Acute respiratory failure

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

airway obstruction

1st line – airway clearance

Back

1st line –

airway clearance

Obstruction of the airway is revealed by the patient's Airway, Breathing, Circulation, Disability, Exposure assessment.

Direct laryngoscopy or bronchoscopy may be required to clear an airway foreign body. Emergency cricothyroidotomy or tracheostomy may be needed to manage structural obstructions at the glottic or infra-glottic level. Acute treatment may be required to reduce the swelling of an airway blocked due to anaphylaxis.

Plus – supplemental oxygen

Back

Plus –

supplemental oxygen

Treatment recommended for ALL patients in selected patient group

This should be administered by nasal cannula, mask, or non-invasive (positive pressure) ventilation (NIV) to all hypoxic patients as part of, or immediately after, the initial Airway, Breathing, Circulation, Disability, Exposure assessment. When tolerated, high flow oxygen by nasal cannula may be as effective as mask delivery.[46][47][48]The American College of Physicians recommends using high-flow nasal oxygen rather than NIV in the initial management of acute respiratory failure, but the evidence for this recommendation is of low certainty.[49]

The most tolerable, least patient restrictive method of delivering supplemental oxygen sufficient to maintain oxygen saturation (as monitored by continuous pulse oximetry and arterial blood gas analysis) should be used. NIV may be recommended for patients who are awake and conscious, and should be used with extreme caution.[22]

Care is required when providing supplemental oxygen to patients with COPD and chronically elevated carbon dioxide partial pressures, as these patients are dependent on central oxygen receptors detecting hypoxaemia to drive ventilation. Acutely increasing blood oxygen levels in these patients can lead to respiratory depression. One systematic review of acutely ill adult patients (patients with chronic respiratory disease excluded) reported increased mortality among those who received liberal oxygen supplementation, compared with those who received conservative oxygen supplementation.[50] A target capillary oxygen saturation (SpO₂) range of 94% to 96% was suggested for all patients with critical illness.[50]

Consider – treatment of underlying causes

Back

Consider –

treatment of underlying causes

Additional treatment recommended for SOME patients in selected patient group

If the underlying cause has been identified, treatment should be started as soon as possible.

Treatment may include antibiotic therapy for infection, adrenaline (epinephrine) for anaphylaxis, opioid reversal with naloxone, bronchodilation/corticosteroid therapy for chronic lung disease, decompression/chest tube insertion for pneumothorax, fluid resuscitation for hypovolaemia, thrombolysis/embolectomy for pulmonary embolus, radiotherapy for malignancy, and surgery for trauma or malignancy.

Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.

Supraglottic airway devices animated demonstration

How to size and insert a laryngeal mask airway.

Nasopharyngeal airway animated demonstration

How to select the correct size naspharyngeal airway and insert the airway device safely.

Oropharyngeal airway animated demonstration

How to size and insert an oropharygeal airway.

Pocket mask ventilation animated demonstration

How to use a pocket mask to deliver ventilation breaths to an adult patient.

no acute upper airway obstruction: stable

conscious

1st line – supplemental oxygen

Back

1st line –

supplemental oxygen

Patients with spontaneous respiration and an intact airway (revealed by an Airway, Breathing, Circulation, Disability, Exposure [ABCDE] assessment) and who are otherwise stable should receive supplemental oxygen administered by nasal cannula, mask, or non-invasive (positive pressure) ventilation (NIV) as part of, or immediately after, the initial ABCDE assessment. When tolerated, high flow oxygen by nasal cannula may be as effective as mask delivery.[46][47][48]The American College of Physicians recommends using high-flow nasal oxygen rather than NIV in the initial management of acute respiratory failure, but the evidence for this recommendation is of low certainty.[49]

Consider – treatment of underlying causes

Back

Consider –

treatment of underlying causes

Additional treatment recommended for SOME patients in selected patient group

If the underlying cause has been identified, treatment should be started as soon as possible.

Insertion of intercostal drain, Seldinger technique: animated demonstration

Supraglottic airway devices animated demonstration

How to size and insert a laryngeal mask airway.

Nasopharyngeal airway animated demonstration

How to select the correct size naspharyngeal airway and insert the airway device safely.

Oropharyngeal airway animated demonstration

How to size and insert an oropharygeal airway.

Pocket mask ventilation animated demonstration

How to use a pocket mask to deliver ventilation breaths to an adult patient.

2nd line – non-invasive (positive pressure) ventilation (NIV)

Back

2nd line –

non-invasive (positive pressure) ventilation (NIV)

NIV can be used for conscious patients with spontaneous respiration and intact gag reflexes, and without rapid deterioration or vital organ compromise.

Non-invasive continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) can be implemented if supplemental oxygen delivered by nasal cannula or a mask has been tried first, but is unsuccessful.

Use of BiPAP or CPAP is favoured for respiratory failure secondary to acute congestive heart failure as they are not associated with a significant decrease in cardiac output. Patients being maintained by CPAP may not require endotracheal intubation if the underlying respiratory system abnormalities are reversed quickly. However, studies of emergency CPAP use for both hypoxic and hypercapnic respiratory failure have failed to show a decrease in mortality for these patients.[55]

There is evidence to suggest that BiPAP is particularly effective for the management of hypercapnic respiratory failure.[56] It works by providing a specific inspiratory positive pressure that augments inspiratory effort and a low-pressure resistance for exhalation.

Consider – treatment of underlying causes

Back

Consider –

treatment of underlying causes

Additional treatment recommended for SOME patients in selected patient group

If the underlying cause has been identified, treatment should be started as soon as possible.

Insertion of intercostal drain, Seldinger technique: animated demonstration

Supraglottic airway devices animated demonstration

How to size and insert a laryngeal mask airway.

Nasopharyngeal airway animated demonstration

How to select the correct size naspharyngeal airway and insert the airway device safely.

Oropharyngeal airway animated demonstration

How to size and insert an oropharygeal airway.

Pocket mask ventilation animated demonstration

How to use a pocket mask to deliver ventilation breaths to an adult patient.

unconscious

1st line – supplemental oxygen

Back

1st line –

supplemental oxygen

This should be administered by nasal cannula or mask to all unconscious hypoxic patients as part of, or immediately after, the initial Airway, Breathing, Circulation, Disability, Exposure assessment. Oxygenation should be monitored by continuous pulse oximetry and arterial blood gas analysis to ensure it is adequate.

Non-invasive (positive pressure) ventilation (NIV) is not used in patients who are unconscious.

Consider – treatment of underlying causes

Back

Consider –

treatment of underlying causes

Additional treatment recommended for SOME patients in selected patient group

If the underlying cause has been identified, treatment should be started as soon as possible.

Insertion of intercostal drain, Seldinger technique: animated demonstration

Supraglottic airway devices animated demonstration

How to size and insert a laryngeal mask airway.

Nasopharyngeal airway animated demonstration

How to select the correct size naspharyngeal airway and insert the airway device safely.

Oropharyngeal airway animated demonstration

How to size and insert an oropharygeal airway.

Pocket mask ventilation animated demonstration

How to use a pocket mask to deliver ventilation breaths to an adult patient.

2nd line – endotracheal intubation and mechanical ventilation

Back

2nd line –

endotracheal intubation and mechanical ventilation

Required if supplemental oxygen therapy is unsuccessful in unconscious patients with spontaneous respiration and intact gag reflexes, and without rapid deterioration or vital organ compromise.

It is performed to protect the airway and reduce the risk of aspiration. Invasive ventilation using mechanical ventilators is the most controlled method to manage respiratory failure.

Tracheal intubation animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

To decrease the length of time and sedation required for ongoing endotracheal intubation and mechanical ventilation for patients with chronic hypercapnic respiratory failure, non-invasive Bi-PAP or CPAP ventilation may be a reasonable weaning strategy.[73]

Consider – rapid sequence induction (RSI)

Back

Consider –

rapid sequence induction (RSI)

Additional treatment recommended for SOME patients in selected patient group

Intubation can be facilitated using RSI of anaesthesia (with sedatives and paralytics) prior to intubation.

It is safe when used by experienced intubators; however, RSI will cause loss of respiratory reflexes that can result in massive aspiration of oral and gastric contents.

Consider – treatment of underlying causes

Back

Consider –

treatment of underlying causes

Additional treatment recommended for SOME patients in selected patient group

If the underlying cause has been identified, treatment should be started as soon as possible.

Insertion of intercostal drain, Seldinger technique: animated demonstration

Supraglottic airway devices animated demonstration

How to size and insert a laryngeal mask airway.

Nasopharyngeal airway animated demonstration

How to select the correct size naspharyngeal airway and insert the airway device safely.

Oropharyngeal airway animated demonstration

How to size and insert an oropharygeal airway.

Pocket mask ventilation animated demonstration

How to use a pocket mask to deliver ventilation breaths to an adult patient.

no acute upper airway obstruction: unstable

1st line – supplemental oxygen

Back

1st line –

supplemental oxygen

Patients with loss of gag reflex, rapid deterioration, or vital organ compromise (revealed by an Airway, Breathing, Circulation, Disability, Exposure [ABCDE] assessment), whether conscious or unconscious, should receive supplemental oxygen administered by nasal cannula, mask, or non-invasive (positive pressure) ventilation (NIV) as part of, or immediately after, the initial ABCDE assessment. When tolerated, high flow oxygen by nasal cannula may be as effective as mask delivery.[46][47][48]The American College of Physicians recommends using high-flow nasal oxygen rather than NIV in the initial management of acute respiratory failure, but the evidence for this recommendation is of low certainty.[49]

NIV is used only for patients who are awake and conscious because of the risk of aspiration if obtunded or unconscious.

Plus – endotracheal intubation and mechanical ventilation

Back

Plus –

endotracheal intubation and mechanical ventilation

Treatment recommended for ALL patients in selected patient group

Required when there is progressive hypoxia or hypercapnia (to the degree that vital organs are compromised and respiratory acidosis cannot be corrected) or when the airway/gag reflex is lost. It is performed to protect the airway and reduce the risk of aspiration. Invasive ventilation using mechanical ventilators is the most controlled method to manage respiratory failure.

Tracheal intubation animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Consider – rapid sequence induction (RSI)

Back

Consider –

rapid sequence induction (RSI)

Additional treatment recommended for SOME patients in selected patient group

Intubation can be facilitated using RSI of anaesthesia (with sedatives and paralytics) prior to intubation.

It is safe when used by experienced intubators; however, RSI will cause loss of respiratory reflexes that can result in massive aspiration of oral and gastric contents.

Consider – treatment of underlying causes

Back

Consider –