Respiratory

Failure

INTRODUCTION:
Respiratory failure occurs when pulmonary system is no longer able to meet the metabolic
demands of the body

Normal ABG
pH 7.35-7.45
PaCO2 4.8 6.0 kPa (35-45mmHg)
PaO2 10.5-13.5 kPa (85-100mmHg)
HCO3 24-26 mmol/l
Base excess -2 to +2
Oxygen saturation 92-99%

Type of respiratory failure

1. Hypoxaemic respiratory failure (Type 1)
-PaO2 8 kPa (60 mmHg) under RA
2. Hypercapnic respiratory failure (Type 2)
-PaCO2 6.7 kPa (50 mmHg) under RA

Resp Failure PaO2 PaCO2
Type 1 decreased Decreased or normal
Type 2 decreased Increased


Type 1 Respiratory Failure

Typically caused by severe V/Q mismatch. In this condition, parts of the lung under ventilate
and blood bypasses (shunted) while other lung part over ventilate but unable to
compensate.
Example of condition that caused T1RF
Low ambient oxygen (e.g. at high altitude)
Ventilation-perfusion mismatch (parts of the lung receive oxygen but not enough
blood to absorb it, e.g. pulmonary embolism)
Alveolar hypoventilation (decreased minute volume due to reduced respiratory
muscle activity, e.g. in acute neuromuscular disease); this form can also cause type 2
respiratory failure if severe
Diffusion problem (oxygen cannot enter the capillaries due to parenchymal disease,
e.g. in pneumonia or ARDS)
Shunt (oxygenated blood mixes with non-oxygenated blood from the venous system,
e.g. right-to-left shunt)




Type 2 Respiratory Failure
T2RF mainly cause by inadequate alveolar ventilation to excrete volume of CO2 being
produced by the tissue metabolism. Underlying causes such as:
Increased airways resistance (chronic obstructive pulmonary disease, asthma,
suffocation)
Reduced breathing effort (drug effects, brain stem lesion, extreme obesity)
A decrease in the area of the lung available for gas exchange (such as in chronic
bronchitis)
Neuromuscular problems (GuillainBarr syndrome, motor neuron disease)
Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail chest.

Clinical Effects
Acute Chronic
SOB Secondary polycythaemia
Restless, confuse, sweating Pulmonary hypertension
Tachycardia Cor pulmonale
Central cyanosis (deceptive esp if Signs of CO2 retention
polycythaemic) 1. Sleep disturbance w early morning
headache
2. Personality changes
Flapping tremors
Warm peripherals
Bounding pulse
Papilloedema


Management:

Acute Chronic
Airway protection Compensated status?
Controlled oxygen (ensure Po2 >8kPa) During acute exacerbation, provide
supplementary O2 without abolishing the
hypoxic drive
Treat underlying causes Long term O2 therapy
Antibiotics for infection Domiciliary assisted nocturnal ventilation
Bronchodilators &steroid for bronchospasm
Consider assisted ventilation (cyanotic,
unconsciousness, high pCO2)
Consider central respiratory stimulant (eg.
Doxapram)






ABG Intepretation:

ABG Component

pH
Inversely proportional to the concentration of hydrogen ions.
When a solution becomes more acidic the concentration of hydrogen ions increases
and the pH falls.
Normally the bodys pH is closely controlled at between 7.35 7.45. This is achieved
through buffering and excretion of acids. Buffers include plasma proteins and
bicarbonate (extracellular) and proteins, phosphate and haemoglobin
(intracellularly).
Hydrogen ions are excreted via the kidney and carbon dioxide is excreted via the
lungs.
Changes in ventilation are the primary way in which the concentration of H+ ions is
regulated. Ventilation is controlled of the concentration of CO2 in the blood.
If the buffers and excretion mechanisms are overwhelmed and acid is continually
produced, the he pH falls. This creates a metabolic acidosis.
If the ability to excrete CO2 is compromised this creates a respiratory acidosis.

*Note that a normal pH doesnt rule out respiratory or metabolic pathology.

Partial pressure

Partial pressure is a way of assessing the number of molecules of a particular gas in a
mixture of gases. It is the amount of pressure a particular gas contributes to the
total pressure. For example, we normally breathe air which at sea level has a
pressure of 100kPa, oxygen contributes 21% of 100kPa, which corresponds to a
partial pressure of 21kPa.
When used in blood gases, Henrys law is used to ascertain the partial pressures of
gases in the blood. This law states that when a gas is dissolved in a liquid the partial
pressure (i.e. concentration of gas) within the liquid is the same as in the gas in
contact with the liquid. Therefore you can measure the partial pressure of gases in
the blood.
PaO2 is the partial pressure of oxygen in arterial blood
PaCO2 is the partial pressure of carbon dioxide in arterial blood.

Base excess
This is the amount of strong base which would need to be added or subtracted from
a substance in order to return the pH to normal (7.40).
A value outside of the normal range (-2 to +2 mEq/L) suggests a metabolic cause for
the acidosis or alkalosis.
In terms of basic interpretation
A base excess more than +2 mEq/L indicates a metabolic alkalosis.
A base excess less than -2 mEq/L indicates a metabolic acidosis.


Bicarbonate
Bicarbonate is produced by the kidneys and acts as a buffer to maintain a normal pH.
The normal range for bicarbonate is 22 26mmol/l.
If there are additional acids in the blood the level of bicarbonate will fall as ions are
used to buffer these acids. If there is a chronic acidosis additional bicarbonate is
produced by the kidneys to keep the pH in range.
It is for this reason that a raised bicarbonate may be seen in chronic type 2
respiratory failure where the pH remains normal despite a raised CO2.

Electrolytes
A venous or arterial blood gas is a good way to quickly check potassium and sodium
values. This is particularly important in the immediate management of cardiac
arrhythmias as it gives an immediate result.

Lactate
Lactate is produced as a by-product of anaerobic respiration. A raised lactate can be
caused by any process which causes tissue to use anaerobic respiration. It is a good
indicator of poor tissue perfusion.

Glucose
Dont forget to check this. Glucose is especially pertinent in the management of the
patient who has decreased consciousness or seizures. It is also important in patients
with known or suspected diabetes.
Glucose may also be raised in patients with severe sepsis or other metabolic stress.


Compensation
Respiratory Compensation
If a metabolic acidosis develops the change is sensed by chemoreceptors centrally in
the medulla oblongata and peripherally in the carotid bodies.
The body responds by increasing depth and rate of respiration therefore increasing
the excretion of CO2 to try to keep the pH constant.
The classic example of this is Kussmaul breathing the deep sighing pattern of
respiration seen in severe acidosis including diabetic ketoacidosis. Here you will see
a low pH and a low pCO2 which would be described as a metabolic acidosis with
partial respiratory compensation (partial as a normal pH has not been reached).

Metabolic Compensation
In response to a respiratory acidosis, for example in CO2 retention secondary
to COPD, the kidneys will start to retain more HCO3 in order to correct the pH.
Here you would see a low normal pH with a high CO2 and high bicarbonate.
This process takes place over days.
It is important to ensure that the compensation that you see is appropriate, i.e. as
you would expect. If not then you should start to think about mixed acid base
disorders.


Tic-tac toe method
1. Know your normal values
2. Acidosis vs Alkalosis
a. pH level below 7.35 is acidosis
b. pH level above 7.45 is alkalosis
3. Respiratory vs metabolic
a. paCO2 = Respiratory
b. HCO3 = Metabolic
4. Remember ROME
a. Respiratory Opposite
i. When pH is up, PaCO2 is down = Alkalosis
ii. When pH is down, PaCO2 is up = Acidosis
b. Metabolic Equal
i. When pH is up, HCO3 is up = Alkalosis
ii. When pH is down, HCO3 is down = Acidosis
5. Draw tic-tac toe
6. Mark the chart
7. Match the pH, Pco2 and HCO3
8. Determine compensation
a. If pH is NORMAL, PaCO2 and HCO3 are both ABNORMAL = Compensated
b. If pH is ABNORMAL, PaCO2 and HCO3 are both ABNORMAL = Partially
Compensated
c. If pH is ABNORMAL, PaCO2 or HCO3 is ABNORMAL = Uncompensated


Scenario

1. You are called to see a 54 year old lady on the ward. She is three days post-
cholecystectomy and has been complaining of shortness of breath. Her ABG is as follows:
pH: 7.49 (7.35-7.45)
pO2: 7.5 (1014)
pCO2: 3.9 (4.56.0)
HCO3: 22 (22-26)
BE: -1 (-2 to +2)
Other values within normal range


2. A 75 year old gentleman living in the community is being assessed for home oxygen. His
ABG is as follows:
pH: 7.36 (7.35-7.45)
pO2: 8.0 (1014)
pCO2: 7.6 (4.56.0)
HCO3: 31 (22-26)
BE: +5 (-2 to +2)
Other values within normal range


3. A 64 year old gentleman with a history of COPD presents with worsening shortness of
breath and increased sputum production.
pH: 7.21 (7.35-7.45)
pO2: 7.2 (1014)
pCO2: 8.5 (4.56.0)
HCO3: 29 (22-26)
BE: +4 (-2 to +2)
Other values within normal range

4. A 21 year-old woman presents feeling acutely lightheaded and short of breath. She has
her final university exams next week.
pH: 7.48 (7.35-7.45)
pO2: 12.1 (1014)
pCO2: 3.5 (4.56.0)
HCO3: 22 (22-26)
BE: +2 (-2 to +2)
Other values within normal range

5. A 32 year-old man presents to the emergency department having been found collapsed
by his girlfriend.
pH: 7.25 (7.35-7.45)
pO2: 11.1 (1014)
pCO2: 3.2 (4.56.0)
HCO3: 11 (22-26)
BE: -15 (-2 to +2)
Potassium: 4.5
Sodium: 135
Chloride: 100
Other values within normal range

6. A 67 year-old man with a history of peptic ulcer disease presents with persistent
vomiting.
pH: 7.56 (7.35-7.45)
pO2: 10.7 (1014)
pCO2: 5.0 (4.56.0)
HCO3: 31 (22-26)
BE: +5 (-2 to +2)
Other values within normal range

7. A normally fit and well 11 year-old boy presents with diarrhoea and vomiting. He is
complaining of non-specific abdominal pain. A venous blood gas shows:
pH: 7.12 (7.35-7.45)
pO2: 11.5 (1014)
pCO2: 3.2 (4.56.0)
HCO3: 9 (22-26)
BE: -17 (-2 to +2)
Lactate: 4.0
 Potassium: 5.5
Glucose: 22
Other values within normal range

8. A 22 year-old lady with a known history of asthma presents to the emergency department
with difficulty in breathing. Her initial ABG on 15 litres of oxygen shows:
pH: 7.54 (7.35-7.45)
pO2: 10.0 (1014)
pCO2: 3.2 (4.56.0)
HCO3: 24 (22-26)
BE: +0 (-2 to +2)
Other values within normal range

9. A 62 year-old woman with a history of diabetes and a long smoking history presents to
the emergency department with worsening shortness of breath. On auscultation of the
chest there are widespread crackles and you notice moderate ankle oedema. ABG shows:
pH: 7.20 (7.35-7.45)
pO2: 8.9 (1014)
pCO2: 6.3 (4.56.0)
HCO3: 17 (22-26)
BE: -8 (-2 to +2)
Other values within normal range