Acute Respiratory Failure and Acute Respiratory Distress Syndrome (ARDS) Flashcards
Acute respiratory failure:
A sudden and life-threatening deterioration of _____ function…which indicates failure of the lungs to provide adequate oxygenation and/or ventilation for the blood.
gas exchange
Difference between acute and chronic:
Chronic: defined as deterioration in gas exchange function that has developed over time or AFTER ________________
Absence of acute symptoms with presence of ________
_____ and _____ disorders are common to have chronic respiratory failure
an episode of acute respiratory failure (prolonged amount of time after)
respiratory acidosis
COPD and neuromuscular
Acute Respiratory Failure: Pathophysiology
Ventilatory failure:
-Impaired CNS (drug overdose, head trauma, infection, hemorrhage, and sleep apnea)
-Neuromuscular dysfunction (myasthenia gravis, Guillian-Barre syndrome, ALS, and spinal cord trauma)
-Musculoskeletal dysfunction (chest trauma, kyphoscoliosis, and malnutrition)
-Pulmonary dysfunction (COPD, asthma, and cystic fibrosis)
Oxygenation failure:
Pneumonia
ARDS
Heart failure
COPD
PE
Restrictive lung diseases (diseases that decrease in lung volumes)
Acute Respiratory Failure: Clinical Manifestations
Early S&S:
Late S&S
Early S&S
Restlessness
Headache
Fatigue
Dyspnea
Air hunger
Increased BP
Tachycardia (mild)
Late S&S
(as hypoxia increases):
Tachycardia
Tachypnea
Central cyanosis
Diaphoresis (on the head) skin will usually be cool & clammy
Confusion & Lethargy
Respiratory arrest
Physical findings
Use of accessory muscles
Decreased breath sounds
Wheezing
Shallow breathing
Inability to speak in full sentences
Acute Respiratory Failure: Diagnostics
ABGs
Remember your values?
pH: 7.35-7,45
paCO2: 35-45
HCO3: 22-26
paO2: 80-100
Respiratory Acidosis (too much CO2)
Respiratory Alkalosis (low level of CO2 in the blood)
Metabolic Acidosis (too much acid in the body fluids)
Metabolic Alkalosis (elevated serum bicarbonate)
Pulse Oximetry
Remember:
paO2 < 60 mmHg
paCO2 > 50 mmHg
PH < 7.35
O2 saturation < 90% on room air
Acute Respiratory Failure: Nursing Management
Assisting with intubation and mechanical ventilation
-ET (endotracheal tube)
-Tracheostomy (surgically placed)
Respiratory assessments
Move to ICU for monitoring
Monitor LOC
ABGs
Pulse oximetry
VS
Implement ICU protocols
-Turning/repositioning
-Mouth care
-Skin care
-ROM
Address the cause that lead to acute respiratory distress and treat
Preventing complications associated with Endotracheal and tracheostomy
Administer adequate warmed humidity
Maintain cuff pressure at appropriate level
Suction as needed per assessment findings
Maintain skin integrity: Change dressing and tape as needed per protocol
Auscultate lung sounds
Monitor for signs and symptoms of infection: Including temperature and WBC count
Administer prescribed oxygen and monitor oxygen saturation
Monitor for cyanosis
Maintain adequate hydration of the patient
Use sterile technique when performing tracheostomy care.
Acute Respiratory Distress Syndrome (ARDS)
A severe inflammatory process causing diffuse alveolar damage that results in:
sudden and progressive pulmonary edema
increasing bilateral infiltrates on chest x-ray
hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP.
PEEP:
Positive End Expiratory Pressure
Positive pressure maintained at the end of exhalation (instead of normal zero pressure)
Increases functional residual capacity & opens collapsed alveoli
Ards (acute respiratory distress syndrome
Spectrum of disease
Progress from mild, moderate, to severe
Acute lung injury
Term used to describe mild ARDS
Mortality rate varies from 27% to 50%
Those that survive initial cause of ARDS, may die later due to ____ or _____
HCAP or sepsis
Initially ARDS resembles severe ________; however, ARDS is marked by a rapid onset of severe dyspnea less than 72 hours after precipitating event
pulmonary edema
Arterial hypoxemia does not respond to ________ which leads to:
-fibrosing alveolitis
-severe hypoxemia
-Increased alveolar dead space (poor perfusion) and decreased pulmonary compliance (stiff lungs)
supplemental oxygen
ARDS: risk factors / Causes:
Aspiration (gastric secretions, drowning, hydrocarbons)
COVID 19 pneumonia
Drug ingestion and overdose
Hematologic disorders (disseminated intravascular coagulopathy, massive transfusions, cardiopulmonary bypass)
Prolonged inhalation of high concentrations of oxygen, smoke, or corrosive substances
Localized infection (bacterial, fungal, viral pneumonia)
Metabolic disorders (pancreatitis, uremia)
Shock (any cause)
Trauma (pulmonary contusion, multiple fractures, head injury)
Major surgery
Fat or air embolism
Sepsis
ARDS clinical manifestations:
Severe Dyspnea (rapid onset)
Hypoxemia
Bilateral infiltrates on CXR
Progresses to fibrosing alveolitis
Increased alveolar dead space
Poor perfusion (with adequate ventilation)
Clinical manifestations: ARDS
P/F ratio
PaO2 (partial pressure of oxygen) divided by FIO2 (fraction of inspired oxygen)
FIO2 = concentration of oxygen that a person inhales
Mild ARDS
P/F ratio: >200 mmHg - </= 300 mmHg
Moderate ARDS
P/F ratio: >100 mmHg - </= 200 mmHg
Severe ARDS
P/F ratio: </= 100 mmHg
ARDS: Diagnostics
Audible crackles & intercostal retractions
ABGs
BNP levels (high levels show decreased odds for ARDS)
Result > 100 is abnormal
</= 200 pg/mL (range)
Echocardiogram
Pulmonary artery catheterization
Normal ABG values:
pH: 7.35 – 7.45
PaCO2: 35 – 45 (flip for computing acidosis/alkalosis)
HCO3: 22 – 26
ARDS: Medical Management
Intubation and mechanical ventilation
-Utilization of PEEP
-PEEP increases functionality by keeping the alveoli open
Circulatory support, adequate fluid volume, and nutritional support
Systemic hypotension may occur secondary to hypovolemia
Inotropic or vasopressors may be required (to treat hypovolemia and not cause further overload)
Inhaled nitric oxide
Prone positioning
Sedation
Paralytics
Nutritional support
ARDS Nursing Management
Frequent respiratory assessments
Repositioning at least every 2 hours
-Changes occur frequently with repositioning…be cautious
-Positioning client into the prone position is commonly performed
-Improved oxygenation especially in COVID 19 pts
-REST
Common interventions:
-O2 administration
-Nebulizer
-Chest physiotherapy
-Endotracheal intubation
-Tracheostomy
-Mechanical ventilation
-Suctioning
-Bronchoscopy
-Reducing anxiety
PEEP Delivery Systems
Continuous Positive Airway Pressure (CPAP):
-Positive pressure applied throughout the respiratory cycle to a spontaneously breathing client to promote alveolar and airway stability and increase functional residual capacity
Bi-level Positive Airway Pressure (BIPAP):
-Also known as non-invasive positive pressure ventilation (NIPPV)
-Noninvasive spontaneous breath mode of mechanical ventilation that allows for the separate control of inspiratory and expiratory pressures; given via a mask
Mechanical Ventilation:
-Intubated with an endotracheal tube
-A positive or negative pressure breathing device that supports ventilation and oxygenation
Cpap – patient must be _________
bipap - breathing is initiated either by:
breathing independently
the patient or the back up setting (which ensures the patient gets a certain amount of breaths per minute)
Indications for mechanical ventilation:
PaO2 < 55 mmHg
PaCO2 > 50 mmHg
pH < 7.32
Apnea or bradypnea
Respiratory distress with confusion
Increased work of breathing not relieved by other interventions
Confusion with need for airway protection
ARDS & Proning
Proning…why is it important?
Improves alveolar ventilation
Improve oxygenation
Improve CO2 clearance
Easier for right ventricle to perfuse lung tissues
Increased lung compliance
Decreased pleural pressure
Ability to decrease PEEP
ARDS Severity Scale
To determine the severity of ARDS (or oxygenation status of our client), we will look at the following:
P/F ratio: PaO2 (from ABG) divided by the FiO2 (O2 being delivered to the client)
Mild 200-300 Mortality - 27%
Moderate 100-200 - 32%
Severe <100 - 45%
The P/F ratio indicates what the PaO2 would be on room air (if patient was taken off oxygen)
> 400 >80 Normal
<400 60-79 Hypoxemia
<300 50-59 Respiratory failure
<250 40-49 Severe respiratory failure
<200 <40 Critical respiratory failure
COPD and Neuromuscular disorders develop a tolerance to the gradually worsening hypoxemia and hypercapnia
** Pts with chronic respiratory failure can develop acute resp. failure **
E.g.: COPD pt. may develop an exacerbation or infection that causes an additional deterioration of the gas exchange
Initially ARDS resembles severe ________; however, ARDS is marked by a :
rapid onset of severe dyspnea less than 72 hours after precipitating event
