Respiratory failure is the condition in which the respiratory system fails to ensure proper oxygenation of the blood and adequate elimination of carbon dioxide.
In practice, the level of oxygen in the blood decreases and / or that of carbon dioxide increases dangerously. Airway obstruction, lung damage, or weakening of the muscles that control breathing can cause this condition.
According to researchers, the incidence of acute forms of this pathology is around 77-88 cases per 100 thousand inhabitants . In particular, with higher values in middle-aged people and very high in the elderly, for respiratory causes in 50% of cases and cardiocirculatory in 25% of cases.
Above all, the presence of respiratory failure is very frequent in chronic respiratory diseases and even appears in 57% of hospitalizations for chronic obstructive pulmonary disease (COPD).
In fact, respiratory failure is often caused by pathologies of different origins.
To prevent it, in addition to flu and pneumococcal vaccination , it is good to adopt a healthy lifestyle that includes a balanced diet, regular physical activity and no smoking.
Respiratory failure: what it is and how it occurs
Respiratory insufficiency occurs when our apparatus is unable to maintain the balance in the exchange of respiratory gases , that is, between the oxygen entering and the carbon dioxide leaving.
As a result, an imbalance of these gases is created in the arterial blood , with a low presence of oxygen or a high presence of carbon dioxide, or even, both situations simultaneously.
When this condition occurs
For example, when there is an actual lack of oxygen in the environment, such as in the high mountains . This is why climbers equip themselves with oxygen cylinders , since the presence of this gas in the air is reduced at high altitude.
But the difficulty in breathing can also be caused by an obstruction of the airways or by the inability of the muscles to expand and compress the lungs (this happens in the case, for example, of diseases that gradually lead to paralysis).
Finally, to cause this condition there are various diseases of the lungs , bronchi and pleura, which can lead to both acute and chronic forms.
The respiratory system: how our body is oxygenated
This apparatus is used to acquire oxygen from the air and to release carbon dioxide from the body. In fact, the latter is formed in our body due to the combustion of food molecules, a fundamental process for obtaining the energy necessary for our body to live.
That’s why our body must be able to eliminate carbon dioxide that ends up in the blood and at the same time absorb oxygen. In addition, everything must happen quickly and in the appropriate quantity.
The breathing part from the nose and mouth, through which accesses the air , which then passes through the throat and larynx. Then, from here it descends into the trachea, which branches out into the bronchi, until it reaches the lungs.
Role of lungs and bronchi
In turn, the lungs are divided into sections, called lobes: we have three in the right lung and two in the left lung. On the left the number of lobes is reduced to leave room for the heart.
For their part, the bronchi branch into increasingly smaller airways, up to the bronchioles, with a diameter of just half a millimeter.
Just at the end of these bronchioles, there are thousands of alveoli , which are nothing but small pockets of air.
Within their walls, there is a dense network of capillaries, that is, tiny blood vessels, through which oxygen passes from the alveoli to the blood and carbon dioxide, vice versa, from the blood to the alveoli.
In conclusion, breathing is nothing more than the incessant work with which the lungs and bronchi transfer the oxygen present in the air to the blood and is necessary for the cells of our body.
Furthermore, at the same time, they always remove carbon dioxide from the blood that is formed during the metabolic processes of the cells.
Respiratory failure: acute or chronic
According to the mode of onset, respiratory failure is distinguished in different forms.
The two main forms are: acute respiratory failure and chronic respiratory failure, persistent foma that can flare up.
Acute respiratory failure
It arises quickly in a healthy respiratory system until the acute episode. In practice, severe lung disease occurs suddenly. However, the acute form can develop even when there is a sudden worsening of a long-standing lung disease.
Chronic respiratory failure
It manifests itself gradually and then stabilizes or evolves over time. It is generally the late manifestation of a respiratory disease that has been present for some time, such as obstructive pulmonary disease (COPD).
Chronic respiratory failure exacerbated
It is the chronic form that flares up due to an event, such as an infection or inflammation of the airways.
In practice, the chronic form worsens because neither the drugs nor the oxygen-based therapy with which it was treated can more compensate for respiratory failure.
Respiratory failure: types
There are two types of respiratory failure: hypoxemia (type 1 or partial) and hypercapnic (type 2 or total).
This type – type 1 or partial – occurs when the concentration of oxygen in the blood is low. It is the most common form and occurs in all those pathological situations affecting the lungs.
In this type – type 2 or total – there is an excess of carbon dioxide which makes the blood acid. This typology occurs in the most severe forms of respiratory failure and in the acute forms.
In practice, in a first phase of respiratory insufficiency the kidneys try to compensate for this excess of acidity by putting bicarbonates into circulation. If at some point this compensatory mechanism is not enough, then respiratory acidosis appears.
But in some cases, both low oxygen levels (hypoxemia) and high carbon dioxide levels (hypercapnic) can occur .
Respiratory failure: causes
Among the causes of hypoxemic or partial respiratory insufficiency there is the alteration of the lung tissue or scarring of the lung, consequent to inflammatory states protracted over time.
As a result, these modifications hinder the normal function of oxygen absorption by the air by the lung tissue.
In addition, this hypoxemic form can occur when the blood flow in the lungs is altered . For example, in the event that a blood clot occludes a pulmonary artery (pulmonary embolism).
In fact, since a part of the lung is not supplied with blood, its functionality is reduced and the quantity of oxygen extracted from the blood is scarce. On the contrary, in the case of hypercapnic or total respiratory insufficiency, a condition in which the levels of carbon dioxide are high, the problem is due to the fact that there are factors that prevent regular breathing.
Respiratory failure: difficulty breathing normally
Among the causes of this impediment are:
- hypothyroidism, i.e. low thyroid hormone levels
- sleep apnea
- sedation caused by an excessive dose of alcohol or opioids, which reduces the respiratory reflex
- obstruction or narrowing of the airways (for example for asthma – see our article or for obstructive pulmonary disease, or by inhalation of a foreign body)
- injury to the lungs or bones and tissues surrounding the lungs
- weakness of the inspiratory muscles.
Respiratory failure: symptoms
Depending on the cause of respiratory failure, the symptoms can be different.
However, some are common in all cases:
- dyspnoea , i.e. difficulty breathing
- tachypnea , that is, accelerated and deep breathing (more than 30 acts in a minute), with which the body tries to eliminate excess carbon dioxide
- cyanosis , i.e. bluish coloring of the skin, lips and nails
- confusional state
- reduced ability to respond to stimuli
- sleepiness to lethargy or unconsciousness
- tachycardia and arrhythmias , respectively acceleration and changes in heart rate.
In particular, the last two symptoms on the list are associated with potential deaths.
In addition, in the case of alcohol or opioid abuse, which reduce the respiratory reflex , extreme drowsiness, slowing of breathing up to coma may occur.
Respiratory failure in children
Over half of the cases of respiratory failure in children occur in the first year of life: in particular, 50% are infants or infants. In fact, in very young children, the organs necessary for the whole breathing process are structurally immature .
Unfortunately , respiratory obstructions in infants are always very serious, precisely because of the smaller size of the airways and their particular shape and functionality.
Symptoms in children
They are similar to those of adults: stridor during breathing, breathlessness, dyspnoea, tachypnea and cyanosis, to which can be added alteration of the voice. In addition, these can be joined by more severe symptoms of hypertension due to hypercapnia, pallor.
The causes of acute respiratory failure in children can be of three types:
- Hypoventilation syndromes in children with healthy and normal lungs due to neuromuscular diseases or structural changes
- primary lung , alveolus or interstitial disorders : edema or inflammation of the alveoli and / or interstitium compromise lung function
- obstructive airway diseases .
In children, respiratory failure is also often caused by the accidental aspiration of a foreign body (toys or small objects) that obstructs the airways.
How it is treated
Intervention is essential, especially in the case of newborns and infants, because it is a condition that puts the life of the child at risk.
In addition to intervening with the specific therapy for the pathology that caused the respiratory insufficiency, it is necessary to monitor the gas balance with a non-invasive instrumentation (for example the oximeter), hydrate and proceed with a ventilatory therapy based on clinical tests, to restore the gas balance.
Furthermore, in the case of obstructive pathologies of the small airways , bronchodilator drugs are used (the same used for asthma), which can be accompanied by corticosteroids, which have an anti-inflammatory action in the bronchial wall.
It is also important to keep the child calm, ensuring that his parents are close and letting him take the position he prefers.
Diagnosis: tests and exams
In addition to analyzing the symptoms and physically examining the patient’s condition, the doctor can also make use of specific instrumental tests and laboratory tests to confirm the diagnosis.
Therefore, depending on the cases and severity, the in-depth analyzes and tests listed and described below may be necessary.
Respiratory failure: tests
Oxygen saturation in the blood
It is measured with the oximeter, a sensor attached to the fingertip that is able to detect low oxygen levels in the blood without having to take the sample. This instrument, also called an oximeter, can also be used at home, but does not allow you to measure carbon dioxide levels.
It is the basic examination for the diagnosis of respiratory failure, because it allows you to know what the concentration of oxygen and carbon dioxide in the arterial blood is (precisely, as the name suggests, analysis of gases in the blood – emo), in addition to the degree of acidity (pH).
It is used to know the number of red blood cells and the concentration of hemoglobin, to determine if there is anemia or, on the contrary, a polycythemia, that is, an excessive amount of red blood cells in the blood.
Allows you to establish some causes that caused respiratory failure , such as:
- pulmonary edema
- pleural effusion
- lung cancer
- pneumothorax, etc.
CT scan or MRI of the chest
Compared to the plate, they are tests that allow a more accurate assessment of the condition of the lungs.
It is an examination which checks respiratory function, measuring and evaluating the volumes and flows of air in the lungs.
In detail, the patient inhales and exhales into a mouthpiece connected to the spirometer; it is a simple and painless exam.
It is typically used to diagnose asthma. In this case it is used to establish which obstructive and restrictive lung diseases could have caused respiratory failure.
Electrocardiogram and echocardiogram
These cardiological tests are used to assess whether cardiac function is affected by respiratory failure.
Pathologies that can cause respiratory failure
There are 5 basic conditions that determine respiratory failure , each caused by different pathologies.
The 5 conditions and related diseases are described below.
1 – Obstruction or restriction of the air flow
This condition can occur in relation to the presence of the following pathologies:
- bronchioectasia: chronic lung disease, characterized by permanent and irreversible dilatations of the wall of the bronchi
- bronchiolitis: acute viral infection affecting the respiratory system of children under one year of age
- chronic obstructive pulmonary disease (COPD): disease of the respiratory system that causes irreversible airway obstruction
- cystic fibrosis: serious genetic disease that mainly affects the respiratory and digestive systems. An altered gene causes too thick mucus production which clogs the bronchi and leads to repeated respiratory infections.
- inhalation of foreign bodies .
2 – Reduction of respiratory flow
This occurs due to inadequate breathing which can be caused by the following factors:
- intoxication from drugs or alcohol
- hypothyroidism : pathology characterized by insufficient action of thyroid hormones
- sleep apnea : sleep disorder in which the breathing stops several times for a rather long time, to the point of disturbing the night’s rest.
3 – Muscle weakness
This condition may be due to some diseases that interfere with the functioning of the muscles that control breathing. Among these:
- amyotrophic lateral sclerosis (ALS)
- some strokes
- muscular dystrophy: neuromuscular disease caused by mutations of different genes, which progressively weaken the muscles to prevent movement
- myasthenia gravis : rare autoimmune disease of the muscle junctions, characterized by weakness and fatigue
- poliomyelitis : infectious disease affecting the central nervous system.
4 – Alteration of lung tissue
This condition because of the following factors:
- acute respiratory distress syndrome : pathology caused by an injury to the capillary wall due to a disease or contusion, so the lungs do not function properly
- reaction to a drug
- pulmonary edema (condition characterized by the excessive presence of fluid in the lungs)
- pulmonary fibrosis: chronic respiratory disease in which scar tissue is formed in the lungs which causes these organs to lose elasticity
- tumor spread.
5 – Alteration of the rib cage
This condition occurs in case of:
- chest injury
- thoracic surgery deformity
- severe obesity
Respiratory failure: how to cure it
The first goal is to increase oxygenation and decrease carbon dioxide in the blood.
However, depending on the case, the therapy can include:
Oxygen therapy is used precisely to correct the decrease in oxygen in the patient’s blood and is the therapy used in case of hypoxemic (or type 1) respiratory failure.
Hence, oxygen delivery can occur in several ways and depends on the patient’s condition. In general, plastic forks are used to be inserted into the nostrils or a mask. It starts with higher doses of oxygen than necessary and then decreases them gradually.
Use of fan supports
With the use of ventilator supports, the goal is to correct acidosis, caused by too high levels of carbon dioxide, and which therefore must be eliminated by the body.
Therefore they are used in case of hypercapnic respiratory insufficiency (or type 2).
In particular, mechanical ventilation is used through an automatic respirator that favors the introduction and the emission of air in the lungs.
Then, the instrument supplies air under pressure with a face mask or a tube inserted in the trachea (this second option is obviously more invasive).
Usually, we proceed first with the least invasive methods and if it does not solve, we move on to the more invasive ones.
In all cases, people with acute respiratory failure are immediately hospitalized and treated in hospital intensive care units .
Finally, after this first phase in which the patient is helped to breathe and the gas levels in the blood are rebalanced, we move on to identifying the cause that caused the respiratory insufficiency to treat it.
For example, if it is a bacterial pneumonia, the cure involves the use of antibiotics. While in case of asthma, the treatment is based on its bronchodilators to reopen the respiratory tract.
Respiratory failure: prevention
There are several factors that increase the risk of developing respiratory failure. Among these, some are modifiable, some are not.
Among the modifiable factors, there are smoking if you suffer from obstructive pulmonary disease (COPD): in these cases you absolutely must stop smoking, perhaps by contacting an anti-smoking center that develops programs and targeted courses.
In the case of obstructive sleep apnea syndrome (OSAS), on the other hand, it is important to lose the extra pounds if you are overweight or obese, because these conditions make breathing even more difficult.
On the other hand, non-modifiable risk factors include genetically transmitted neurodegenerative diseases.
Secondary and tertiary prevention
In addition to primary prevention of the underlying disease (for example COPD), the possibility of slowing down the onset and evolution of respiratory failure also depends on secondary prevention.
This consists in a correct diagnosis of the disease that causes respiratory failure, and in the adequate choice of drug and non-drug therapy (for example long-term home oxygenation and rehabilitation).
Finally, tertiary prevention must also be put in place, dealing with complications quickly.
Respiratory rehabilitation is recommended for acute and chronic respiratory failure, and also in the case of some respiratory diseases, such as pulmonary fibrosis.
It is a personalized path that includes different types of exercises and which aims to teach the patient to breathe correctly, increase ventilation levels and promote tissue oxygenation.
In fact, the ultimate goal is to improve respiratory capacity , especially in the case of chronic respiratory diseases, reduce symptoms and increase resistance to exercise.
Furthermore, especially in the event that the patient has been intubated for a long time in the hospital, once discharged he can feel tired and breathless even in carrying out simple daily activities.
So it is necessary that the patient is helped to recover both muscle tone, weakened by the bedtime, as well as respiratory capacity.
Finally, in the case of chronic respiratory diseases, respiratory rehabilitation can be combined with drug therapy.
With the advice of pharmacists and scientific consultants, communication experts on health and well-being.