Guidelines
Guidelines Summary
Summary of guidelines on acute respiratory failure (ARF) by the European Respiratory Society/American Thoracic Society
Bilevel noninvasive mechanical ventilation (NIV) may be considered in chronic obstructive pulmonary disease (COPD) patients with an acute exacerbation in the following three clinical settings [18] :
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To prevent acute respiratory acidosis (ie, when the arterial carbon dioxide tension [PaCO 2] is normal or elevated but pH is normal)
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To prevent endotracheal intubation and invasive mechanical ventilation in patients with mild-to-moderate acidosis and respiratory distress, with the aim of preventing deterioration to a point when invasive ventilation would be considered
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As an alternative to invasive ventilation in patients with severe acidosis and more severe respiratory distress
Bilevel NIV also may be used as the only method for providing ventilatory support in patients who are not candidates for or decline invasive mechanical ventilation. [18]
Bilevel NIV is recommended as follows [18] :
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Patients with ARF leading to acute or acute-on-chronic respiratory acidosis (pH ≤7.35) due to COPD exacerbation
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Patients considered to require endotracheal intubation and mechanical ventilation, unless the patient is immediately deteriorating
Either bilevel NIV or continuous positive airway pressure (CPAP) is recommended for patients with ARF due to cardiogenic pulmonary edema. [18]
CPAP or bilevel NIV is suggested for patients with ARF due to cardiogenic pulmonary edema in the prehospital setting. [18]
Early NIV is suggested for immunocompromised patients with ARF. [18]
NIV use is suggested as follows [18] :
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For patients with postoperative ARF
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Can be offered to dyspneic patients for palliation in the setting of terminal cancer or other terminal conditions
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For the prevention of postextubation respiratory failure in high-risk patients; not suggested to prevent postextubation respiratory failure in non–high-risk patients
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To facilitate weaning from mechanical ventilation in patients with hypercapnic respiratory failure
Media Gallery
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Bilateral airspace infiltrates on chest radiograph film secondary to acute respiratory distress syndrome that resulted in respiratory failure.
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Extensive left-lung pneumonia caused respiratory failure; the mechanism of hypoxia is intrapulmonary shunting.
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A 44-year-old woman developed acute respiratory failure and diffuse bilateral infiltrates. She met the clinical criteria for the diagnosis of acute respiratory distress syndrome. In this case, the likely cause was urosepsis.
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This patient developed acute respiratory failure that turned out to be the initial presentation of systemic lupus erythematosus. The lung pathology evidence of diffuse alveolar damage is the characteristic lesion of acute lupus pneumonitis.
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A Bilevel positive airway pressure support machine is shown here. This could be used in spontaneous mode or timed mode (backup rate could be set).
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Headgear and full face mask commonly are used as the interface for noninvasive ventilatory support.
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Bilevel positive airway pressure (BiPAP) and inspiratory positive airway pressure (IPAP) settings are shown. IPAP or expiratory positive airway pressure (EPAP) and frequency can be preset.
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Noninvasive ventilation with bilevel positive airway pressure for acute respiratory failure secondary to exacerbation of chronic obstructive pulmonary disease.
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Wave forms of a volume-targeted ventilator: Pressure, flow, and volume waveforms are shown with square-wave flow pattern. A is baseline, B is increase in tidal volume, C is reduced lung compliance, and D is increase in flow rate. All 3 settings lead to increase in peak airway pressures. Adapted from Spearman CB et al.
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The cause of respiratory failure may be suggested by spirometry.
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A 65-year-old man developed chronic respiratory failure secondary to usual interstitial pneumonitis. Loss of normal architecture is seen upon biopsy. Also seen are varying degrees of inflammation and fibrosis.
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Lung biopsy from a 32-year-old woman who developed fever, diffuse infiltrates seen on chest radiograph, and acute respiratory failure. The lung biopsy shows acute eosinophilic pneumonitis; bronchoscopy with bronchoalveolar lavage also may have helped reveal the diagnosis.
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Lung biopsy on this patient with acute respiratory failure and diffuse pulmonary infiltrates helped yield the diagnosis of pulmonary edema. Therefore, cardiogenic pulmonary edema should be excluded as the cause of respiratory failure prior to considering lung biopsy.
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Pressure-volume curve of a patient with acute respiratory distress syndrome (ARDS) on mechanical ventilation can be constructed. The lower and the upper ends of the curve are flat, and the central portion is straight (where the lungs are most compliant). For optimal mechanical ventilation, patients with ARDS should be kept between the inflection and the deflection point.
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Surgical lung biopsy was performed in the patient described in Image 3. The histology shows features of diffuse alveolar damage, including epithelial injury, hyperplastic type II pneumocytes, and hyaline membranes.
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