The Management of Respiratory Failure in a Country Hospital

RESPIRATORY FAILURE, which may be defined as a "condition in which the amount of oxygen and carbon dioxide in the blood stream is altered by an abnormality of the respiratory system" (Arnott, 1960), may arise from many causes among them diseases of, injury to, or intoxications of the central or peripheral nervous systems, thoracic skeleton, diaphragm and other respiratory muscles, and lung parenchyma. Many of these lesions are reversible, and if the patient is adequately resuscitated during the period of temporary respiratory inadequacy, a full recovery may be expected. The use of artificial respiration to maintain life in animals unable to breathe was described by Hooke (1667), and in curarized man by Waterton (1879). These descriptions were primarily of experimental work. The application of prolonged artificial respiration in clinical medicine was described by Drinker and McKhann (1929) and Eve (1932). Since then the development of efficient compact lung ventilators, and the widespread use of curariform drugs in anaesthesia following their use by Griffith and Johnston (1943) has increased the use of artificial respiration in clinical medicine. It has been suggested that patients requiring artificial or intermittent positive ventilation (I.P.V.) should be treated in the intensive care or respiratory failure unit of a large hospital (Windsor and Dwyer, 1961). From the point of view of the economy of use of medical staff (Dundee and Gray, 1963) and availability of laboratory facilities this system has much to commend it. It has, however, two disadvantages: (1) Patients with crushing chest wall trauma, which commonly causes reversible respiratory failure, frequently have multiple injuries. They may have lost much blood, or be shocked and do not tolerate movement well. Furthermore, the presence of internal haemorrhage, arising from a ruptured spleen, liver or kidney can be most easily diagnosed by close observation of changes in pulse rate and blood pressure. A rising pulse rate or fall in blood pressure will often be regarded as an indication for laparotomy. Movement of an injured patient may easily provoke cardio-vascular changes simulating those of internal haemorrhage. Unnecessary movement may thus render the diagnosis of associated internal injuries more difficult and result in delay in their treatment.