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Respiratory Failure Out line

 Definition

 Classification of RF

 Pathophysiologic causes of Acute RF

 Diagnosis of RF

 Causes

 Clinical presentation

 Investigations

 Management of RF

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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

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Acute Respiratory Failure

 Not a disease but a condition

 Outcome of one or more diseases involving the

lungs or other body systems

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 The partial pressure of oxygen also known

as PaO2 is a measurement of oxygen
pressure in arterial blood. It reflects how
well oxygen is able to move from the lungs
to the blood, and it is often altered by severe
illnesses.

 The partial pressure of carbon dioxide

(PaCO2) is one of several measures
calculated by an (ABG) test performed
specifically to evaluates how well carbon
dioxide (CO2) moves from the lungs into the
blood.

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Acute Respiratory Failure

 Classification

 Hypoxemic respiratory failure

 Hypercapnic respiratory failure

Classification of Respiratory Failure

Fig. 68-2

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Acute Respiratory Failure

 Hypoxemic respiratory failure

 (PaO2) <60 mm Hg on inspired O2 concentration

>60%

 Hypercapnic respiratory failure

 PaCO2 above normal ( >45 mm Hg)

 Acidemia (pH <7.35)

Causes of Hypoxemic Respiratory Failure

 Ventilation-perfusion (V/Q) mismatch

 COPD
 Pneumonia

 Asthma

 Atelectasis

 Pulmonary embolus

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Causes of Hypoxemic Respiratory Failure

 Shunt

 Anatomic shunt

 Intrapulmonary shunt

 An extreme V/Q mismatch

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Causes of Hypoxemic Respiratory Failure

 Diffusion limitation

 Severe emphysema

 Recurrent pulmonary emboli

 Pulmonary fibrosis

 Hypoxemia present during exercise

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Diffusion Limitation

Fig. 68-5

Causes of Hypoxemic Respiratory Failure

 Alveolar hypoventilation
 Restrictive lung disease

 CNS disease

 Chest wall dysfunction

 Neuromuscular disease

 Interrelationship of mechanisms
 Combination of two or more physiologic mechanisms

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Causes of Hypercapnic Respiratory Failure

 Imbalance between ventilatory supply and
demand

 Airways and alveoli

 Asthma

 Emphysema

 Chronic bronchitis

 Cystic fibrosis

Causes of Hypercapnic Respiratory Failure

 Central nervous system

 Drug overdose

 Brainstem infarction

 Spinal cord injuries

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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

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

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Respiratory Failure
Clinical Manifestations
 Sudden or gradual onset

 A sudden decrease in PaO2 or rapid increase in PaCO2

indicates a serious condition.

 When compensatory mechanisms fail, respiratory

failure occurs

 Signs may be specific or nonspecific

Respiratory Failure
Clinical Manifestations
 Severe morning headache

 Tachycardia and mild hypertension

 Early signs

 Cyanosis

 Late sign

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Consequences of hypoxemia and hypoxia

 Metabolic acidosis and cell death

 Decreased cardiac output

 Impaired renal function

Specific clinical manifestations

Rapid, shallow breathing pattern
Tripod position
Dyspnea

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Specific clinical manifestations

 Pursed-lip breathing
 Retractions
 Change in I:E ratio

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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)

Nursing and Collaborative Management

 Nursing Assessment

 Health information
 Health history

 Medications

 Surgery

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Nursing Assessment

 Functional health pattern

 Health perception–health management

 Nutritional-metabolic

 Activity-exercise

 Sleep-rest

 Cognitive-perceptual

 Coping–stress tolerance

 Physical assessment
 General

 Integumentary

 Respiratory

 Cardiovascular

 Gastrointestinal

 Neurologic

 Laboratory findings

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Nursing Diagnoses

 Impaired gas exchange

 Ineffective airway clearance

 Ineffective breathing pattern

 Risk for fluid volume imbalance

 Anxiety

 Imbalanced nutrition: Less than body requirements

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

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Prevention of acute respiratory Failure

 Thorough history and physical assessment to identify

at-risk patients

 Early recognition of respiratory distress

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

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Respiratory therapy

 Mobilization of secretions

 Hydration and humidification

 Chest physical therapy

 Airway suctioning

 Effective coughing and positioning

Augmented Cough

Fig. 68-6

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 Respiratory therapy

 Positive pressure ventilation (PPV)

 Noninvasive PPV

 BiPAP

 CPAP

Noninvasive PPV & BiPAP

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Noninvasive PPV & CPAP

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Drug Therapy

 Relief of bronchospasm

 Bronchodilators

 Reduction of airway inflammation

 Corticosteroids

 Reduction of pulmonary congestion

 Diuretics, nitrates if heart failure present

Drug Therapy
 Treatment of pulmonary infections

 IV antibiotics
 Reduction of severe anxiety, pain, and agitation

 Benzodiazepines

 Narcotics

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Nutritional Therapy

 Maintain protein and energy stores

 Enteral or parenteral nutrition

 Nutritional supplements

Medical Supportive Therapy

 Treat the underlying cause

 Maintain adequate cardiac output and hemoglobin

concentration

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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

Alveolar hypoventilation
 Less available physiologic reserve

 Cardiovascular

 Respiratory

 Autonomic nervous system

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 Nursing Diagnosis*
 Impaired gas exchange related to alveolar
hypoventilation, intrapulmonary shunting,
V/Q mismatch, and diffusion
impairment as evidenced by hypoxemia
and/or hypercapnia

 Patient Goal
 Maintains adequate tissue oxygenation as indicated by
normal or baseline arterial blood gases

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Nursing Management Ventilation

Assistance
 Monitor respiratory and oxygenation
status to detect systemic and clinical
manifestations of decreased oxygen and
increased carbon dioxide levels.

• Initiate and maintain supplemental oxygen

as prescribed and titrate to increase
PaO2 and SaO2 levels and improve clinical
assessment findings.

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 Monitor the effects of position change on

oxygenation: ABGs, SpO2, ScvO2/SvO2,
end-tidal CO2 to assess pulmonary gas
exchange.

Acid-Base Management:
Respiratory Acidosis
 Monitor for symptoms of respiratory failure
(e.g., low PaO2 and elevated PaCO2 levels
and respiratory muscle fatigue) to identify
need for ventilatory assistance.

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• Monitor determinants of tissue oxygen

delivery (e.g., PaO2, SaO2, hemoglobin
levels, cardiac output) to plan appropriate
interventions.
 • Provide mechanical ventilatory support, if
necessary, to maintain adequate gas
exchange.

Dysrhythmia Management
 • Monitor for and correct oxygen deficits,
acid-base imbalances, and electrolyte
imbalances that may precipitate
dysrhythmias.
 • Apply ECG electrodes and connect to
cardiac monitor to identify dysrhythmias

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 Nursing Diagnosis
 Ineffective airway clearance related to excessive
secretions, decreased level of consciousness,
presence of an artificial airway, neuromuscular
dysfunction, and pain as evidenced by difficulty in
expectorating sputum, presence of rhonchi or
crackles, ineffective or absent cough

Airway Management
 Encourage slow, deep breathing; turning;
and coughing to promote secretion removal.
 Perform endotracheal or nasotracheal

suctioning to remove secretions and

improve oxygenation.

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 • Position patient to maximize ventilation

potential (e.g., head of bed elevated at least
45 degrees or in the tripod position) to
promote maximal chest expansion and
effective cough.
 • Administer humidified air or oxygen to
prevent drying of the mucosa.

 • Perform chest physical therapy to enhance removal of

secretions.
 • Regulate fluid intake to optimize fluid balance to
liquefy secretions.
 • Administer aerosol treatments (e.g., nebulizer) as
ordered to promote better airflow and secretion
removal.

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Nursing Diagnosis
Ineffective breathing pattern relatedto neuromuscular
impairment of respirations, pain, anxiety, decreased level of
consciousness, respiratory muscle fatigue, and
bronchospasm as evidenced by respiratory rate <12 or >24
breaths/min, altered I : E ratio, irregular breathing pattern,
use of accessory muscles, paradoxic breathing, wheezing,
and apnea

Patient Goal
Demonstrates normal or baseline respiratory rate, rhythm,
and depth of respirations

Ventilation Assistance
 Auscultate breath sounds, noting areas of
decreased or absent ventilation and
presence of adventitious sounds to assess for
compromised ability to sustain lung
ventilation.

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 Monitor for respiratory muscle fatigue to

provide ventilatory support as needed.
 Position to minimize respiratory efforts
(e.g., elevate the head of the bed and
provide overbed table for patient to lean
on) to preserve energy for breathing.

 Teach pursed-lip breathing techniques to

reverse altered I : E ratio.
 Initiate resuscitation efforts (e.g., assisted
ventilation with bag-valve-mask) because
airway support may be needed in the event
of severely impaired ventilation or apnea.

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Airway Insertion & Stabilization

 Assist with insertion of an endotracheal tube by
gathering necessary intubation and emergency
equipment, positioning patient, ensuring adequate
intravenous (IV) access.
 Administering medications as ordered, and
monitoring the patient for complications during
insertion to achieve adequate oxygenation and
effective ventilation.

Nursing Diagnosis
 Imbalanced nutrition: less than body requirements related
to poor appetite, shortness of breath, presence of artificial
airway, decreased energy level, and increased caloric
requirements as evidenced by weight loss, weakness,
muscle wasting, dehydration, poor muscle tone, and poor
skin integrity

Patient Goals
 1. Maintains intake adequate to meet body’s nutritional
needs
 2. Experiences stable weight and muscle tone

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Nutrition Therapy
 Determine in collaboration with the dietitian, the number of
calories and type of nutrients needed to meet nutrition
requirements.
 Provide needed nourishment within limits of prescribed diet to

meet increased nutritional requirements.

 Select nutritional supplements to maintain adequate caloric intake.

 Administer enteral feedings to meet nutritional needs if patient

cannot tolerate oral feedings.

 Administer parenteral feeding to meet nutritional needs if patient
cannot tolerate oral or enteral feedings.

 Acid-Base Management: Respiratory Acidosis

 Provide low-carbohydrate, high-fat diet (e.g., Pulmocare
feedings) to reduce CO2 production (if indicated) for
patients with respiratory acidosis.

 Oxygen Therapy
 Monitor patient’s ability to tolerate removal of oxygen while
eating to prevent shortness of breath and blood oxygen
desaturation while eating.

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Nursing Diagnosis
Risk for imbalanced fluid volume related to sodium
and water retention

Patient Goals
1. Maintains stable body weight and balanced
intake and output

2. Experiences normal hemodynamic status

Fluid Management
• Monitor for indications of fluid
overload/retention (e.g., crackles, edema, neck
vein distention, ascites) to identify problem.

• Weigh patient daily to evaluate trends in fluid

status.
 Administer prescribed diuretics to prevent or
reduce fluid overload.

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 Monitor hemodynamic status, including VS,

CVP, MAP, SVV, PAP, and PAWP, to detect changes
in systemic fluid volume, cardiac output, and
pulmonary vascular resistance consequent to altered
lung ventilation and/or complications of mechanical
ventilation.
 Maintain accurate intake and output record
daily to evaluate trends in fluid status.

Complications of ARF
 Pulmonary
 Pulmonary embolism
 barotrauma
 pulmonary fibrosis (ARDS)
 Nosocomial pneumonia
 Cardiovascular
 Hypotension, ↓COP
 Arrhythmia
 MI, pericarditis
 GIT
 Stress ulcer, ileus, diarrhea,
hemorrhage
 Infections
 Nosocomial infection
 Pneumonia, UTI,
catheter related sepsis
 Renal
 ARF (hypoperfusion,
nephrotoxic drugs)
 Poor prognosis
 Nutritional
 Malnutrition, diarrhea
hypoglycemia,
electrolyte disturbances

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Prognosis of ARF
 Mortality rate for ARDS → 40%
 Younger patient <60 has better survival rate

 75% of patient survive ARDS have impairment of

pulmonary function one or more years after recovery

 Mortality rate for COPD →10%

 Mortality rate increase in the presence of hepatic,

cardiovascular, renal, and neurological disease

True or False
Dead space ventilation
decreases when blood flow is
reduced

٧٨

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True or False
Shunt occurs when areas of lung
are perfused but not ventilated

٧٩

True or False
In myasthenia gravis
mechanism of hypoxia may be
due to alveoli being perfused
but not ventilated

٨٠

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True or False
Arterial hypoxemia may be
caused by alveolar
hypoventilation alone

٨١

True or False
 The distinction between ventilation/perfusion
mismatch and intrapulmonary shunting can be made
by measuring the response to the administration of
100% oxygen

٨٢

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True or False
 There is a good relationship between dyspnea and
arterial hypoxemia but a poor relationship between
dyspnea and arterial carbon dioxide retention

٨٣

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