Unit 2: Acute Respiratory Failure Flashcards
Acute Respiratory Failure
when one or both of the gas exchange functions (oxygenation or ventilation/CO2 removal) of the lungs are compromised
-life-threatening/ high mortality
Gas Exchange Functions of the Lungs
- Oxygenation
- Ventilation/ CO2 removal
Compromise of the Gas exchange functions of the lungs leads to?
hypoxemia and/or hypercapnia/hypercarbia (increased PaCO2)
Types of Respiratory Failure
- Hypoxemic Respiratory Failure (Type I)
- Hypercapnic Respiratory Failure
Hypoxemic Respiratory Failure
-PaO2 less than 60 mmHg
Hypercapnic Respiratory Failure
- respiratory acidosis
- PaCO2 greater than 50 mmHg
- pH less than 7.35
Risk Factors for Hypoxemic Respiratory Failure (Type I)
include disease processes that produce a V/Q mismatch (ventilation/ perfusion) or impair oxygen diffusion at the alveolar level
- pneumonia
- pulmonary edema
- PE
Risk Factors for Hypercapnic Respiratory Failure (Type II)
include diseases that impair ventilation or cause hypoventilation
>seen in patients with impaired chest-wall movement and thus impaired ventilation
-acute asthma
-narcotic overdose
-peripheral nervous system disorders
Risk Factors for Acute Respiratory Failure
> Impaired Ventilation (Hypoventilation):
- airway obstruction
- respiratory muscle weakness/paralysis that can occur w/ neuromuscular disease (myasthenia gravis)
- chest-wall injury
- anesthesia
- opioid administration
> Ventilation-perfusion Mismatch (V/Q mismatch):
- COPD
- Restrictive lung diseases (pulmonary fibrosis)
- Atelectasis
- Pulmonary embolus (PE)
- Pneumothorax
- ARDS
> Impaired Diffusion (Alveolar):
- Pulmonary Edema
- ARDS
Early Clinical Manifestations of Acute Respiratory Failure
- dyspnea
- restlessness
- anxiety
- fatigue
- increased BP from baseline
- tachycardia
Intermediate Clinical Manifestations of Acute Respiratory Failure
- confusion
- lethargy (d/t increased CO2)
- pink skin coloration (d/t increased CO2)
Late Clinical Manifestations of Acute Respiratory Failure
- cyanosis
- coma
Laboratory and Diagnostic Tests
- ABGs
- Venous Oxygen Saturation
- Hemoglobin and Hematocrit
- Chest x-ray
- Sputum cultures
ABGs
assess oxygenation and ventilation in the lungs
- hypoxemic respiratory failure has an initial respiratory alkalosis d/t hyperventilation along w/ hypoxemia
- once initial blood gases analyzed and treatment initiated, pulse oximetry is used to monitor oxygenation ( SpO2 greater than 94%; PaO2 of 80 mmHg)
Hemoglobin and Hematocrit
- analyzed to make certain there is enough binding sites for oxygen to ensure adequate oxygen-carrying capacity
- RBCs carry oxygen to the cells for cellular oxygenation; if not sufficient RBCs, the oxygen carrying capacity of the blood is diminished
Chest X-ray
- show underlying pathology
ex: heart failure, pulmonary congestion, pneumonia, or pneumothorax
Sputum Culture
to r/o a pathogenic (i.e. bacterial or viral) cause of failure
Respiratory Failure
not a disease
- condition caused by another disease or disorder
- treat failure and underlying cause
Treatment for Acute Respiratory Failure
- begins w/ oxygen
- based on severity: start with Nasal cannula or Venturi Mask
- in acute respiratory failure, placed on nonrebreather mask w/ 100% FiO2
Treatment for Cases of severe V/Q mismatch
- Noninvasive positive-pressure ventilation (BIPAP or CPAP)
- Invasive positive-pressure ventilation: requires an advanced airway such as an endotracheal tube (ETT) and mechanical ventilation
Medications used
- inhaled bronchodilators
- inhaled steroids
- diuretics
- sedation
- antibiotics
Inhaled Bronchodilators
open the airways by stimulating beta-2 receptor within the lungs
-helps to improve airflow b/c of an increase in the diameter of the airways
Inhaled Steroids
help decrease the inflammatory response
- decreases bronchoconstriction
- increasing airway diameter
- can be used synergistically w/ bronchodilators
Diuretics
to decrease pulmonary congestion
Sedation
- to control agitation and anxiety that increase the work of breathing and oxygen consumption
- needed if patient requires mechanical ventilation
Antibiotics
- initially broad spectrum to treat a suspected pneumonia
- adjusted if sputum culture is positive for bacterial infection
Complications of Acute Respiratory Failure
if supplemental oxygen, mechanical ventilation, and medications do not halt the progression of respiratory failure at high risk for cardiac failure, multiple organ dysfunction, and death
Nursing Management: Assessment and Analysis
clinical manifestations d/t hypoxemia and hypercapnia of acute respiratory failure
- ABGs = decreasing oxygenation status and/or increased CO2 levels
- Changes in mental status d/t decrease in cerebral perfusion
- Agitation indicates hypoxia
- Somnolence indicates hypercarbia
- New-onset dyspnea, increased work of breathing, and tachypnea = early indicators of impending respiratory compromise
- Tachycardia and Hypertension present initially as a compensatory response
Nursing Diagnoses
- Impaired gas exchange r/t alveolar hypoventilation, V/Q mismatching, and/or intrapulmonary shunting
- Ineffective breathing pattern r/t muscular fatigue and/or neurological impairment
Nursing Assessments
- Airway
- Vital Signs and Oxygen Saturation
- ABGs
- Cardiac Monitoring
- Neurological Assessment (Agitation vs Somnolence)
- Breath Sounds
- Skin Coloration
Assessments: Airway
- airway patent?
- breathing comfortably?
- is there increased work of breathing?
- does patient require suctioning or assistance w/ airway secretions?
Assessments: Vital Signs and Oxygenation Saturation
- BP, Pulse, and Respiratory rate increase as compensatory mechanisms to increase oxygenation in presence of hypoxemia
- Fever may develop b/c of inflammation and/or infection
- Pulse oximetry decreases from baseline b/c of V/Q mismatch, impaired diffusion, and/or alveolar hypoventilation
Assessments: ABGs
- Hypoventilation of type II failure results in CO2 retention, acidosis, and decrease PaO2
- V/Q mismatch or diffusion defects of type I failure result in decreased PaO2
Assessment: Cardiac Monitoring
-hypoxia and increased oxygen demand d/t tachycardia may lead to dysrhythmias
Assessment: Neurological Assessment
change in mental status = early indication of impending respiratory failure
- Agitation caused by hypoxemia
- Somnolence caused by hypercapnia
Assessment: Breath Sounds
underlying cause of respiratory failure may result in
>Crackles (pulmonary edema)
>Rhonchi (pneumonia, COPD)
>Diminished/Absent (hypoventilation)
Assessment: Skin Coloration
- Cyanosis: visible in nail beds and around the mouth in initial stages of hypoxemia
- Central cyanosis: body takes on a blue or gray tinge
- Deep pink coloration of skin: increased CO2 levels
Nursing Actions
- Administer oxygen (w/ humidity) as ordered
- Medications (brochodilators, steroids, diuretics, sedation)
- Elevate HOB; sit up in chair
- Position patient w/ “good lung down”
- Chest physical therapy and suctioning; ambulate as able
- Administer IV fluids/hydration
- Nutritional support
- Be prepared for noninvasive or invasive positive-pressure ventilatory support
Administer Oxygen w/ Humidity
- supplemental oxygen necessary to treat hypoxemia
- humidity helps prevent mucosal drying; helps keep secretions thin so that they can be more easily coughed or suctioned up
Administer Bronchodilating meds as ordered
bronchial smooth muscle relaxants help open the airways
Administer Steroids as ordered
-reduce inflammation
-synergistic effect w/ bronchodilators
>administer bronchodilator first, then inhaled steroids to allow the steroids to be inhaled more easily into bronchial tree
Administer Diuretics as Ordered
helps decrease pulmonary congestion that impairs ventilation
Administer Sedation as ordered
- helps decrease anxiety and agitation
- helps decrease work of breathing and oxygen consumption
- usually for mechanical ventilated patients
Elevated HOB; Sit patient up in bed
- optimizes gas exchange
- aids in the work of breathing
- decreases risk of aspiration
Position patient with “good lung down”
if underlying disease is unilateral, positioning w/ the good lung down improves gas exchange by optimizing the V/Q ratio
-gravity ensures the healthy lung maintains adequate blood flow to optimize ventilation to perfusion
Chest Physical Therapy and suctioning; ambulate as able
-if excessive sputum is part of the underlying cause, positioning, postural therapy, percussion, vibration, and ambulation combined w/ assisted coughing or suctioning help mobilize and clear secretions
Administer IV fluids/Hydration
- decreases viscosity of secretions
- helps maintain intravascular volume
Administer Nutritional Support
metabolic needs must be met to promote healing
Be prepared for noninvasive or invasive positive-pressure ventilatory support
a severe V/Q mismatch may require the addition of positive pressure to adequately promote gas exchange
Nurse Teachings
- Disease process
- Medications
- Pulmonary Rehabilitation (breathing techniques, energy conservation, exercise)
- Infection prevention
- Diet and adequate hydration
- Smoking Cessation
Evaluating Care Outcomes
Goal: improve gas exchange
- pulmonary rehabilitation in the form of exercise training, nutritional counseling, and breathing strategies to assist in recovery
- successfully tx = able to return to baseline respiratory function
- except in cases where the use of supplemental oxygenation use is the patients norm, a well-managed patient should not require supplemental oxygenation upon discharge
- patient should be able to return to baseline activities of daily living, work, and social commitments
