Respiratory Failure


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Respiratory Failure

  1. 1. Respiratory Failure Artificial Airways Mechanical Ventilation
  2. 2. Learning Outcomes <ul><li>Describe respiratory failure </li></ul><ul><li>Describe artificial airways </li></ul><ul><li>Describe mechanical ventilation </li></ul><ul><li>Apply nursing management across life span </li></ul>
  3. 3. Respiratory Failure <ul><li>Sudden, life threatening deterioration of the gas exchange function of the lung </li></ul><ul><li>Patient can not eliminate CO2 from the alveoli </li></ul><ul><li>CO2 retention results in hypoxemia </li></ul><ul><li>O2 reaches the alveoli but can not be absorbed or used properly. </li></ul>
  4. 4. Respiratory failure Continued <ul><li>Lung can move air sufficiently but cannot oxygenate the pulmonary blood properly </li></ul><ul><li>Respiratory failure occurs as a result of: </li></ul><ul><ul><li>mechanical abnormality of the lungs or chest wall </li></ul></ul><ul><ul><li>defect in the respiratory control center in the brain or </li></ul></ul><ul><ul><li>Impairment in the function of the respiratory muscles </li></ul></ul>
  5. 5. Acute Respiratory Failure (ARF) <ul><li>Defined as: </li></ul><ul><ul><li>PaO2 < 50 mm Hg (hypoxemia) </li></ul></ul><ul><ul><li>PaCO2 > 50 mm Hg (hypercapnia) </li></ul></ul><ul><ul><li>Arterial pH < 7.35 </li></ul></ul>
  6. 6. Chronic Respiratory Failure (CRF) <ul><li>Defined as: </li></ul><ul><ul><li>Deterioration in gas exchange that has occurred over a long period of time after an episode of ARF </li></ul></ul><ul><ul><li>Absence of acute symptoms and presence of chronic respiratory acidosis </li></ul></ul><ul><ul><li>Patient develop tolerance to gradual worsening hypoxemia and hypercapnia </li></ul></ul><ul><ul><li>COPD and neuromuscular diseases </li></ul></ul>
  7. 7. Pathophysiology ARF <ul><li>Ventilation or perfusion mechanism impaired </li></ul><ul><ul><li>Alveolar hypoventilation </li></ul></ul><ul><ul><li>Diffusion abnormalities </li></ul></ul><ul><ul><li>Ventilation-perfusion mismatching </li></ul></ul><ul><ul><li>shunting </li></ul></ul>
  8. 8. ARF Causes <ul><li>Decreased respiratory drive </li></ul><ul><li>Dysfunction of the chest wall </li></ul><ul><li>Dysfunction of the lung parenchyma </li></ul><ul><li>Post op after major thoracic or abdominal surgery </li></ul>
  9. 9. Decreased Respiratory Drive <ul><li>Severe brain injury </li></ul><ul><li>Lesions of the brain stem (MS) </li></ul><ul><li>Use of sedative medications </li></ul><ul><li>Metabolic disorders (hypothyroidism) </li></ul><ul><li>Theory: These disorders impair chemoreceptors in the brain to normal respiratory stimulation </li></ul>
  10. 10. Dysfunction of Chest Wall <ul><li>Any disease of the nerves, spinal cord, muscles or neuromuscular junction involved in respiration seriously affects ventilation e.g. Muscular dystrophy, Polymyositis, Myasthenia gravis, ALS </li></ul><ul><li>Theory: impulses arising in the respiratory center travel through nerves that extend from the brainstem down the spinal cord to receptors in the muscles of respiration </li></ul>
  11. 11. Dysfunction of Lung Parenchyma <ul><li>Pleural effusion </li></ul><ul><li>Hemothorax </li></ul><ul><li>Upper airway obstruction </li></ul><ul><li>Pneumonia </li></ul><ul><li>PE </li></ul>
  12. 12. Assessment <ul><li>Dyspnea </li></ul><ul><li>Headache </li></ul><ul><li>Restlessness </li></ul><ul><li>Confusion </li></ul><ul><li>Tachycardia </li></ul><ul><li>Cyanosis </li></ul><ul><li>Dysrhythmias </li></ul><ul><li>Decreased LOC </li></ul><ul><li>Alterations in respirations and breath sounds </li></ul>
  13. 13. Nursing Management <ul><li>Identify and treat the cause of respiratory failure </li></ul><ul><li>Administer O2 to maintain PaO2 level above 60 to 70 mm Hg </li></ul><ul><li>High fowlers </li></ul><ul><li>Encourage deep breathing </li></ul><ul><li>Bronchodilators </li></ul><ul><li>Prepare patient for mechanical ventilation if supplemental O2 cannot maintain acceptable PaO2 levels </li></ul>
  14. 14. Acute respiratory Distress Syndrome (ARDS) <ul><li>Form of ARF caused by diffuse lung injury leading to extravascular lung fluid </li></ul><ul><li>Major site of injury is the alveolar capillary membrane </li></ul><ul><li>Interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance </li></ul>
  15. 15. ARDS Continued <ul><li>ABG’s identify respiratory acidosis and hypoxemia that does not respond to an increased percentage of O2 </li></ul><ul><li>Chest x-ray shows interstitial edema </li></ul><ul><li>Sepsis, fluid overload, shock, trauma, neurological injuries, burns, aspiration amongst some of the causes </li></ul>
  16. 16. Assessment <ul><li>One of the earliest signs, tachypnea </li></ul><ul><li>Dyspnea </li></ul><ul><li>Decreased breath sounds </li></ul><ul><li>Deteriorating blood gas levels </li></ul><ul><li>Hypoxemia despite high concentrations of delivered O2 </li></ul><ul><li>Decreased pulmonary compliance </li></ul><ul><li>Decreased infiltrates </li></ul>
  17. 17. Nursing Management <ul><li>Administer O2 </li></ul><ul><li>High Fowlers </li></ul><ul><li>Restrict fluid </li></ul><ul><li>Respiratory treatments </li></ul><ul><li>Diuretics, anticoagulants, corticosteroids </li></ul><ul><li>Prepare patient for intubation and mechanical ventilation, using positive end-expiratory pressure (PEEP) </li></ul>
  18. 18. Artificial Airways <ul><li>Adequate ventilation dependent on free movement of air through the upper and lower airways. </li></ul><ul><li>Many disorders either narrow or block as a result of disease. </li></ul><ul><li>Foreign bodies or secretions can also impede ventilation </li></ul>
  19. 19. Endotracheal Intubation <ul><li>Involves passing endotracheal tube through mouth or note into the trachea with aide of a laryngoscope </li></ul><ul><li>Once passed a cuff is inflated to prevent air from leaking around the outer part of the tube, to minimize the possibility of aspiration and movement of tube </li></ul><ul><li>Provides a patent airway </li></ul><ul><li>Method of choice in emergency care </li></ul>
  20. 21. Nursing Management <ul><li>Assess chest expansion for symmetry </li></ul><ul><li>Auscultate breath sounds </li></ul><ul><li>Obtain chest x-ray </li></ul><ul><li>Check cuff pressure every 8-12 hours </li></ul><ul><li>Monitor for signs of aspiration </li></ul><ul><li>Secure tube to patients face with tape and mark proximal end for position </li></ul>
  21. 22. Nursing Management <ul><li>Provide for oral care, usually need two professionals as tube needs to be moved from side to side of mouth </li></ul><ul><li>Suction prn </li></ul><ul><li>Excessive suctioning, speaking can dislodge tube </li></ul><ul><li>Maintain cuff inflation </li></ul><ul><li>Administer O2 as ordered </li></ul><ul><li>Ensure high humidity </li></ul>
  22. 23. Nursing Management Continued <ul><li>Prevent premature removal of tube. </li></ul><ul><li>Explain to patient and family purpose of tube </li></ul><ul><li>Last resort is use of soft wrist restraints. </li></ul><ul><li>Maintain skin integrity </li></ul>
  23. 24. Extubation <ul><li>Usually respiratory therapist at hospital does this. </li></ul><ul><li>Semifowlers position </li></ul><ul><li>Cuff is deflated </li></ul><ul><li>Monitor for respiratory difficulty e.g. stridor </li></ul><ul><li>O2 as prescribed </li></ul><ul><li>Inform patient may experience hoarseness or sore throat. </li></ul>
  24. 25. Tracheostomy <ul><li>Surgical incision into the trachea for the purpose of establishing an airway </li></ul><ul><li>Tracheostomy is the stoma or opening that results from the tracheotomy </li></ul><ul><li>Can be permanent or temporary </li></ul>
  25. 27. Types (See table 20-1) <ul><li>Double Lumen </li></ul><ul><li>Single Lumen </li></ul><ul><li>Cuffed Tube </li></ul><ul><li>Cuffless tube </li></ul><ul><li>Fenestrated tube </li></ul><ul><li>Cuffed fenestrated tube </li></ul><ul><li>Metal tracheostomy tube </li></ul><ul><li>Talking tracheostomy tube </li></ul>
  26. 28. Double Lumen <ul><li>Outer cannula: fits into stoma and keeps airway open </li></ul><ul><li>Inner cannual: fits into outer cannula and locks into place. Some can e removed and cleaned and reused. </li></ul><ul><li>Obturator: stylet with a blunt end used to facilitate direction of tube when inserting. Removed after tube placement </li></ul>
  27. 29. Fenestrated <ul><li>Used to wean patient from a tracheostomy </li></ul><ul><li>Allows patient to speak </li></ul><ul><li>Cuffed used with spinal cord paralysis: can facilitate mechanical ventilation and speech. </li></ul>
  28. 30. Nursing Management <ul><li>Assess respirations for bilateral breath sounds </li></ul><ul><li>Monitor ABGs and pulse ox </li></ul><ul><li>Encourage deep breathing and coughing </li></ul><ul><li>Maintain semi to high fowlers position </li></ul><ul><li>Monitor for bleeding </li></ul><ul><li>Suction prn </li></ul><ul><li>Assess stoma </li></ul><ul><li>If tube dislodges, initial nursing action is to grasp the retention sutures to spread the opening </li></ul>
  29. 31. Mechanical Ventilation <ul><li>Controls patients respirations during surgery or during treatment of severe head injury </li></ul><ul><li>Oxygenate the blood when patients ventilator efforts are inadequate </li></ul><ul><li>Rest the respiratory muscles </li></ul><ul><li>Positive or negative pressure device that maintains ventilation and oxygen delivery for a prolonged period of time </li></ul>
  30. 32. Indications <ul><li>PaO2 < 50 mm Hg with pH < 7.25 </li></ul><ul><li>Vital capacity < 2 times the tidal volume </li></ul><ul><li>Negative inspiratory force <25 cm H2O </li></ul><ul><li>Respiratory rate >35/min </li></ul>
  31. 33. Classification of Ventilators <ul><li>Negative-pressure </li></ul><ul><ul><li>Simple and do not require intubation of the airway </li></ul></ul><ul><ul><li>The iron lung, also known as the Drinker and Shaw tank, was one of the first negative-pressure machines used for long-term ventilation. </li></ul></ul><ul><ul><li>The machine is a large elongated tank, which encases the patient up to the neck. </li></ul></ul>
  32. 35. Positive Pressure Ventilators <ul><li>Work by increasing the patient's airway pressure through an endotracheal or tracheostomy tube. </li></ul><ul><li>The positive pressure allows air to flow into the airway until the ventilator breath is terminated </li></ul><ul><li>Subsequently, the airway pressure drops to zero, and the elastic recoil of the chest wall and lungs push the tidal volume, the breath out through passive exhalation </li></ul>
  33. 36. Types <ul><li>Pressured Cycled </li></ul><ul><ul><li>Delivers a flow of air (inspiration) until it reaches a preset pressure and then cycles off </li></ul></ul><ul><ul><li>Expiration occurs passively </li></ul></ul><ul><ul><li>Intended only for short term </li></ul></ul><ul><ul><li>Most common type IPPB machine </li></ul></ul>
  34. 37. Types continued <ul><li>Timed Cycled </li></ul><ul><ul><li>Pushes air into lungs until a preset time has elapsed </li></ul></ul><ul><ul><li>Used in newborns or neonatal client </li></ul></ul>
  35. 38. Types Continued <ul><li>Volume-cycled </li></ul><ul><ul><li>Pushes air into the lungs until a preset volume is delivered </li></ul></ul><ul><ul><li>A constant tidal volume is delivered regardless of changing compliance of the lungs and chest wall or the airway resistance in the client or ventilator </li></ul></ul>
  36. 39. Types Continued <ul><li>Noninvasive positive pressure </li></ul><ul><ul><li>Given via face mask cover nose and mouth, nasal mask </li></ul></ul><ul><ul><li>CPAP: continuous positive airway pressure </li></ul></ul><ul><ul><li>BPAP: bi-level positive airway pressure </li></ul></ul><ul><ul><li>Used for sleep apnea, positive pressure act as a splint keeping the upper airway and trachea open during sleep. </li></ul></ul>
  37. 40. Modes of Ventilation <ul><li>Controlled </li></ul><ul><ul><li>Set tidal volume at set rate </li></ul></ul><ul><ul><li>Used for patients who can not initial respiration </li></ul></ul><ul><ul><li>Least used mode because if patient tries to initiate a breath, the efforts are blocked by the ventilator </li></ul></ul>
  38. 41. Modes continued <ul><li>Assist control (AC) </li></ul><ul><ul><li>Most commonly used </li></ul></ul><ul><ul><li>Tidal volume and ventilator rate are preset </li></ul></ul><ul><ul><li>Ventilator takes over the work of breathing for client </li></ul></ul><ul><ul><li>Programmed to respond should the patient initiate a breath </li></ul></ul>
  39. 42. Modes Continued <ul><li>Synchronized intermittent mandatory ventilation (SIMV) </li></ul><ul><ul><li>Similar to AC however allows patient to breath spontaneously at their own rate </li></ul></ul><ul><ul><li>Can be used as primary or weaning mode. </li></ul></ul><ul><ul><li>When used in weaning mode, the number of SIMV breaths is gradually decreased and the patient gradually resumes spontaneous breathing </li></ul></ul>
  40. 43. Ventilator controls and settings <ul><li>Tidal volume: volume of air that the client receives with each breath </li></ul><ul><li>Rate: number of ventilator breaths delivered per minute </li></ul><ul><li>Fraction of inspired oxygen (FiO2): concentration of oxygen delivered to patient. Determined by ABG </li></ul>
  41. 44. Controls and settings <ul><li>Sighs: volumes of air that are 1.5 to 2 times the set tidal volume, delivered 6 to 10 times per hour </li></ul><ul><li>PIP: peak airway inspiratory pressure: pressure needed by ventilator to deliver a set tidal volume at a given compliance </li></ul>
  42. 45. Positive End Expiratory Pressure (PEEP) <ul><li>Positive pressure exerted during the expiratory phase of ventilation </li></ul><ul><li>Improved oxygenation by enhancing gas exchange and preventing adelectasis </li></ul><ul><li>Need indicates a severe gas exchange disturbance </li></ul>
  43. 46. Nursing management <ul><li>Assess patient first, ventilator second </li></ul><ul><li>VS, lung sounds, respiratory status and breathing pattern </li></ul><ul><li>Monitor skin color, lips and nail beds </li></ul><ul><li>Monitor chest for bilateral expansion </li></ul><ul><li>Assess ventilator settings </li></ul><ul><li>Ensure alarms are set </li></ul><ul><li>Empty ventilator tubing when moisture collects </li></ul><ul><li>T&P client at least every 2 hours </li></ul>