Treatment of Unspecified Respiratory Failure When Initial Oxygenation Strategy Fails

In acute respiratory failure (ARF), when an initial oxygenation strategy — including high-flow nasal cannula and targeted arterial oxygen maintenance — does not sustain the required physiological range, escalation of respiratory support becomes necessary. This protocol addresses that next clinical step.

Previous Line: Failure Condition

The initial management line employed a traditional oxygenation strategy, including high-flow nasal cannula (HFNC), aiming to maintain PaO₂ between 70 and 110 mmHg and avoid both excess hypoxemia and hyperoxemia. Pharmacotherapy was directed at the underlying disease causing hypoxemia.

When that PaO₂ target range is not achieved or maintained, this escalation protocol defines the structured next course of action.

Next-Line Approach — Partial Overview

This protocol escalates to positive pressure ventilation — either noninvasive or invasive — selected according to the clinical context and severity of respiratory failure. Ventilatory management incorporates specific strategies around tidal volume and airway pressures.

Full selection criteria, ventilator parameters, weaning protocolisation, and post-extubation management are available in the complete protocol below.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1186/s40560-023-00658-3

In ARF, the choice between the use of nasal cannula, HFNC, NPPV, or invasive positive pressure ventilation (IPPV) is based on the presence of underlying disease and severity of hypoxemia.
Low tidal volume ventilation is weakly recommended for ARF in SSCG2021 and SRLF-GL2019, and strongly recommended for ARDS in JRS/JSICM/JSRCM-GL2021, SSCG2021, SRLF-GL2019 and FICM/ICS-GL2018.
Limiting plateau pressure and high-level PEEP is recommended weakly to strongly in all guidelines, although the most recent Cochrane analysis did not find a survival benefit for high-level PEEP.

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