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Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
RespiratoryFailure
Revised1.5.17Chapter68
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
AcuteRespiratoryFailure• Resultsfrominadequategasexchange
• InsufficientO2transferredtotheblood• Hypoxemia
• InadequateCO2removal• Hypercapnia
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GasExchangeUnit
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AcuteRespiratoryFailure• NotadiseasebutacondiFon• oneormorediseasesinvolvingthelungsorotherbodysystems
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Classi9icationofRespiratoryFailure
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CaseStudy
• J.D.,a75-year-oldmalewithalong-standinghistoryofCOPD,developsarespiratoryinfecFonthatisunresponsivetotreatment.• HeisadmiMedtotheEDinmoderaterespiratorydistress.• RR32andshallow,andheisanxious.
• WhattypeofrespiratorydistressJ.D.isexperiencing.• Whatinforma7onandassessmentdatawillhelpindiagnosisandtreatment?
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HypoxemicRespiratoryFailureEtiologyandPathophysiology• Causes• Ven7la7on-perfusion(V/Q)mismatch• COPD• Pneumonia• Asthma• Atelectasis• Resultofpain• Pulmonaryembolus
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RegionalDifferencesinV/QMismatch
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RangeofV/QRelationships
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HypoxemicRespiratoryFailureEtiologyandPathophysiology
• Causes• Shunt• Anatomicshunt• Intrapulmonaryshunt
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HypoxemicRespiratoryFailureEtiologyandPathophysiology
• Causes• Diffusionlimita7on• SevereCOPD• Recurrentpulmonaryemboli• Pulmonaryfibrosis• ARDS• IntersFFallungdisease• Hypoxemiapresentduringexercise
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DiffusionLimitation
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HypoxemicRespiratoryFailureEtiologyandPathophysiology• Causes• Alveolarhypoven7la7on• RestricFvelungdisease• CNSdisease• ChestwalldysfuncFon• Neuromusculardisease
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HypoxemicRespiratoryFailureEtiologyandPathophysiology• Interrela7onshipofmechanisms• CombinaFonoftwoormorephysiologicmechanisms• V/Qmismatch• Shunt• DiffusionlimitaFon• AlveolarhypovenFlaFon
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CaseStudy• J.D.’schestx-rayshowsbilateralinfiltrates.ABGresults:• pH7.18• PaO258mmHg• PaCO260mmHg• O2saturaFon85%
• Hiswifeisyellingatthehealthcareteamto“dosomethingorhewilldie.”
• WhatdohisABGresultsindicate?• Whatisthecauseofhisrespiratoryfailure?• Howwouldyouaddresshiswife’sconcern?• Howissheaffec7nghisresponsesandanxiety?
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HypercapnicRespiratoryFailureEtiologyandPathophysiology
• ImbalancebetweenvenFlatorysupplyandvenFlatorydemand
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HypercapnicRespiratoryFailureEtiologyandPathophysiology• Airwaysandalveoliabnormali7es• Asthma• COPD• CysFcfibrosis
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HypercapnicRespiratoryFailureEtiologyandPathophysiology• Centralnervoussystemabnormali7es• Drugoverdose• BrainsteminfarcFon• Spinalchordinjuries
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HypercapnicRespiratoryFailureEtiologyandPathophysiology• Chestwallabnormali7es• Flailchest• Kyphoscoliosis• Severeobesity• Fractures• MechanicalrestricFon• Musclespasm
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HypercapnicRespiratoryFailureEtiologyandPathophysiology• Neuromuscularcondi7ons• Musculardystrophy• Guillain-Barrésyndrome• MulFplesclerosis• Exposuretotoxins• MusclewasFng
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RespiratoryFailureClinicalManifestations
• Suddenorgradualonset• AsuddendecreaseinPaO2orrapidincreaseinPaCO2indicatesaseriouscondiFon
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CaseStudy• J.D.’swifereportsthathehashadincreaseddifficultysleeping.• HehasbeenconfusedatFmesoverthepastweek.• Heappearsrestlessnowandinsistsonleaningontheoverbedtable.
• Howdothesemanifesta/onsrelatetorespiratoryfailure?• Whatotherclinicalmanifesta/onswouldyouassessfor?
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RespiratoryFailureClinicalManifestations
• SpecificclinicalmanifestaFons• Rapid,shallowbreathingpaMern• Orthopnea• TripodposiFon• Dyspnea• Pursed-lipbreathing• RetracFons• ChangeinI:EraFo
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CaseStudy
• J.D.’swifestatesthathehasahistoryofMI,hypertension,andGERD.• Asputumcultureisorderedforhim.
• Whatotherdiagnos/cstudieswouldbeorderedforhim?
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RespiratoryFailureDiagnosticStudies• Historyandphysicalassessment• ABGanalysis• Chestx-ray• CBC,sputum/bloodcultures,electrolytes• ECG• Urinalysis• V/Qlungscan• Pulmonaryarterycatheter(severecases)
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CaseStudy• J.D.’swifesharesthatheisareFredteacher.• Hehasenjoyedwoodworkingbutstrugglestoworkonprojectsnow.• J.D.walksshortdistancesinhisneighborhoodwhenheiswell.• Hetoleratessmallfrequentmealsbest.
• Discussthesefindingsandotherques/onstheymightaskhimorhiswiferelatedtofunc/onalhealthpa>erns.• Discusshead-to-toeassessmentfocus.
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CaseStudy• J.D.isplacedonoxygenviafacemask.
• Whatothercollaborativecareareappropriate?
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AugmentedCough
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• Huffcoughing• Seriesofcoughsperformedwhilesaying“huff”• EffecFveinclearingcentralairways
• Stagedcough• Sitleaningforward• Takethreedeepbreathsthroughmouthandcough
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• HydraFonandhumidificaFon• Adequatefluidintake• IVhydraFon• HumidificaFondevices• O2viaaerosolmask
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• Chestphysicaltherapy• Posturaldrainage• Percussion• VibraFon
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• AirwaysucFoning• Nasopharyngeal• Oropharyngeal• Nasotracheal
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• Respiratorytherapy• PosiFvepressurevenFlaFon(PPV)• NoninvasivePPV• BiPAP• CPAP
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NoninvasivePPV
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CaseStudy
• Thesputumcultureisobtainedandsenttothelab.• Hissputumisthickandtanincolor.
• Whatdrugtherapywouldbeusedforhim?
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• Drugtherapy• Reliefofbronchospasm• Bronchodilators
• ReducFonofairwayinflammaFon• CorFcosteroids
• ReducFonofpulmonarycongesFon• DiureFcs,nitratesifheartfailurepresent
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• Drugtherapy• TreatmentofpulmonaryinfecFons• IVanFbioFcs
• ReducFonofsevereanxiety,pain,andagitaFon• Benzodiazepines• Opioids
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• MedicalsupporFvetherapy• Treattheunderlyingcause• MaintainadequatecardiacoutputandhemoglobinconcentraFon
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AcuteRespiratoryFailureNursingandCollaborativeManagement
• NutriFonaltherapy• Maintainproteinandenergystores• EnteralorparenteralnutriFon• NutriFonalsupplements
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Evaluation• Expectedoutcomes• MaintainapatentairwaywitheffecFveremovalofsecreFons• NormalorbaselineRR,breathsounds,oxygenaFon• Normalhemodynamicstatus
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CaseStudy
• J.D.wasadmiMedtoamedicalunitandisslowlyrecoveringfromhisrespiratoryinfecFon.• Heandhiswifeaskabouthowthismightbepreventedinthefuture.
• Whatwillbeyourteachingplanfordischarge?
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ApaFent’sABGresultsincludepH7.31,PaCO250mmHg,PaO251mmHg,andHCO324mEq/L.Oxygenisadministeredat2L/min,andthepaFentisplacedinhigh-Fowler’sposiFon.Anhourlater,theABGsarerepeatedwithresultsofpH7.36,PaCO240mmHg,PaO260mmHg,andHCO324mEq/L.Whatismostimportantforthenursetodo?a. Increasetheoxygenflowrateto4L/min.b. DocumentthefindingsinthepaFent’srecord.c. ReposiFonthepaFentinasemi-Fowler’sposiFon.d. PreparethepaFentforendotrachealintubaFonandmechanical
venFlaFon.
AudienceResponseQuestion
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ApaFentwithseverechroniclungdiseaseishospitalizedwithrespiratorydistress.WhichfindingwouldsuggesttothenursethatthepaFenthasdevelopedrapiddecompensaFon?a. AnSpO2of86%b. AbloodpHof7.33c. AgitaFonorconfusiond. PaCO2increasesfrom48to55mmHg
AudienceResponseQuestion
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WhichpaFentisathighestriskforhypoxemicrespiratoryfailure?a. ApaFentwhohasrespiratorymuscleparalysisb. ApaFentwhohasfracturedribsandaflailchestc. ApaFentwhohasamassivepulmonaryembolismd. ApaFentwhohasslowbreathingfromadrug
overdose
AudienceResponseQuestion
