From the Guidelines
The treatment of choice for a patient with impending respiratory failure is immediate airway management and ventilatory support, which should be initiated promptly when a patient shows signs of respiratory distress that cannot be managed with supplemental oxygen alone. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of early recognition and treatment of impending respiratory failure to prevent rapid progression to complete respiratory arrest, resulting in hypoxic brain injury or death 1.
Key Considerations
- Prior to intubation, preoxygenation with 100% oxygen via a non-rebreather mask for 3-5 minutes is essential.
- Rapid sequence intubation medications commonly include sedatives like etomidate (0.3 mg/kg IV) or ketamine (1-2 mg/kg IV), along with paralytics such as succinylcholine (1-1.5 mg/kg IV) or rocuronium (1-1.2 mg/kg IV).
- Once intubated, initial ventilator settings typically include a tidal volume of 6-8 mL/kg ideal body weight, respiratory rate of 12-16 breaths/minute, PEEP of 5 cmH2O, and FiO2 of 100% (to be titrated down).
- Concurrent treatment of the underlying cause is crucial, which may include bronchodilators for bronchospasm, antibiotics for infection, diuretics for pulmonary edema, or other specific interventions based on etiology.
Adjunctive Therapies
- Intravenous magnesium sulfate may be considered in patients with life-threatening exacerbations or those whose exacerbations remain severe after 1 hour of intensive conventional treatment 1.
- Non-invasive ventilation (NIV) is preferred over invasive ventilation as the initial mode of ventilation to treat acute respiratory failure in patients hospitalized for acute exacerbations of COPD, with a success rate of 80 to 85% 1.
Oxygen Therapy
- For acutely breathless patients not at risk of hypercapnic respiratory failure who have saturations below 85%, treatment should be started with a reservoir mask at 15 L/min in the first instance, with the goal of maintaining a target saturation of 94-98% 1.
Clinical Judgment
The decision to intubate should not be delayed once it is deemed necessary, as intubation of a severely ill patient can be difficult and result in complications 1. Clinical judgment and continuous monitoring of the patient's condition are essential in guiding the treatment approach.
From the Research
Treatment Options for Impending Respiratory Failure
- The treatment of choice for patients with impending respiratory failure involves the use of supplemental oxygen and noninvasive respiratory supports 2.
- High-flow nasal cannula oxygen (HFNC) is recommended as a first-line noninvasive respiratory support for patients requiring more than 6 L/min of oxygen or with a PaO2/FiO2 ratio ≤ 200 mm Hg and a respiratory rate above 25 breaths/minute or clinical signs of respiratory distress 2.
- Noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP) may not be beneficial as first-line treatments if HFNC is available 2, 3.
- Dual oxygen therapy using a nasal cannula with a flow meter and a BiPAP mask with an additional flow meter may be useful in preventing intubation in patients on BiPAP 4.
Conditions for Noninvasive Ventilation
- Noninvasive ventilation (NIV) is beneficial for conditions such as acute exacerbation of COPD, cardiogenic pulmonary edema, and COVID-19 5.
- The effectiveness of bi-level positive airway pressure (BiPAP) in patients with acute hypercapnic respiratory failure due to etiologies other than COPD is unclear, but it may be similar to CPAP in reducing the rates of endotracheal intubation and mortality 3.
Timing of Intubation
- The optimal timing of intubation in acute hypoxaemic respiratory failure is uncertain and depends on various parameters, including the ratio of arterial oxygen tension to fraction of inspired oxygen 6.
- Clinicians must balance the risks of premature intubation with the potential harms of unassisted breathing, including disease progression and worsening multiorgan failure 6.