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Immediate Priorities
Stabilization priorities
Airway patency and protection risk
GCS < 8
Copious secretions
Refractory hypoxemia
Severe hypercapnia with acidemia
Breathing status
SpO2 target strategy by risk group
Most patients 92% to 96%
COPD or chronic hypercapnia risk 88% to 92%
Carbon monoxide poisoning target 100% after high flow oxygen
Work of breathing severity
Accessory muscle use
Paradoxical breathing
Inability to speak full sentences
Circulation threats
Shock signs
SBP < 90 mmHg or MAP < 65 mmHg
Altered mental status
Mottling
Immediate monitoring
Continuous pulse oximetry
Poor waveform as unreliable reading trigger
Low perfusion state as unreliable reading trigger
Cardiac monitoring
Dysrhythmia trigger for airway escalation
Noninvasive blood pressure cycling
Q3 to Q5 minute frequency in unstable patient
End tidal CO2 if ventilatory support
Rising ETCO2 as hypoventilation marker
Escalation triggers
Resuscitation bay activation
SpO2 < 90% despite nonrebreather
RR > 35 breaths per minute with fatigue
pH < 7.25 with rising PaCO2
Immediate airway team activation
Apnea
Severe agitation or obtundation preventing mask therapy
Hemodynamic collapse
Oxygenation and Ventilation Strategy
Stepwise support selection
Standard oxygen
Nasal cannula 1 to 6 L/min
Simple mask 6 to 10 L/min
Nonrebreather 10 to 15 L/min
High flow nasal cannula
Hypoxemic respiratory failure with intact airway reflexes
Initial flow 40 to 60 L/min
FiO2 titration to SpO2 target
Noninvasive ventilation
COPD exacerbation with hypercapnic acidemia
Cardiogenic pulmonary edema
Obesity hypoventilation with acute on chronic hypercapnia
Endotracheal intubation and invasive ventilation
Failure of HFNC or NIV
Inability to protect airway
Severe ARDS with refractory hypoxemia
Key Concepts
Definitions and coding
Acute respiratory failure with hypoxemia
ICD-10 J96.01
SNOMED CT 409622000
Acute respiratory failure with hypercapnia
ICD-10 J96.02
SNOMED CT 409623005
Acute respiratory failure with hypoxia and hypercapnia
ICD-10 J96.00 with supporting gas data
Physiologic patterns
Hypoxemic failure
VQ mismatch
Shunt physiology
Diffusion limitation
Hypercapnic failure
Alveolar hypoventilation
Increased dead space ventilation
Impending fatigue pattern
Rising PaCO2 with falling RR
Diminishing tidal volumes
PITFALLS
Common errors
Over oxygenation in chronic CO2 retainers with loss of hypoxic drive risk
Target SpO2 88% to 92% when COPD or chronic hypercapnia risk
Delayed intubation after clear NIV failure
Worsening mental status
Persistent acidemia after 1 to 2 hours NIV
Unrecognized pneumothorax during positive pressure support
Sudden hypotension
Unilateral breath sound decrease
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.