Key messages

• Acute respiratory failure is the final common pathway of many pulmonary and extrapulmonary pathologies.

• Coexisting disease influences the assessment of acute respiratory failure. A pan-systemic approach is an important aspect of management.

• Augmentation of oxygenation and carbon dioxide clearance are therapeutic goals.

• Ventilation is indicated where acute respiratory failure is not responsive to continuous positive airways pressure (CPAP) or oxygen therapy alone, or where the use of CPAP is inappropriate.

• All modes of positive-pressure ventilation aim at maximizing alveolar recruitment by increasing mean airway pressure. Avoiding high peak-inspiratory pressures and large tidal volumes reduces the risk of barotrauma and volotrauma.

• Normal arterial blood gases may not be appropriate targets in severe acute respiratory failure.

• Patient posture may influence the degree of ventilation-perfusion mismatch

• Inhaled nitric oxide or nebulized prostacyclin may improve oxygenation and ameliorate pulmonary hypertension.

• Early CT scanning in acute respiratory failure indicates the nature and degree of pulmonary involvement and influences management strategy.

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