Acute Respiratory Failure and Acute Respiratory Distress Syndrome (ARDS)

Question 1

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.

Answer 1

gas exchange

Question 2

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

Answer 2

an episode of acute respiratory failure (prolonged amount of time after)

respiratory acidosis

COPD and neuromuscular

Question 3

Acute Respiratory Failure: Pathophysiology

Answer 3

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)

Question 4

Acute Respiratory Failure: Clinical Manifestations

Early S&S:

Late S&S

Answer 4

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

Question 5

Acute Respiratory Failure: Diagnostics

Answer 5

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

Question 6

Acute Respiratory Failure: Nursing Management

Answer 6

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

Question 7

Preventing complications associated with Endotracheal and tracheostomy

Answer 7

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.

Question 8

Acute Respiratory Distress Syndrome (ARDS)

A severe inflammatory process causing diffuse alveolar damage that results in:

Answer 8

sudden and progressive pulmonary edema

increasing bilateral infiltrates on chest x-ray

hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP.

Question 9

PEEP:

Answer 9

Positive End Expiratory Pressure

Positive pressure maintained at the end of exhalation (instead of normal zero pressure)

Increases functional residual capacity & opens collapsed alveoli

Question 10

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 _____

Answer 10

HCAP or sepsis

Question 11

Initially ARDS resembles severe ________; however, ARDS is marked by a rapid onset of severe dyspnea less than 72 hours after precipitating event

Answer 11

pulmonary edema

Question 12

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)

Answer 12

supplemental oxygen

Question 13

ARDS: risk factors / Causes:

Answer 13

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

Question 14

ARDS clinical manifestations:

Answer 14

Severe Dyspnea (rapid onset)

Hypoxemia

Bilateral infiltrates on CXR

Progresses to fibrosing alveolitis

Increased alveolar dead space
Poor perfusion (with adequate ventilation)

Question 15

Clinical manifestations: ARDS

P/F ratio

Answer 15

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

Question 16

ARDS: Diagnostics

Answer 16

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

Question 17

Normal ABG values:

Answer 17

pH: 7.35 – 7.45

PaCO2: 35 – 45 (flip for computing acidosis/alkalosis)

HCO3: 22 – 26

Question 18

ARDS: Medical Management

Answer 18

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

Question 19

ARDS Nursing Management

Answer 19

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

Question 20

PEEP Delivery Systems

Answer 20

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

Question 21

Cpap – patient must be _________

bipap - breathing is initiated either by:

Answer 21

breathing independently

the patient or the back up setting (which ensures the patient gets a certain amount of breaths per minute)

Question 22

Indications for mechanical ventilation:

Answer 22

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

Question 23

ARDS & Proning

Proning…why is it important?

Answer 23

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

Question 24

ARDS Severity Scale

To determine the severity of ARDS (or oxygenation status of our client), we will look at the following:

Answer 24

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%

Question 25

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

Question 26

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

Question 27

Initially ARDS resembles severe ________; however, ARDS is marked by a :

Answer 27

rapid onset of severe dyspnea less than 72 hours after precipitating event