Respiratory failure

Classification according to ICD-10
J96	Respiratory failure, not elsewhere classified
J96.0	Acute respiratory failure, not elsewhere classified
J96.1	Chronic respiratory failure, not elsewhere classified
J96.9	Respiratory failure, unspecified
J98.4	Other changes in the lungs
J95.1	Acute pulmonary insufficiency after chest surgery
J95.2	Acute pulmonary insufficiency after non-thoracic surgery
J95.3	Chronic pulmonary insufficiency after surgery
ICD-10 online (WHO version 2019)

As respiratory failure or respiratory failure or respiratory insufficiency disorders are referred to, to reduced the oxygen requirement is less comprehensive pulmonary oxygen uptake to hypoxemia and corresponding changes of blood gas values lead. The main causes are gas exchange disorders due to lung diseases ( pulmonary insufficiency ) or disorders of the breathing pump including the respiratory center ( ventilatory insufficiency ).

With reference to the various causes, this restricted ventilation of the lungs is divided into obstructive and restrictive ventilation disorders.

The first fundamental findings on insufficiency of external respiration come from the internists Max Anton Wintrich (1854) and Ludolph Brauer . Brauer defines (global) respiratory failure as an insufficiency in which breathing is no longer sufficient to supply enough oxygen to the blood and to free it from carbonic acid.

Classification

A distinction is made between disorders of oxygenation ( hypoxemic or hypoxic respiratory insufficiency , formerly called respiratory partial insufficiency ), in which the oxygen partial pressure in the arterial blood falls, but the carbon dioxide partial pressure can still be compensated, and disorders of ventilation in which both parameters are pathologically changed ( hypercapnic respiratory Insufficiency , formerly called global respiratory failure ). Respiratory failure is defined as a serious disruption of pulmonary gas exchange. If oxygen uptake is affected, there is hypoxemic insufficiency. In the blood gas analysis , a reduced oxygen partial pressure (P _a O ₂ ) is shown with a normal to reduced carbon dioxide partial pressure (P _a CO ₂ ). The causes are pathological changes in the alveolar surface, for example through a reduction in surface area, through water retention in the pulmonary interstitium ( pulmonary edema ) or through inflammatory infiltration , for example in pneumonia. Such a hypoxemic disorder, which was previously also known as pneumonosis , associated with diffusion disorders, is primarily accessible to oxygen therapy. In hypercapnic insufficiency, the elimination of the carbon dioxide (CO ₂ ) formed in the metabolism is altered. Mostly there is a disturbance of the breathing mechanics (' breathing pump'). As a result, ( atmospheric ) oxygen cannot be inhaled enough and the carbon dioxide can be exhaled. An increase in carbon dioxide in the blood serum (respiratory acidosis) is the result. The focus of the treatment is the mechanical support of the overloaded ' breathing pump' (in particular the diaphragm ) by means of appropriate ventilation technology, for example by means of non-invasive ventilation or even invasive ventilation .

Depending on the time course, insufficiencies are divided into acute and chronic forms.

Chronic respiratory failure (CRI)

The chronic respiratory failure is by far the more common form. As a result, difficulties in breathing , coughing , poor performance and, under certain circumstances, cyanosis occur individually . Clinical signs such as drumstick fingers and watch glass nails can only be observed over a longer period of time. The causes of chronic respiratory insufficiency are chronic bronchitis , pneumoconiosis , emphysema or tumors . Respiratory insufficiency can also occur after operations involving the removal of a lung lobe ( lobectomy ) or a lung (pneumectomy).

Acute respiratory failure (ARI)

An acute respiratory insufficiency ( acute respiratory failure ) exists, in particular, when the ratio of arterial oxygen partial pressure and offered or required concentration of oxygen in the inhaled air below the age norm is (sequence can, such as atelectasis in a pneumonia and functional shunt (vascular short circuit with circulation without adequate ventilation of served by pulmonary vessels areas) in the lungs, hypoxic respiratory failure be) and the carbon dioxide in the arteries over the standard value (or its partial pressure rises above 45 mmHg) ( hypercapnic respiratory failure , hypercapnic respiratory failure or hypercapnic respiratory failure ).

The cardinal symptoms of the acute primary disease, acute decompensation (or exacerbation) of a chronic disease (such as chronic pulmonary impairment in COPD ), complications of intensive care measures ( e.g. barotrauma ), consequences of acute trauma, concomitant diseases of other diseases ( sepsis , multiple organ failure , also ARDS ) or as postoperative respiratory insufficiency that can be triggered by various causes after an operation or anesthesia are the same as in the chronic form. The sudden onset, however, often results in a pronounced affective reaction with fear and a feeling of suffocation. According to Scheidegger, an early and sure sign of acute respiratory failure is increased pulmonary artery pressure .

The acute causes are severe pneumonia , aspiration (inhalation) of foreign bodies or water (drowning) and injuries to the lungs ( pneumothorax ). The acute asthma attack is an example of paroxysmal (attack-like) respiratory dysfunction. Serious systemic diseases can lead to the appearance of shock lung ( ARDS ), and here too, critical respiratory insufficiency quickly occurs.

In cardiac decompensations with the development of pulmonary edema ( heart failure , myocardial infarction ) or pulmonary vascular obstruction ( pulmonary embolism ), shortness of breath is a typical symptom the resulting stress on the right ventricle) as a result of respiratory insufficiency.

In addition to the mentioned disorders of the lung function ( lung insufficiency ) itself, an impairment of the respiratory center in the brain stem , for example through poisoning with opiates , or other central nervous causes (e.g. traumatic brain injury, status epilepticus) can lead to acute respiratory insufficiency (respiratory depression) . The leading symptom in this case is no shortness of breath; instead, impaired consciousness quickly occurs and, in the worst case, death.

therapy

In therapy , priority is given to improving the oxygen supply to the organism and maintaining breathing, as well as treating the underlying disease. Symptomatic improvement can be achieved by indicated breathing aids, particularly in the case of respiratory muscle failure or "pump failure" (centrally or peripherally caused "pump weakness" with increased carbon dioxide partial pressure in the arterial blood) or lung parenchymal failure (disruption of the alveolocapillary membrane with reduced oxygen partial pressure in the arterial blood) (with decreased peripheral oxygen saturation below 95%) the continuous administration of oxygen at around 2–5 liters / minute via a nasogastric tube should also be included. In some cases (ventilation insufficiency with hypoventilation, earlier global respiratory insufficiency, e.g. in the case of respiratory failure due to exhaustion of the respiratory muscles , secondary respiratory exhaustion) with increased pCO ₂ values ​​(hypercapnia), the supply of oxygen and exhalation of the carbon dioxide is only possible with simultaneous mechanical breathing aid ( artificial ventilation , possibly also non-invasive ) is possible, especially if there are pathological breathing patterns or an increasing clouding of consciousness, whereby a reduction in the work of breathing and (with the use of PEEP ) the reopening of atelectasis can be achieved through non-invasive ventilation .

literature

• Non-invasive ventilation as a therapy for acute respiratory failure . In: AWMF online. 2015.
• Invasive ventilation and the use of extracorporeal procedures in acute respiratory insufficiency. In: AWMF online. 2017 ( website (guideline) ).
• Jörg Braun: Lungs. In: Jörg Braun, Roland Preuss (Ed.): Clinic Guide Intensive Care Medicine. 9th edition. Elsevier, Munich 2016, ISBN 978-3-437-23763-8 , pp. 285-310, in particular pp. 286-288 ( acute respiratory failure ).
• Hilmar Burchardi: Etiology and pathophysiology of acute respiratory failure (ARI). In: J. Kilian, H. Benzer, FW Ahnefeld (ed.): Basic principles of ventilation. Springer, Berlin a. a. 1991, ISBN 3-540-53078-9 , 2nd, unchanged edition, ibid. 1994, ISBN 3-540-57904-4 , pp. 47-91.
• Thomas Pasch , S. Krayer, HR Brunner: Definition and measurands of acute respiratory insufficiency: ventilation, gas exchange, breathing mechanics. In: J. Kilian, H. Benzer, FW Ahnefeld (ed.): Basic principles of ventilation. Springer, Berlin a. a. 1991, ISBN 3-540-53078-9 , 2nd, unchanged edition, ibid 1994, ISBN 3-540-57904-4 , pp. 93-108.
• D. Scheidegger: Definition and measurands of acute respiratory insufficiency: pulmonary circulation, cardiac function. In: J. Kilian, H. Benzer, FW Ahnefeld (ed.): Basic principles of ventilation. Springer, Berlin a. a. 1991, ISBN 3-540-53078-9 , 2nd, unchanged edition, ibid. 1994, ISBN 3-540-57904-4 , pp. 109-120.

Individual evidence

1. ↑ Gerd Herold and colleagues: Internal Medicine 2020. Self-published, Cologne 2020, ISBN 978-3-9814660-9-6 , p. 336.
2. ↑ Joachim Frey : Diseases of the respiratory organs. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 599-746, here: pp. 605-619 ( General Pathology of Respiratory Insufficiency ).
3. ↑ Joachim Frey: Diseases of the respiratory organs. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 599-746, here: p. 614.
4. ↑ Joachim Frey : Diseases of the respiratory organs. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 599-746, here: p. 614.
5. ^ Rolf Dembinski: Non-invasive forms of ventilation. In: Anesthesia & Intensive Care Medicine. Volume 60, June 2019, pp. 308-315, here: pp. 309 and 312-314.
6. ↑ Joachim Frey : Diseases of the respiratory organs. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 599-746, here: pp. 614-619 ( General treatment of respiratory insufficiency ).
7. ^ H. Benzer: Therapy of respiratory failure. In: J. Kilian, H. Benzer, FW Ahnefeld (ed.): Basic principles of ventilation. Springer, Berlin a. a. 1991, ISBN 3-540-53078-9 , 2nd, unchanged edition, ibid. 1994, ISBN 3-540-57904-4 , pp. 215-278.
8. ↑ Manio of Maravic: Neurological emergencies. In: Jörg Braun, Roland Preuss (Ed.): Clinic Guide Intensive Care Medicine. 9th edition. Elsevier, Munich 2016, ISBN 978-3-437-23763-8 , pp. 311-356, here: pp. 319 f. ( Respiratory failure ).
9. ↑ Non-invasive ventilation as a therapy for acute respiratory failure. Edited by the German Society for Pneumology and Respiratory Medicine. In: AWMF online. 2015.
10. ^ Rolf Dembinski: Non-invasive forms of ventilation. In: Anesthesia & Intensive Care Medicine. Volume 60, June 2019, pp. 308-315.

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