Pulmonary Disorders

Question 1

What is Acute Respiratory failure (ARF)?

Answer 1

Inadequate gas exchange marked by HYPOXEMIA (low O2 in blood)

Question 2

What are the three main causes of ARF?

Answer 2

Intrapulmonary shunting
V/Q mismatch
Alveolar hypoventilation

Question 3

S/S of ARF

Answer 3

Tachycardia, tachypnea, use of accessory muscles, nasal flaring, grunting
-any pt who exhibits confusion, agitation or restlessness must be assessed for HYPOXEMIA FIRST

PaO2 <60 / SaO2 <90% OR paCO2 >50 with acidosis (low pH)

Question 4

Management of ARF

Answer 4

Supplemental O2 therapy- goal is SaO2 >90%

• supplemental O2 effective with alveolar hypoventilation or V/Q mismatch but NOT in shunt
  -Intrapulmonary shunt requires positive pressure (CPAP, BiPAP, or Ventilator)

Question 5

Alveolar hypoventilation, causes, and interventions

Answer 5

Same as Resp. Acidosis with hypoxemia

Causes:
- anything that limits ventilation (neuro trauma, pneumothorax, lung trauma, oversedation, pain)

Interventions:
- optimize ventilation (positioning, pain relief, secretion removal, correct underlying cause)
-if on ventilator, increase rate and/or tidal volume to breathe off CO2

PaCO2 is a direct reflection of alveolar hypoventilation

Question 6

How does patient positioning affect ventilation (V) and perfusion (Q)?

Answer 6

When sitting upright,
- upper zone of the lungs has more ventilation and less perfusion (V>Q)
-middle zone has equal ventilation and perfusion
-lower zone has more perfusion than ventilation

More perfusion will go to the alveoli that are closer to the ground (affected by gravity)

When laying down, the weight of the heart and diaphragm compress the dependent alveoli and secretions pool in posterior lungs where perfusion is higher
-why we prone

Question 7

What are the benefits of heated and humidified air?

Answer 7

Heated and humidified O2:
- decrease airway inflammation
- maintain mucociliary function
-increase mucous clearance
- reduce caloric expenditure (decrease work on lungs)

Question 8

What is the benefit for the patient when using a high-flow rate?

Answer 8

-increases FiO2
- decreases dead space
- provides low level positive pressure (PEEP)
- decreases the work of breathing

Question 9

What are the benefits of using a High-flow nasal cannula (HFNC)?

Answer 9

• reduces the need for intubation
• decreases the work of breathing
• provides a low level of positive pressure

Question 10

What is proning and why is it used?

Answer 10

Proning positions the patient on their stomach in a “swimmer” position or places them with their good lung down to improve expansion in the bad lung
—improved V/Q matching

Reduces alveolar compression by the heart and diaphragm, allowing for better expansion of the dorsal lung, more surface area = alveolar recruitment

Question 11

Nursing management for ARF

Answer 11

-positioning that is optimal for oxygenation
-pulmonary exercises
—deep breath hold 3 seconds; IS
—no dry coughing
-hydrate and suction secretions
-increase movement when possible
-don’t cluster care to allow for rest

Question 12

Medications for ARF

Answer 12

Medication treatment depends on the cause of the respiratory failure and the patient’s condition

-steroids
-sedation
-neuromuscular blockers
-analgesia

Question 13

What is pneumonia?

Answer 13

Acute inflammation of the lung parenchyma caused by an infectious agent

-often related to dental plaque and aspiration of plaque organisms
—BASIC MOUTH CARE is so important

HAP= hospital acquired pneumonia
-occurs after 48 hours in the hospital

Question 14

Pneumonia management

Answer 14

-O2 therapy (non-invasive but mechanical ventilation if necessary)
-nursing same as ARF
-Drugs including antibiotics and bronchodilators

Question 15

What happens when a patient aspirates acid?

Answer 15

-bronchospasm and atelectasis
-may cause an inflammatory response with severe hypoxemia, V/Q mismatch, and shunt
- frequently progresses into ARDS

If aspirated high pH gastric contents, bacterial pneumonia may develop

**patients with aspiration are at high risk of developing ARDS

Question 16

Management of aspiration

Answer 16

-supportive care first
-O2 therapy
-Nursing: HOB up, good lung down, deep breathing, IS
-possible bronchoscopy

NO steroids
Antibiotics after 48 hours

Question 17

Best practices for preventing aspiration in adults

Answer 17

• maintain HOB 30-45 degrees
• use sedatives sparingly
• maintain endotracheal cuff pressures at an appropriate level

Question 18

What is acute respiratory distress syndrome (ARDS)?

Answer 18

Inflammatory syndrome marked by:
- disruption of the alveolar-capillary membrane
- non-Cardiogenic pulmonary edema

In ARDS, the alveolar-capillary membrane leaks fluid out of capillaries and into the alveolar space AND alveoli leaks into the interstitial space
—causes ‘junk’ in the alveoli
—CO2 is smaller so it can still pass through, but O2 is larger and has a harder time entering the capillary
THEREFORE, O2 is a more sensitive indicator of ARDS

Question 19

What are the causes and major risk factors for ARDS?

Answer 19

May be caused by direct injury to pulmonary epithelium or secondary to non-pulmonary insult
- sepsis (non-pulm.)
-aspiration (pulm. Or non-pulm.)
- pneumonia (non-pulm.)
- trauma (pulm.)

Question 20

What clinical symptoms would you expect to see with ARDS?

Answer 20

Persistent hypoxemia despite supplemental oxygen

Diagnostic criteria: P/F ratio < 300

Question 21

Care for ARDS

Answer 21

Most effective treatment is supportive care

Ventilator
-maintain pH 7.2 or higher

Proning
-at least 16 hours/day to improve V/Q matching and alveolar recruitment

Maintain C.O.
-but keep the patient dry (adequate preload but not high)

Question 22

Outcomes for ARDS

Answer 22

Mortality about 40%

Pulmonary fibrosis is common afterwards

Potential for permanent neurologic impairment with impaired quality of life

Communicate that recovery will take time and there will be residual pulmonary damage