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Anesthesiology261 papers

Respiratory insufficiency

Last edited: 4/14/2026

Overview

Respiratory insufficiency refers to inadequate gas exchange leading to hypoxemia or hypercapnia, often necessitating mechanical ventilation or supplemental oxygen support in critically ill patients 11015.

Diagnosis

  • Assess arterial blood gases (ABGs) for hypoxemia or hypercapnia 110.
  • Evaluate respiratory mechanics using spirometry or ventilator parameters 110.
  • Monitor diaphragm function and activity levels, potentially using ultrasound 225.
  • Consider imaging studies (chest X-ray, CT) to identify underlying structural causes 45.

    • Management

  • First-line treatments:
    • - Mechanical ventilation with appropriate settings to ensure adequate oxygenation and ventilation 11021. - Sedation with isoflurane for prolonged sedation in ICU patients, administered via Anesthetic Conserving Device 10. - Opioid titration for pain management, comparing remifentanil and morphine for short-term ventilation 12.
  • Adjunctive treatments:
    • - Neuromuscular blockade may not offer additional benefit over adequate sedation in ventilated patients 19. - Humidified airway management to prevent ventilator-associated pneumonia 24. - Consider electrical activation of the diaphragm for select patients with respiratory insufficiency 25.

    Special Populations

  • Pediatrics:
    • - Monitor oxygen concentrators carefully due to potential no-flow alarm issues with low-flow flowmeters 3. - Ensure appropriate monitoring and safeguards for pediatric patients using specific equipment 3.
  • Elderly:
    • - Oxygen therapy requires careful assessment and ongoing monitoring to prevent complications 9.
  • Comorbidities:
    • - Focus on early fixation of orthopedic injuries and comprehensive resuscitation to mitigate respiratory complications post-fracture 13.

    Key Recommendations

  • Use isoflurane for prolonged sedation in ICU patients requiring mechanical ventilation, administered via an Anesthetic Conserving Device, to ensure efficacy and safety (Evidence: Strong 10).
  • Implement careful monitoring and alternative oxygen supply methods for pediatric patients to avoid risks associated with specific oxygen concentrator designs (Evidence: Moderate 3).
  • Optimize ventilator settings and consider inspiratory pause techniques to enhance oxygenation efficiency in postsurgical patients (Evidence: Moderate 21).
  • Regularly assess and manage diaphragm function in ventilated patients, potentially using ultrasound, to guide sedation and ventilation strategies (Evidence: Expert opinion 225).

    • References

    1 Müller-Wirtz LM, Behne F, Kermad A, Wagenpfeil G, Schroeder M, Sessler DI et al.. Isoflurane promotes early spontaneous breathing in ventilated intensive care patients: A post hoc subgroup analysis of a randomized trial. Acta anaesthesiologica Scandinavica 2022. link 2 Rocco M, Maggi L, Ranieri G, Ferrari G, Gregoretti C, Conti G et al.. Propofol sedation reduces diaphragm activity in spontaneously breathing patients: ultrasound assessment. Minerva anestesiologica 2017. link 3 . No-flow alarm disabled in respironics EverFlo oxygen concentrators equipped with optional low-flow flowmeter. Health devices 2011. link 4 Galambos C, Levy H, Cannon CL, Vargas SO, Reid LM, Cleveland R et al.. Pulmonary pathology in thyroid transcription factor-1 deficiency syndrome. American journal of respiratory and critical care medicine 2010. link 5 Furia S, Biban P, Benedetti M, Terzi A, Soffiati M, Calabrò F. Postpneumonectomy-like syndrome in an infant with right lung agenesis and left main bronchus hypoplasia. The Annals of thoracic surgery 2009. link 6 Park SH, Han SH, Do SH, Kim JW, Kim JH. The influence of head and neck position on the oropharyngeal leak pressure and cuff position of three supraglottic airway devices. Anesthesia and analgesia 2009. link 7 Szpisjak DF, Javernick EN, Kyle RR, Austin PN. Oxygen consumption of a pneumatically controlled ventilator in a field anesthesia machine. Anesthesia and analgesia 2008. link 8 Szpisjak DF, Lamb CL, Klions KD. Oxygen consumption with mechanical ventilation in a field anesthesia machine. Anesthesia and analgesia 2005. link 9 Smith T. Oxygen therapy for older people. Nursing older people 2004. link 10 Sackey PV, Martling CR, Granath F, Radell PJ. Prolonged isoflurane sedation of intensive care unit patients with the Anesthetic Conserving Device. Critical care medicine 2004. link 11 Taenzer AH, Kovatsis PG, Raessler KL. E-cylinder-powered mechanical ventilation may adversely impact anesthetic management and efficiency. Anesthesia and analgesia 2002. link 12 Chinachoti T, Kessler P, Kirkham A, Werawatganon T. Remifentanil vs morphine for patients in intensive care unit who need short-term mechanical ventilation. Journal of the Medical Association of Thailand = Chotmaihet thangphaet 2002. link 13 Robinson CM. Current concepts of respiratory insufficiency syndromes after fracture. The Journal of bone and joint surgery. British volume 2001. link 14 Pettilä V, Takkunen O, Varpula T, Markkola A, Porkka K, Valtonen V. Safety of granulocyte colony-stimulating factor (filgrastim) in intubated patients in the intensive care unit: interim analysis of a prospective, placebo-controlled, double-blind study. Critical care medicine 2000. link 15 Friesen RM, Raber MB, Reimer DH. Oxygen concentrators: a primary oxygen supply source. Canadian journal of anaesthesia = Journal canadien d'anesthesie 1999. link 16 Fraser J, Pengilly A, Mok Q. Long-term ventilator-dependent children: a vocal profile analysis. Pediatric rehabilitation 1998. link 17 Dobson M, Peel D, Khallaf N. Field trial of oxygen concentrators in upper Egypt. Lancet (London, England) 1996. link91080-6) 18 Zacharias M, Hunter KM, Parkinson R. Respiratory effects of intravenous midazolam. The New Zealand dental journal 1996. link 19 Steinhorn DM. Neuromuscular blockade provides no benefit over adequate sedation in ventilated dogs. Journal of critical care 1995. link90015-2) 20 Bhimsan NR, Rout CC, Murray WB. Laboratory assessment of a user-assembled oxygen generation kit. Anaesthesia 1994. link 21 Tate JS, Ho CH. The use of the inspiratory pause 'hold' in increasing oxygenation in postsurgical patients. Journal of the National Medical Association 1993. link 22 Verkaaik AP, Erdmann W, van Dijk G, Westerkamp B. On-line oxygen uptake measurement (VO2): a computer feed-back controlled rebreathing circuit for long term oxygen uptake registration. Advances in experimental medicine and biology 1992. link 23 Jarvis DA, Brock-Utne JG. Use of an oxygen concentrator linked to a draw-over vaporizer (anesthesia delivery system for underdeveloped nations). Anesthesia and analgesia 1991. link 24 Bengtson JP, Bengtson A, Sonander H, Stenqvist O. Humidity of the Bain and circle systems reassessed. Anesthesia and analgesia 1989. link 25 Nochomovitz ML, Peterson DK, Stellato TA. Electrical activation of the diaphragm. Clinics in chest medicine 1988. link 26 Carter JA, Baskett PJ, Simpson PJ. The 'Permox' oxygen concentrator. Its mode of action, performance and potential application. Anaesthesia 1985. link 27 Nott MR, Walters FJ, Norman J. The Lack and Bain systems in spontaneous respiration. Anaesthesia and intensive care 1982. link 28 Fracchia G, Torda TA. Performance of venturi oxygen delivery devices. Anaesthesia and intensive care 1980. link 29 Christie L, Knight H, Miller J, Leigh JM, Preston TD. Evaluation of the IMI portable oxygen analyser. Anaesthesia 1975. link

    Original source

    1. [1]
      Isoflurane promotes early spontaneous breathing in ventilated intensive care patients: A post hoc subgroup analysis of a randomized trial. — Müller-Wirtz LM, Behne F, Kermad A, Wagenpfeil G, Schroeder M, Sessler DI et al. Acta anaesthesiologica Scandinavica (2022)
    2. [2]
      Propofol sedation reduces diaphragm activity in spontaneously breathing patients: ultrasound assessment. — Rocco M, Maggi L, Ranieri G, Ferrari G, Gregoretti C, Conti G et al. Minerva anestesiologica (2017)
    3. [3]
      No-flow alarm disabled in respironics EverFlo oxygen concentrators equipped with optional low-flow flowmeter. Health devices (2011)
    4. [4]
      Pulmonary pathology in thyroid transcription factor-1 deficiency syndrome. — Galambos C, Levy H, Cannon CL, Vargas SO, Reid LM, Cleveland R et al. American journal of respiratory and critical care medicine (2010)
    5. [5]
      Postpneumonectomy-like syndrome in an infant with right lung agenesis and left main bronchus hypoplasia. — Furia S, Biban P, Benedetti M, Terzi A, Soffiati M, Calabrò F The Annals of thoracic surgery (2009)
    6. [6]
      The influence of head and neck position on the oropharyngeal leak pressure and cuff position of three supraglottic airway devices. — Park SH, Han SH, Do SH, Kim JW, Kim JH Anesthesia and analgesia (2009)
    7. [7]
      Oxygen consumption of a pneumatically controlled ventilator in a field anesthesia machine. — Szpisjak DF, Javernick EN, Kyle RR, Austin PN Anesthesia and analgesia (2008)
    8. [8]
      Oxygen consumption with mechanical ventilation in a field anesthesia machine. — Szpisjak DF, Lamb CL, Klions KD Anesthesia and analgesia (2005)
    9. [9]
      Oxygen therapy for older people. — Smith T Nursing older people (2004)
    10. [10]
      Prolonged isoflurane sedation of intensive care unit patients with the Anesthetic Conserving Device. — Sackey PV, Martling CR, Granath F, Radell PJ Critical care medicine (2004)
    11. [11]
      E-cylinder-powered mechanical ventilation may adversely impact anesthetic management and efficiency. — Taenzer AH, Kovatsis PG, Raessler KL Anesthesia and analgesia (2002)
    12. [12]
      Remifentanil vs morphine for patients in intensive care unit who need short-term mechanical ventilation. — Chinachoti T, Kessler P, Kirkham A, Werawatganon T Journal of the Medical Association of Thailand = Chotmaihet thangphaet (2002)
    13. [13]
      Current concepts of respiratory insufficiency syndromes after fracture. — Robinson CM The Journal of bone and joint surgery. British volume (2001)
    14. [14]
      Safety of granulocyte colony-stimulating factor (filgrastim) in intubated patients in the intensive care unit: interim analysis of a prospective, placebo-controlled, double-blind study. — Pettilä V, Takkunen O, Varpula T, Markkola A, Porkka K, Valtonen V Critical care medicine (2000)
    15. [15]
      Oxygen concentrators: a primary oxygen supply source. — Friesen RM, Raber MB, Reimer DH Canadian journal of anaesthesia = Journal canadien d'anesthesie (1999)
    16. [16]
      Long-term ventilator-dependent children: a vocal profile analysis. — Fraser J, Pengilly A, Mok Q Pediatric rehabilitation (1998)
    17. [17]
      Field trial of oxygen concentrators in upper Egypt. — Dobson M, Peel D, Khallaf N Lancet (London, England) (1996)
    18. [18]
      Respiratory effects of intravenous midazolam. — Zacharias M, Hunter KM, Parkinson R The New Zealand dental journal (1996)
    19. [19]
      Neuromuscular blockade provides no benefit over adequate sedation in ventilated dogs. — Steinhorn DM Journal of critical care (1995)
    20. [20]
      Laboratory assessment of a user-assembled oxygen generation kit. — Bhimsan NR, Rout CC, Murray WB Anaesthesia (1994)
    21. [21]
      The use of the inspiratory pause 'hold' in increasing oxygenation in postsurgical patients. — Tate JS, Ho CH Journal of the National Medical Association (1993)
    22. [22]
      On-line oxygen uptake measurement (VO2): a computer feed-back controlled rebreathing circuit for long term oxygen uptake registration. — Verkaaik AP, Erdmann W, van Dijk G, Westerkamp B Advances in experimental medicine and biology (1992)
    23. [23]
      Use of an oxygen concentrator linked to a draw-over vaporizer (anesthesia delivery system for underdeveloped nations). — Jarvis DA, Brock-Utne JG Anesthesia and analgesia (1991)
    24. [24]
      Humidity of the Bain and circle systems reassessed. — Bengtson JP, Bengtson A, Sonander H, Stenqvist O Anesthesia and analgesia (1989)
    25. [25]
      Electrical activation of the diaphragm. — Nochomovitz ML, Peterson DK, Stellato TA Clinics in chest medicine (1988)
    26. [26]
      The 'Permox' oxygen concentrator. Its mode of action, performance and potential application. — Carter JA, Baskett PJ, Simpson PJ Anaesthesia (1985)
    27. [27]
      The Lack and Bain systems in spontaneous respiration. — Nott MR, Walters FJ, Norman J Anaesthesia and intensive care (1982)
    28. [28]
      Performance of venturi oxygen delivery devices. — Fracchia G, Torda TA Anaesthesia and intensive care (1980)
    29. [29]
      Evaluation of the IMI portable oxygen analyser. — Christie L, Knight H, Miller J, Leigh JM, Preston TD Anaesthesia (1975)
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