Focus on Respiratory Failure (Relates to Chapter 68, “Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome,” in the textbook)

Acute Respiratory Failure Results from inadequate gas exchange Insufficient O2 transferred to the blood Hypoxemia Inadequate CO2 removal Hypercapnia

Gas Exchange Unit Fig. 68-1

Acute Respiratory Failure Not a disease but a condition Result of one or more diseases involving the lungs or other body systems

Acute Respiratory Failure Classification Hypoxemic respiratory failure Hypercapnic respiratory failure

Classification of Respiratory Failure Fig. 68-2

Acute Respiratory Failure Hypoxemic respiratory failure PaO2 <60 mm Hg on inspired O2 concentration >60%

Acute Respiratory Failure Hypercapnic respiratory failure PaCO2 above normal ( >45 mm Hg) Acidemia (pH <7.35)

Range of V/Q Relationships Fig. 68-4

Hypoxemic Respiratory Failure Etiology and Pathophysiology Causes Ventilation-perfusion (V/Q) mismatch COPD Pneumonia Asthma Atelectasis Pulmonary embolus

Hypoxemic Respiratory Failure Etiology and Pathophysiology Causes Shunt Anatomic shunt Intrapulmonary shunt An extreme V/Q mismatch

Hypoxemic Respiratory Failure Etiology and Pathophysiology Causes Diffusion limitation Severe emphysema Recurrent pulmonary emboli Pulmonary fibrosis Hypoxemia present during exercise

Diffusion Limitation Fig. 68-5

Hypoxemic Respiratory Failure Etiology and Pathophysiology Causes Alveolar hypoventilation Restrictive lung disease CNS disease Chest wall dysfunction Neuromuscular disease

Hypoxemic Respiratory Failure Etiology and Pathophysiology Interrelationship of mechanisms Combination of two or more physiologic mechanisms

Hypercapnic Respiratory Failure Etiology and Pathophysiology Imbalance between ventilatory supply and demand

Hypercapnic Respiratory Failure Etiology and Pathophysiology Airways and alveoli Asthma Emphysema Chronic bronchitis Cystic fibrosis

Hypercapnic Respiratory Failure Etiology and Pathophysiology Central nervous system Drug overdose Brainstem infarction Spinal chord injuries

Hypercapnic Respiratory Failure Etiology and Pathophysiology Chest wall Flail chest Fractures Mechanical restriction Muscle spasm

Hypercapnic Respiratory Failure Etiology and Pathophysiology Neuromuscular conditions Muscular dystrophy Multiple sclerosis

Respiratory Failure Tissue Organ Needs Major threat is the inability of the lungs to meet the oxygen demands of the tissues

Respiratory Failure Clinical Manifestations Sudden or gradual onset A sudden decrease in PaO2 or rapid increase in PaCO2 indicates a serious condition

Respiratory Failure Clinical Manifestations When compensatory mechanisms fail, respiratory failure occurs Signs may be specific or nonspecific

Respiratory Failure Clinical Manifestations Severe morning headache Cyanosis Late sign Tachycardia and mild hypertension Early signs

Respiratory Failure Clinical Manifestations Consequences of hypoxemia and hypoxia Metabolic acidosis and cell death Decreased cardiac output Impaired renal function

Respiratory Failure Clinical Manifestations Specific clinical manifestations Rapid, shallow breathing pattern Tripod position Dyspnea

Respiratory Failure Clinical Manifestations Specific clinical manifestations Pursed-lip breathing Retractions Change in I:E ratio

Respiratory Failure Diagnostic Studies History and physical assessment ABG analysis Chest x-ray CBC, sputum/blood cultures, electrolytes ECG Urinalysis V/Q lung scan Pulmonary artery catheter (severe cases)

Acute Respiratory Failure Nursing and Collaborative Management Nursing Assessment Health information Health history Medications Surgery

Acute Respiratory Failure Nursing and Collaborative Management Nursing Assessment Functional health patterns Health perception–health management Nutritional-metabolic Activity-exercise Sleep-rest Cognitive-perceptual Coping–stress tolerance

Acute Respiratory Failure Nursing and Collaborative Management Nursing Assessment Physical assessment General Integumentary Respiratory Cardiovascular Gastrointestinal Neurologic Laboratory findings

Acute Respiratory Failure Nursing and Collaborative Management Nursing Diagnoses Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Risk for fluid volume imbalance Anxiety Imbalanced nutrition: Less than body requirements

Acute Respiratory Failure Nursing and Collaborative Management Planning: Overall goals ABG values within patient’s baseline Breath sounds within patient’s baseline No dyspnea or breathing patterns within patient’s baseline Effective cough and ability to clear secretions

Acute Respiratory Failure Nursing and Collaborative Management Prevention Thorough history and physical assessment to identify at-risk patients Early recognition of respiratory distress

Acute Respiratory Failure Nursing and Collaborative Management Respiratory therapy Oxygen therapy: Delivery system should Be tolerated by the patient Maintain PaO2 at 55 to 60 mm Hg or more and SaO2 at 90% or more at the lowest O2 concentration possible

Acute Respiratory Failure Nursing and Collaborative Management Respiratory therapy Mobilization of secretions Hydration and humidification Chest physical therapy Airway suctioning Effective coughing and positioning

Augmented Cough Fig. 68-6

Acute Respiratory Failure Nursing and Collaborative Management Respiratory therapy Positive pressure ventilation (PPV) Noninvasive PPV BiPAP CPAP

Noninvasive PPV Fig. 68-7

Acute Respiratory Failure Nursing and Collaborative Management Drug Therapy Relief of bronchospasm Bronchodilators Reduction of airway inflammation Corticosteroids Reduction of pulmonary congestion Diuretics, nitrates if heart failure present

Acute Respiratory Failure Nursing and Collaborative Management Drug Therapy Treatment of pulmonary infections IV antibiotics Reduction of severe anxiety, pain, and agitation Benzodiazepines Narcotics

Acute Respiratory Failure Nursing and Collaborative Management Nutritional Therapy Maintain protein and energy stores Enteral or parenteral nutrition Nutritional supplements

Acute Respiratory Failure Nursing and Collaborative Management Medical Supportive Therapy Treat the underlying cause Maintain adequate cardiac output and hemoglobin concentration

Acute Respiratory Failure Gerontologic Considerations Physiologic aging results in ↓ Ventilatory capacity Alveolar dilation Larger air spaces Loss of surface area Diminished elastic recoil Decreased respiratory muscle strength ↓ Chest wall compliance

Acute Respiratory Failure Gerontologic Considerations Lifelong smoking Poor nutritional status Less available physiologic reserve Cardiovascular Respiratory Autonomic nervous system