1. RESPIRATORY FAILURE TYPE- I AND TYPE II
DR ZAHOOR

2. RESPIRATORY FAILURE What is Respiratory failure?
Respiratory failure is the condition when pulmonary gas exchange fails to maintain normal arterial O2 and CO2 levels.
There are TWO types of Respiratory failure
- Type I
- Type II

3. Respiratory failure What is Type - I Respiratory failure ?
There is Arterial Hypoxemia with normal or low CO2.
eg Pneumonia
Acute Asthma
What is Type II Respiratory failure ?
There is Arterial Hypoxemia with Hypercapnia.
eg.
Acute severe asthma
Acute exacerbation of COPD

4. RESPIRATORY FAILURE
What is normal Arterial PO2 and PCO2 and what happens in Type I and Type II to these values ?
Normal PaO KPa ( mmHg)
Normal PaCO2 – KPa (36-46 mmHg )

5. RESPIRATORY FAILURE Blood Gases in TYPE -1 Respiratory failure
- PaO2 less than 8KPa ( 60 mmHg ) Hypoxia
- PaCO2 less than 6.6 KPa (50 mmHg ) Normal or low CO2
Blood Gases in Type – II Respiratory failure
PaO2 less than 8KPa ( 60 mmHg ) Hypoxia
PaCO2 more than 6.6 Kpa ( 50 mmHg ) Raised CO2

6. RESPIRATORY FAILURE Causes of ACUTE TYPE-1 Respiratory failure
Acute asthma
Pneumonia
Pulmonary oedema
Pneumothorax
Pulmonary embolus
Lobar collapse
ARDS

7. RESPIRATORY FAILURE
Causes of CHRONIC TYPE-I Respiratory failure(cont )
Emphysema
Lung fibrosis
Brain stem lesion
Right to left shunt

8. RESPIRATORY FAILURE Causes of TYPE II ACUTE Respiratory failure
Acute severe asthma
Acute exacerbation COPD
Narcotic drugs
Upper airway obstruction
Acute neuropathies/ paralysis
Flail chest

9. RESPIRATORY FAILURE Causes of TYPE II CHRONIC Respiratory failure
COPD with exacerbation
Sleep apnoea
Kyphoscoliosis
Myopathies/ muscular dystrophy
Ankylosing spondylitis

10. RESPIRATORY FAILURE Management of Acute Type I Respiratory failure .
Management of cause eg Pneumonia, Bronchial asthma,
High O2 concentration 40-60% by mask
It will relieve hypoxia by increasing the alveolar PO2 in poorly ventilated lung.

11. RESPIRATORY FAILURE Management of Acute Type II Respiratory failure
Acute type II respiratory failure is an EMERGENCY . It requires immediate intervention

12. RESPIRATORY FAILURE
Distinguish between Type II respiratory failure patient who have
Rapid respiratory rate and accessory muscle recruitment – who can not move sufficient air.
And those with reduced respiratory effort eg Respiratory depression .

13. RESPIRATORY FAILURE
1- In high respiratory effort Type II respiratory failure cause may be
Upper airway obstruction from foreign body
Laryngeal obstruction ( Angioedema , vocal card paralysis )
CONSIDER
Heimlich maneuver
Immediate intubation
Emergency tracheostomy
They may be life saving

14. RESPIRATORY FAILURE
2- Patient with type II respiratory failure may have reduced level of consciousness , cause may be
CO2 narcosis
Sedative poisoning
Intracerebral hemorrhage
Head injury ( affecting respiratory center )
Treatment will be for the cause eg opiate antagonist, but should not delay mechanical ventilation in required cases

15. CHRONIC AND ACUTE ON CHRONIC TYPE II RESPIRATORY FAILURE
The most common cause of chronic type II respiratory failure is COPD . In chronic cases there is no persisting academia because kidneys retain HCO-3 correcting PH to normal.
If there is Acute exacerbation in chronic case of COPD than respiratory failure with academia and respiratory distress, drowsiness and coma occurs.

16. Management of Acute on Chronic Type II Respiratory Failure
Aim of treatment is to achieve a safe PaO2 , more than 7KPa ( 52 mmHg ) without increasing PaCO2 and acidosis.
Do Arterial blood gases
X- Ray chest

17. MANAGEMENT Acute on Chronic Type II Respiratory Failure ( Cont )
Maintenance of airway
Controlled O2 therapy-start 24% Venturimask our aim is to get PaO2 more than 7KPa ( 52 mmHg )
Treat precipitating cause eg Antibiotics for infection
Nebulized bronchodilators
Physiotherapy / Pharyngeal suction
Diuretics

18. RESPIRATORY FAILURE IMPORTANT
Some patient with severe chronic COPD and type II respiratory failure may become dependent on Hypoxic drive for their breathing.
In these patients lower concentration of O % should be used ( to avoid worsening depression of respiration )

19. Acute On Chronic Type II Respiratory Failure
Progress of Patient
If PaCO2 continues to rise or patient can not achieve a safe PaO2 without severe hypercapnia and acidosis than Mechanical Ventilatory support may be required.

20. Acute on Chronic Type II Respiratory Failure
Management (cont )
Note – Doxapram slow I/V infusion , is respiratory stimulant and occasionally used in acute on chronic type II respiratory failure and low respiratory drive.
Patients who are conscious with adequate respiratory drive may benefit from Non- invasive ventilation (NIV )- It is positive pressure ventilation delivered through face mask

21. Home Ventilation For Chronic Respiratory Failure Type II
In Chronic Respiratory failure Type II, when PaO2 is less than 7.3 ( 55mmHg ) home ventilation is good for long term treatment .
O2 at 2L/min via nasal prongs is given continuously for hours daily.

22. LUNG TRANSPLANTATION
Lung transplantation is now established treatment in selected patients with advanced lung disease, unresponsive to Medical treatment.
Single Lung Transplant is done in
Advanced Emphysema
Lung Fibrosis

23. LUNG TRANSPLANTATION ( cont )
Bilateral Lung Transplantation is done in
Cystic fibrosis
Bronchiectasis
Because single transplanted lung is vulnerable to cross infection in these cases.

24. LUNG TRANSPLANTATION ( cont )
After Lung Transplantation Prognosis is improving with modern immunosuppressive drugs it is over 60%, 5 year survival in some U.K centres

25. Lung Transplantation Drugs used to prevent Lung rejection .
Short term ( Prevent Acute rejection)
Corticosteriods
Maintenance Treatment to prevent Chronic Rejection
Ciclosporin
Mycophenolate
Tacrolimus

26. CASE HISTORY
An 80 year old male having history of smoking since last 40 years is admitted with dyspnoea. He had fever with green sputum for last 5 days .The patient is confused unable to give proper history. His daughter tells normally he is independent and walks about 3 km every morning. He has not done walking since last week. He is normally not breathless.

27. CASE HISTORY (cont) EXAMINATION
Patient is disoriented. He has fever of 39.2oC, Resp rate 32/ min and O2 saturation of 80%.
His heart rate 110/min. BP 120/65 mmHg. WBC count 18000/ mm3, ( 90% N )
CHEST EXAMINATON
There is reduced expansion of right lower chest where crackles and pleuritic rub are audible. There is no wheeze and Expiration is not prolonged

28. CASE HISTORY ( cont) Q-1 What is the diagnosis ?
Exacerbation of COPD
Community acquired pneumonia
Lung cancer
Empyema
Q- 2 How much O2 should be given to patient?
None
24%
35%
High flow O2 with a non-rebreath mask with reservoir bag (FiO2 :6O% to 100%)

29. CASE HISTORY ( cont)
Q- 3The patient became increasingly drowsy. ABG is performed on high flow O2 and results are shown.
pH – 7.25
PaO2 – 8kPa
PaCo2 – 8.5 kPa
Hco mmol/L
SaO2 – 90%
Which of the following is correct?
Change to 40% O2
Change to 28% O2
Take off O2 altogether
Patient needs to be intubated and mechanically ventilated.

30. Answers Answer – B - Community acquired pneumonia Q – 2
Answer – D - High flow O2 with a non-rebreath mask with reservoir bag
Q – 3
Answer – D Patient needs to be intubated and mechanically ventilated.

31. THANK YOU