Acute respiratory failure

Emergency Medicine

Clinicals - History

Fact Explanation
Sepsis Sepsis is the commonest risk factor for the development of acute lung injury. Sepsis
Sepsis is the commonest risk factor for the development of acute lung injury.
Symptoms of respiratory tract infection Fever, chest pain and productive cough are the usual complains. Symptoms of respiratory tract infection
Fever, chest pain and productive cough are the usual complains.
Chronic lung disease Patients with chronic lung disease are at risk of developing acute respiratory failure. Chronic lung disease
Patients with chronic lung disease are at risk of developing acute respiratory failure.
Aspiration Patients with chronic alcohol abuse or near drowning are at risk due to aspiration. Aspiration
Patients with chronic alcohol abuse or near drowning are at risk due to aspiration.
Burns Patients with facial burns are especially at risk. Acute respiratory failure occurs due to the inhalational injury. Burns
Patients with facial burns are especially at risk. Acute respiratory failure occurs due to the inhalational injury.
History of inhalational drug abuse People who are inhaling illicit drugs are at risk of acute respiratory failure. History of inhalational drug abuse
People who are inhaling illicit drugs are at risk of acute respiratory failure.
History of blood transfusion Transfusion associated respiratory distress syndrome occurs within 6 hours of transfusion. History of blood transfusion
Transfusion associated respiratory distress syndrome occurs within 6 hours of transfusion.
Shortness of breath This is seen in almost every patient. Shortness of breath
This is seen in almost every patient.

Clinicals - Examination

Fact Explanation
Fever Patients with sepsis and pneumonia are febrile. Fever
Patients with sepsis and pneumonia are febrile.
Tachypnea Tachypnea is a common examination finding. Tachypnea
Tachypnea is a common examination finding.
Cyanosis Bluish discoloration of the skin and mucus membranes occur when the deoxygenated hemoglobin in the capillaries or tissues is equal or more than 5 g/dL. Cyanosis
Bluish discoloration of the skin and mucus membranes occur when the deoxygenated hemoglobin in the capillaries or tissues is equal or more than 5 g/dL.
Asterixis Asterixis can occur with carbon dioxide retention. Asterixis
Asterixis can occur with carbon dioxide retention.
Signs of right ventricular failure Some patients develop right ventricular failure secondary to pulmonary hypertension. Signs of right ventricular failure
Some patients develop right ventricular failure secondary to pulmonary hypertension.

Investigations - Diagnosis

Fact Explanation
Pulse oxymetry Arterial hypoxemia is characteristically refractory to oxygen treatment. Pulse oxymetry
Arterial hypoxemia is characteristically refractory to oxygen treatment.
Lung function test If lung function does not improve with the treatment within the 1st week, it indicates poor prognosis. Lung function test
If lung function does not improve with the treatment within the 1st week, it indicates poor prognosis.
Chest X-ray Pulmonary edema and pleural effusions are present. Coexisting pneumothorax is also evident in chest X-ray. Chest X-ray
Pulmonary edema and pleural effusions are present. Coexisting pneumothorax is also evident in chest X-ray.
CT scan of the chest Chest CT will demonstrate, fluid filled alveoli, consolidation, and atelectasis predominantly in the dependent parts of the lungs. CT scan of the chest
Chest CT will demonstrate, fluid filled alveoli, consolidation, and atelectasis predominantly in the dependent parts of the lungs.
Bronchoalveolar-lavage Lavage has high counts of neutrophils, macrophages, red blood cells and protein-rich edema fluid. Bronchoalveolar-lavage
Lavage has high counts of neutrophils, macrophages, red blood cells and protein-rich edema fluid.
Arterial blood gas analysis Hypoxemia and respiratory acidosis are common. Arterial blood gas analysis
Hypoxemia and respiratory acidosis are common.
Full blood count Aids in diagnosing sepsis. White blood cell count of more than 12,000 per mm3 or less than 4,000 mm3 or immature white cell count of more than 10% are supportive of sepsis. Full blood count
Aids in diagnosing sepsis. White blood cell count of more than 12,000 per mm3 or less than 4,000 mm3 or immature white cell count of more than 10% are supportive of sepsis.
C- reactive protein Elevated in sepsis. C- reactive protein
Elevated in sepsis.

Investigations - Management

Fact Explanation
Lung function tests Most patients recover completely with normal lung capacities. Lung function tests
Most patients recover completely with normal lung capacities.
Serum electrolytes Renal function should be monitored as a guide to fluid administration. Fluid administration should be sufficient enough to maintain adequate renal perfusion. Serum electrolytes
Renal function should be monitored as a guide to fluid administration. Fluid administration should be sufficient enough to maintain adequate renal perfusion.
Serum creatitine Serum creatinine will reflect the adequacy of fluid replacement. Serum creatitine
Serum creatinine will reflect the adequacy of fluid replacement.
Arterial blood gas analysis Progression of the disease and the success of treatment is monitored with arterial blood gas analysis. Arterial blood gas analysis
Progression of the disease and the success of treatment is monitored with arterial blood gas analysis.
Chest X-ray Although some patients recover completely from the acute attack, some develop pulmonary hypertension, right heart failure and fibrosing alveolitis. Once the patient develop fibrosing alveolitis chest Xray will show linear opacities. Chest X-ray
Although some patients recover completely from the acute attack, some develop pulmonary hypertension, right heart failure and fibrosing alveolitis. Once the patient develop fibrosing alveolitis chest Xray will show linear opacities.
CT scan of the chest Diffuse interstitial opacities and bullae are seen in fibrosing alveolitis. CT scan of the chest
Diffuse interstitial opacities and bullae are seen in fibrosing alveolitis.

Management - Supportive

Fact Explanation
Treat coexisting infection Pneumonia and sepsis are commonly seen and proper antibiotic treatment should be prescribed. Treat coexisting infection
Pneumonia and sepsis are commonly seen and proper antibiotic treatment should be prescribed.
Nutrition Enteral feeding is considered a better approach when compared to parenteral feeding. A nasogastric tube can be used in patients with significant risk of aspiration. Nutrition
Enteral feeding is considered a better approach when compared to parenteral feeding. A nasogastric tube can be used in patients with significant risk of aspiration.
Adherence to standards of patient care Patients should be handled according to the standard practices to minimize the risk of nosocomial infections. Adherence to standards of patient care
Patients should be handled according to the standard practices to minimize the risk of nosocomial infections.
Fluid management Fluid should be administered in order to maintain sufficient systemic circulation, renal perfusion, metabolic homeostasis and to avoid worsening of pulmonary edema. If the volume resuscitation is not enough to maintain tissue perfusion avoiding the risk of volume overload, vasopressors can be administered. Fluid management
Fluid should be administered in order to maintain sufficient systemic circulation, renal perfusion, metabolic homeostasis and to avoid worsening of pulmonary edema. If the volume resuscitation is not enough to maintain tissue perfusion avoiding the risk of volume overload, vasopressors can be administered.

Management - Specific

Fact Explanation
Mechanical ventilation Mechanical ventilation is necessary in maintaining tissue oxygenation till the lungs recover from the acute distress. Mechanical ventilation
Mechanical ventilation is necessary in maintaining tissue oxygenation till the lungs recover from the acute distress.
Surfactant-replacement therapy This is beneficial in infants with respiratory distress syndrome. Adults with acute lung injury may also benefit from surfactant therapy. Surfactant-replacement therapy
This is beneficial in infants with respiratory distress syndrome. Adults with acute lung injury may also benefit from surfactant therapy.
Nitric oxide This is a potent vasodilator. When administered by inhalation localized vasodilatation in the pulmonary circulation can be achieved. But this is not very effective mode of treatment and used only if hypoxia is refractory to other treatment modalities. Nitric oxide
This is a potent vasodilator. When administered by inhalation localized vasodilatation in the pulmonary circulation can be achieved. But this is not very effective mode of treatment and used only if hypoxia is refractory to other treatment modalities.
Glucocorticoids Glucocorticoids has an anti-inflammatory action, which can be used to treat severe and refractory disease. Glucocorticoids
Glucocorticoids has an anti-inflammatory action, which can be used to treat severe and refractory disease.

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