Respiratory failure oxygen therapy and endotracheal intubation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Oxygen therapy

• The aim of oxygen therapy is to correct hypoxia
• These therapies may include:
  • Non-invasive ventilatory support
  • Extracorporeal membrane oxygenation

Non-invasive ventilatory support (NIV)

• Non-invasive ventilatory support (NIV) uses positive pressure ventilation delivered through a face or nasal mask or nasal prongs as a non-invasive way of delivering oxygen.
• Non-invasive ventilatory support (NIV) is indicated for:
  • Acute hypoxemic respiratory failure
  • Chronic obstructive pulmonary disease (COPD) complicated by hypercapnic acidosis
• Use of (NIV) is contraindicated in cases of need of emergent intubation, such as:
  • Myocardial arrest
  • Respiratory arrest
  • Inability to preserve a patent airways
  • Severely altered consciousness
  • Life threatening organ failiure of nonpulmonary origin
  • Abnormalities of facial structure for any reason
  • High risk of aspiration
  • Expected long term treatment with mechanical ventilation
  • Recent esophageal surgery with anastomoses

Mask selection

• Studies have demonstrated that a face mask confers the largest physiological improvement, whilst nasal masks and prongs are tolerated the best.
• Face masks are preferred in several studies and have the following advantages:
  • Less air leaks compared to volumes lost with nasal masks through the oral cavity
  • Nasal masks increase resistance to air flow and therefore, increase respiratory effort
  • Face masks make it easier to assess aspiration risk in comparison to a nasal mask

Ventilatory modes

Will be discussed in the mechanical ventilation section of this chapter.

Monitoring NIV

• Success or failure of NIV therapy is established within an initial observation period of 8 hours.
  • During this time adjustments should be made, whilst looking for signs of destabilization.
• An improvement in arterial carbon dioxide tension (PaCO2) and pH within 1.5 - 2 hours is indicative of successful NIV.
• Indications of failed NIV include:
  • A lack of improvement in arterial carbon dioxide tension (PaCO2) and pH within 1.5 - 2 hours
  • Encephalopathy
  • Agitation
  • Unclearable secretions
  • Intolerable mask interface
  • Decreased oxygen saturation
  • Hemodynamic instability
• Successful selection of patients with indications for NIV by physicians is poor and therefore, a third of patients that receive a trial of NIV fail.
• The use of sedatives and analgesics, for purposes of comfort and anxiety is not recommended as studies have demonstrated an increase in NIV failure rates with pretreatment of these agents.