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.

Weaning

• Weaning is carried out through progressively decreasing positive pressure settings, whilst permitting the patient longer durations without ventilation.

Advantages of NIV

• NIV has lower mortality rates (23%) in comparison to traditional mechanical ventilation (39%).
• NIV therapy carries less risk of nosocomial infection transmission such as ventilator - associated pneumonias, sinusitis and line sepsis.
• NIV facilitates a decreased need for invasive mechanical ventilation.