9/10/15 TREATMENT OF ACUTE RESPIRATORY FAILURE
OF VARIABLE CAUSES: INVASIVE VS. NONINVASIVE VENTILATION
Louisa Chika Ikpeama, DNP, CCRN, ACNP-BC
Objectives
Identify health care significance of acute respiratory
failure (ARF)
¨  List potential causes of acute respiratory failure
¨  Discuss the four different types of ARF
¨  Identify standard conservative medical treatment for
ARF
¨  Discuss appropriateness of invasive versus noninvasive mechanical ventilation
¨ 
Health care significance of ARF
The most common reasons for admission to the
intensive care unit (ICU)
¨  Common diagnosis in patients admitted for acute
care.
¨  The leading cause of death from pneumonia and
chronic obstructive pulmonary disease (COPD) in the
United States.
¨  Expensive health care resource utilization
¨ 
(Fournier, 2014)
1 9/10/15 Respiratory System
Central (Medulla) & Peripheral (Phrenic) NS
Respiratory Muscles
¨  Chest Wall
¨  Lung
¨  Upper Airway
¨  Bronchial Tree
¨  Alveoli
¨  Pulmonary Vasculature
¨ 
¨ 
The Respiratory System and Critical Functions
http://classes.midlandstech.com/carterp/Courses/bio211/chap22/chap22.htm
Ventilator Control
(Carvalho, P.)
2 9/10/15 Critical Functions of Resp. System
Breathing
Gas Exchange
¨  Ventilation
¨  Oxygenation
¨ 
¨ 
The respiratory system performs critical functions.
Transfers O2 from atmosphere to blood
v  Removes CO2 from blood
v 
v 
Acute Respiratory Failure (ARF)
Inability of the respiratory system to do its job:
- Meet metabolic demands of the body
- Fail to oxygenate the body
- Fail to meet CO2 homeostasis
¨  Clinically defined as PaO2 < 60mmHg or a PaCO2
> 45mmHg while breathing
¨  Respiratory failure (RF) is classified into four types
(I, II, III, & IV)
¨ 
Common Respiratory Disorders
Chronic obstructive pulmonary disease (COPD)
Obstructive Sleep Apnea (OSA)
q  Obesity Hypoventilation Syndrome (OHS)
q  Volume Overload/Flash Pulmonary Edema/CHF
q  Pneumonia
q  Acute Respiratory Distress Syndrome (ARDS)
q  Etc
q 
q 
3 9/10/15 Classification of Respiratory Failure (RF)
Type I or hypoxemic RF
is failure to exchange
oxygen
¨  Indicated by a PaO2
value < 60 with a
normal or low PaCO2
value.
¨  The most common
causes of type 1 RF are
V/Q mismatch & shunts.
¨ 
¨ 
¨ 
¨ 
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¨ 
Type 2 or hypercapnic
RF is failure to exchange
or remove CO2
Indicated by PaCO2
above 50 mm Hg.
PH depends on the
HCO3 level
HCO3 is influenced by
hypercapnia duration.
Any disease that affects
alveolar ventilation can
result in type 2 RF
Classification of Respiratory Failure
TYPE III RESPIRATORY FAILURE
¨ 
¨ 
¨ 
¨ 
Caused by lung
atelectasis.
Seen following general
anesthesia and surgery
Characterized by
reduction in functional
residual capacity
Collapse of dependent
lung units
TYPE IV RESPIRATORY FAILURE
Seen in shock due to
hypo-perfusion of
respiratory muscles.
¨  May be seen in
pulmonary edema and
cardiogenic shock
¨ 
Basic Process of Gas Exchange
¨ 
¨ 
¨ 
(FOURNIER, 2014)
Gases (O2 & CO2) move
through the alveoli and
cells by simple diffusion
Hgb transports O2 from
the lungs to the tissues.
Diffusion rate is
inversely proportional to
the thickness of the
respiratory membrane.
4 9/10/15 Basic Process of Gas Exchange
Lung’s large surface area is influenced by alveolar
size and inflation.
¨  Surface area is directly proportional to diffusion; a
large surface area favors diffusion
¨  gas has an inherent
¨  Gas has inherent solubility and molecular weight.
¨  Driving pressure is the gradient between PaO2 or
PaCO2 in the alveoli and the pressure
¨  of these gases in the blood.
¨ 
Ventilation and Perfusion (V/Q)
(FOURNIER, 2014)
Chronic Obstructive Pulmonary Disease (COPD)
COPD is a partially reversible progressive disease
characterized by airway obstruction & abnormal
inflammatory changes within the lung parenchyma
¨  Sometimes called emphysema
¨  COPD exacerbation is an acute change in patient’s
baseline symptoms (cough, dyspnea, sputum, and
O2 need)
q  Most common cause of exacerbation is infection
¨ 
5 9/10/15 COPD Exacerbation
3rd leading cause of death in the United
States
¨  12 million diagnosed and additional 12 million
undiagnosed
q  1.5 million emergency room visits in 2000
¨  726,000 hospitalizations in 2000
q  $18 b in direct costs & $14.1 billion in
indirect costs
¨ 
Obstructive Sleep Apnea (OSA)
¨ 
¨ 
¨ 
Condition of recurrent episodes of breathing pauses
due to complete or partial airway collapse resulting
in O2 desaturation.
Diagnosis by polysomnography
Presence of at least 5 obstructive respiratory events
(apneas, hypopneas, or respiratory effort related
arousals) in 1 hour. HTN/Mortality and Sudden
Death
Obstructive Sleep Apnea (OSA)
Snoring/gasping/choking during sleep
Restless Sleep
¨  Fatigue, Irritability
¨  Daytime Sleepiness
¨  Headaches
¨  Depression
¨  Difficulty Concentrating
¨  éBP/ Weight Gain
¨  Behavioral Problems/Poor Grades
¨ 
¨ 
6 9/10/15 Obstructive Sleep Apnea (OSA)
Impact of OSA
Systemic HTN
¨  Atherosclerosis
¨  CHF/Diastolic Dysfunction
¨  Cardiac Arrhythmias
¨  Stroke
¨  Increased Mortality and Sudden Death
v 
¨ 
Heart Failure
Structural or functional abnormality that impairs the
pump mechanism (Systolic or diastolic dysfunction)
¨  Results in excess fluid accumulation & resultant
symptoms (SOB, dyspnea, edema, congestion)
¨  Decreases cardiac output (weakness, fatigue)
¨  Various classifications (NY I, II, III, IV; AHA ABCD)
¨ 
Obesity Hypoventilation Syndrome (OHS)
OHS is a diagnosis of exclusion
Linked with obstructive sleep apnea (OSA)
¨  90% OF OSA patients have simple sleep
disordered breathing (obstructive apnea)
¨  10% have sleep hypoventilation without significant
apneic events
¨  Differentiating both is through polysomnography
¨ 
¨ 
7 9/10/15 Obesity Hypoventilation Syndrome (OHS)
Body mass index > 30 kg/m2
Awake daytime hypoventilation
- PaCO2 > 45 mmHg
- Pao2 < 70 mmHg
¨  Non-obstructive sleep hypoventilation
¨  Exclusion of other causes of alveolar
hypoventilation
¨ 
¨ 
Obesity Hypoventilation Syndrome
(OHS)
Prevalence of OHS among hospitalized patients
with BMI > 35 IS 35%
¨  Conflicting prevalence in men versus women
th
th,
th
¨  Diagnosis usually made in the 5 , 6 or 7 decade
¨  Respiratory failure usually prompts work-up for
diagnosis
¨ 
Signs & Symptoms of ARF
Respiratory System - Dyspnea, Tachypnea,
accessory muscles, shallow breathing, poor air entry,
stridor etc.
¨  Integumentary System - Pallor, Cyanosis,
Diaphoresis
¨  Cardiovascular System - tachycardia, arrhythmias,
chest pain, HTN/Hypotension
¨  Neuro/CNS System – lethargy, anxiety, restlessness,
confusion, fatigue, agitation, obtundation, Coma
¨ 
8 9/10/15 Principles of RF Management
Reverse and prevent hypoxemia
Secondary goal is control of respiratory acidosis
¨  Support oxygenation and ventilation
¨  Reduce work of breathing
¨  Monitor CNS and CVS closely
¨  Treat underlying causes
¨  Optimize pulmonary function
¨ 
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Pharmacologic Agents
Bronchodilators (Short- and long-acting)
Corticosteroids in certain patients
Antibiotics to treat infection
Mucolytics as needed
Oxygen Therapy
Diuretics
Optimizing Lung Function
Smoking Cessation
Various formulations and delivery system available
¨  Pulmonary Rehabilitation
¨  Incentive Spirometry
¨  Chest Physiotherapy
¨ 
§ 
9 9/10/15 Mechanical Ventilation
Invasive vs Non-Invasive Ventilation
Invasive vs Non-Invasive Ventilation
Severity of distress or illness?
Patent Airway
¨  Appropriate mental status?
¨  Cooperation with treatment plan?
¨  Exclusion of comorbid conditions?
¨  Secretion management?
¨  Hemodynamically stable?
¨ 
¨ 
Invasive vs Non-invasive Ventilation
Inability to maintain or protect airway or manage
secretions
¨  Facial trauma
¨  Vomiting
¨  Upper airway obstruction
¨  AMS/Confusion/agitation
¨  Bowel obstruction
¨  Untreated Pneumothorax
¨  Hemodynamic instability
¨ 
10 9/10/15 Non-Invasive Ventilation
Established in the 1980s
A valuable tool in the management of acute
respiratory failure (ARF).
¨  Any form of ventilator support applied through a
non-invasive interface
¨  Includes expiratory pressure (CPAP), bi-level with
both inspiratory and expiratory pressure support
(BIPAP), Volume and pressure-cycled systems, and
Proportional assist ventilation
¨ 
¨ 
Non-Invasive Ventilation
NIV modality has been shown to reduce the need
for endotracheal (ET) intubation
¨  Decreases adverse effects associated with invasive
mechanical ventilation
¨  Decreases time in intensive care
¨  Lowers mortality rate
¨  Reduces overall length of hospital stay.
¨  Should be considered in all acute respiratory failure
despite optimum medical treatment.
¨ 
Non-Invasive Ventilation
Important treatment strategy when invasive ET
intubation is not an option
¨  Few requirements for sedation, central venous
catheters, urinary catheters, and other invasive lines
compared to ET intubation
¨  Interfaces fit tight on the face or nose and are held
in place with straps.
¨  Interfaces include nasal prongs, total face masks,
oro-nasal masks, and helmets.
¨ 
11 9/10/15 Non-Invasive Ventilation
Mode chosen (C-PAP or BiPAP) optimizes lung
function
¨  Should be adequate to maintain patients comfort &
ensure optimum vent/o2
¨  C-PAP is usually adequate in chronic respiratory
failure
¨  Bi-PAP mode required in acute on chronic failure not
at goal on CPAP
¨ 
Contraindications to NIV
Facial trauma or recent facial surgery
Intracranial Bleeding
¨  Untreated abdominal distention
¨  Active GI bleeding
¨  Inability to protect airway or clear secretions
¨  Uncooperative or agitated patient
¨  Hemodynamic instability
¨ 
¨ 
NIPPV Mask Interfaces
Mask Interfaces
12 9/10/15 Mask Interfaces
Choice of mask can greatly affect outcome more
than the ventilator mode for patients with
hypercapnic respiratory failure, irrespective of
underlying pathology.
q  Tolerance greatly affected by mask comfort
q  Comfort of mask extends time on the ventilator
q 
Non-invasive Ventilation
q 
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Critical Elements for success continued
Selection of a comfortable mask, full-face at initiation
Close clinical monitoring is crucial especially at initial
period
Ongoing assessment to identify treatment failure
ABG 1 hour after initiation
Adequate pressure and oxygen titration based on
ABG
Wean on individual patient response to treatment
Features of NIV Failure
Worsening mental status
Lack of improvement of ABG values
¨  Persistent hypoxia
¨  Increased use of accessory muscles/Dyspnea
¨  Poor mask interface tolerance
¨  Hypotension and bradycardia
¨ 
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13 9/10/15 Non-invasive Ventilation
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Ethical Considerations
NIPPV is considered a life support measure
Ethical implications for pts who opt out of advanced
life support
Determine and clarify pts understanding of NIPPV
Update Do Not Resuscitate orders to reflect
preference for NIPPV
Invasive Ventilation
Reserved for life threatening situations
NIV not appropriate
¨  Requires an endotracheal or tracheal tube
interface
¨  Severe hypercapnia and worsening hypoxemia
¨  Goal is to provide respiratory support till reversal
of cause(s) of deterioration
¨ 
¨ 
Invasive & Non-invasive Ventilation
Critical Elements for success
¨  Selection of appropriate patients
¨  Selection of appropriate level of care
¨  Trained and experienced personnel ( NP, MD, RT,
RN, PA)
¨  Initiate appropriate ventilation as early as possible
¨  Selection of a comfortable mask
¨  Close clinical monitoring is crucial
14 9/10/15 Invasive & Non-invasive Ventilation
Critical Elements for success
¨  Ongoing assessment to identify treatment failure
¨  ABG 1 hour after initiation
¨  Adequate titration based on ABG
¨  Wean on individual patient response to treatment
¨  Prevent complications of immobility
¨  Address nutritional needs
Practice Implications
¨ 
Practice Implication
- Providers should make optimized decision related to
invasive and non-invasive ventilation when optimized
medical therapy proves inadequate
- Maintain effectiveness & efficiency of care
- Use evidence-based care approach
- Be responsible health care spending
Contact
Louisa Chika Ikpeama, DNP, RN, CCRN,ACNP-BC
Michael E. Debakey VA Medical Center
2002 Holcombe Boulevard
Houston Texas 77030
[email protected]
15