfusion-mismatching
· ·
(1) decreased ratio of VA/Q
underventilated in relation to their perfusion

asthma, chronic bronchitis, obstructive emphysema, fibrosis,

edema
· ·
VA/ Q↓ part alveolar ventilatory ↓

functional shunt↑>30% respiratory failure

 · ·
(2) increased ratio of VA/Q
poor perfusion in relation to their ventilation with air

pulmonary artery embolization, DIC in lung, vessels contract, pulmonary

arteritis,

dead space like ventilation V·A/Q·↑ poor perfusion↓

respiratory failure
 3 ） increased of anatomical shunt
Right-to-left shunts or anatomic shunt

▲ increased of anatomical shunt

bronchiectasis anatomic shunt↑

Pulmonary A-V
▲ increased of shunt open↑
anatomical-like shunt
pulmonary
consolidation,At true
electasis
shunt↑

anatomical-like
Respiratory
shunt
failure
Ⅲ. Acute respiratory distress syndrome （ ARDS ）

[concept]
ARDS is a clinical description of severe lung injury
characterized by increased permeability of alveolar-capillary
membranes, development of protein-rich pulmonary edema,
marked hypoxemia refractory to increase in inspired oxygen
concentration, and the absence of left ventricular failure.
[etiology]
 shock from any cause,
 multisystem trauma,
 infection including bacterial and nonbacterial pneumonia,
 inhaled toxic substances,
 overdose of some drug,
 acute pancreatitis.
[ pathogenesis of ARDS]
1 ． direct injury of damage factor

2 ． indirect injury of inflammation medium

 ARDS

[Mechanisms of respiratory failure]

1. diffusion disorders
damage of alveolar-capillary membrane increased permeability

diffusion disorders

2. ventilatory disorders
▲edema, type Ⅱalveolar epithelial cells damage decreased lung volume

airway obstruction obstructive ventilatory restrictive ventilatory

disorders disorders

▲inflammation medium bronchia spasm respiratory failure

• •
3 ． VA/Q mismatching
 Effects of respiratory failure

1. Acid-base disturbances & disorders of electrolyte balance

2. Alteration of the respiratory system
peripheral chemoreceptor
■ PaO2↓ ＜ 60mmHg respiratory center(+) respiratory movement↑

＜ 30mmHg respiratory center (-) respiratory

movement ↓

■ PaCO2↑ central chemoreceptor (+) respiratory movement↑

＞ 80mmHg respiratory center (-) respiratory

movement ↓
 3. Alteration of the respiratory system
■ compensatory reaction

PaO2<60 mmHg ， PaCO2 increase cardiovascular center(+)

 increase in cardiac output : increase in stroke volume and heart

rate

 redistribution of blood flow

■ injurious changes

PaO2< 40 mmHg ， PaCO2> 80 mmHg cardiovascular

center(-)
 rate slow, decreased blood pressure
 cardiac output decrease
 pulmonary hypertension
■ co pulmonale

pulmonary
RBC↑ blood viscosity ↑
■PaO2↓ vasoconstriction

Pulmonary vascular wall blood resistance↑

Stenosis
thickening and hardening
chronic pulmonary hypertension
■pulmonary arterial embolism, capillary damage

afterload to right ventricle↑

■ Hypoxia, acidosis myocardial systolic

and diastolic function(-)
■difficulty breathing Restricted diastolic co pulmonale
 4. Alteration of the nervous system
(1) Hypoxia: the nervous system is very sensible to oxygen lack.
< 40~50 mmHg, serious but reversible deterioration in cerebral function
( orientation, arithmetic tasks, memory) occurs, and restlessness and
confusion are common.
< 30 mmHg, loss of consciousness results.
< 20 mmHg, irreversible damage of neural cells.
(2) Hypercapnia: CO2 nacosis.
a condition of confusion, tremors, convulsions, and possible coma that

may occur if blood levels of carbon dioxide increase to 80 mm Hg or higher.

 [pulmonary encephalopathy]

■ cerebrovascular injury
PaCO2↑, acidosis Cerebral vasodilation Cerebral blood flow↑

hypoxia vascular endothelial damage extracellular brain edema

edema on brain cell Intracranial pressure↑ Vascular compression

■ Brain cell injury Increased cerebral anoxia

CSF pH↓ ＜ 7.25 EEG slow or stop

GABA↑ pulmonary
encephalopathy

lysosomal membrane stability↓ lysosomal enzyme release nerve cell necrosis

4. Alteration of the renal function

5. Alteration of the digestive system

Thanks for attention