Acute respiratory failure in older adults: warning signs, hospital care and recovery

Breathing is not just the lungs. Royal Papworth Hospital points out that the respiratory system needs a gas-exchanging organ, the lungs, an effective pump to move air, meaning the breathing muscles such as the diaphragm, and effective control of the depth and rate of breathing by the brain. A problem with any of those parts can lead to respiratory failure.

In practical terms the body is not getting enough oxygen, or is not getting rid of enough carbon dioxide, or both. The word "failure" describes the gas exchange, not that breathing has stopped, which is why someone can be awake, talking and still in serious trouble.

In older adults the problem often arrives on top of an existing illness. A person with long-standing lung disease may cope for years and then tip into acute respiratory failure with a chest infection or a flare-up, which is described as acute-on-chronic failure.

Royal Papworth lists the effects of too little oxygen as restlessness, confusion, agitation and breathlessness, and of too much carbon dioxide as headaches, drowsiness and confusion. These are in addition to the symptoms of whatever illness caused the failure.

The overlap with confusion matters in later life. The NHS, describing pneumonia, notes that feeling confused is common in older people. A relative who is suddenly drowsy, muddled or restless, with fast or laboured breathing, may be showing the effects of low oxygen rather than a primary problem with the brain.

• Struggling for breath, gasping, or unable to speak in full sentences.

• New confusion, agitation, restlessness or unusual drowsiness.

• Headache on waking, or marked sleepiness during the day.

• Pale, blue or blotchy skin, lips or tongue (on brown or black skin it may be easier to see on the palms of the hands).

• Worsening breathlessness with a chest infection, fever, or cough producing coloured phlegm.

The NHS says to call 999 or go to A&E if you are struggling to breathe, you have pale, blue or blotchy skin, lips or tongue, you are coughing up blood, or you suddenly feel confused. It also says not to drive yourself to A&E: ask someone to drive you or call 999 and ask for an ambulance, and bring any medicines you take.

If breathlessness is new but not severe, the NHS advises asking for an urgent GP appointment or contacting NHS 111, particularly if you are feeling short of breath, have chest pain that comes and goes, or have had a cough for up to 3 weeks.

Royal Papworth gives long-term lung disease as the classic route into type 1 failure, citing chronic obstructive pulmonary disease and bronchiectasis as examples. In the NHS description, COPD is a group of lung conditions that cause breathing difficulties, can limit normal activities, and may have periods when symptoms suddenly get worse, known as a flare-up or exacerbation.

Acute illness is the other common trigger. The NHS notes that pneumonia is inflammation of the lungs, usually caused by infection, and that older people and people with heart or lung conditions are at risk of becoming seriously ill and may need treatment in hospital. Royal Papworth adds that failure can also come from problems with the chest wall, the nerves and muscles that power breathing, or the brain's control of breathing, which is why people with neuromuscular or neurological conditions can be affected.

Royal Papworth says respiratory failure can usually be confirmed by an arterial blood gas sample. This is taken from an artery rather than a vein, usually at the wrist, and gives accurate information about how well the lungs exchange oxygen and carbon dioxide. The NHS lists a blood oxygen test, using a peg-like device attached to the finger, among the tests used in lung disease assessment.

Doctors then look for the cause. In the NHS description of pneumonia, hospital tests may include a chest X-ray and blood tests. If the problem is longer term, Royal Papworth says more comprehensive assessment may involve an overnight sleep study and lung function studies.

Treatment has two parts: support the breathing and treat the cause. For type 1 failure, Royal Papworth says that if the problem is simply a lack of oxygen, treatment with oxygen alone may be sufficient. For type 2 failure it says carbon dioxide can only be removed effectively by helping the person to take deeper breaths, which is done using non-invasive ventilation.

Non-invasive ventilation, or NIV, blows air into the lungs via a nasal or face mask, and the machine recognises when the person starts to breathe in and assists each breath. The NHS notes that in COPD, if you are taken to hospital because of a bad flare-up you may have NIV, and that nebulised medicine, steroid tablets and antibiotics for signs of a chest infection may be used. For pneumonia the NHS says hospital care usually includes antibiotics, sometimes steroids and oxygen to help breathing.

If oxygen is needed at home afterwards, the NHS warns not to smoke when using oxygen because the increased level of oxygen is highly flammable.

Recovery depends on the cause and on how well the lungs worked beforehand. The NHS says that most people with pneumonia get better in 2 to 4 weeks. After a flare-up of COPD it describes pulmonary rehabilitation, a programme of exercise and education usually involving 2 or more group sessions a week for at least 6 weeks, as a way to improve how much you can do before feeling out of breath.

Prevention rests on vaccination and avoiding smoking. The NHS lists the pneumococcal vaccine for adults over 65 and people at higher risk, the flu vaccine for adults over 65 and people with certain long-term conditions, and the RSV vaccine for adults aged 75 and over. If you smoke, stopping is described as the most important step for COPD.

In the UK, acute respiratory failure is managed through NHS emergency and hospital respiratory services. Home ventilation, where long-term support is needed, is assessed by specialist respiratory units; Royal Papworth notes that the aims of home NIV are to reduce symptoms and improve quality of life, and that it is usually only needed during sleep.