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]


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

Non-invasive ventilatory support (NIV)

Mask selection

  • 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

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

Monitoring NIV

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

Advantages of NIV

Extracorporeal membrane oxygenation (ECMO)

  • 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., shows ECMO circuit by Jürgen Schaub. de:User:Mr.Flintstone - transfrered from de:Datei:Ecmo schema.jpgOwn work, CC BY-SA 2.0 de,

ECMO procedure

  • 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.


  • 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

Contraindications to ECMO

  • 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

  • Patients with respiratory failure may be weaned off ECMO, when the following improvements are noted:[20][21]
  • 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:


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