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Acute Respiratory Failure: What’s Still Current? What’s New?

Robin Donohoe Dennison, DNP, APRN, CCNS, CNE

1 copyright Robin Donohoe Dennison 2015

Objectives

• differentiate between Type I and Type II acute respiratory failure

• select the primary management strategy for selected causes of acute respiratory failure.

• discuss new concepts in the management of acute respiratory failure

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ARF: Definition

• Failure of the respiratory system to provide for the exchange of oxygen and carbon dioxide between the environment and tissues in quantities sufficient to sustain life

– Hypoxemic normocapnic respiratory failure (Type I): low PaO2 with normal PaCO2

– Hypoxemic hypercapnic respiratory failure (Type II): low PaO2 with high PaCO2

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Type I respiratory failure

• Pneumonia

• Pulmonary edema

• Pulmonary fibrosis

• Pleural effusion

• Pneumothorax

• Asthma

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Type I respiratory failure

• Atelectasis

• Aspiration pneumonitis

• ARDS (early)

• Smoke inhalation

• Pulmonary embolism

• Kyphoscoliosis

• Fat embolism

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Type II respiratory failure

• COPD with acute exacerbation

• Status asthmaticus

• CNS depressant drugs

• Anesthesia

• Neuromuscular blocking drugs – Muscle paralytics

– Aminoglycosides

– Organophosphate poisoning

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Type II respiratory failure

• Head trauma

• Poliomyelitis

• Amyotrophic lateral sclerosis

• Spinal cord injury

• Guillain-Barré syndrome

• Myasthenia gravis

• Multiple sclerosis

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Type II respiratory failure

• Muscular dystrophy • Morbid obesity • Chest trauma • Surgery: especially thoracic, abdominal, flank

incision • Sleep apnea • Tracheal obstruction • Epiglottis • Cystic fibrosis • Near-drowning

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ARF: Pathophysiology

• Hypoventilation

• Ventilation-perfusion mismatching

• Shunting

• Diffusion defects

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V/Q Ratio: pathologic imbalances

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Determinants of Diffusion

• Surface area

• Thickness of alveolar-capillary membrane

• Diffusion coefficient of the gas

• Driving pressure of the gas – fraction x pressure (e.g., FIO2 x barometric

pressure)

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ARF: Clinical presentation

• History of precipitating factor

• Clinical indications of respiratory distress

• Clinical indications of hypoxia

• Clinical indications of hypercapnia

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Clinical indications of respiratory distress

• Nasal flaring

• Sternal retractions

• Intercostal retractions

• Pursed lip breathing

• Tripod positioning

• Use of accessory muscles

• Speaking only one or two words between breaths

• Cough

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Clinical indications of hypoxia

• Restlessness confusion lethargy coma

• Tachycardia dysrhythmias

• Tachypnea

• Dyspnea

• Use of accessory muscles

• Mild hypertension (early) hypotension (late)

• Cyanosis may be present (depending on hemoglobin level)

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Clinical indications of hypercapnia

• Irritability, confusion

• Inability to concentration somnolence coma

• Bradypnea

• Tachycardia dysrhythmias

• Hypotension

• Headache

• Facial rubor (plethora)

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ARF: Diagnostic

• Arterial blood gas changes

– PaO2 < 50-60 mm Hg

– PaCO2 > 50 mm Hg with a pH of < 7.30

• Chest X-ray: may identify cause

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Acute Respiratory Failure

Collaborative management

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Acute Respiratory Failure

• #1: Treatment of Cause

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__Upper airway obstruction

__Airway secretions

__Overdosage of narcotics

__Bronchospasm

__Pneumothorax

__Pneumonia

__Postoperative pain

__ARDS

__Myasthenic crisis

__Atelectasis

a. antimicrobials

b. deep breathing and incentive spirometry

c. chest tube

d. positioning and airway placement

e. cholinergic drugs and mechanical ventilator

f. encouragement of coughing, suctioning if cannot effectively cough

g. PEEP

h. bronchodilators

i. naloxone (Narcan)

j. analgesics

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Airway and ventilation

• Positioning

– Head of bed to 30

– Overbed table for patient to lean on

– “Good lung down” if unilateral lung condition exists (exception: pneumonectomy)

– Prone position especially in ARDS

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HOB 30°

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Positioning: good lung down

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Prone positioning in ARDS • Increased PaO2 by 42-70 mm Hg and

remained elevated for several hours; facilitated a decrease in FIO2 and PEEP

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Hydration

• Two to three liters/24 hours unless contraindicated by cardiac or renal disease

– Oral fluids: noncaffeinated

– Intravenous fluids: usually D5NS

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Bronchial hygiene and chest physiotherapy

• Inspiratory maneuvers: deep breathing; incentive spirometry

• Analgesics in doses adequate to allow patient to deep breath and cough as indicated

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Bronchial hygiene and chest physiotherapy

• Encouragement of the patient to cough if rhonchi are audible; suctioning if the patient is unable to clear airways – Suction only if necessary

– Hyperoxygenate prior to, during, and after suctioning

– Limit suctioning to 10-15 seconds with 100-120 mm Hg negative pressure

– Rinse catheter but do not instill saline • Saline instillation (i.e., lavage) is ineffective, decreases

oxygen levels, and contributes to VAP

• Adequate humidification and hydration must be ensured

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Bronchial hygiene and chest physiotherapy

• Postural drainage, percussion, vibration may be necessary

• Bronchoscopy may be necessary if airway clearance techniques are inadequate

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Noninvasive Positive Pressure Ventilation

• Does not require intubation

• Used to try to avert intubation and mechanical ventilation

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Noninvasive Positive Pressure Ventilation

• COPD: Standard of care for COPD if no contraindications

• Cardiogenic pulmonary edema: Evidence is strong

• Obesity: Require higher positive pressures and it takes longer to reduce PaCO2

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Noninvasive Positive Pressure Ventilation

• Asthma: Evidence is weak but positive

• Hypoxemic respiratory failure: Evidence is weak but positive

• Post-extubation respiratory failure: Evidence weak but negative

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Berg, Clardy, Donnino, 2012 31

Noninvasive Positive Pressure Ventilation

• Modes

– CPAP increases driving pressure of oxygen

– Bi-PAP = pressure support + CPAP

• Decreases work of breathing

• Increases driving pressure of oxygen

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Intubation and Mechanical Ventilation

• Intubation and mechanical ventilation may be necessary if PaCO2 continues to rise and acidosis develops

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The goal of mechanical ventilation is to normalize the pH, not

necessary the PaCO2

• It is not appropriate to normalize the PaCO2 in patients with COPD and chronic hypercapnia (this causes metabolic alkalosis, eventual excretion of sodium bicarbonate, and weaning difficulties)

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Mismanagement of ARF in COPD

pH 7.35 7.30 7.50 7.40 7.35

PaCO2 50 60 40 40 50

HCO3 30 30 30 24 30

PaO2 64 55 88 88 64

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Intubation and Mechanical Ventilation

– Mechanical ventilation is indicated for respiratory muscle fatigue to allow respiratory muscle rest and recovery

– Permissive hypercapnia may be used to prevent VILI especially in patients with ARDS

– Helium-oxygen mixture may be used in airway obstruction such as status asthmaticus or tumor disease

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Drug therapy

• Bronchodilators may be indicated

– Long (salmeterol [Serevent]) and/or short-acting beta2 adrenergic agonists (e.g., metaproterenol [Alupent], albuterol [Proventil])

– Xanthines (e.g., aminophylline, theophylline)

– Anticholinergic (e.g., ipratropium bromide [Atrovent])

– Magnesium

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Drug therapy

• Pulmonary vasodilator may be indicated

– Xanthines (e.g. aminophylline, theophylline)

– Nitric oxide

– Prostanoids

• Epoprostenol (Flolan)

• Iloprost (Ventavis)

• Treprostinil (Remodulin [IV], Tyvaso [inhalation])

– Endothelin receptor antagonists: bosentan (Tracleer)

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Drug therapy

• Antibiotics are indicated for bacterial infection

• Steroids are indicated in asthma

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Drug therapy

• Fibrinolytics are indicated for pulmonary embolism with right ventricular failure and/or refractory hypoxemia; anticoagulants are indicated for pulmonary embolism (primary if fibrinolytics are not indicated or after fibrinolytics if fibrinolytics are indicate) – Lepirudin (Refludan), a recombinant hirudin, or

argatroban may be used in patients with history of HITT • These are direct thrombin inhibitors

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Drug therapy

• Expectorants (e.g. guaifenesin [Robitussin], potassium iodide [SSKI]) may be used but hydration is most important

• Mucolytics (e.g. acetylcysteine [Mucomyst]) may be used to decrease the tenacity of the mucus

• Sedatives: generally avoided unless patient is very agitated

• Antitussives: avoid use of antitussives

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Optimization of oxygen delivery and minimization of oxygen

consumption

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Oxygen as indicated for hypoxemia

• Nasal cannula or mask; masks are contraindicated in hypercapnic patients as the high concentration of oxygen provided by these delivery system would likely eliminate the hypoxic drive

• Flow rate or oxygen concentration to keep SpO2 approximately 95% unless contraindicated; in patients with chronic hypercapnia, adjust flow rate or oxygen concentration to keep SpO2 approximately 88-92%

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Optimization of oxygen delivery and minimization of oxygen consumption

• Positive end-expiratory pressure (PEEP): may be necessary to maintain adequate SaO2, PaO2

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PEEP

• Decrease shunt

• Decrease surface tension and work of breathing

• Increase driving pressure to achieve

– Same PaO2 on lower FIO2

– Better PaO2 on same FIO2

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Optimization of oxygen delivery and minimization of oxygen consumption

• Rest periods especially after meals or activities

• Quiet, restful environment

• Treatment of fever: antipyretics; cooling blankets

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Optimization of oxygen delivery and minimization of oxygen consumption

• Blood administration: may be necessary to provide adequate tissue delivery of oxygen if hemoglobin is low

• Fluid administration, inotropes, intra-aortic balloon pump, etc.: may be necessary to provide adequate tissue delivery of oxygen if cardiac output/index is low

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Treat infection if present

• Antibiotics

• Bronchial hygiene techniques

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Nutritional Support

• Malnutrition impairs:

– respiratory muscle function

– functioning of the immune system

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Nutritional Support

• Enteral nutrition: helps to prevent translocation of bacteria from the GI tract to the lymphatics and blood vessels

• High protein and calorie diet rich in omega 3

• Multivitamin and mineral replacement: vitamins A, C, E, zinc, selenium

• Reduced carbohydrates during weaning

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Monitor for complications

• Dysrhythmias

• Pulmonary infections: pneumonia

• Pulmonary edema

• Pulmonary embolism

• Barotrauma or volutrauma

• Pulmonary fibrosis

• Oxygen toxicity

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Monitor for complications

• Acid-base imbalance

– Respiratory acidosis

– Respiratory alkalosis: when ventilation is excessive

– Metabolic alkalosis: when PaCO2 is normalized rather than the pH

• Electrolyte imbalance: frequently iatrogenic

• Renal failure

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Monitor for complications

• GI complications: abdominal distention; ileus; ulcer; hemorrhage – ? PPI, H2 antagonists, antacids

• Thromboembolism: LMWH

• Disseminated intravascular coagulation

• Sepsis; septic shock

• Psychologic responses: psychosis; depression

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Evaluation

• Baseline oxygenation parameters: lower baseline oxygenation is a poor prognostic marker

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Patient and Family Education

• Respiratory treatments

• Pharmacology therapies

• Recognition of clinical indications of infection and impending respiratory failure

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Case Study

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References • Berg, K. M., Clardy, P., & Donnino, M. W. (2012). Noninvasive

ventilation for acute respiratory failure: a review of the literature and current guidelines. Intern Emerg Med, 7(6), 539-545.

• Chlan, L., Tracy, M. F., & Grossbach, I. (2011). Achieving quality patient-ventilator management: advancing evidence-based nursing care. Crit Care Nurse, 31(6), 46-50.

• Choi, W. I., Shehu, E., Lim, S. Y., Koh, S. O., Jeon, K., Na, S., . . . Korean Study group on Respiratory, F. (2014). Markers of poor outcome in patients with acute hypoxemic respiratory failure. J Crit Care, 29(5), 797-802.

• Corbridge, S., & Corbridge, T. C. (2010). Asthma in adolescents and adults. Am J Nurs, 110(5), 28-38; quiz 39-40.

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References • Dennison, R. D. [2013]. Pass CCRN! [4 ed]. Philadelphia: Elsevier.

• Fournier, M. (2014). Caring for patients in respiratory failure. American Nurse Today, 9(11), 18-23.

• Kjonegaard, R., Fields, W., & King, M. L. (2010). Current practice in airway management: A descriptive evaluation. Am J Crit Care, 19(2), 168-173; quiz 174.

• Walkey, A. J., & Wiener, R. S. (2013). Use of noninvasive ventilation in patients with acute respiratory failure, 2000-2009: a population-based study. Ann Am Thorac Soc, 10(1), 10-17.

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Which parameter differentiates between type I and type II acute respiratory failure? (more than one may be correct) a. SaO2 b. PaO2 c. pH d. PaCO2

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In a patient on noninvasive mechanical ventilation, which of the following would be an indication for intubation and mechanical ventilation? (more than one may be correct) a. Altered level of consciousness b. Hemodynamic instability c. Progressive increase in PaCO2 and worsening respiratory acidosis

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