Effective management skill of respiratory failure- Correction of Hypoxia

This is the mainstay in the management of respiratory failure

. Oxygen is administered with nasal catheter or by more effective methods such as masks or tents. If given by nasal catheter, the rate is 2-3 liters per minute and the catheter tip should be located 15cm from the nostril. The venture mask which delivers oxygen at a preset low concentration of oxygen can be adjusted at 24, 28 or 35% by giving oxygen at rates ranging from 4-8 liters/min. It is desirable to bring the PaO2 level above 50mm Hg and pH above 7.25. In chronic respiratory failure administration of oxygen should be closely supervised to avoid the development of carbon-dioxide narcosis. Once the emergency has been tided over, the patient is weaned off from oxygen gradually.

Supportive measures

Administration of fluid and electrolytes, preferably with monitoring of central venous pressure (CVP) and maintenance of nutrition are important. Respiratory stimulants like nikethemide (2-4 ml 25% solution given intravenously), doxapram hydrochloride (intravenous infusion 2.8 mg/min). or ethamivan (3.4g in 540ml as intravenous drip) help in improving the respiratory rate and amplitude if their respiratory centre is depressed. The value of respiratory stimulants is only slight.

Assistance to ventilation

Mechanical assistance should be considered when the patient's own effort is inadequate to maintain oxygenation. If the PaO2 remains below 70mm of Hg and PaCO2 remians above 55 mm Hg while receiving oxygen therapy, respiratory assistance is indicated. Different types of ventilators are available.

Volume cycled ventilators are superior since these are more efficient and safe. If the patient's respiratory mechanism is active, it is desirable to assist it (assisted ventilation). On the other hand, in patients in whom spontaneous respiration is abolished, controlled ventilation using a pre-set volume and rate is employed. Modern respirators are designed to assist respiration when the patient's own respiratory effort goes down and they in turn are reciprocally inhibited when the patient's breathing recovers.

Positive end expiratory pressure (PEEP)

One of the problems encountered in patients with respiratory failure on maintained assisted respiration is premature closure of the terminal air ways during expiration, giving rise to air traping, This is prevented by maintaining a positive end expiratory pressure. In addition, it helps in reopening bronchioles and alveoli which remain closed. The tidal respiration is improved. Positive end expiratory pressure also helps in reducing functional intra-pulmonary shunts thereby increasing the PaO2. The disadvantage of PEEP is reduction in venous return to the heart due to increased intra-thoracic pressure and consequent cardiac failure. Assistance to ventilation should be carried out by specially trained teams. As the patient improves, he is gradually weaned off the ventilator, under supervision.

The use of extracorporeal membrane oxygenators is under study for the management of severe hypoxemic respiratory failure when conventional methods fail. As the patient improves, he is encountered to undertake mild exercises. Respiratory exercises are advised to increase the tidal volume and help expectoration. He is also instructed on methods to avoid the precipitating factors.

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Effective management skill of respiratory failure- Correction of Hypoxia

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