Acute Respiratory Failure

Question 1

If pulse ox is 89 on pneumonia with antibiotis what do you do first

Answer 1

Assess probe site to ensure accurate reading, apply oxygen after then tell Dr bc change condition

Question 2

purpose of pursed lip breathing with COPD

Answer 2

reduce the overal work of breathing

Question 3

ARF vs ALI

Answer 3

ALI is milder from of ARDSand can lead to sudden deterioration in pulmonary gas exchange resulting in CO2 retention & inadequate oxygenation
Ventilation issues
Oxygenation (gas exchange) issues
-ARF- from infection, decreased perfusion to lungs hypoxia, increased rr, doesnt have to be lung injury
ARF, ALI, ARDS
can lead to resp arrest

Question 4

type 1 or hypoxemic respiratory failure PaO2<60(norm 75-100)

Answer 4

Failure of oxygen exchange
Abnormal O2 transport with resultant inadequate oxygenation
Hypoxemia refractory to supplemental oxygen
-COPD and CHF pt
-could have normal SAO2

Question 5

Type II or Hypercapnic (PaCO2 >45) resp failure

Answer 5

Failure to exchange or remove carbon dioxide
Decreased alveolar minute ventilation (hypoventilation of alveoli)
-drug overdose, alcohol, chronic COPD requiring O2, emphysema, HR

Question 6

Type 3 Mixed Hypoxemic-Hypercapnic

Answer 6

SAO2 low, CO2 high
Inadequate alveolar ventilation and abnormal O2 transport
-harder to manage
-treat with bipap- positive pressure in to control rr to blow off CO2

Question 7

type 4 resp failure: SHOCK

Answer 7

patients who are intubated and ventilated in the process of resuscitation for shock
Goal of ventilation is to  stabilize gas exchange and to unload the respiratory muscles, lowering their oxygen consumption
-almost always sedated or paralyxed to not consume extra oxygen

Question 8

Goals ARF

Answer 8

correct cause, alleviate hypoxemia and hypercapnia
-SAO2 is low so put back in bed to decrease amt oxygen demand
cause of ARF- infection, airway obstruction(mucus plugging,anaphylaxis, pills), cardiac function

Question 9

how to figure hypoxemic or hypercapnic

Answer 9

cant get O2 up, pt gets restless, look tired , tachypnic

Question 10

Infection

Answer 10

If the lung injury pattern is accompanied by a significant increase in neutrophils, areas of necrosis, viral cytopathic effect, and/or granulomas, infection should lead the differential diagnosis.
-pneumonia- can lead to resp prob because wait too long
-

Question 11

Resp distress problems

Answer 11

Asthma- bronchospasms
COPD- mucus plugging alveoli, bronchoconstriction, two classic signs - chronic bronchitis and ed stage emphysems
chronic bronhcitis- SOB, cough, steroidt reatment from chroninc inflam response causing bronchoconstriction
emphysems- alveoli dont work and lung capacity is limited so always SOB
lung cancer- tumor decreased blood and O2
-cystic fibrosis- excessive mucus plugging lead to scarring and not reversible
-pneumonia- aspiration can put int resp distrss
pleural effusion-fluid decreases lung capacity
Covid 19- into resp failure bc high oxygen demand and consumption bc large amt mucus, alveolar damage cant perfuse through them and walls collapse and dont allow blood and oxygen to get through, both sides of lungs

Question 12

ARDS patho(high mortality rate)- nebulizer treatments every four hours, cant move far, alwasy sob

Answer 12

lung injury
Decreased blood flow to lungs
Alveolar membrane damage
Increased membrane permeability
Interstitial & intra-alveolar edema
Further impaired oxygenation
“Leaky” membranes cause osmotic pressure changes
Pulmonary edema
Inflammatory changes can lead to fibrosis

Question 13

Stage 1 ARDS (first 12 hr)

Answer 13

increased SOB, RR, few CXR changes

Question 14

Stage 2 ARDs (exudative) 24 hr

Answer 14

hypoxemia is resistant to supplemental oxygen (mechanical ventilation required)

Question 15

Stage 3 ARDS (proliferative) day 2-10

Answer 15

hemodynamically unstable, evidence of SIRS(systemic inflammatory response- increased temp, HR, leUKOCYTOSIS ELEVATED WBC NOT JUST INFECTION-INFLAMMATOIN, Decreased BP bc cant diffuse and no oxygen recovery)

Question 16

Satge 4 ARDS (fibrotic) over10 days

Answer 16

lung fibrosis issues; ventilator management issues

Question 17

Symptoms ARDS

Answer 17

develop quickly after lung insult
Covid- headache, sore throat, muscle aches, cough, SOB
hypoxic, cough, poor oxygen exhange, TACHYPNEA, HYPOTENSION, CONFUSION, LETHARGY, SOMNOLENT

Question 18

Diagnostic ARDS

Answer 18

PaO2 : FiO2 ratio < 200 (greater 300 optimal)
B/L infiltrates on CXR “white out”
Elevated serum lactate levels
No cardiac etiology for pulmonary edema(LINKED TO HF)
*Deterioration of ABG’s despite intervention

Question 19

End of ARDS support

Answer 19

-Proned so lungs can expand more in lungs on belly, bad thing about proned-all drips, tube, 8 ppl to flip body sedated,
pharm-SUPPORTIVEE
Antibiotics – if known microorganisms
Bronchodilators
Corticosteroids
Diuretics-intervascular system cant support this
Neuromuscular blocking agents-paralytic to DECREASE O2 DEMAND (NIMBEX)

Question 20

Mechanical ventilation

Answer 20

increase F1O2(at 100% baseline 40%)(fraction of inspired O2)(norm 21%) and peep(positive end expiratory pressure) to correct hypoxemia
pressure support(keep alveoli open to crrect hypoxi)- amount tidal needed inhalation
norm tidal fem400ml 500m
increase rr, tidal volume to enhance ventilation
decrease preload, afterload, metabolic demans to optimize cardiac function.
hyperventilation may be used as a short term adgustment to treat elevate ICP
-first thing to do to give body a break so it doesnt lead to resp failure
-airway protection and optimal control of organs
assistance for neural or muscle dysfunction
Correct respiratory acidosis, providing goals of lung protective ventilation are met
Match metabolic demand
Rest respiratory muscles
intubate if cant clear secretions,trauma

Question 21

Guillan- barrea

Answer 21

autominne secondary to infection or immunization and body function shuts down
paralyzes
goes on vent
starts at bottum and goes up

Question 22

Indication for intubation

Answer 22

Altered mental status or coma-high CO2(35-40norm) levels, drug use, do wear O2
Severe respiratory distress/arrest
Extremely low or agonal(mistaken as true breathing, looks painful deep breath in and moans, inconsisten breathing pattern) respiratory rate
Shock-cardiogenic, hypovolemic
Peripheral cyanosis-decreased perfusion to body
Acute respiratory acidosis
Inability to clear secretions with impaired gas exchange or excessive resp work
Obvious respiratory muscle fatigue-tripod,look tired
Newly diagnosed neuromuscular disease(MS,parkinsons,ALS) with vital capacity <10-15mLair /kg weight- the bigger the person, more tidal volume needd
Impending cardiopulmonary arrest-Bp low,PVCs,pulm edema-crackles, pink frothy sputum
-drug overdose reversed with narcan bt if it cant- coma

Question 23

Priorities vent

Answer 23

1. Monitor & evaluate
   patient response (touch them, decrease HR, inc BP, sedate(large doe can cause neuro defiicitand stroke) may decrease bp and then do vasopressors
2. Manage ventilator system- nasal canula, bipap
3. Prevent complications-vent pneumonia, tissue breakdown, third space fluid cap leak, foley
   elevate hob, vital signs SAO2, notify provider if requiring oxygen,medication prn
   -stay with pt get RN to help for orders

Question 24

volume cycled

Answer 24

pushes air in until preset volume delivered. alveoli collapse mucuc limited o2.
ensure with every breath rihgt am according to weight is given

Question 25

time cycled

Answer 25

pushes air in until preset time reached

Question 26

assist modes

Answer 26

patient can assist but vent takes over work of breathing to control insoiratory and expiratory volume and rate

Question 27

pressure support

Answer 27

weaning mode, dont do tidal volume or rate
pt takesdeep breathand if not enough it puts more pressure
-close eye on pt

Question 28

Airway pressure release ventilation

Answer 28

allows little of everything, pt pull in tidal volume, release for exhalation with little support, prevent atelectasis

Question 29

Monitor & evaluate patient response

Answer 29

ABGsz(30 min after vent to see if it is set correct), suctioning(increase fi02), may have to manually ventilate (if you don’t think ventilating well)(ambu bag), CXR(placement and examine lungs), assessing lung sounds, ETT placement(CO2detection)
ir unresponsive concern aspiration

Question 30

Manage the ventilator safely

Answer 30

with the Respiratory Therapist, nurses are also responsible for checking vent settings! and if tube in placement , visitors touch
check size of et tubek vent settings

Question 31

Prevent complications

Answer 31

HOB elevated(30 d always with 02 ), VAP protocols(chlorihexidine, HOB, brush teeth,, DVT prophylaxis, prevent barotrauma (damage to lungs by positive pressure)(barrel chest bc cant expand due to too much pressure), chest PT to mobilize secretions and suction

Question 32

lung protective ventilation strategy for patients with Acute Lung Injury

Answer 32

TV ~ 6 ml/kg ideal body weight)

Question 33

sedation

Answer 33

comfort and oxygenation, reposition, mechanics, gas exchange
When minimal settings are required for oxygenation (FI O2 <55%, PEEP<8) and patient is hemodynamically stable, perform a spontaneous breathing trial daily

Question 34

SIRS

Answer 34

see befoer resp distress or critical illnes identified in ER
2 or more of the following:
Temp > 100.4 F (38 C) or < 98.6F (36 C)
HR > 90 bpm
RR > 20 breaths/min or PaCO2 < 32
WBC > 12,000 or < 4,000
or/ > 10% bands (normal is usually 0-5%)
-initatiate antibiotic within 2hours

Question 35

___are at

Answer 35

increased risk for MODS(multi organ with less chance of recovery from ARDS***

Question 36

Pulmonary embolism

Answer 36

-confirm with D dimer
-see on CAT or V/Q scan
-analysis-activity intolerance, impaired gas exhange
evaluate- improved activity and gas exchange
risk factors-AFIb, aflutter bed ridden, sedentary, surgery, long travel
-SOB, chest pain adn tightness, cyanosis, decreased cap refill, pale, activity intolerance
-prevent-antiarryhthmic, anticoagulants, mobility
anticagulation for maintanance
thrombolytics when complete blockage
surgery-IVC (inferioir vena cava )filter to catch clot

Question 37

nutrition support

Answer 37

helps attenuate these matabolic responses to stress. Malnutrition can increase risk infection and mortality
ppn, tpn, cor flow ng