2.1 Respiratory Failure

Question 1

Explain the difference between hypoxia and hypoxemia

Answer 1

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

Question 2

Analyze the two types of respiratory failure and some common causes for each
RESPIRATORY INSUFFICIENCY
RESPIRATORY FAILURE

Answer 2

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

Question 3

Identify ABG changes in each type of of acute respiratory failure

Answer 3

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

Question 4

Compare the goals of interventions in respiratory insufficiency and respiratory failure

Answer 4

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)

Question 5

Pathology of pleural effusions?

Answer 5

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

Question 6

Complications of pleural effusions

Answer 6

Lung scarring
Pneumothorax (secondary to thoracentesis)
Empyema (Infection that turns into an abscess)
Sepsis

Significant morbidity and to death

Question 7

Treatment of of pleural effusions

Answer 7

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

Question 8

Analyze methods to oxygenate/ventilate patients utilizing noninvasive techniques (NIV)

Answer 8

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

Question 9

What assessment indicates appropriate oxygenation/ventilation

Answer 9

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

Question 10

Review assessments/interventions for patients receiving NIV (non-invasive ventilation)

Answer 10

Nasal cannula
Face mask
CPAP
BiPAP
Assist Controlled
Synchronized Intermittent
Positive End Expiratory (PEEP)

Assess:
Correct settings per orders
O2
Proper fitting

Question 11

Identify indications for mechanical ventilatioin

Answer 11

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

Question 12

What is endotracheal intubation?

Answer 12

Inserted by provider

Place between right and left lung

Question 13

Discuss rationale for insertion of endotracheal intubation

Answer 13

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

Question 14

Discuss procedure, equipment, assistance needed, cuff, signs of successful intubation of endotracheal intubation

Answer 14

.

Question 15

Discuss oral endotracheal intubation complications, advantages and disadvantages

Answer 15

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

Question 16

Discuss endotracheal intubation extubation

Answer 16

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

Question 17

Describe positive pressure ventilation

Answer 17

More commonly used
Push air into the lungs
Can be used with noninvasive and invasive ventilators

Question 18

Compare volume-cycled and pressure cycled ventilators

Answer 18

Volume cycled: air delivery until a preset volume is delivered

Pressure cycled: cycle off when a present pressure is achieved within the airways

Question 19

What is the controlled method of ventilating a patient

Answer 19

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

Question 20

What is the assist-control method of ventilating a patient

Answer 20

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

Question 21

What is the SIMV method of ventilating a patient.

Answer 21

SIMV: synchronized Intermittent Mandatory Ventilation

Vent breaths synchronized between patient’s own (unassisted) breaths
Used with weaning

Question 22

What is the ventilator settings for respiratory rate

Answer 22

Number of ventilator-delivered breath per minute

Usually 12-15/min for adults using ACMV (assist-controlled), may be slower with SIMV (synchronized intermittent)

Question 23

What is the ventilator settings for tidal volume

Answer 23

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

Question 24

What is the ventilator settings for FiO2 (fraction of inspired oxygen)

Answer 24

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%

Question 25

Explain how these settings (respiratory rate, tidal volume, FiO2) are adjusted to correct abnormal ABG results

Answer 25

.

Question 26

Review CPAP

Answer 26

``` 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 ```

Question 27

Review Bi-PAP

Answer 27

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

Question 28

Review PEEP

Answer 28

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

Question 29

Review PSV

Answer 29

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

Question 30

Review high flow oxygen

Answer 30

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

Question 31

Identify CPAP and PEEP complications

Answer 31

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

Question 32

List complications of mechanical ventilation

Answer 32

``` Pulmonary complications Hemodynamic alterations Fluid retention CNS disturbances Infection GI disturbances: ulcer/ileus Psych trauma Upper airway damage ```

Question 33

Nursing interventions related to the complications of mechanical ventilation

Answer 33

``` Prevention of VAP LOC assessment Respiratory rate, depth, patterns HR, BP, lung sounds Skin color O2 ABG's ```

Question 34

Identify evidence based strategies for preventing ventilator associated pneumonia (VAP)

Answer 34

Good hand hygiene HOB 30 degrees Suction when needed Oral care

Question 35

Identify nutritional needs of the patient on a ventilator

Answer 35

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

Question 36

Discuss weaning and how it is accomplished

Answer 36

``` 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 ```

Question 37

Discuss ARDS high risk patients

Answer 37

``` Shock Infection (sepsis most common) Trauma Fat emboli Aspiration Inhaled toxins Drug overdose Hematological disorders Metabolic disorders Radiation ```

Question 38

Discuss ARDS pathological changes in the lungs | NON CARDIOGENIC PULMONARY EDEMA

Answer 38

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

Question 39

Discuss ARDS pathological changes in the lungs | ATELECTASIS

Answer 39

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

Question 40

Discuss ARDS intrapulmonary (right to left) shunt

Answer 40

Hypoxia can be aggravated by intracardiac right-to-left shunt through a patent foramen ovale Positive pressure ventilation and PEEP may increase shunting

Question 41

Discuss ARDS signs and symptoms

Answer 41

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

Question 42

Discuss ARDS diagnostic tests (ABCs, x-ray)

Answer 42

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

Question 43

Discuss ARDS treatment and rationale

Answer 43

``` 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 ```

Question 44

What CVEs (cardiovascular event) indicate a need for sedation and neuromuscular blocking medications

Answer 44

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Question 45

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

Answer 45

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Question 46

Complication of mechanical ventilation | PULMONARY COMPLICATIONS

Answer 46

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 ```

Question 47

Complication of mechanical ventilation | HEMODYNAMIC ALTERATIONS

Answer 47

``` 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 ```

Question 48

Complication of mechanical ventilation | FLUID RETENTION

Answer 48

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

Question 49

Complication of mechanical ventilation | CNS DISTURBANCES

Answer 49

.

Question 50

Complication of mechanical ventilation | INFECTION

Answer 50

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 ```

Question 51

Complication of mechanical ventilation | GI DISTURBANCES

Answer 51

``` 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

Question 52

Complication of mechanical ventilation | PSYCH TRAUMA

Answer 52

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 ```

Question 53

Complication of mechanical ventilation | UPPER AIRWAY DAMAGE

Answer 53

.

Question 54

Discuss nasal endotracheal intubation complications, advantages and disadvantages

Answer 54

``` 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