Respiratory failure

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Respiratory Failure
Ms . Amandeep KaurMs . Amandeep Kaur
M.M.College of NursingM.M.College of Nursing

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

Gas Exchange Unit

Not a disease but a conditionNot a disease but a condition
Result of one or more diseasesResult of one or more diseases
involving the lungs or other bodyinvolving the lungs or other body
systemssystems

Classification of Respiratory Failure
Fig. 68-2

Range of V/Q Relationships
Fig. 68-4

Hypoxemic Respiratory Failure
Etiology and Pathophysiology
1. Ventilation-perfusion (V/Q) mismatch1. Ventilation-perfusion (V/Q) mismatch
 COPD
 Pneumonia
 Asthma
 Atelectasis
 Pulmonary embolus

2. Shunt
 Anatomic shunt
 Intrapulmonary shunt
 An extreme V/Q mismatch

3. Diffusion limitation
 Severe emphysema
 Recurrent pulmonary emboli
 Pulmonary fibrosis
 Hypoxemia present during exercise

Diffusion Limitation
Fig. 68-5

4. Alveolar hypoventilation
 Restrictive lung disease
 CNS disease
 Chest wall dysfunction
 Neuromuscular disease

5. Interrelationship of mechanisms5. Interrelationship of mechanisms
 Combination of two or more
physiologic mechanisms

Hypercapnic Respiratory Failure
1. Imbalance between ventilatory1. Imbalance between ventilatory
supply and demandsupply and demand

2. Airways and alveoli2. Airways and alveoli
 Asthma
 Emphysema
 Chronic bronchitis
 Cystic fibrosis

3. Central nervous system3. Central nervous system
 Drug overdose
 Brainstem infarction
 Spinal chord injuries

4. Chest wall4. Chest wall
 Flail chest
 Fractures
 Mechanical restriction
 Muscle spasm

5. Neuromuscular conditions5. Neuromuscular conditions
 Muscular dystrophy
 Multiple sclerosis

Clinical Manifestations
Sudden or gradual onsetSudden or gradual onset
A suddenA sudden decrease in PaOdecrease in PaO22 or rapidor rapid
increase in PaCOincrease in PaCO22 indicates a seriousindicates a serious
conditioncondition

When compensatory mechanismsWhen compensatory mechanisms
fail, respiratory failure occursfail, respiratory failure occurs
Signs may be specific or nonspecificSigns may be specific or nonspecific

Severe morning headacheSevere morning headache
CyanosisCyanosis
 Late sign
Tachycardia and mild hypertensionTachycardia and mild hypertension
 Early signs

Consequences of hypoxemia andConsequences of hypoxemia and
hypoxiahypoxia
 Metabolic acidosis and cell death
 Decreased cardiac output
 Impaired renal function

Specific clinical manifestationsSpecific clinical manifestations
 Rapid, shallow breathing pattern
 Tripod position
 Dyspnea

Specific clinical manifestationsSpecific clinical manifestations
 Pursed-lip breathing
 Retractions
 Change in I:E ratio

Diagnostic Studies
 History and physical assessmentHistory and physical assessment
 ABG analysisABG analysis
 Chest x-rayChest x-ray
 CBC, sputum/blood cultures, electrolytesCBC, sputum/blood cultures, electrolytes
 ECGECG
 UrinalysisUrinalysis
 V/Q lung scanV/Q lung scan
 Pulmonary artery catheter (severe cases)Pulmonary artery catheter (severe cases)

Treatment Goals
O2 therapyO2 therapy
Mobilization of secretionsMobilization of secretions
Positive pressure ventilation(PPV)Positive pressure ventilation(PPV)

O2 Therapy
 If secondary to V/Q mismatch- 1-3L or 24%-If secondary to V/Q mismatch- 1-3L or 24%-
32% by mask32% by mask
 If secondary to intrapulmonary shunt- positiveIf secondary to intrapulmonary shunt- positive
pressure ventilation-PPVpressure ventilation-PPV
 May be via ET tube
 Tight fitting mask
 **Goal is PaO2 of 55-60 with SaO2 at 90% or more
at lowest O2 concentration possible
 **O2 at high concentrations for longer than 48
hours causes O2 toxicity

O2 toxicity
 Oxygen toxicity may occur when too high aOxygen toxicity may occur when too high a
concentration of oxygen (greater than 50%) isconcentration of oxygen (greater than 50%) is
administered for an extended period(longeradministered for an extended period(longer
than 48 hours).than 48 hours).
 It is caused by overproduction of oxygen freeIt is caused by overproduction of oxygen free
radicals, which are byproducts of cellradicals, which are byproducts of cell
metabolism. If oxygen toxicity is untreated,metabolism. If oxygen toxicity is untreated,
these radicals can severely damage or kill cells.these radicals can severely damage or kill cells.

Contd....
Signs and symptoms of oxygen toxicitySigns and symptoms of oxygen toxicity
include:include:
 substernal discomfort,substernal discomfort,
paresthesias,paresthesias,
dyspnea,dyspnea,
 restlessness, fatigue, malaise,restlessness, fatigue, malaise,
progressiveprogressive respiratory difficulty, andrespiratory difficulty, and
alveolar infiltrates evident onchest x-alveolar infiltrates evident onchest x-
rays.rays.

Prevention of oxygen toxicity
 If high concentrations of oxygen are necessary, it isIf high concentrations of oxygen are necessary, it is
important to minimize the duration of administrationimportant to minimize the duration of administration
and reduce its concentration as soon as possible.and reduce its concentration as soon as possible.
 Often, positive end expiratory pressure (PEEP) orOften, positive end expiratory pressure (PEEP) or
continuous positive airway pressure (CPAP) is usedcontinuous positive airway pressure (CPAP) is used
with oxygen therapy to reverse or preventwith oxygen therapy to reverse or prevent
microatelectasis, thus allowing a lower percentage ofmicroatelectasis, thus allowing a lower percentage of
oxygen to be used.oxygen to be used.
 The level of PEEP that allows the best oxygenationThe level of PEEP that allows the best oxygenation
without hemodynamic compromise is known as “bestwithout hemodynamic compromise is known as “best
PEEPPEEP

Mobilization of secretions
 Effective coughing- quad cough(asisst cough), huffEffective coughing- quad cough(asisst cough), huff
cough(own gentle way to cough ), staged cough(seriescough(own gentle way to cough ), staged cough(series
of deep breaths, then one little cough…..so on)of deep breaths, then one little cough…..so on)
 Positioning- Head of bed 45 degrees or recliner chairPositioning- Head of bed 45 degrees or recliner chair
or bedor bed
 “Good lung down”
 Hydration - fluid intake 2-3 L/dayHydration - fluid intake 2-3 L/day
 Humidification- aerosol treatments- mucolytic agentsHumidification- aerosol treatments- mucolytic agents
 Chest PT- postural drainage, percussion andChest PT- postural drainage, percussion and
vibrationvibration
 Airway suctioningAirway suctioning

Positive Pressure Ventilation
 Invasively through oro or nasotrachealInvasively through oro or nasotracheal
intubationintubation
 Noninvasively( NIPPV) through maskNoninvasively( NIPPV) through mask
 Used for acute and chronic respiratory failure
 BiPAP- different levels of pressure for inspiration
and expiration- (IPAP) higher for inspiration,
(EPAP) lower for expiration
 CPAP- for sleep apnea
 **Used best in chronic resp failure in patients with
chest wall and neuromuscular disease, also with HF
and COPD.

Drug Therapy
 Relief of bronchospasm- bronchodilatorsRelief of bronchospasm- bronchodilators
 Reduction of airway inflammation-Reduction of airway inflammation-
Corticosteroids by inhalation or IVCorticosteroids by inhalation or IV
 Reduction of pulmonary congestion-diureticsReduction of pulmonary congestion-diuretics
and nitroglycerine with heart failure-and nitroglycerine with heart failure-
 Treatment of pulmonary infections- IVTreatment of pulmonary infections- IV
antibiotics, vancomycinantibiotics, vancomycin
 Reduction of anxiety, pain and agitationReduction of anxiety, pain and agitation
 May need sedation or neuromuscularMay need sedation or neuromuscular
blocking agent if on ventilatorblocking agent if on ventilator

Nutrition
During acute phase- enteral orDuring acute phase- enteral or
parenteral nutritionparenteral nutrition
In a hypermetabolic state- needIn a hypermetabolic state- need
more caloriesmore calories
 If retain CO2- avoid high carb diet

Nursing and Collaborative Management
Nursing AssessmentNursing Assessment
 Health information
 Health history
 Medications
 Surgery

Nursing AssessmentNursing Assessment
 Functional health patterns
 Health perception–health management
 Nutritional-metabolic
 Activity-exercise
 Sleep-rest
 Cognitive-perceptual
 Coping–stress tolerance

 Nursing AssessmentNursing Assessment
 Physical assessment
 General
 Integumentary
 Respiratory
 Cardiovascular
 Gastrointestinal
 Neurologic
 Laboratory findings

Nursing DiagnosesNursing Diagnoses
 Impaired gas exchange
 Ineffective airway clearance
 Ineffective breathing pattern
 Risk for fluid volume imbalance
 Anxiety
 Imbalanced nutrition: Less than body
requirements

Planning: Overall goalsPlanning: 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

PreventionPrevention
 Thorough history and physical
assessment to identify at-risk
patients
 Early recognition of respiratory
distress

Respiratory therapyRespiratory 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

 Mobilization of secretions
 Hydration and humidification
 Chest physical therapy
 Airway suctioning
 Effective coughing and positioning

 Positive pressure ventilation (PPV)
 Noninvasive PPV
 BiPAP
 CPAP

Noninvasive PPV
Fig. 68-7

Gerontologic Considerations
Physiologic aging results inPhysiologic aging results in
 ↓ Ventilatory capacity
 Alveolar dilation
 Larger air spaces
 Loss of surface area
 Diminished elastic recoil
 Decreased respiratory muscle strength
 ↓ Chest wall compliance

Gerontologic Considerations
Lifelong smokingLifelong smoking
Poor nutritional statusPoor nutritional status
Less available physiologic reserveLess available physiologic reserve
 Cardiovascular
 Respiratory
 Autonomic nervous system

Respiratory failure

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Respiratory failure