Acute Respiratory Failure and Pulmonary Complications in End-Stage Liver Disease

Nida Qadir, MD; Tisha Wang, MD; Igor Barjaktarevic, MD, PhD; Steven Y. Chang, MD, PhD


Semin Respir Crit Care Med. 2018;39(5):546-555. 

In This Article

Acute Liver Failure

Herniation from cerebral edema is the most serious complication of acute liver failure. Patients with acute liver failure frequently require endotracheal intubation due to a decreased level of consciousness. Mechanical ventilation should be approached with the goal of neuroprotection and attenuating intracranial hypertension. Hypercapnia should be avoided, as it may increase cerebral blood flow. However, hyperventilation, which causes cerebrovascular constriction, should only be used for a short period in the setting of acute decompensation, preferably with the end point of a definitive therapeutic intervention such as OLT. Prolonged hyperventilation has not been shown to prevent cerebral edema in fulminant hepatic failure,[94] is not recommended in the management of brain-injured patients,[95] and may result in cerebral hypoxia.[96] Although optimal oxygenation targets are not known, normoxemia is a reasonable goal, as both hypoxia and hyperoxia are known to increase cerebral blood flow in brain-injured patients.[97–99] PEEP should be adjusted to maintain normoxemia. Brain-injured patients have demonstrated tolerance of moderate levels of PEEP[100–102] as have post-liver transplant patients.[77–79] However, the effects of PEEP have not been studied in acute liver failure, and there is evidence that it may decrease hepatic blood flow in animal models.[103,104] Therefore, maintaining the PEEP at the lowest level needed to meet oxygenation targets may be a cautious approach, despite the lack of definitive evidence in favor or against this method. Additionally, deeper sedation may need to be maintained, and suctioning, which can cause increases in intracranial pressures, should be minimized. Paralytics should be considered if aggressive suctioning or procedures such as bronchoscopies are needed (Table 3).