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TERM PAPER ON

ACUTE RESPIRATORY FAILURE AND CHEST TRAUMA

BY

NWANNA CHIDINMA

MAT NO.

SUBMITTED TO THE DEPARTMENT OF NURSING SCIENCE

FACULTY OF HEALTH SCIENCE IMO STATE
UNIVERSITY, OWERRI

IN PARTIAL FULFILLMENT OF ADVANCED CONCEPT OF

CRITICAL CARE NURSING NSC 723

LECTURER
DR. VINCENT CHINELO

FEBRUARY, 2022
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Introduction

Acute respiratory failure and chest trauma is a potentially fatal medical

condition caused by fluid buildup in the lung’s air sacs. This buildup

interferes with critical pulmonary functions in two ways (Cherian, Kumar, &

Akasapu, 2016). First, the lungs are blocked from transmitting oxygen to the

bloodstream, leading to the gradual starvation of the body’s organs.

Secondly, the lungs are prevented from removing carbon dioxide, a waste

product of cellular respiration. This results in high levels of bloodstream

toxins (Brodie & Bacchetta 2016).

Despite many technical advances in diagnosis, monitoring and therapeutic

intervention, acute respiratory failure continues to be a major cause of

morbidity and mortality in intensive care unit (ICU) setting (Brodie &

Bacchetta 2016). Respiratory failure (RF) is diagnosed when the patient

loses the ability to ventilate adequately or to provide sufficient oxygen to the

blood and systemic organs. Clinically respiratory failure is diagnosed when

PaO2 is less than 60mm of Hg with or without elevated CO2 level, while

breathing room air. High mortality rates are common for patients with acute

respiratory failure, even in ICUs specializing in modern critical care

techniques. In an International multicenter study, only 55.6% patients with

acute respiratory failure survived their hospitalization whereas 44.4% died in

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the hospital (Zambon, and Vincent, 2014). Urgent resuscitation of the

patient requires airway control, ventilator management, and stabilization of

the circulation. At the same time patient should be evaluated for the cause of

respiratory failure and therapeutic plan should be derived from an informed

clinical and laboratory examination supplemented by the results of special

intensive care unit (ICU) interventions. Recent advances in the ICU

management and monitoring technology facilitates early detection of the

pathophysiology of vital functions, with the potential for prevention and

early titration of therapy for the patients with acute respiratory failure which

improves the outcome (Shrestha, Khanal, Sharma, and Nepal 2020).

Aim and Objectives

The aim of this seminar paper is to review the Acute Respiratory Failure and

chest trauma. The specific objectives:-

1. To review the concept of Acute Respiratory Failure

2. To review the concept of Acute Respiratory Failure and Chest
Trauma
3. To review the classification of Acute Respiratory Failure
4. To review the signs or symptoms Acute Respiratory Failure and
Chest Trauma
5. To review the causes of Acute Respiratory Failure and Chest Trauma
6. To review the diagnosis of Acute Respiratory Failure
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7. To review the complications Resulting From Acute Respiratory

Failure
8. To review the management of Acute Respiratory Failure and Chest
Trauma

Concept of Acute Respiratory Failure

The loss of the ability to ventilate adequately or to provide sufficient oxygen

to the blood and systemic organs (Brodie & Bacchetta 2016). The

pulmonary system is no longer able to meet the metabolic demands of the

body with respect to oxygenation of the blood and/or CO 2 elimination.

Respiratory failure is classified as type 1 respiratory failure or type 2

respiratory failure. 2 Type 1 respiratory failure is defined by a PaO2 of

<60mmHg with a normal or low PaCO2. Type 2 respiratory failure is

defined by a PaO2 of <60mHg and a

PaCO2 of >45mHg. Respiratory failure is also classified as acute, acute on

chronic or chronic. This distinction is important in deciding on whether the

patient needs to be treated in intensive care unit (ICU) or can be managed in

general medical ward and most appropriate treatment strategy, particularly

in type 2 respiratory failure (Rawal, Yadav and Kumar2021).

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Concept of Acute Respiratory Failure and Chest Trauma

The thoracic cavity contains three major anatomical systems: the airway,

lungs, and the cardiovascular system. As such, any blunt or penetrating

trauma can cause significant disruption to each of these systems that can

quickly prove to be life threatening unless rapidly identified and treated.

Chest trauma accounts for approximately 25% of mortality in trauma

patients.  This rate is much higher in patients with polytraumatic injuries and

acute respiratory failure. 85-90% of chest trauma patients can be rapidly

stabilized and resuscitated by a handful of critical procedures. Unlike other

disease entities, trauma patients often present with a known traumatic

mechanism such as a car collision, fall, gunshot or stab wound. In rare

cases, a patient may present in a state of significant altered mental status

and be unable to provide any significant history.  In these situations, certain

physical examination clues to the presence of trauma include findings such

as contusions, lacerations, or deformities.  Palpation of crepitus over the

chest wall may also be appreciated (Prescott, and Sjoding 2021).  

Classification of Acute Respiratory Failure

Type 1 (Hypoxemic ) - PO2 < 50 mmHg on room air. Usually seen in

patients with acute pulmonary edema or acute lung injury. These disorders
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interfere with the lung's ability to oxygenate blood as it flows through the

pulmonary vasculature.

Type 2 (Hypercapnic/ Ventilatory ) - PCO2 > 50 mmHg (if not a chronic

CO2 retainer). This is usually seen in patients with an increased work of

breathing due to airflow obstruction or decreased respiratory system

compliance, with decreased respiratory muscle power due to neuromuscular

disease, or with central respiratory failure and decreased respiratory drive.

1. Type 3 (Peri-operative). This is generally a subset of type 1 failure

but is sometimes considered separately because it is so common.

2. Type 4 (Shock) - secondary to cardiovascular instability.

Signs or Symptoms Acute Respiratory Failure and Chest Trauma

Kress and Hall (2011) noted trouble breathing and chest trauma is the main

symptom of acute respiratory failure. Symptoms may also include:

1. Severe shortness of breath

2. Labored and unusually rapid breathing

3. Low blood pressure

4. Confusion and extreme tiredness

5. Rapid breathing.

6. Restlessness or anxiety.
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7. Skin, lips, or fingernails that appear blue (cyanosis).

8. Rapid heart rate.

9. Abnormal heart rhythms (arrhythmias).

10.Confusion or changes in behavior.

11.Tiredness or loss of energy.

12.Feeling sleepy or having a loss of consciousness.

13. Difficulty breathing,

14. Failure of the chest to expand normally,

Causes of Acute Respiratory Failure and Chest Trauma

Guzman (2016) noted acute respiratory failure and chest trauma has wide-

ranging and disparate causes:

 Acute respiratory distress syndrome (ARDS): ARDS is a medical

condition marked by low levels of oxygenated blood. It often results

from a prior medical problem, such as pneumonia, pancreatitis, or

septic infection, and, in turn, proceeds the onset of respiratory failure.

 Alcohol or drug abuse: Excessive alcohol or drug consumption can

reduce the brain’s ability to properly regulate breathing.

 Breathing obstructions: Windpipe injuries or foreign objects lodged

in the throat can impede the flow of oxygen to the lungs. Narrowing
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of the bronchial tubes by asthma,  chronic obstructive pulmonary

disorder (COPD), or cystic fibrosis can have a similar effect.

 Cardiac failure: The heart and lungs work in tandem to respirate and

nourish the body. Heart failure can therefore have a catastrophic effect

on pulmonary functions.

 Chemical inhalation: Breathing in heavy smoke, harsh fumes, or

toxic chemicals can initiate respiratory failure.

 Infections: Infections, including pneumonia, are frequently behind

cases of respiratory failure.

 Physical injury: The neurological system plays a key role in the

healthy functioning of the respiratory system. Injuries to the brain or

spinal column can greatly weaken the pulmonary function. Scoliosis,

an excessive curvature of the spine, can also be an issue.

 Stroke: A stroke is the death of brain tissue, leading to a loss of

physiological function. Since the brain is involved in breathing, a

major stroke can result in respiratory failure.

Diagnosis of Acute Respiratory Failure

Kress and Hall (2011) acute respiratory failure is a medical emergency

requiring immediate action. To confirm a diagnosis, the physician may:

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 Document medical history: This will include general information

about the health, as well as questions about the nature and severity of

the current symptoms.

 Conduct a physical exam: A stethoscope will allow the doctor to

listen for abnormal breathing patterns or behaviors, including

evidence of infected or fluid-filled lungs.

 Order a chest X-ray or CT scan: X-rays and CT scans provide non-

invasive, visual evidence of lung injury or inflammation.

 Conduct pulse oximetry: A pulse oximeter is a non-invasive means

of measuring the lung’s effectiveness in oxygenating the blood.

Poorly oxygenated blood is indicative of a respiratory disorder. An

arterial blood gas test is similar, but requires a blood draw.

Complications Resulting From Acute Respiratory Failure

Guzman (2016) noted that multiple organ-system complications involving

the cardiovascular, pulmonary, gastrointestinal system may occur

subsequent to respiratory failure

Chest Trauma. Unstable chest trauma, severe respiratory

distress or profound shock requiring emergent resuscitation.

Pulmonary: pulmonary embolism, pulmonary fibrosis, complications

secondary to the use of mechanical ventilator

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Cardiovascular: hypotension, reduced cardiac output, cor pulmonale,

arrhythmias, pericarditis and acute myocardial infarction

Gastrointestinal: haemorrhage, gastric distention, ileus, diarrhoea,

pneumoperitoneum and duodenal ulceration- caused by stress is common in

patients with acute respiratory failure

Infectious: noscomial- pneumonia, urinary tract infection and catheter-

related sepsis. Usually occurs with use of mechanical devices.

Renal: acute renal failure, abnormalities of electrolytes and acid-base

balance.

Nutritional: malnutrition and complications relating to parenteral or enteral

nutrition and complications associated with NG tube- abdominal distention

and diarrhea

Management of Acute Respiratory Failure and Chest Trauma

According to Gehlbach and Hall (2011) the management of acute

respiratory failure can be divided into an urgent resuscitation this includes

supportive measures and treatment of the underlying cause.

Supportive measures which depend on depending on airways management to

maintain adequate ventilation and correction of the blood gases

abnormalities
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1. Correction of Hypoxemia

 The goal is to maintain adequate tissue oxygenation, generally

achieved with an arterial oxygen tension (PaO2) of 60 mm Hg or

arterial oxygen saturation (SaO2), about 90%.

 Un-controlled oxygen supplementation can result in oxygen toxicity

and CO2 (carbon dioxide) narcosis. Inspired oxygen concentration

should be adjusted at the lowest level, which is sufficient for tissue

oxygenation.

 Oxygen can be delivered by several routes depending on the clinical

situations in which we may use a nasal cannula, simple face mask

nonrebreathing mask, or high flow nasal cannula.

 Extracorporeal membrane oxygenation may be needed in refractory

cases

2. Correction of hypercapnia and respiratory acidosis

 This may be achieved by treating the underlying cause or providing

ventilatory support.

3. Ventilatory support for the patient with respiratory failure

The goals of ventilatory support in respiratory failure are:

 Correct hypoxemia

 Correct acute respiratory acidosis

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 Resting of ventilatory muscles

Non-invasive respiratory support: is ventilatory support without tracheal

intubation/ via upper airway. Considered in patients with mild to moderate

respiratory failure. Patients should be conscious, have an intact airway and

airway protective reflexes. Noninvasive positive pressure ventilation

(NIPPV) has been shown to reduce complications, duration of ICU stay and

mortality (Guzman, 2016). It has been suggested that NIPPV is more

effective in preventing endotracheal intubation in acute respiratory failure

due to COPD than other causes. The etiology of respiratory failure is an

important predictor of NIPPV failure (Cremer, and Schultz, 2012).

Invasive respiratory support: indicated in persistent hypoxemia despite

receiving maximum oxygen therapy, hypercapnia with impairment of

conscious level. Intubation is associated with complications such as

aspiration of gastric content, trauma to the teeth, barotraumas, trauma to the

trachea etc

Permissive hypercapnia - A ventilatory strategy that allows arterial carbon

dioxide(PaCO2) to rise by accepting a lower alveolar minute ventilation to

avoid the risk of ventilator-associated lung injury in patients with ALI and

minimize intrinsic positive end-expiratory pressure (auto PEEP) in patients

with COPD thereby protecting the lungs from barotrauma. Permissive

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hypercapnia could increase survival in immunocompromised children with

severe ARDS (Cherian Kumar & Akasapu 2016).

Physiotherapy Management

Cooke & Erikson (2017) noted that physio-therapeutic interventions aim to

maximize function in pump and ventilatory systems and improve quality of

life.

 In mechanically ventilated patients, early physiotherapy has been

shown to improve quality of life and to prevent ICU-associated

complications like de-conditioning, ventilator dependency and

respiratory conditions.

 Main indications for physiotherapy are excessive pulmonary

secretions and atelectasis.

 Timely physical therapy interventions may improve gas exchange and

reverse pathological progression thereby avoiding ventilation.

Nurse management

Nursing management of a patient with Acute Respiratory Failure using

nursing processes
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The key role of the nurse is to identify the patents as high risk for Acute

Respiratory Failure in all patients

Nursing management using the nursing process e.g. nursing assessment,

nursing diagnosis, planning, implementation and evaluation

Nursing assessment for acute respiratory failure and chest trauma

Nursing diagnosis-1: Ineffective breathing pattern 

Expected outcomes

The patient takes relaxed breathing at a normal rate and depth. There is the

absence of dyspnea and blood gas analysis shows normal parameters. 

The patient verbalizes his/her comfort without any sign of dyspnea. 

Nursing care plane for acute respiratory failure and chest trauma
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Date Diagnosis Objectives plan Nursing intervention Rational on scientific principle Evaluation
Impaired gas Assess the rate, Reassure the patient and Change in rate and depth of respiration Take cardiac output
exchange related to rhythm, and depth of reduce the anxiety during is the early sign of respiratory difficulty. measurements after a change in
Decreased lung respiration acute episodes of respiratory positive pressure ventilation.
compliance, Low distress.
amount of
surfactant,
Increased breathing
rate, Any primary
medical problem
Check for the use of Check for the use of Provide proper position to When lung compliance decreases, it Check vital signs and level of
accessory muscles. accessory muscles. the client. A prone position is impacts the work of breathing and it consciousness in each half an
recommended. increases significantly. hour with changes in positive
pressure ventilation and
inotrope administration.
Assess the breath Assess the breath Schedule daily activities in An increase in pulmonary oedema Check peripheral pulses,
sound of the lungs. sound of the lungs. such a way that it will provide cause fluid to move into alveoli, as a capillary refill and skin
rest periods between result, a crackles sound is heard. temperature.
activities.
Check for any sign Check for any sign of Maintain oxygen saturation Dyspnea causes an increase in anxiety Check the fluid balance by
of dyspnea. dyspnea. at 90% or above. in the patient. Anxiety leads to increase maintaining an intake output
oxygen demand of the body and chart, and taking the daily
breathing pattern is altered. weight of the patient.
Assess for any sign Assess for any sign of Administer medications Bluish discolourisation of the tongue, Administer drugs as per
of cyanosis. cyanosis. according to the physician’s mucus membrane and skin indicates a physicians prescription and
prescriptions. (e.g., decrease in oxygen concentration in observe for the response of the
antibiotics, bronchodilators, the blood. drug.
steroids, and antianxiety
medications).
Check oxygen Check oxygen Do suction if required. Pulse oxymetry and ABG analysis help Administer fluid to maintain
concentration in concentration in to interpret the current oxygen status fluid status.
pulse oximeter and pulse oximeter and in the blood. In ARDS, oxygen
do an arterial blood do an arterial blood saturation decreases.
gas analysis. gas analysis.
Assess for any Check for the energy All the team members who are An increase in pulmonary oedema and fibrin Check the ventilator setting. Ensure
cough]tcykf. level of the patient. involved in the care of the build up stimulate cough reflex and it leads the alarms of the ventilator are on.
patient must be informed about to an increase in cough.
the patients respiratory status.
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Conclusions

Despite advances in critical care, ARF still has high morbidity and mortality.

Even those who survive can have a poorer quality of life. While many risk

factors are known for ARF, there is no way to prevent the condition. Besides

the restriction of fluids in high-risk patients, close monitoring for hypoxia by

the team is vital. The earlier the hypoxia is identified, the better the outcome.

Those who survive have a long recovery period to regain functional status.

Many continue to have dyspnea even with mild exertion and thus are

dependent on care from others. Even though many risk factors for ARF are

known, there is no way of preventing ARF. However, careful management

of fluid in high-risk patients can be helpful. Steps should be taken to prevent

aspiration by keeping the head of the bed elevated before feeding. Discharge

planning should include medication reconciliation, detailed home care

planning (whether by family members or in-home/visiting nursing), and

plans for follow-up visits and evaluations. Patients and caregivers must be

counseled on signs of when to contact the clinician in the event of

exacerbation or deterioration of the patient's condition.

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