Acute respiratory failure

Acute respiratory failure is a common reason for admission to the intensive care ward and it is frequently accompanied by haemodynamic instability. Obligatory assessments in every patient should include left ventricular function, left atrial and left ventricular filling pressures in addition to an assessment of right ventricular function and the pulmonary circulation. A systematic echo protocol is warranted to judiciously decide on treatment strategy, including optimization of the patient’s preload, contractility, heart rate, and afterload. This allows for a more effective management of the respiratory disequilibrium, which can continue to be monitored by ultrasound examination. Monitoring of lung parenchyma and pleural space adds to the echo derived information and assist the physician in deciding on an optimal ventilation strategy, need for bronchoscopy, pleural drainage, and patient positioning including proning. The appropriateness of prescribed therapy for the acute respiratory failure can then be monitored by echocardiography and lung ultrasonography to optimize pulmonary gas exchange without haemodynamic deterioration and conversely improve the patient’s haemodynamic status without adding an unnecessary burden onto the respiratory system. After respiratory failure responds to treatment, echocardiography can then assist with the weaning and subsequent withdrawal of mechanical ventilatory support. Where respiratory failure does not respond to conventional measures, a rapid assessment with echocardiography and chest ultrasound helps to decide whether to proceed to extracorporeal life support and, if adopted, its optimal configuration.