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Hypercapnic respiratory failure

Hypercapnic respiratory failure (type II respiratory failure) is a state of reduced alveolar ventilation with subsequent respiratory acidosis (PaCO₂ > 50 mmHg).
Hypercapnic respiratory failure is most frequently caused by drug overdose, COPD, obesity hypoventilation syndrome, obstructive sleep apnea, and the overlap syndrome of COPD and obstructive sleep apnea.
The overall prevalence of hypercapnic respiratory failure in patients with severe COPD is approximately 25%.
Disease course
Acute hypercapnic respiratory failure develops rapidly (within minutes to hours). Clinical manifestations include increasing dyspnea, lethargy, hypoxemic, disorientation, tachycardia, altered mental status, hypoventilation, hyperinflation, and need for ventilatory support. The disease decreases the QoL with increased risk of readmission and longer periods of hospital stay.
Prognosis and risk of recurrence
Hypercapnic respiratory failure in hospitalized patients is associated with significant mortality (36%).
Key sources
The following summarized guidelines for the evaluation and management of hypercapnic respiratory failure are prepared by our editorial team based on guidelines from the European Respiratory Society (ERS 2017) and the British Thoracic Society (BTS/ICS 2016).


1.Classification and risk stratification

Prognostic tools: consider the use of validated tools to inform discussion regarding prognosis and appropriateness of invasive mechanical ventilation, keeping in mind that such tools are poorly predictive for individual patient use.
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2.Medical management

Patients with chronic obstructive pulmonary disease exacerbation: as per ERS 2017 guidelines, initiate bilevel noninvasive ventilation for patients with acute respiratory failure due to an acute exacerbation of COPD that leads to respiratory acidosis (pH ≤ 7.35).
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  • Patients with acute asthma

  • Patients with bronchiectasis

  • Patients with cystic fibrosis

  • Patients with restrictive lung disease

  • Patients with neuromuscular disease

  • Patients with obesity hypoventilation syndrome

3.Inpatient care

General principles: treat the precipitant cause of acute hypercapnic respiratory failure, normalize pH, correct chronic hypercapnia and address fluid overload.

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  • Noninvasive ventilation strategy

  • Invasive ventilation strategy

  • Oxygenation targets

  • Sedative agents (noninvasive ventilation)

  • Sedative agents (mechanical ventilation)

  • Volume status optimization

  • Assessment for extubation

  • Weaning of ventilatory support

  • Monitoring for ventilator asynchrony

4.Therapeutic procedures

Tracheostomy: consider mini-tracheostomy to aid secretion clearance in patients with weak cough due to neuromuscular/chest wall disease, or in patients with excessive airway secretions such as in COPD or cystic fibrosis.

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  • Extracorporeal CO2 removal

5.Follow-up and surveillance

Post-extubation care: consider prophylactic use of noninvasive ventilation to provide post-extubation support in patients with identified risk factors for extubation failure.

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  • Palliative care

  • Quality improvement