Respiratory failure oxygen therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

## Overview

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A trial of non-invasive ventilation (NIV) may be carried out in order to achieve hypoxemic correction. NIV is advantageous in carrying less infection and mortality rates than traditional mechanical ventilation. ECMO is a cardiopulmonary support machine that is useful in cases of acute severe respiratory failure.

## Oxygen therapy

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* The aim of oxygen therapy is to correct hypoxia.[1]
* These therapies may include:
* Non-invasive ventilatory support
* Extracorporeal membrane oxygenation

### Non-invasive ventilatory support (NIV)

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* Non-invasive ventilatory support (NIV) uses positive pressure ventilation delivered through a face or nasal mask or nasal prongs as a non-invasive way of delivering oxygen. (Different pressure types will be discussed in the mechanical ventilation section of this chapter).[2][3][4][5]
* Non-invasive ventilatory support (NIV) is indicated for:
* Acute hypoxemic respiratory failure
* Chronic obstructive pulmonary disease (COPD) complicated by hypercapnic acidosis
* Use of (NIV) is contraindicated in cases of need of emergent intubation, such as:
* Myocardial arrest
* Respiratory arrest
* Inability to preserve a patent airways
* Severely altered consciousness
* Life threatening organ failure of nonpulmonary origin
* Abnormalities of facial structure for any reason
* High risk of aspiration
* Expected long term treatment with mechanical ventilation
* Recent esophageal surgery with anastomoses

#### Mask selection

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* Studies have demonstrated that a face mask confers the largest physiological improvement, whilst nasal masks and prongs are tolerated the best.[4][6][5][7]
* Face masks are preferred in several studies and have the following advantages:
* Less air leaks compared to volumes lost with nasal masks through the oral cavity
* Nasal masks increase resistance to air flow and therefore, increase respiratory effort
* Face masks make it easier to assess aspiration risk in comparison to a nasal mask

#### Ventilatory modes

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Will be discussed in the mechanical ventilation section of this chapter.

#### Monitoring NIV

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* Success or failure of NIV therapy is established within an initial observation period of 8 hours.[8]
* During this time adjustments should be made, whilst looking for signs of destabilization.
* An improvement in arterial carbon dioxide tension (PaCO2) and pH within 1.5 - 2 hours is indicative of successful NIV.
* Indications of failed NIV include:
* A lack of improvement in arterial carbon dioxide tension (PaCO2) and pH within 1.5 - 2 hours
* Encephalopathy
* Agitation
* Unclearable secretions
* Intolerable mask interface
* Decreased oxygen saturation
* Hemodynamic instability
* Successful selection of patients with indications for NIV by physicians is poor and therefore, a third of patients that receive a trial of NIV fail.
* The use of sedatives and analgesics, for purposes of comfort and anxiety is not recommended as studies have demonstrated an increase in NIV failure rates with pretreatment of these agents.

#### Weaning

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Weaning is carried out through progressively decreasing positive pressure settings, whilst permitting the patient longer durations without ventilation.

#### Advantages of NIV

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* NIV has lower mortality rates (23%) in comparison to traditional mechanical ventilation (39%).[9][10]
* NIV therapy carries less risk of nosocomial infection transmission such as ventilator - associated pneumonias, sinusitis and line sepsis.
* NIV facilitates a decreased need for invasive mechanical ventilation.

### Extracorporeal membrane oxygenation (ECMO)

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* Extracorporeal membrane oxygenation (ECMO) is a mechanical cardiopulmonary support, which can run temporarily in place of the heart and lungs.
* ECMO is most often applied intraoperatively to facilitate cardiac surgery.

Source:commons.wikimedia.org, shows ECMO circuit by Jürgen Schaub. de:User:Mr.Flintstone - transfrered from de:Datei:Ecmo schema.jpgOwn work, CC BY-SA 2.0 de, https://commons.wikimedia.org/w/index.php?curid=8756034

#### ECMO procedure

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* During ECMO blood is extracted from the vascular system and circulated invitro to a mechanical pump outside the body.[11][12][13][14][15]
* During this period where the blood is outside the body, the blood passes through an oxygenator and a heat exchanger.
* The blood is fully saturated with oxygen and waste gases, such as carbon dioxide are removed.
* The rate of oxygenation depends on the flow rate through the ECMO circuit, whilst C02 exchange is dependent upon the rate of countercurrent flow through the oxygenator.
* The blood is then returned to the body.

#### Indications

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* ECMO may be indicated in two types of severe acute respiratory failure:[16][17][18]
* Type I hypoxemic respiratory failure where the PaO2/FiO2 (a ratio of arterial oxygen tension to fraction of inspired oxygen) is less than 100mmHg, whilst the tidal volume, inspiratory to expiratory (I:E) ratio, and positive end-expiratory pressure are all optimal.
* Type II hypercapnic respiratory failure with an arterial pH less than 7.20.
* Survival rates in patients with acute severe respiratory failure who receive ECMO compared to those that don't receive ECMO are 71% and 50% respectively.

#### Types of ECMO

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* VV (Venovenous) ECMO:[17][18]
* Blood is drawn from the vena cava or right atrium and returned to the right atrium.
* VA (Venoarterial) ECMO:
* Blood is drawn from the right atrium and returned to the arterial system, bypassing the heart and lungs.

#### Contraindications to ECMO

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* Absolute contraindications:[19]
* Severe neurologic impairment
* Advanced stage malignancy
* Relative contraindications:
* Primary condition has a poor prognosis
* Severe unremitting bleeding

#### Weaning and complications of ECMO

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* Patients with respiratory failure may be weaned off ECMO, when the following improvements are noted:[20][21]
* Improvements on chest radiograph
* Increase in pulmonary compliance
* Increase in arterial oxyhemoglobin saturation
* Weaning with VV (Venovenous) ECMO:
* Weaning trials are carried out by allowing the blood to continue flowing through the ECMO circuit, however without gas transference.
* Weaning with VA (Venoarterial) ECMO:
* Weaning trials are carried out by temporary clamping of both the drainage and infusion lines, whilst allowing the ECMO circuit to circulate to avoid thromboembolism.
* Complications of ECMO include:
* Bleeding
* Thromboembolism

## References

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1. ↑ Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S (August 2017). "Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure". Eur. Respir. J. 50 (2). doi:10.1183/13993003.02426-2016. PMC 5593345. PMID 28860265.
2. ↑ "International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure". Am. J. Respir. Crit. Care Med. 163 (1): 283–91. January 2001. doi:10.1164/ajrccm.163.1.ats1000. PMID 11208659.
3. ↑ Ferguson GT, Gilmartin M (April 1995). "CO2 rebreathing during BiPAP ventilatory assistance". Am. J. Respir. Crit. Care Med. 151 (4): 1126–35. doi:10.1164/ajrccm.151.4.7697242. PMID 7697242.
4. ↑ 4.0 4.1 Liesching T, Kwok H, Hill NS (August 2003). "Acute applications of noninvasive positive pressure ventilation". Chest. 124 (2): 699–713. PMID 12907562.
5. ↑ 5.0 5.1 Soo Hoo GW, Santiago S, Williams AJ (August 1994). "Nasal mechanical ventilation for hypercapnic respiratory failure in chronic obstructive pulmonary disease: determinants of success and failure". Crit. Care Med. 22 (8): 1253–61. PMID 8045145.
6. ↑ Holland AE, Denehy L, Buchan CA, Wilson JW (January 2007). "Efficacy of a heated passover humidifier during noninvasive ventilation: a bench study". Respir Care. 52 (1): 38–44. PMID 17194316.
7. ↑ Antón A, Güell R, Gómez J, Serrano J, Castellano A, Carrasco JL, Sanchis J (March 2000). "Predicting the result of noninvasive ventilation in severe acute exacerbations of patients with chronic airflow limitation". Chest. 117 (3): 828–33. PMID 10713013.
8. ↑ Demoule A, Girou E, Richard JC, Taille S, Brochard L (November 2006). "Benefits and risks of success or failure of noninvasive ventilation". Intensive Care Med. 32 (11): 1756–65. doi:10.1007/s00134-006-0324-1. PMID 17019559.
9. ↑ Guérin C, Girard R, Chemorin C, De Varax R, Fournier G (October 1997). "Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia. A prospective epidemiological survey from a single ICU". Intensive Care Med. 23 (10): 1024–32. PMID 9407237.
10. ↑ Hess DR (July 2005). "Noninvasive positive-pressure ventilation and ventilator-associated pneumonia". Respir Care. 50 (7): 924–9, discussion 929–31. PMID 15972113.
11. ↑ Ullrich R, Lorber C, Röder G, Urak G, Faryniak B, Sladen RN, Germann P (December 1999). "Controlled airway pressure therapy, nitric oxide inhalation, prone position, and extracorporeal membrane oxygenation (ECMO) as components of an integrated approach to ARDS". Anesthesiology. 91 (6): 1577–86. PMID 10598597.
12. ↑ Rich PB, Awad SS, Kolla S, Annich G, Schreiner RJ, Hirschl RB, Bartlett RH (March 1998). "An approach to the treatment of severe adult respiratory failure". J Crit Care. 13 (1): 26–36. PMID 9556124.
13. ↑ Kolla S, Awad SS, Rich PB, Schreiner RJ, Hirschl RB, Bartlett RH (October 1997). "Extracorporeal life support for 100 adult patients with severe respiratory failure". Ann. Surg. 226 (4): 544–64, discussion 565–6. PMC 1191077. PMID 9351722.
14. ↑ Davies A, Jones D, Bailey M, Beca J, Bellomo R, Blackwell N, Forrest P, Gattas D, Granger E, Herkes R, Jackson A, McGuinness S, Nair P, Pellegrino V, Pettilä V, Plunkett B, Pye R, Torzillo P, Webb S, Wilson M, Ziegenfuss M (November 2009). "Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome". JAMA. 302 (17): 1888–95. doi:10.1001/jama.2009.1535. PMID 19822628.
15. ↑ Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL (December 2009). "Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database". Intensive Care Med. 35 (12): 2105–14. doi:10.1007/s00134-009-1661-7. PMID 19768656.
16. ↑ Hemmila MR, Rowe SA, Boules TN, Miskulin J, McGillicuddy JW, Schuerer DJ, Haft JW, Swaniker F, Arbabi S, Hirschl RB, Bartlett RH (October 2004). "Extracorporeal life support for severe acute respiratory distress syndrome in adults". Ann. Surg. 240 (4): 595–605, discussion 605–7. PMC 1356461. PMID 15383787.
17. ↑ 17.0 17.1 Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK (September 1997). "Extracorporeal membrane oxygenation for adult respiratory failure". Chest. 112 (3): 759–64. PMID 9315812.
18. ↑ 18.0 18.1 Lewandowski K, Rossaint R, Pappert D, Gerlach H, Slama KJ, Weidemann H, Frey DJ, Hoffmann O, Keske U, Falke KJ (August 1997). "High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation". Intensive Care Med. 23 (8): 819–35. PMID 9310799.
19. ↑ Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, Rhodes A, Slutsky AS, Vincent JL, Rubenfeld GD, Thompson BT, Ranieri VM (October 2012). "The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material". Intensive Care Med. 38 (10): 1573–82. doi:10.1007/s00134-012-2682-1. PMID 22926653.
20. ↑ Braune S, Sieweke A, Brettner F, Staudinger T, Joannidis M, Verbrugge S, Frings D, Nierhaus A, Wegscheider K, Kluge S (September 2016). "The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case-control study". Intensive Care Med. 42 (9): 1437–44. doi:10.1007/s00134-016-4452-y. PMID 27456703.
21. ↑ Rush B, Wiskar K, Berger L, Griesdale D (October 2017). "Trends in Extracorporeal Membrane Oxygenation for the Treatment of Acute Respiratory Distress Syndrome in the United States". J Intensive Care Med. 32 (9): 535–539. doi:10.1177/0885066616631956. PMID 26893318.

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