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

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

3. Gas Exchange Unit
Fig. 68-1

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

5. Acute Respiratory Failure
Classification
Hypoxemic respiratory failure
Hypercapnic respiratory failure

6. Classification of Respiratory Failure
Fig. 68-2

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

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

9. Range of V/Q Relationships
Fig. 68-4

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

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

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

13. Diffusion Limitation
Fig. 68-5

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

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

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

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

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

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

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

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

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

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

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

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

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

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

28. 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)

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

30. 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

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

32. 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

33. 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

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

35. 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

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

38. Augmented Cough
Fig. 68-6

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

40. Noninvasive PPV
Fig. 68-7

41. 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

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

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

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

45. 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

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