| Respiratory failure is a general term that describes the respiratory system's inability to effectively exchange carbon dioxide and oxygen, a critical function that oxygenates the body's tissues and organs and removes carbon dioxide from arterial blood. Almost any condition that affects breathing or the lungs can lead to respiratory failure. The cause can originate outside the lungs (extrapulmonary) or within the lungs (intrapulmonary).
Respiratory failure is commonly classified as either acute or chronic. Acute respiratory failure occurs when the body's lungs cannot meet metabolic demands. It is a medical emergency in which the individual is hospitalized and almost always intubated. Chronic respiratory failure results in chronically low oxygen levels or chronically high carbon dioxide levels; it can often be treated less urgently than the acute type, and individuals may not necessarily need to be hospitalized.
Causes of acute respiratory failure include dysfunction of the lung structure (parenchyma), pneumonia, fluid accumulation (pulmonary edema), acute respiratory distress syndrome (ARDS), pulmonary embolism, and chest wall trauma.
Chronic respiratory failure is caused by lung conditions such as emphysema, asthma, cystic fibrosis, bronchitis, and chronic obstructive pulmonary disease (COPD); muscle diseases that paralyze respiratory muscles such as myasthenia gravis, muscular dystrophy, or spinal cord injury; structural defects of the chest wall caused by kyphoscoliosis or severe injury; and conditions that depress the respiratory center such as sleep apnea and extreme obesity.Risk: Advanced age is a primary risk factor for respiratory failure. |
Source: Medical Disability Advisor
| History: Symptoms may include shortness of breath (dyspnea), cough, sputum production, bluish discoloration of the skin (cyanosis), restlessness, anxiety, confusion, headache, and generalized fatigue. Respiratory rate may be increased or less commonly, decreased. The individual may have had a previously diagnosed condition involving the lungs; symptoms may have developed suddenly or appeared after a cold, viral infection, or other illness. Physical exam: Listening through a stethoscope (auscultation) may reveal abnormal breath sounds, irregular heart rhythm, and lack of bowel sounds in the abdomen. A neurological exam may indicate impaired sensory and motor function. If the individual is suffering from ventilation fatigue, the chest may heave when breathing, indicating overworking of the ventilatory muscles. Tests: Laboratory tests include routine blood chemistries and hematologic evaluation. Arterial blood gases will be ordered to measure oxygen and carbon dioxide levels and evaluate the gas exchange function of the lungs. Chest x-rays may be done as well as sputum cultures to evaluate underlying infection. A flexible, lighted fiberoptic instrument (bronchoscope) may be passed through the trachea and into the lungs to examine the bronchial area for possible obstruction. Organ systems will be evaluated to help determine the underlying cause or the possible effects on organs from the respiratory failure. |
Source: Medical Disability Advisor
| The initial goal of treatment is to assure that enough oxygen is getting to body organs. Supplemental oxygen therapy may be necessary to improve oxygenation. Many individuals can use noninvasive ventilation such as a nasal mask. In acute cases, however, invasive interventions may be required. If intubation is required, an oral or nasal tube (endotracheal tube, or ETT) is passed through the nose or mouth into the trachea to deliver a carefully controlled amount of oxygen. Mechanical ventilation (respirator), continuous positive airway pressure (CPAP), or supportive breathing (positive end expiratory pressure, or PEEP) can be used to support ventilation. Sedation is necessary in many individuals to relieve restlessness and anxiety that occur when breathing is compromised. Cardiac function must be stabilized; drug therapy may be necessary to maintain cardiac function, especially if hypoxemia is present. Fluid balance must be maintained to avoid compromising kidneys or other vital organs by the accumulation of fluids and to reduce the work of the heart and lungs in removing excess fluid.
Treatment is aimed eliminating the underlying cause, promoting adequate gas exchange, reducing the workload of the lungs, and preventing multiple organ damage due to impaired oxygenation. Drug therapy to facilitate removal of secretions (expectorants) and dilate airways (bronchodilators) may be administered either intravenously or through inhalation (mechanical ventilation). Antibiotics may be given to treat or prevent infections.
If respiratory failure is due to obstruction of the airflow, the cause must be corrected. Treatment may include forced coughing (chest physical therapy), suctioning, and respiratory or physical therapy. Frequent changing of position is usually recommended as well. If there is no relief, a flexible light source with camera (fiberoptic bronchoscopy) is passed down the trachea and into the bronchi to identify and remove the obstruction. |
Source: Medical Disability Advisor
| If respiratory failure is due to an airway obstruction, removal of the obstruction usually restores effective ventilation. When due to abnormal lung function the outcome may depend on the underlying cause, the degree of hypoxemia or abnormally high levels of carbon dioxide in the blood (hypercarbia), and the degree of organ dysfunction as a result of insufficient oxygenation. Respiratory distress can accelerate rapidly, progressing from tissue hypoxia to respiratory arrest and death. |
Source: Medical Disability Advisor
| Individuals with respiratory failure require occupational, physical, and respiratory therapy. All therapies begin in the hospital with occupational and physical therapy continuing after discharge.
Respiratory therapy addresses improving lung function and decreasing risk for the buildup of lung secretions. For individuals with COPD, respiratory therapists teach individuals pursed lip breathing to increase the airflow to the lungs. Individuals may also use a device that measures and displays the amount of air inspired (incentive spirometer) to help motivate deeper breathing. Individuals also learn to produce an effective cough through techniques such as huffing, in which air is forcefully breathed out while the mouth is open. Positions that relieve shortness of breath are also demonstrated, such as leaning forward while sitting with the arms resting on the thighs.
For individuals with continued shortness of breath, occupational therapy addresses fatigue or discomfort that may occur during activities of daily living. Individuals learn to use equipment such as a shower chair to decrease the energy expended during bathing or a long-handled sponge to decrease the amount of forward bending. Energy conservation techniques may be taught to ease the activities of daily living such as meal preparation. Tasks are broken up into smaller components to make them more manageable.
Physical therapy addresses decreased endurance, strength, and range of motion. Individuals learn to stretch shoulder and chest muscles to promote normal posture that in turn improves respiration. Individuals perform strengthening exercises of the arms, legs, and upper back to improve overall endurance and improve posture. Individuals also learn abdominal breathing exercises to strengthen the diaphragm. Aerobic activities such as walking on a treadmill or riding a stationary bicycle further increase endurance. Individuals learn to rate the amount of energy they expend by using a scale to rate perceived exertion from "very, very light" to "very, very hard." This helps individuals stay within safe exercise parameters as advised by their physicians. A pulse oximeter may also be used to help monitor blood oxygen levels to assure that a sufficient level is maintained. |
Source: Medical Disability Advisor
| Respiratory failure may cause an inadequate supply of oxygen to the tissues (hypoxia) of major organ systems. Hypoxia in the heart muscle causes chest pain (angina pectoris) and heart rhythm irregularities (arrhythmias). Hypoxia of the brain may initially cause confusion, dizziness, and uncoordinated movements. If the condition persists, it can progress to unconsciousness and death. Severe hypoxia may lead to complete absence of oxygen in a tissue (anoxia). If prolonged, anoxia may result in tissue death and organ system failure.
Individuals on ventilators are at risk for deep vein thrombosis, pulmonary embolism, gastritis and ulcers, decubitus ulcers, and nosocomial infections (infections caused by being in the hospital). The ventilator itself introduces risk for damage to the lung, acute respiratory alkalosis, hypotension, and ventilator-associated pneumonia.
Up to 16% of individuals with respiratory distress will progress to acute respiratory distress syndrome (ARDS), which has much higher morbidity and mortality (Vincent). |
Source: Medical Disability Advisor
| Work restrictions or accommodations must be determined on an individual basis depending on job requirements. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have a history of extrapulmonary conditions such as myasthenia gravis, muscular dystrophy, polio, Guillain-Barré syndrome, polymyositis, or amyotrophic lateral sclerosis? History of intrapulmonary disorders such as pulmonary fibrosis, COPD, emphysema, bronchiectasis, cystic fibrosis, asthma, bronchiolitis, bronchitis, or pulmonary embolism?
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Has individual experienced drug overdose, inhalation of toxic gases, near drowning, or burns?
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Does individual complain of shortness of breath (dyspnea), cough, bluish discoloration of the skin (cyanosis), restlessness, anxiety, confusion, headache, and generalized fatigue?
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Were arterial blood gases (ABGs) performed? Were chest x-ray, blood chemistry, sputum culture, and pulmonary function tests done?
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Was the underlying cause of the respiratory failure determined?
Regarding treatment:
- If there was an obstruction of air flow, how was it corrected?
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How was obstruction of airflow corrected?
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Did individual require fiberoptic bronchoscopy to identify and remove the obstruction?
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Did individual receive oxygen via a nasal cannula or was intubation required?
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Was the use of positive pressure mechanical ventilation required?
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Were medications to treat or prevent infections (antibiotics), facilitate removal of secretions (expectorants), and dilate airways (bronchodilators) used?
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Was sedation required to relieve restlessness and anxiety?
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Were respiratory, physical, and/or occupational therapy recommended?
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Did treatment restore adequate air exchange?
Regarding prognosis:
- Did individual obtain prompt treatment for respiratory failure?
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What was the underlying cause for respiratory failure and how was it treated? Is additional treatment required to adequately control the underlying cause?
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Has individual participated in respiratory, occupational, and/or physical therapy as prescribed?
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Has the lack of oxygen affected other organs such as the heart or brain? If so, how severely were these organs damaged?
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If individual required mechanical ventilation, have complications occurred such as deep vein thrombosis, pulmonary embolism, gastritis and ulcers, decubitus ulcers, or infections?
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Did the ventilator cause damage to the lung (barotrauma), hypotension, or ventilator-associated pneumonia?
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Have complications occurred as a result of respiratory failure or treatment? How will complications be treated and what is the expected outcome with treatment?
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How will individual's daily activities be affected?
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Source: Medical Disability Advisor
| Vincent, J. L., Y. Sakr, and V. M. Ranieri. "Epidemiology and Outcome of Acute Respiratory Failure in Intensive Care Unit Patients." Critical Care Medicine 31 Suppl 4 (2003): S296-S299. MD Consult. Elsevier, Inc. 28 Dec. 2004 <http://home.mdconsult.com/das/journal/view/43517974-2/N/13052893?sid=327248405&source=MI>. |
Source: Medical Disability Advisor
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