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Respiratory Failure: Differential Diagnoses & Workup

Author: Ata Murat Kaynar, MD, Assistant Professor, Departments of Critical Care Medicine and Anesthesiology, University of Pittsburgh School of Medicine
Coauthor(s): Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Contributor Information and Disclosures

Updated: May 20, 2009

Differential Diagnoses

Acute Respiratory Distress Syndrome
Pneumonia, Viral
Apnea, Sleep
Pneumothorax
Asthma
Pulmonary Edema, Cardiogenic
Atelectasis
Pulmonary Edema, Neurogenic
Cardiogenic Shock
Pulmonary Embolism
Cardiomyopathy, Diabetic Heart Disease
Pulmonary Fibrosis, Idiopathic
Cardiomyopathy, Dilated
Pulmonary Fibrosis, Interstitial (Nonidiopathic)
Cardiomyopathy, Hypertrophic
Pulmonary Hypertension, Primary
Cor Pulmonale
Pulmonary Hypertension, Secondary
Cyanosis
Respiratory Acidosis
Diaphragmatic Paralysis
Restrictive Lung Disease
Emphysema
Shock, Distributive
Myocardial Infarction
Ventilation, Mechanical
Myocardial Ischemia
Ventilation, Noninvasive
Pneumonia, Aspiration
Pneumonia, Bacterial
Pneumonia, Community-Acquired

Workup

Laboratory Studies

  • Respiratory failure may be associated with a variety of clinical manifestations. However, these are nonspecific, and very significant respiratory failure may be present without dramatic signs or symptoms. This emphasizes the importance of measuring arterial blood gases in all patients who are seriously ill or in whom respiratory failure is suspected.
  • A complete blood count may indicate anemia, which can contribute to tissue hypoxia, whereas polycythemia may indicate chronic hypoxemic respiratory failure.
  • A chemistry panel may be helpful in the evaluation and management of a patient in respiratory failure. Abnormalities in renal and hepatic function may either provide clues to the etiology of respiratory failure or alert the clinician to complications associated with respiratory failure. Abnormalities in electrolytes such as potassium, magnesium, and phosphate may aggravate respiratory failure and other organ function.
  • Measuring serum creatine kinase with fractionation and troponin I helps exclude recent myocardial infarction in a patient with respiratory failure. An elevated creatine kinase with a normal troponin I may indicate myositis, which occasionally can cause respiratory failure.
  • In chronic hypercapnic respiratory failure, serum thyroid-stimulating hormone should be measured to evaluate the possibility of hypothyroidism, a potentially reversible cause of respiratory failure.

Imaging Studies

  • Chest radiograph
    • Chest radiography is essential because it frequently reveals the cause of respiratory failure. However, distinguishing between cardiogenic and noncardiogenic pulmonary edema often is difficult.
    • Increased heart size, vascular redistribution, peribronchial cuffing, pleural effusions, septal lines, and perihilar bat-wing distribution of infiltrates suggest hydrostatic edema; the lack of these findings suggests acute respiratory distress syndrome (ARDS).
  • Echocardiography
    • Echocardiography need not be performed routinely in all patients with respiratory failure. However, it is a useful test when a cardiac cause of acute respiratory failure is suspected.
    • The findings of left ventricular dilatation, regional or global wall motion abnormalities, or severe mitral regurgitation support the diagnosis of cardiogenic pulmonary edema.
    • A normal heart size and normal systolic and diastolic function in a patient with pulmonary edema would suggest acute respiratory distress syndrome (ARDS).
    • Echocardiography provides an estimate of right ventricular function and pulmonary artery pressure in patients with chronic hypercapnic respiratory failure.

Other Tests

  • Patients with acute respiratory failure generally are unable to perform pulmonary function tests (PFTs). However, PFTs are useful in the evaluation of chronic respiratory failure.
    • Normal values of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) suggest a disturbance in respiratory control.
    • A decrease in FEV1 -to-FVC ratio indicates airflow obstruction, whereas a reduction in both the FEV1 and FVC and maintenance of the FEV1 -to-FVC ratio suggest restrictive lung disease.
    • Respiratory failure is uncommon in obstructive diseases when the FEV1 is greater than 1 L and in restrictive diseases when the FVC is more than 1 L.
  • An ECG should be performed to evaluate the possibility of a cardiovascular cause of respiratory failure; it also may detect dysrhythmias resulting from severe hypoxemia and/or acidosis.

Procedures

  • Right heart catheterization
    • This remains a controversial issue in the management of critically ill patients.
    • Invasive monitoring probably is not routinely needed in patients with acute hypoxemic respiratory failure, but when significant uncertainty about cardiac function, adequacy of volume resuscitation, and systemic oxygen delivery remain, right heart catheterization should be considered.
    • Measurement of pulmonary capillary wedge pressure may be helpful in distinguishing cardiogenic from noncardiogenic edema.
    • The pulmonary capillary wedge pressure should be interpreted in the context of serum oncotic pressure and cardiac function.

More on Respiratory Failure

Overview: Respiratory Failure
Differential Diagnoses & Workup: Respiratory Failure
Treatment & Medication: Respiratory Failure
Follow-up: Respiratory Failure
Multimedia: Respiratory Failure
References
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References

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Further Reading

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Keywords

respiratory failure, hypoxemic respiratory failure, chronic respiratory failure, hypercapnic respiratory failure, type I respiratory failure, type II respiratory failure, chronic obstructive pulmonary disease, COPD, chronic obstructive pulmonary disease, respiratory system failure, respiratory system, system failure, PaO2 value, oxygenation, carbon dioxide elimination, hypoxemic, hypercapnic

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Contributor Information and Disclosures

Author

Ata Murat Kaynar, MD, Assistant Professor, Departments of Critical Care Medicine and Anesthesiology, University of Pittsburgh School of Medicine
Ata Murat Kaynar, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Chest Physicians, American Society of Anesthesiologists, American Society of Critical Care Anesthesiologists, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Cory Franklin, MD, Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science; Director, Division of Critical Care Medicine, Cook County Hospital
Cory Franklin, MD is a member of the following medical societies: New York Academy of Sciences and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Harold L Manning, MD, Associate Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School
Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair, Academic Affairs, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

 
 
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