The incidence of chronic pulmonary insufficiency, most commonly due to obstructive emphysema, is increasing. The gradual down-hill course of patients with chronic obstructive emphysema and/or pulmonary fibrosis may be punctuated with episodes of acute pulmonary insufficiency. These episodes are usually triggered by respiratory infection. However, they may also result from sedation, anesthetics, and congestive heart failure, strokes, or vomiting with aspiration. Two functional derangements may occur, either alone or in combination. Most frequently there is plugging of bronchi with material which the patient is unable to clear by coughing. This results in an uneven distribution of inspired air with blood flow continuing to unventilated alveoli. Because of the nature of the oxygen hemoglobin dissociation curve this cannot be compensated by increasing ventilation to other alveoli, and anoxemia results. However, there is no such limitation to the removal of carbon dioxide, so there is little increase in the arterial carbon dioxide
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