TY - CHAP M1 - Book, Section TI - Acute-On-Chronic Respiratory Failure A1 - Douglas, Ivor S. A2 - Schmidt, Gregory A. A2 - Kress, John P. A2 - Douglas, Ivor S. PY - 2023 T2 - Hall, Schmidt and Wood’s Principles of Critical Care, 5th Edition AB - KEY POINTSAcute-on-chronic respiratory failure (ACRF) occurs when often minor, although commonly multiple, insults cause acute deterioration in a patient with chronic respiratory insufficiency and is associated with a significant morbidity and mortality burden.ACRF is usually seen in patients known to have severe chronic obstructive pulmonary disease or interstitial lung disease, including idiopathic pulmonary fibrosis, but occasionally it manifests as cryptic respiratory failure or postoperative ventilator dependence in a patient with no known lung disease.The wide variety of causes of ACRF may be compartmentalized into causes of incremental load, diminished neuromuscular competence, or depressed drive, superimposed on a limited ventilatory reserve.Intrinsic positive end-expiratory pressure (PEEPi) is a central contributor to the excess work of breathing in patients with ACRF.The most important therapeutic interventions are administration of oxygen, bronchodilators, and corticosteroids, heated high-flow nasal cannula oxygen, and noninvasive positive-pressure ventilation (NPPV). NPPV can be used in most patients to avoid intubation and has been shown to improve survival.The decision to intubate a patient with ACRF benefits from clinical judgment and a bedside presence. Hypotension, delirium, and severe alkalemia commonly complicate the immediate peri-intubation course, but they are usually avoidable. However, delaying intubation when NPPV is ineffective may worsen outcomes.Ventilator settings should mimic the patient’s breathing pattern with a modest respiratory rate (eg, 20/min) and small tidal volume (eg, 450 mL); some PEEP (eg, 5 cm H2O) should be added.Prevention of complications such as gastrointestinal hemorrhage, venous thrombosis, and nosocomial infection is a crucial component of the care plan.The key to liberating the patient from the ventilator is to increase neuromuscular competence while reducing respiratory system load. Early mobilization and cautious supplemental enteral nutrition can play a key role.In selected patients, extubation to NPPV despite failed spontaneous breathing trials reduces ventilator and ICU days and further improves survival. SN - PB - McGraw Hill CY - New York, NY Y2 - 2024/11/06 UR - accessanesthesiology.mhmedical.com/content.aspx?aid=1206745098 ER -