Respiratory Failure/ARDS Flashcards
what is acute respiratory failure
when oxygenation, ventilation, or both are inadequate
Description
1. One or both of gas exchange functions of lungs compromised
2. Insufficient O2 transferred to the blood
3. Inadequate CO2 removal
classifications for acute respiratory failure
- Impaired gas exchange - Hypoxemic respiratory failure (failure of
oxygenation) - Impaired ventilation - Hypercapnic respiratory failure (failure of
ventilation) - Combined failures (failures of oxygenation & ventilation)
mechanisms of hypoxemia respiratory failure
- Ventilation-perfusion mismatch
a. Management - Oxygen therapy: first step to reverse V/Q mismatch; treat underlying cause - Shunt
a. anatomic or intrapulmonary shunt
b. Management: Oxygen therapy not enough; may require mechanical ventilation with high FiO2 - Diffusion limitation
a. Thickened alveolar membrane - Alveolar hypoventilation (Seen primarily with Hypercapnic respiratory
Failure)
a. Leads to increased PaCO2
Categories of Hypercapnic respiratory failure
- CNS problems
- Neuromuscular conditions
- Chest wall abnormalities
- Conditions affecting the airways and/or alveoli (obstruction and air trapping leading to respiratory muscle fatigue)
clinical manifestations of acute respiratory failure
- Sudden or gradual onset
- Change in mental status – FIRST sign resp failure
- EARLY signs – tachycardia, tachypnea, mild hypertension
- Dyspnea
- Other respiratory findings: prolonged expiration, nasal flaring, retractions, use accessory muscles, SpO2 <80%
- Skin cool/clammy, diaphoretic
- Anxiety
- Fatigue, inability to speak in complete sentences without pausing to Breathe
- Decreasing LOC - Lethargy
- LATE signs- hypotension, dysrhythmias, cyanosis ( PaO2 45 mmHg or less), paradoxical breathing or abdominal wall movement, coma
acute respiratory failure management: diagnosis
(1) Chest xray
(2) ABGs
(3) Oxygen saturation
(4) CBC, BMP, urinalysis
(5) Sputum, blood cultures
(6) CT or V/Q lung scan
acute respiratory failure management
(1) Result of one or more diseases involving the lungs or other body systems
(2) Must treat the respiratory failure as well as the underlying cause
(3) Oxygen therapy
(a) Correct hypoxemia (maintain PaO2 60 mmHg or > SaO2 >90%)
(4) Mobilization of secretions
(a) positioning, effective cough, chest physiotherapy, Suctioning and airway management, hydration and Humidification, positive pressure ventilation
(5) Medications
(a) Reduce airway inflammation and bronchospasm w/Steroids, bronchodilators
(b) Relieve pulmonary congestion. with Diuretics, Morphine, Nitroglcerin
(c ) Treat infection with IV Antibiotics
(d) Reduce anxiety, pain and restlessness w/ Benzodiazepines, opioids
(4) Nutritional therapy
(a) Adequate protein intake
(b) Enteral or parenteral feeding start in 24-48 hours
complications with acute respiratory failure
(1) Cardiac failure
(2) Multi-organ dysfunction
diagnoses for acute respiratory failure
(1) Impaired gas exchange
(2) Impaired respiratory system function
assessment for acute respiratory failure
(a) Vital signs, RAP, and O2 sats
(b) Cardiac Monitoring - Dysrhythmias
(c) Neuro assessment – changes LOC
(d) Respiratory
(i) Breath Sounds
(ii) Patient’s position
(iii) Assess work of breathing
(e) Skin assessment
actions for acute respiratory failure
(a) Administer oxygen as prescribed
(b) Be prepared for intubation and mechanical ventilation.
(c) Administer medications as ordered
(d) Elevate the head of the bed at least 30 degrees, mobilize to chair
(e) Bilateral lung disorders - Reposition q 2 hours.
(f) If unilateral lung disease, position good lung down
(g) Assess need for suctioning, chest physiotherapy (postural drainage, percussion, vibration)
(h) Administer IV fluids, monitor I&O
(i) Monitor lab values, ABG’s, cultures
(j) Administer nutritional support
teaching for acute respiratory failure
(a) Disorder or disease teaching
(b) Medications
(c) Breathing techniques (pursed lip breathing, diaphragmatic breathing), effective coughing
(d) Energy conservation
(e) Exercise
(f) Prevention of infection
(g) Diet and adequate hydration
(h) Smoking cessation
prevention for acute respiratory failure
(a) identify at-risk patients, initiate early interventions
(b) Deep breathing and coughing, incentive spirometry, early ambulation
(c) Prevent: atelectasis, pneumonia, complications of immobility, and optimize hydration and nutrition
describe Adult respiratory distress syndrome (ARDS)
Acute onset (less than 7 days) of refractory hypoxemia and bilateral infiltrates
causes for ARDS
- Caused by direct or indirect injury to lungs – Sepsis most common
- Direct injury
a) Aspiration, pneumonia, sepsis
b) Other causes: chest trauma, embolism, inhalation injury, near-drowning, O2 toxicity - Indirect injury
a) Sepsis, massive trauma, severe TBI, shock
b) Other: pancreatitis, cardiopulmonary bypass, DIC, opioid overdose, multiple blood transfusions (TRALI)
ARDS criteria
- Refractory hypoxemia
- P/F ratio < 300 mmHg
- Bilateral infiltrates on chest x-ray
what are. the 3 phases of ARDS
phase 1: injury/exudative
phase 2: reparative/proliferative
phase 3: fibrotic/fibroproliferative
describe phase 1 of ARDS
a) Interstitial edema and alveolar edema (non-cardiogenic pulmonary edema) leading to severe V/Q mismatch
b) Hypoxemia – becomes refractory hypoxemia
c) Atelectasis (collapse of alveoli)
Manifestations – tachypnea, tachycardia, respiratory alkalosis,
describe phase 2 of ARDS
a). Hypercarbia and worsening hypoxemia, increased peak Inspiratory pressures (mechanical ventilation), pulmonary htn
(V/Q mismatch, diffusion limitation, shunting)
b). Diseased lung is replaced with dense fibrosis tissue
describe phase 3 of ARDS
a) decreased lung compliance
b) decreased area for gas exchange
c) worsening pulmonary hypertension
Manifestations:
-Decreased BP and CO
-worsening hypoxemia
-severe tissue hypoxia
-lactic acidosis
clinical manifestations for ARDS (initial)
subtle changes for 24-72 hrs
a) Mild dyspnea, tachypnea, cough and restlessness
b) Crackles
c) ABGs – mild hypoxemia and respiratory
d) Chest x-ray– normal or diffusely scattered infiltrates
clinical manifestations for ARDS (with progression)
a) Respiratory distress, increased work of breathing, decreased lung compliance
b) Tachypnea, intercostal retractions
c) Tachycardia, diaphoresis, cyanosis, pallor
d) Altered LOC, anxiety, confusion
e) Crackles, Rhonchi
f) ABGs -refractory hypoxemia, hypercapnia
clinical manifestations for ARDS (cont. progression)
a). Profound dyspnea, hypoxemia, increased WOB, respiratory distress
b) Chest x-ray -Infiltrates - “whiteout” and pleural effusion
c) severe hypoxemia, hypercapnia, metabolic acidosis, organ dysfunction
how to find ARDS severity
Calculate PaO2/FiO2 ratio daily & trend value
ARDS severity scale
mild: 200-300
moderate: 100-200
severe: <100
***remember to divide PaO2/FiO2 to get the number
complications of ARDS
- *MODS, sepsis
- Abnormal lung function
- Ventilator-associated pneumonia
- Barotrauma
- Stress ulcers
- VTE
- Acute kidney injury
- Psychological issues
diagnosis of ARDS
a). chest x-ray: Serial
b) ABGs
c) Laboratory testing – CBC, CMP, coagulation studies, liver and renal function tests, serum lactate
d) Sputum, blood, urine cultures
e) pulmonary function studies
d) Identify and treat underlying cause
e) Oxygen administration (Correct hypoxemia – high-flow O2 delivery, BiPAP)
f) Mechanical ventilation – Goal – SaO2 > 90% with FiO2 < 60%
(1) Pressure A/C
(2) Low tidal volume ventilation (4-6 mL/kg) predicted body weight
(3) Permissive hypercapnia (PaCO2 60 acceptable (not used TBI or increased ICP)
(4) PEEP
g) Prone Positioning
(1) Recruit collapsed alveoli in posterior part lungs, helps mobilize secretions
(2) Dependent areas of lungs are more heavily damaged than nondependent areas
(3) Guidelines
(a) Time frame
(b) Side-lying position – assess response to position
(c) Monitor vs and response to medications closely while prone
(d) Complications
(e) Complications leading to termination of proning
h). Other positioning techniques -continuous lateral rotation therapy
i) Extracorporeal membrane oxygenation (ECMO)
j) Medications
k) Adequate hydration (IV fluids-crystalloids, colloids)
(1) Adequate blood volume to maintain organ perfusion
(2) Avoid thick, dry secretion, mucous plugs
l) Improve O2 carrying capacity of blood: Administer packed RBCs (keep Hgb 7g/dL)
m). Nutrition
(1) Enteral or parenteral feedings – initiate in 48 – 72 hours of initiation of mechanical ventilation
medications for ARDS
(1) Analgesics, sedatives (IVP or continuous IV infusion): Decrease discomfort, help reduce work of breathing, prevent ventilator dyssynchrony
(2) Neuromuscular blockers – when given must give concurrent analgesia and sedation
(3) Inotropics and vasopressors
(4) Steroids
(5) Diuretics
complications from management of ARDS
a) Ventilator associated pneumonia
b) Renal failure/Multiorgan dysfunction syndrome
c) Barotrauma
nursing diagnoses. of ARDS
(1) Impaired gas exchange
(2) Impaired respiratory system function
assessment of ARDS
(a) Respiratory assessment, level of sedation, P/F ratio (Calculate and trend P/F ratio)
(b) Vital signs, hemodynamic monitoring, and continuous pulse oximetry (CVP/RAP or PAP monitoring)
(c) Laboratory tests
(i) ABGs
(ii) Serum lactate
(iii) CBC, CMP
(iv) Liver/Renal function tests
(v) Blood/ sputum/urine culture
(d) Skin assessment
(e) Renal assessment - Urine output, I&O
(f) Chest x-ray (serial)
(g) Monitor and trouble shoot mechanical ventilation
(h) Cardiac Monitoring & Dysrhythmias
action for ARDS
(a) Suction airway based for assessed need
(b) Administer medications as prescribed
(c) Patient positioning/activity
(i) Proning
(ii) Elevate the head of the bed
(iii) Frequent position changes q2hrs
(iv) Range of motion
(d) Infection protection/ prevention
teaching for ARDS
(a) Disease process
(b) Medications
(c) Family support
(d) Smoking Cessation
(e) Pulmonary rehabilitation
