Treatments for respiratory failure

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Any patient with acute respiratory failure should be admitted to a respiratory care unit or other level 2-3 facility. Hypoxaemia is the most life-threatening facet of respiratory failure. The goal is to ensure adequate oxygen delivery to tissues which is generally achieved with a PaO2 above 8 0 kPA (60 mmHg) or SaO2 of at least 94%. However, patients who normally have hypoxaemia, hypercapnia, and breathlessness require different therapeutic targets than patients without lung disease. One would not necessarily aim for "normal" values in such patients.

Apart from oxygen therapy (see Chapter 2), various types of respiratory support are used to treat respiratory failure. These can be extremely confusing for the uninitiated. A simplified

Invasive airway

Non-invasive (mask)

Invasive airway

Non-invasive (mask)

IPPV

(several modes)

(used in weaning) (usually BiPAP)

CPAP

IPPV

CPAP

Figure 4.3 Different types of respiratory support. Modes of IPPV (intermittent positive pressure ventilation): volume control; pressure control; pressure support; synchronised intermittent mandatory ventilation; biphasic positive airway pressure (BiPAP)

version is as follows. As well as treatment of the underlying cause (for example, antibiotics for pneumonia), the lungs can be supported in the following ways:

• through an invasive airway, for example the patient is intubated

• non-invasive respiratory support via a tight-fitting mask.

Whether the patient is intubated or has a tight-fitting mask, various modes of respiratory support exist (Figure 4.3), which are described below.

The most important decision when faced with a person with acute respiratory failure is to decide which should be the first line method of respiratory support. Some situations require intubation whereas others can be managed non-invasively.

Non-invasive ventilation (NIV) is contraindicated in:

• patients with recent facial or upper airway surgery, facial burns or trauma

• recent upper gastrointestinal surgery, bowel obstruction

• inability to protect own airway

• copious respiratory secretions

• other organ system failure, for example haemodynamic instability

• severe confusion/agitation.

Table 4.1 First-line methods of respiratory support in different

conditions

Non-invasive ventilation

Non-invasive

Intubation

(NIV or BiPAP)

CPAP

Asthma

COPD pH 7-25--7-35

Acute cardiogenic

pulmonary

oedema

ARDS

Decompensated sleep

Hypoxaemia in

apnoea

chest trauma

Severe respiratory

Acute on chronic hypercapnic

acidosis

respiratory failure due to

chest wall deformity/

neuromuscular disease

Any cause with

impaired

conscious level

Pneumonia*

* If NIV or CPAP is used as a trial of treatment in pneumonia or postoperative respiratory failure, this should be done on an ICU with close monitoring and rapid access to intubation. ARDS, acute respiratory distress syndrome; BiPAP, bilevel positive airway pressure; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; NIV, non-invasive ventilation.

* If NIV or CPAP is used as a trial of treatment in pneumonia or postoperative respiratory failure, this should be done on an ICU with close monitoring and rapid access to intubation. ARDS, acute respiratory distress syndrome; BiPAP, bilevel positive airway pressure; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; NIV, non-invasive ventilation.

However, NIV is sometimes used in drowsy or confused patients if it is decided that the patient is not suitable for intubation because of severe chronic lung disease.

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