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]
Overview
Oxygen therapy
- The aim of oxygen therapy is to correct hypoxia.[1]
- 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.[2][3][4][5]
- 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.[4][6][5][7]
- 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.[8]
- 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%).[9][10]
- 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.
Extracorporeal membrane oxygenation (ECMO)
- Extracorporeal membrane oxygenation (ECMO) is a mechanical cardiopulmonary support, which can run temporarily in place of the heart and lungs.
- ECMO is most often applied intraoperatively to facilitate cardiac surgery.
- It is indicated in two types of severe acute respiratory failure:
- Type I hypoxemic respiratory failure where the PaO2/FiO2 (a ratio of arterial oxygen tension to fraction of inspired oxygen) is less than 100mmHg, whilst the tidal volume, inspiratory to expiratory (I:E) ratio, and positive end-expiratory pressure are all optimal.
- Type II hypercapnic respiratory failure with an arterial pH less than 7.20.
- Survival rates in patients with acute severe respiratory failure who receive ECMO compared to those that don't receive ECMo are 71% and 50% respectively.
Contraindications to ECMO
- Absolute contraindications:
- Severe neurologic impairment
- Advance stage malignancy
- Relative contraindications:
- Primary condition has a poor prognosis
- Severe unremitting bleeding
Weaning and complications of ECMO
- Patients with respiratory failure may be weaned off ECMO, when the following improvements are noted:
- Improvements on chest radiograph in radiographic appearance
- Increase in pulmonary compliance
- Increase in arterial oxyhemoglobin saturation
- Complications of ECMO include:
- Bleeding
- Thromboembolism
References
- ↑ Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S (August 2017). "Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure". Eur. Respir. J. 50 (2). doi:10.1183/13993003.02426-2016. PMC 5593345. PMID 28860265.
- ↑ "International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure". Am. J. Respir. Crit. Care Med. 163 (1): 283–91. January 2001. doi:10.1164/ajrccm.163.1.ats1000. PMID 11208659.
- ↑ Ferguson GT, Gilmartin M (April 1995). "CO2 rebreathing during BiPAP ventilatory assistance". Am. J. Respir. Crit. Care Med. 151 (4): 1126–35. doi:10.1164/ajrccm.151.4.7697242. PMID 7697242.
- ↑ 4.0 4.1 Liesching T, Kwok H, Hill NS (August 2003). "Acute applications of noninvasive positive pressure ventilation". Chest. 124 (2): 699–713. PMID 12907562.
- ↑ 5.0 5.1 Soo Hoo GW, Santiago S, Williams AJ (August 1994). "Nasal mechanical ventilation for hypercapnic respiratory failure in chronic obstructive pulmonary disease: determinants of success and failure". Crit. Care Med. 22 (8): 1253–61. PMID 8045145.
- ↑ Holland AE, Denehy L, Buchan CA, Wilson JW (January 2007). "Efficacy of a heated passover humidifier during noninvasive ventilation: a bench study". Respir Care. 52 (1): 38–44. PMID 17194316.
- ↑ Antón A, Güell R, Gómez J, Serrano J, Castellano A, Carrasco JL, Sanchis J (March 2000). "Predicting the result of noninvasive ventilation in severe acute exacerbations of patients with chronic airflow limitation". Chest. 117 (3): 828–33. PMID 10713013.
- ↑ Demoule A, Girou E, Richard JC, Taille S, Brochard L (November 2006). "Benefits and risks of success or failure of noninvasive ventilation". Intensive Care Med. 32 (11): 1756–65. doi:10.1007/s00134-006-0324-1. PMID 17019559.
- ↑ Guérin C, Girard R, Chemorin C, De Varax R, Fournier G (October 1997). "Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia. A prospective epidemiological survey from a single ICU". Intensive Care Med. 23 (10): 1024–32. PMID 9407237.
- ↑ Hess DR (July 2005). "Noninvasive positive-pressure ventilation and ventilator-associated pneumonia". Respir Care. 50 (7): 924–9, discussion 929–31. PMID 15972113.