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Respiratory failure
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Respiratory Failure
Ms . Amandeep KaurMs . Amandeep Kaur
M.M.College of NursingM.M.College of Nursing
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Acute Respiratory Failure
Results from inadequate gas exchangeResults from inadequate gas exchange
Insufficient O2 transferred to the blood
Hypoxemia
Inadequate CO2 removal
Hypercapnia
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Gas Exchange Unit
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Acute Respiratory Failure
Not a disease but a conditionNot a disease but a condition
Result of one or more diseasesResult of one or more diseases
involving the lungs or other bodyinvolving the lungs or other body
systemssystems
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Classification of Respiratory Failure
Fig. 68-2
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Range of V/Q Relationships
Fig. 68-4
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Hypoxemic Respiratory Failure
Etiology and Pathophysiology
1. Ventilation-perfusion (V/Q) mismatch1. Ventilation-perfusion (V/Q) mismatch
COPD
Pneumonia
Asthma
Atelectasis
Pulmonary embolus
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Hypoxemic Respiratory Failure
Etiology and Pathophysiology
2. Shunt
Anatomic shunt
Intrapulmonary shunt
An extreme V/Q mismatch
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Hypoxemic Respiratory Failure
Etiology and Pathophysiology
3. Diffusion limitation
Severe emphysema
Recurrent pulmonary emboli
Pulmonary fibrosis
Hypoxemia present during exercise
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Diffusion Limitation
Fig. 68-5
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Hypoxemic Respiratory Failure
Etiology and Pathophysiology
4. Alveolar hypoventilation
Restrictive lung disease
CNS disease
Chest wall dysfunction
Neuromuscular disease
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Hypoxemic Respiratory Failure
Etiology and Pathophysiology
5. Interrelationship of mechanisms5. Interrelationship of mechanisms
Combination of two or more
physiologic mechanisms
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Hypercapnic Respiratory Failure
Etiology and Pathophysiology
1. Imbalance between ventilatory1. Imbalance between ventilatory
supply and demandsupply and demand
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Hypercapnic Respiratory Failure
Etiology and Pathophysiology
2. Airways and alveoli2. Airways and alveoli
Asthma
Emphysema
Chronic bronchitis
Cystic fibrosis
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Hypercapnic Respiratory Failure
Etiology and Pathophysiology
3. Central nervous system3. Central nervous system
Drug overdose
Brainstem infarction
Spinal chord injuries
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Hypercapnic Respiratory Failure
Etiology and Pathophysiology
4. Chest wall4. Chest wall
Flail chest
Fractures
Mechanical restriction
Muscle spasm
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Hypercapnic Respiratory Failure
Etiology and Pathophysiology
5. Neuromuscular conditions5. Neuromuscular conditions
Muscular dystrophy
Multiple sclerosis
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Clinical Manifestations
Sudden or gradual onsetSudden or gradual onset
A suddenA sudden decrease in PaOdecrease in PaO22 or rapidor rapid
increase in PaCOincrease in PaCO22 indicates a seriousindicates a serious
conditioncondition
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Clinical Manifestations
When compensatory mechanismsWhen compensatory mechanisms
fail, respiratory failure occursfail, respiratory failure occurs
Signs may be specific or nonspecificSigns may be specific or nonspecific
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Clinical Manifestations
Severe morning headacheSevere morning headache
CyanosisCyanosis
Late sign
Tachycardia and mild hypertensionTachycardia and mild hypertension
Early signs
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Clinical Manifestations
Consequences of hypoxemia andConsequences of hypoxemia and
hypoxiahypoxia
Metabolic acidosis and cell death
Decreased cardiac output
Impaired renal function
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Clinical Manifestations
Specific clinical manifestationsSpecific clinical manifestations
Rapid, shallow breathing pattern
Tripod position
Dyspnea
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Clinical Manifestations
Specific clinical manifestationsSpecific clinical manifestations
Pursed-lip breathing
Retractions
Change in I:E ratio
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Diagnostic Studies
History and physical assessmentHistory and physical assessment
ABG analysisABG analysis
Chest x-rayChest x-ray
CBC, sputum/blood cultures, electrolytesCBC, sputum/blood cultures, electrolytes
ECGECG
UrinalysisUrinalysis
V/Q lung scanV/Q lung scan
Pulmonary artery catheter (severe cases)Pulmonary artery catheter (severe cases)
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Treatment Goals
O2 therapyO2 therapy
Mobilization of secretionsMobilization of secretions
Positive pressure ventilation(PPV)Positive pressure ventilation(PPV)
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O2 Therapy
If secondary to V/Q mismatch- 1-3L or 24%-If secondary to V/Q mismatch- 1-3L or 24%-
32% by mask32% by mask
If secondary to intrapulmonary shunt- positiveIf secondary to intrapulmonary shunt- positive
pressure ventilation-PPVpressure ventilation-PPV
May be via ET tube
Tight fitting mask
**Goal is PaO2 of 55-60 with SaO2 at 90% or more
at lowest O2 concentration possible
**O2 at high concentrations for longer than 48
hours causes O2 toxicity
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O2 toxicity
Oxygen toxicity may occur when too high aOxygen toxicity may occur when too high a
concentration of oxygen (greater than 50%) isconcentration of oxygen (greater than 50%) is
administered for an extended period(longeradministered for an extended period(longer
than 48 hours).than 48 hours).
It is caused by overproduction of oxygen freeIt is caused by overproduction of oxygen free
radicals, which are byproducts of cellradicals, which are byproducts of cell
metabolism. If oxygen toxicity is untreated,metabolism. If oxygen toxicity is untreated,
these radicals can severely damage or kill cells.these radicals can severely damage or kill cells.
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Contd....
Signs and symptoms of oxygen toxicitySigns and symptoms of oxygen toxicity
include:include:
substernal discomfort,substernal discomfort,
paresthesias,paresthesias,
dyspnea,dyspnea,
restlessness, fatigue, malaise,restlessness, fatigue, malaise,
progressiveprogressive respiratory difficulty, andrespiratory difficulty, and
alveolar infiltrates evident onchest x-alveolar infiltrates evident onchest x-
rays.rays.
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Prevention of oxygen toxicity
If high concentrations of oxygen are necessary, it isIf high concentrations of oxygen are necessary, it is
important to minimize the duration of administrationimportant to minimize the duration of administration
and reduce its concentration as soon as possible.and reduce its concentration as soon as possible.
Often, positive end expiratory pressure (PEEP) orOften, positive end expiratory pressure (PEEP) or
continuous positive airway pressure (CPAP) is usedcontinuous positive airway pressure (CPAP) is used
with oxygen therapy to reverse or preventwith oxygen therapy to reverse or prevent
microatelectasis, thus allowing a lower percentage ofmicroatelectasis, thus allowing a lower percentage of
oxygen to be used.oxygen to be used.
The level of PEEP that allows the best oxygenationThe level of PEEP that allows the best oxygenation
without hemodynamic compromise is known as “bestwithout hemodynamic compromise is known as “best
PEEPPEEP
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Mobilization of secretions
Effective coughing- quad cough(asisst cough), huffEffective coughing- quad cough(asisst cough), huff
cough(own gentle way to cough ), staged cough(seriescough(own gentle way to cough ), staged cough(series
of deep breaths, then one little cough…..so on)of deep breaths, then one little cough…..so on)
Positioning- Head of bed 45 degrees or recliner chairPositioning- Head of bed 45 degrees or recliner chair
or bedor bed
“Good lung down”
Hydration - fluid intake 2-3 L/dayHydration - fluid intake 2-3 L/day
Humidification- aerosol treatments- mucolytic agentsHumidification- aerosol treatments- mucolytic agents
Chest PT- postural drainage, percussion andChest PT- postural drainage, percussion and
vibrationvibration
Airway suctioningAirway suctioning
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Positive Pressure Ventilation
Invasively through oro or nasotrachealInvasively through oro or nasotracheal
intubationintubation
Noninvasively( NIPPV) through maskNoninvasively( NIPPV) through mask
Used for acute and chronic respiratory failure
BiPAP- different levels of pressure for inspiration
and expiration- (IPAP) higher for inspiration,
(EPAP) lower for expiration
CPAP- for sleep apnea
**Used best in chronic resp failure in patients with
chest wall and neuromuscular disease, also with HF
and COPD.
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Drug Therapy
Relief of bronchospasm- bronchodilatorsRelief of bronchospasm- bronchodilators
Reduction of airway inflammation-Reduction of airway inflammation-
Corticosteroids by inhalation or IVCorticosteroids by inhalation or IV
Reduction of pulmonary congestion-diureticsReduction of pulmonary congestion-diuretics
and nitroglycerine with heart failure-and nitroglycerine with heart failure-
Treatment of pulmonary infections- IVTreatment of pulmonary infections- IV
antibiotics, vancomycinantibiotics, vancomycin
Reduction of anxiety, pain and agitationReduction of anxiety, pain and agitation
May need sedation or neuromuscularMay need sedation or neuromuscular
blocking agent if on ventilatorblocking agent if on ventilator
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Nutrition
During acute phase- enteral orDuring acute phase- enteral or
parenteral nutritionparenteral nutrition
In a hypermetabolic state- needIn a hypermetabolic state- need
more caloriesmore calories
If retain CO2- avoid high carb diet
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Nursing and Collaborative Management
Nursing AssessmentNursing Assessment
Health information
Health history
Medications
Surgery
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Nursing and Collaborative Management
Nursing AssessmentNursing Assessment
Functional health patterns
Health perception–health management
Nutritional-metabolic
Activity-exercise
Sleep-rest
Cognitive-perceptual
Coping–stress tolerance
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Acute Respiratory Failure
Nursing and Collaborative Management
Nursing AssessmentNursing Assessment
Physical assessment
General
Integumentary
Respiratory
Cardiovascular
Gastrointestinal
Neurologic
Laboratory findings
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Acute Respiratory Failure
Nursing and Collaborative Management
Nursing DiagnosesNursing Diagnoses
Impaired gas exchange
Ineffective airway clearance
Ineffective breathing pattern
Risk for fluid volume imbalance
Anxiety
Imbalanced nutrition: Less than body
requirements
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Acute Respiratory Failure
Nursing and Collaborative Management
Planning: Overall goalsPlanning: Overall goals
ABG values within patient’s baseline
Breath sounds within patient’s
baseline
No dyspnea or breathing patterns
within patient’s baseline
Effective cough and ability to clear
secretions
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Acute Respiratory Failure
Nursing and Collaborative Management
PreventionPrevention
Thorough history and physical
assessment to identify at-risk
patients
Early recognition of respiratory
distress
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Acute Respiratory Failure
Nursing and Collaborative Management
Respiratory therapyRespiratory therapy
Oxygen therapy: Delivery system
should
Be tolerated by the patient
Maintain PaO2 at 55 to 60 mm Hg or
more and SaO2 at 90% or more at
the lowest O2 concentration possible
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Acute Respiratory Failure
Nursing and Collaborative Management
Respiratory therapyRespiratory therapy
Mobilization of secretions
Hydration and humidification
Chest physical therapy
Airway suctioning
Effective coughing and positioning
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Acute Respiratory Failure
Nursing and Collaborative Management
Respiratory therapyRespiratory therapy
Positive pressure ventilation (PPV)
Noninvasive PPV
BiPAP
CPAP
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Noninvasive PPV
Fig. 68-7
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Acute Respiratory Failure
Gerontologic Considerations
Physiologic aging results inPhysiologic aging results in
↓ Ventilatory capacity
Alveolar dilation
Larger air spaces
Loss of surface area
Diminished elastic recoil
Decreased respiratory muscle strength
↓ Chest wall compliance
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Acute Respiratory Failure
Gerontologic Considerations
Lifelong smokingLifelong smoking
Poor nutritional statusPoor nutritional status
Less available physiologic reserveLess available physiologic reserve
Cardiovascular
Respiratory
Autonomic nervous system