Acute Respiratory failure

MANAGEMENT OF PATIENT
WITH ACUTE RESPIRATORY
FAILURE
MATHEW VARGHESE V
MSN(RAK),FHNP (CMC Vellore),CPEPC
Nursing officer
AIIMS Delhi
mathewvmaths@yahoo.co.in
1

INTRODUCTION
 Respiratory failure is a sudden and life-threatening
deterioration of the gas exchange function of the
lung.
 It exists when the exchange of oxygen for carbon
dioxide in the lungs cannot keep up with the rate of
oxygen consumption and carbon dioxide production
by the cells of the body.
 Respiratory failure is a condition in which your
blood doesn't have enough oxygen or has too much
carbon dioxide.
 Sometimes you can have both problems.
2

DEFINITION OF RESPIRATORY FAILURE
 Respiratory failure is a syndrome of inadequate gas
exchange due to dysfunction of one or more
essential components of the respiratory system:
Such as
 Chest wall (including pleura and diaphragm)
 Airways
 Alveolar – capillary units
 Pulmonary circulation
 Nerves
 CNS or Brain Stem
4

EPIDEMIOLOGY OF RESPIRATORY FAILURE
 Incidence: about 360,000 cases per year in the
United States
 36% die during hospitalization
 Morbidity and mortality rates increase with age and
presence of co morbidities
 It is the main cause of death from pneumonia and
chronic obstructive pulmonary disease (COPD),
which together comprise the third-leading cause of
death in the United States today.
6

TYPES OF RESPIRATORY FAILURE
Respiratory
Failure
Acute
Chronic
7

ACUTE RESPIRATORY FAILURE
 Acute respiratory failure (ARF) is defined as a fall in
arterial oxygen tension (PaO2) to less than 50 mm
Hg (hypoxemia) and a rise in arterial carbon dioxide
tension (PaCO2) to greater than 50 mm Hg
(hypercapnia), with an arterial pH of less than 7.35.
8

ARF
 Respiratory system mechanisms leading to ARF
include:
 Alveolar hypoventilation
 Diffusion abnormalities
 Ventilation–perfusion mismatching
 Shunting
9

CHRONIC RESPIRATORY FAILURE
 Chronic respiratory failure is defined as
deterioration in the gas exchange function of the
lung that has developed insidiously or has persisted
for a long period after an episode of ARF.
 The absence of acute symptoms and the presence
of a chronic respiratory acidosis suggest the
chronicity of the respiratory failure.
10

CAUSES OF CHRONIC RESPIRATORY FAILURE
 Two causes of chronic respiratory failure are COPD
and neuromuscular diseases.
 Patients with these disorders develop a tolerance to
the gradually worsening hypoxemia and
hypercapnia.
 However, a patient with chronic respiratory failure
may develop ARF.
 This is seen in the COPD patient who develops an
exacerbation or infection that causes additional
deterioration of the gas exchange mechanism.
11

TYPES OF ACUTE RESPIRATORY FAILURE
Type I or Hypoxemic respiratory failure
Type II or Hypercapnic respiratory failure
Type III Respiratory Failure: Perioperative
Respiratory Failure
Type IV Respiratory Failure: Shock
12

TYPE I OR HYPOXEMIC RESPIRATORY FAILURE
 It means that a person is not exchanging oxygen
properly in their lungs.
 This may be due to swelling or damage to the
lungs.
 A person with type 1 acute respiratory failure has
very low oxygen levels.
 PaO2<60 mm of Hg
 Failure of oxygen exchange
13

DEFINITION
 Type 1 respiratory failure is defined as a low level of
oxygen in the blood (hypoxemia) with either a
normal (normocapnia) or low (hypocapnia) level of
carbon dioxide (PaCO2) but not an increased level
(hypercapnia).
 It is typically caused by a ventilation/perfusion (V/Q)
mismatch; the volume of air flowing in and out of
the lungs is not matched with the flow of blood to
the lungs.
14

CAUSES OF TYPE 1 ARF
ARF
• Low ambient oxygen
• Ventilation-perfusion mismatch
ARF
• Alveolar hypoventilation
• Diffusion problem
ARF
• Shunt
15

TYPE II OR HYPERCAPNIC RESPIRATORY FAILURE :
(PACO2> 45 MM OF HG): FAILURE TO EXCHANGE OR REMOVE CARBON DIOXIDE
 In type II ARF ,the lungs are not removing enough
carbon dioxide
 The lungs usually exchange carbon dioxide for
fresh oxygen.
 This type of respiratory failure causes carbon
dioxide levels to be high.
 It may result from a drug overdose that has caused
a person to breathe too slowly or because of lung
damage from smoking, which causes COPD.
16

CAUSES OF TYPE II
Increased airways resistance
Reduced breathing effort
A decrease in the area of the lung available for gas exchange
Neuromuscular problems
Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail
chest
17

TYPE III RESPIRATORY FAILURE:
PERIOPERATIVE RESPIRATORY FAILURE
 It occurs when a person has had surgery, and the
small airways in the lungs have closed in greater
numbers.
 Factors such as pain or stomach surgery, which
places higher pressure on the lungs, can also
contribute to this type of respiratory failure.
18

TYPE IV RESPIRATORY FAILURE: SHOCK
 Type 4 respiratory failure is a shock state.
 It means that the body cannot adequately provide
oxygen and maintain blood pressure on its own.
 This can result from serious illness or injury, such
as when a person loses too much blood
19

PRECIPITATING CONDITIONS LEADING TO
ACUTE RESPIRATORY FAILURE
 Acute exacerbation of
asthma
 Pulmonary embolism
 Pulmonary edema
 Acute respiratory distress
syndrome
 Pneumonia
 Acute epiglottitis
 Cardiogenic pulmonary
edema
 Pulmonary trauma
 Inhalation injury
 Upper/lower airway
obstruction
 Pneumothorax
 Chronic lung disease
 Bronchiectasis
 Alveolar abnormalities
 Chest wall abnormalities
(e.g., kyphoscoliosis)
 Malignancy
 Decompensate congestive
cardiac failure
 Collagen vascular disease.
20

CLASSIFICATION OF CAUSES
Decreased respiratory
drive
Dysfunction of the chest
wall
Dysfunction of the lung
parenchyma
Other causes
21

CLINICAL MANIFESTATIONS
EARLY SIGNS
Restlessness
Fatigue
Headache
Dyspnea
Air hunger
Tachycardia
 Increased blood pressure.
22

LATE SIGNS
Confusion
Lethargy
Tachycardia
Tachypnea
Central cyanosis
Diaphoresis
Finally respiratory arrest
23

PATHOPHYSIOLOGY OF ACUTE RESPIRATORY
FAILURE – TYPE I
Ventilation/
Perfusion
(V/Q)
mismatch
Pulmonary
Shunt
Other
mechanisms
Alveolar unit
failure
Pulmonary
vasculature
failure
24

TYPE II FAILURE (HYPERCAPNIC FAILURE)
PATHOPHYSIOLOGIC MECHANISMS
Decreased minute ventilation (MV) relative to
demand
Increased dead space ventilation
Nervous system failure
Chest wall and pleural space failure
Airway failure
Neuromuscular transmission failure
Muscle (pump) failure
25

DIAGNOSIS
 History
 Physical Examination Findings
 Lab investigations
• ABG
• Complete blood count
• Cardiac serologic markers
• Microbiology
 Chest X Ray
 Electrocardiogram
 Echocardiography
 Pulmonary function tests/bedside spirometry
 Bronchoscopy
26

MANAGEMENT
27

ALGORITHM
28

MANAGEMENT MEASURES
ABC’s
 Ensure airway is adequate
 Ensure adequate supplemental oxygen and
assisted ventilation, if indicated
 Support circulation as needed
Treatment of a specific cause when possible
 Infection management
Antimicrobials
Source control
29

MANAGEMENT MEASURES
 Airway obstruction
Bronchodilators
Glucocorticoids
 Improve cardiac function
Positive airway pressure
Diuretics,
Vasodilators
Morphine
Ionotrops
Revascularization
30

MANAGEMENT MEASURES
 Mechanical ventilation
 Non - invasive (if patient can protect airway and is
hemodynamically stable)
 Mask: usually orofacial to start
 Invasive
 Endotracheal tube (ETT)
 Tracheostomy – if upper airway is obstructed
31

INDICATIONS FOR MECHANICAL VENTILATION
 Cardiac or respiratory arrest
 Tachypnea or bradypnea
with respiratory fatigue or
impending arrest
 Acute respiratory acidosis
 Refractory hypoxemia
(when the P a O 2 could not
be maintained above 60
mm Hg with inspired O 2
fraction (F I O 2 )>1.0)
 Inability to protect the
airway associated with
depressed levels of
consciousness
 Shock associated with
excessive respiratory work
 Inability to clear secretions
with impaired gas exchange
or excessive respiratory
work
 Newly diagnosed
neuromuscular disease with
a vital capacity <10-15ml/kg
 Short term adjunct in
management of acutely
increased intracranial
pressure (ICP)
32

NON - INVASIVE VENTILATION INDICATION
 COPD exacerbation
 Cardiogenic pulmonary edema
 Obesity hypoventilation syndrome
 Noninvasive ventilation may be tried in selected
patients with asthma or non patients with asthma or
non - cardiogenic hypoxemic respiratory failure
respiratory failure
33

 Goals of Mechanical Ventilation
 Improve ventilation by augmenting respiratory rate
and tidal volume
 Assistance for neural or muscle dysfunction
 Sedated, comatose or paralyzed patient
 Neuropathy, myopathy or muscular dystrophy
 Intra - operative ventilation
 Correct respiratory acidosis, providing goals of lung
- protective ventilation are met
 Match metabolic demand
 Rest respiratory muscles
34

NURSING DIAGNOSIS AND INTERVENTIONS
 Nursing Diagnosis: Impaired gas exchange
related to ventilation–perfusion inequality
 Goal: Improvement in gas exchange
 Nursing Diagnosis: Ineffective airway clearance
related to bronchoconstriction, increased mucus
production, ineffective cough, bronchopulmonary
infection, and other complications
 Goal: Achievement of airway clearance
35

 Nursing Diagnosis: Ineffective breathing pattern
related to shortness of breath, mucus,
bronchoconstriction, and airway irritants
 Goal: Improvement in breathing pattern
 Nursing Diagnosis: Self-care deficits related to
fatigue secondary to increased work of breathing
and insufficient ventilation and oxygenation
 Goal: Independence in self-care activities
36

 Nursing Diagnosis: Activity intolerance due to fatigue,
hypoxemia, and ineffective breathing patterns
 Goal: Improvement in activity tolerance
 Nursing Diagnosis: Ineffective coping related to
reduced socialization, anxiety, depression, lower activity
level and the inability to work
 Goal: Attainment of an optimal level of coping
 Nursing Diagnosis: Deficient knowledge about self-
management to be performed at home.
 Goal: Adherence to therapeutic program and home care
37

RESEARCH STUDIES
 Title :Patients’ Outcomes After Acute Respiratory
Failure: A Qualitative Study With the PROMIS
Framework
 Author :Michelle N. Eakin, PhD,Yashika Patel, BA,
BS ; Pedro Mendez-Tellez, MD
 Am J Crit Care (2017) 26 (6): 456–465.
 https://doi.org/10.4037/ajcc2017834
38

RESEARCH STUDY
 Objective
 To describe the survivorship experience of patients who
had acute respiratory failure by using the Patient
Reported Outcomes Measurement Information System
(PROMIS) framework.
 Methods
 A total of 48 adult patients who had acute respiratory
failure completed at least 1 semistructured telephone-
based interview between 5 and 18 months after their
stay in the intensive care unit. Participants were asked
about overall well-being and important health outcomes.
39

RESULTS
 Major themes were identified within each of the 3
PROMIS components: physical health, mental health,
and social health.
 The following themes were particularly prominent:
mobility impairments, pulmonary symptoms, fatigue,
anxiety and depression symptoms, and decreased
ability to work and participate in valued activities.
 Impacts on overall well-being and on relationships with
friends and family members varied among the survivors.
 Some survivors reported gratitude, increased
appreciation of life, and closer relationships to loved
ones. Other survivors reported boredom, social
isolation, and wishing they had not survived.
40

CONCLUSIONS
 Survivors of acute respiratory failure reported
substantial issues with their physical, mental, and
social health.
 Holistic assessments of outcomes of survivors of
critical illness should capture the complex beneficial
and adverse impacts of critical illness on survivors’
well-being and social health.
41

REFERENCES
 Midelton G.T., Frishman W.H., Passo S.S. (2002). Congestive
heart failure and continuous positive airway pressure therapy:
support of a new mo continuous positive airway pressure
therapy: support of a new mo dality for improving the
prognosis and survival of patients with advanced congestive
heart failure. heart failure. Heart Disease, Volume 4 Disease,
Volume 4 , Number 2, p 102 Number 2, p 102 - 109 .
 Arora ,V.K., Shankar Shankar , U. (1995). Acute Lung Injury. ,
U. (1995). Acute Lung Injury. Lung India, Volume Lung India,
Volume XIII, Number 1, p 32 1, p 32 - 34.
 Behrendt C.F. (2000). Acute respiratory failure in the United
States: Inc C.F. (2000). Acute respiratory failure in the United
States: Inc idence and 31 - day survival. day survival. Chest,
Volume 118, Number 4, p 1100 Chest, Volume 118, Number 4,
p 1100 - 1105.
42

Acute Respiratory failure

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