2.1 Respiratory Failure Flashcards
Explain the difference between hypoxia and hypoxemia
Hypoxia:
Arterial blood paO2 of <60 (norm 60-100)
Reduced level of tissue oxygenation
Hypoxia is a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis; this can result from inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood (hypoxemia)
Hypoxemia: Inadequate oxygenation at the cellular (tissue) level Low oxygen content in the blood Decrease O2 in blood Life threatening Leads to cardiac dysrhythmias
Analyze the two types of respiratory failure and some common causes for each
RESPIRATORY INSUFFICIENCY
RESPIRATORY FAILURE
Respiratory Insufficiency:
Resp function not adequate to meet needs of body
Compensatory mech working to prevent harm
May be acute or chronic
Respiratory Failure: Unable to achieve adequate gas exchange even at rest Compensatory mech no longer working Inadequate tissue O2 Severe acid/base disturbance
Identify ABG changes in each type of of acute respiratory failure
PaO2: <60mm HG on oxygen or room air (60-100 norm)
PaCO2: >50mm HG (35-45 norm)
Resp rate: >30 or <8/min
Vital capacity: <15ml/kg
Compare the goals of interventions in respiratory insufficiency and respiratory failure
Goal:
Restore the PaO2 (60-100 norm) and PaCO2 (35-45 norm) to previous levels
Low paO2 and high paCO2 = ventilation problem
Hypoxemia with hypercapnia (excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration)
Pathology of pleural effusions?
Excess pleural fluid between the parietal and visceral pleura
Transudative:
- protein poor excessive fluid
- heart failure most common
- may also have renal failure, nephrosis, liver failure and malignancy
Exudative:
- protein rich excessive fluid
- seen with inflammatory process such as infection, systemic inflammation, pulmonary infarction, malignancy
Complications of pleural effusions
Lung scarring
Pneumothorax (secondary to thoracentesis)
Empyema (Infection that turns into an abscess)
Sepsis
Significant morbidity and to death
Treatment of of pleural effusions
Treatment:
Monitor: O2, no intervention if not problems
Thoracentesis: invasive procedure to remove fluid, analyze for appearance, cell count, protein, glucose
Pleurodesis: chemical or surgical. Creation of adhesions between the parietal and visceral pleura. Instilling chemical agent to produce an inflammatory response that creates scar tissue and adhesions between the layers
Nursing care: Pre: Consent Patient understanding of procedure Fasting or sedation before Cough suppressant Patient upright, leaning forward Post: Monitor pulse, color, O2, dressing on site Position patient on unaffected side for 1 hour Label specimen Vital signs Obtain chest x-ray
Diagnosis: Auscultation Percussion Tactile fremitus Chest x-ray CT
Analyze methods to oxygenate/ventilate patients utilizing noninvasive techniques (NIV)
High flow O2: Must be able to vent on own Normal inhale speed of 20-30 LPM High flow is up to 60 LPM Heated to body temp, 100% humidified Washes dead space to decrease CO2, increased O2
CPAP:
Continuous positive airway pressure
Pt received set amount of pressure
Can be delivered via ETT or mask
BiPAP:
2 levels of positive pressure
Higher on inspiration
Lower on expiration
Full face (nasal interface):
Less risk for aspiration and claustrophobia
Easier secretion clearance, communication, nutrition
Easy to fit and secure
What assessment indicates appropriate oxygenation/ventilation
Monitoring O2 BP Respiratory Lung sounds Skin color Capillary refill ABG within normal ranges -pH 7.35-7.45 -PaCO2 35-45 -HCO3 22-26
Review assessments/interventions for patients receiving NIV (non-invasive ventilation)
Nasal cannula Face mask CPAP BiPAP Assist Controlled Synchronized Intermittent Positive End Expiratory (PEEP)
Assess:
Correct settings per orders
O2
Proper fitting
Identify indications for mechanical ventilatioin
Apnea or progression of resp failure
Hypoxemia that is unresponsive to other methods
Increased work of breathing with progressive fatigue
Most common indicator is actual/potential resp muscle fatigue
What is endotracheal intubation?
Inserted by provider
Place between right and left lung
Discuss rationale for insertion of endotracheal intubation
Rationale for insertion:
To keep airways open
Protect the lungs
Stopped breathing or having difficulty breathing
Head injury and can’t breath on own
Sedation needed for period of time for recovery
Discuss procedure, equipment, assistance needed, cuff, signs of successful intubation of endotracheal intubation
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Discuss oral endotracheal intubation complications, advantages and disadvantages
Endotracheal intubation
Complications:
Obstruction or displacement
Pressure necrosis of lips
Tracheoesophageal fistula
Advantages:
Easier insertion
Larger tube can be used facilitating breathing and suctioning
Disadvantages:
More difficult to secure
Can be obstructed by biting
Communication and mouth care more difficult
Increased risk of lower respiratory infection
Discuss endotracheal intubation extubation
Can be performed when patient can maintain effective respirations and ventilation
Gag, cough and swallowing reflex must be intact
After oxygenation and suctioning, cuff is deflated and tube removed
Provide humidified oxygen immediately after
Close observation of respiratory distress
Inspiratory striders w/in 24 hr indicates laryngeal edema
Sore throat, hoars voice common
Slowly reintroduce oral intake
Assess swallowing
Describe positive pressure ventilation
More commonly used
Push air into the lungs
Can be used with noninvasive and invasive ventilators
Compare volume-cycled and pressure cycled ventilators
Volume cycled: air delivery until a preset volume is delivered
Pressure cycled: cycle off when a present pressure is achieved within the airways
What is the controlled method of ventilating a patient
Ventilation controlled breaths is usually triggered by a present time intervals.
Ex: a breath is delivered every 5 seconds of a rate of 12 breaths per minute
What is the assist-control method of ventilating a patient
Used when patients at risk for respiratory arrest (head injury, OD)
Assisted breaths are triggered by inspiratory effort
If respiratory rate drops below present number, ventilator-controlled breaths are delivered
All breaths, assisted and controlled are delivered at a specific tidal volume or pressure and inspiratory flow rate
What is the SIMV method of ventilating a patient.
SIMV: synchronized Intermittent Mandatory Ventilation
Vent breaths synchronized between patient’s own (unassisted) breaths
Used with weaning
What is the ventilator settings for respiratory rate
Number of ventilator-delivered breath per minute
Usually 12-15/min for adults using ACMV (assist-controlled), may be slower with SIMV (synchronized intermittent)
What is the ventilator settings for tidal volume
Amount of gas delivered with each ventilator breath
Usually 8-10 ml/kg
Tidal volume is the amount of air that moves in or out of the lungs with each respiratory cycle
What is the ventilator settings for FiO2 (fraction of inspired oxygen)
For all supplemental oxygen delivery devices, the patient is not just breathing the direct oxygen, but rather is breathing a combination of room air plus the oxygen from the supplemental device
Percentage of oxygen delivered with ventilator breaths
Can be set at 21 (room air) and 100%
Meaning that the concentration of oxygen at room air is 21%
Explain how these settings (respiratory rate, tidal volume, FiO2) are adjusted to correct abnormal ABG results
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Review CPAP
CPAP: Continuous positive airway pressure Pt received set amount of pressure Can be delivered mask Must be spontaneous breather Can be used with endotracheal intubation Used to help maintain open airways and alveoli Decreases work of breathing
Review Bi-PAP
BiPAP:
2 levels of positive pressure
Higher on inspiration
Lower on expiration
Bilevel ventilation is mode of high PEEP and low PEEP
Three modes:
S: spontaneous breathing
T: timed mode- pressure supported breaths are delivered at a predetermined rate
S/T: spontaneous timed- ventilator switches to timed mode if spontaneous breathing falls below preset rate
Review PEEP
PEEP:
Positive End Expiratory Pressure
Requires intubation
Positive pressure is maintained during exhalation and between breaths to keep alveoli open between breaths
Reduces hypoxemia
Allows lower percentages of inspired oxygen
Used to treat ARDS
Review PSV
PSV: Positive supportive ventilation
Patient breaths spontaneously
Ventilator delivers present level of pressure assistance with each spontaneous breath
Used for weaning
Allows patient to strengthen pulmonary muscles without compromising oxygenation and ventilation during weaning
Deceases work of breathing
Cycle is flow limited; inspiration is terminated when inspiratory airflow rate falls below present rate
Review high flow oxygen
High Flow
Must be able to vent on own
Normal inhale speed of 20-30 LPM
High flow is up to 60 LPM
Heated to body temp, 100% humidified
Washes dead space to decrease CO2, increased O2
Usually used after patient fails on nasal canula
Identify CPAP and PEEP complications
Complications
Over distention of alveoli (pneumothorax)
Subcutaneous emphysema (fluid retention in face)
Ventilation-perfusion (V/Q) mismatch (either the ventilation (airflow) or perfusion (blood flow) in the lungs is impaired)
Fall in cardiac output due to decreased venous return r/t increased intrathoracic pressure (low BP)
May affect other organs: liver, kidney, brain
List complications of mechanical ventilation
Pulmonary complications Hemodynamic alterations Fluid retention CNS disturbances Infection GI disturbances: ulcer/ileus Psych trauma Upper airway damage
Nursing interventions related to the complications of mechanical ventilation
Prevention of VAP LOC assessment Respiratory rate, depth, patterns HR, BP, lung sounds Skin color O2 ABG's
Identify evidence based strategies for preventing ventilator associated pneumonia (VAP)
Good hand hygiene
HOB 30 degrees
Suction when needed
Oral care
Identify nutritional needs of the patient on a ventilator
Enteral or parenteral nutrition is provided because endotracheal tube prevent eating
Nasogastric, gastrostomy, jejunostomy is placed
Mechanical ventilation promotes Na and water retention due to its effects on cardiac output
Discuss weaning and how it is accomplished
Maintaining O2 saturation at determined level Patient request: medications, water, communicate, food Mouth care Resume if patient deteriorates Assess skin How does the patient tolerate it Sub with nasal canula and assess Is O2 improving
Discuss ARDS high risk patients
Shock Infection (sepsis most common) Trauma Fat emboli Aspiration Inhaled toxins Drug overdose Hematological disorders Metabolic disorders Radiation
Discuss ARDS pathological changes in the lungs
NON CARDIOGENIC PULMONARY EDEMA
ARDS is characterized as non-cardiogenic pulmonary edema caused by inflammatory damage to alveolar and capillary walls
Acute onset secondary to an underlying inflammatory process such as: sepsis, pneumonia, gastric aspiration
Discuss ARDS pathological changes in the lungs
ATELECTASIS
Partial or total lung collapse and airlessness
Most common cause is obstruction of bronchus ventilating
Other causes: pneumothorax, pleural effusion, tumor, loss of pulmonary surfactant and inability to keep alveoli open
Acute or chronic
Discuss ARDS intrapulmonary (right to left) shunt
Hypoxia can be aggravated by intracardiac right-to-left shunt through a patent foramen ovale
Positive pressure ventilation and PEEP may increase shunting
Discuss ARDS signs and symptoms
Early: subtle, minor change in orientation, restless, change in VS, anxiety, tachypnea (abnormally rapid breathing), dyspnea (difficult or labored breathing)
Middle: hypocapnia, worsening hypoxemia, dyspnea, hyperventilation
Late: crackles tachycardia, hypertension, confusion, restless
Discuss ARDS diagnostic tests (ABCs, x-ray)
Diagnosis:
Chest x-ray: white out with pulmonary infiltrates
PaO2 low in spite of O2 treatment (refractory hypoxemia)
PaCO2 low due to hyperventilation
pH high: respiratory alkalosis
Discuss ARDS treatment and rationale
Intervention: Prevent Correct underlying problem O2 at lowest % to produce oxygenation Careful admin of fluids Prevent/control infection Mech vent with PEEP Chest physical therapy and C&DB Frequent position changes
What CVEs (cardiovascular event) indicate a need for sedation and neuromuscular blocking medications
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Discuss collaboration of the nurse with the respiratory therapist, physician and RN case manager in care of patients with acute resp failure, ARDS and pneumothorax
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Complication of mechanical ventilation
PULMONARY COMPLICATIONS
Barotrauma: lung injury due to overdistention of alveolar. Volume and pressure of delivered gas can contribute to Barotrauma leading to overextended alveolar rupture.
Sub-q emphysema: causing air in subcutaneous tissue causing swelling of face, neck, chest
Pneumothorax: unequal chest expansion, decreased breath sound on affected side, chest tube insertion is necessary
Alveolar hypoventilation: caused by system leads, increased secretions
Alveolar hyperventilation: may lead to respiratory alkalosis
Ventilator-associated pneumonia (VAP): loss of humidification and trapping pathogens. Oral secretions and gastric content can enter through the open epiglottis. Cough reflex inhibited/impaired
Upper airway damage: gentle insertion of ETT, firm stabilization of tube, frequent monitoring of cuff pressures (high volume/low pressure), humidification to prevent drying
Oxygen toxicity: monitor O2 saturation, decrease oxygen need by keeping pt afebrile, block care, sedation, monitor hgb, add/increase PEEP
Nursing: monitor for crepitus Auscultate lungs sounds bilaterally Look for equal chest expansion Be alert to high inspiratory pressure Keep tidal volume low Closed in-line technique with suctioning
Complication of mechanical ventilation
HEMODYNAMIC ALTERATIONS
Positive pressure ventilation and PEEP increase intrathoracic pressure Decreased venous return Restriction of ventricular filling Restricted blood flow through the lungs Dysrhythmias Check weight daily
Complication of mechanical ventilation
FLUID RETENTION
Na and water imbalance
Fluid retention:
Progressive fluid retention often occurs after 24-48 hours of positive pressure ventilation, especially with PEEP
Associated with decrease urine out put and Na retention
Causes:
Renin-angiotensin system activated with decrease CO2
Intrathoracic pressure changes lead to Na retention
Increased ADH with stress response
Decreased insensible fluid loss via airway
NI:
Strict I/O, daily weight, maintain IV therapy, monitor electrolytes
Complication of mechanical ventilation
CNS DISTURBANCES
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Complication of mechanical ventilation
INFECTION
Causes:
Endotracheal tube bypasses normal filtering, cleansing, humidifying of nasal and oral pharynx
Suctioning and tubing are entrances for bacteria
Ventilator associate pneumonia: primary cause of hospital acquired pneumonia, 10-25% occurrence in vented pts
NI: use humidified air Consistent hand washing Use in-line suctioning; sterile technique Change tubing per protocol
Complication of mechanical ventilation
GI DISTURBANCES
GI bleeding/Ulcers/Infection Medications to maintain gastric pH of >4 -to decrease nosocomial infection, stress ulcer, contamination of resp tract r/t reflux and aspiration -histamine receptor blocker: famotidine -proton pump inhibitor: omeprazole
Constipation/ileus
- monitor bowel sounds
- monitor tube feeding residuals
Complication of mechanical ventilation
PSYCH TRAUMA
Cause:
Patient unable to speak (major cause of fear), eat, move or breath normally
Needs: knowledge, control, hope, trust
NI: Explain all procedures Alternate communication methods Allow freq family interaction Accept patients feeling, frustration
Complication of mechanical ventilation
UPPER AIRWAY DAMAGE
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Discuss nasal endotracheal intubation complications, advantages and disadvantages
Complications: Obstruction or displacement Pressure necrosis of nares Obstruction of sinus drainage, sinusitis Tracheoesophageal fistula
Advantages:
More easily secured and stabilized
More tolerated by patient
Facilitates oral care and communication
Disadvantages:
Smaller tube, infers with suctioning and oral secretions
Increased risk of lower respiratory infection
