Respiratory Failure
Etiology/Pathophysiology
1. Respiratory system as it relates to acute respiratory failure.
a. Major function of the respiratory system is gas exchange
(oxygen and carbon dioxide) between atmosphere and blood.
(Lewis 1800 Fig 68-1)
b. ABG analysis
1) Is the pH normal? (7.4; range 7.35-7.45)
2) Is the PaCO2 normal? (40; range 35-45 mmHg)
3) Is the PaHCO3 normal? (24; range 22-26 mEq/L)
4) Match the PaCO2 or PaHCO3 with the pH.
5) Does the PaCO2 or the PaHCO3 go the opposite
direction of the pH?
6) Are the PaO2 (80-100 mmHg) and the O2 saturation
(95-100%) normal?
c. Example of analysis:
1) Look at the pH. Normal blood pH is 7.4 plus or minus
0.05, forming a normal range of 7.35 to 7.45. If blood
pH falls below 7.35 it is acidotic. If the blood pH rises
above 7.4, it is alkalotic. If it falls into the normal range,
label what side of 7.4 it falls on. Lower than 7.4 is
normal/acidotic, higher than 7.4 is normal/alkalotic.
Label it _____.
2) Look at PaCO2. Normal PaCO2 levels are 35-45 mmHg.
Below is alkalotic, above is acidotic.
Label it ____.
3) Look at PaHCO3 levels. A normal PaHCO3 level is 22-26
mEq/L. If the HCO3 is below 22, the patient is acidotic.
If the HCO3 is above 26, the patient is alkalotic.
Label it _____.
4) Match either the CO2 or the HCO3 with the pH to
determine the acid-base disorder. For example, if the
pH is acidotic, and the CO2 is acidotic, then the acidbase disturbance is being caused by the respiratory
system, respiratory acidosis. However if the pH is
alkalotic and the HCO3 is alkalotic, the acid-base
disturbance is being caused by the metabolic (or renal)
system. Therefore, metabolic alkalosis.
5) Does either the CO2 or HCO3 go in the opposite
direction of the pH? If so, there is compensation by that
system. For example, the pH is acidotic, the CO2 is
acidotic, and the HCO3 is alkalotic. The CO2 matches
the pH making the primary acid-base disorder
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d.
e.
f.
g.
h.
i.
j.
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Table 68-3)
(1)
Specific:
a. Respiratory: Dyspnea; tachypnea;
prolonged expiration; intercostal muscle
retraction; use of accessory muscles in
resp;< 80% SpO2; paradoxic chest/abd
wall movement with resp cycle (late);
cyanosis (late)
(2)
Nonspecific:
a. Cerebral: agitation, disorientation,
delirium, restless, combative, confusion,
dec LOC, coma (late)
b. Cardiac: tachycardia, hypertension, skin
cool/clammy, dysrhythmias (late),
hypotension (late)
c. Other: fatigue; need to pause to breath
when speaking
g. Treatment of hypoxemia- treat cause, O2 and
mechanical ventilation
2. Hypercapnic Respiratory Failure:
a. Ventilatory failure- insufficient CO2 removal. PaCO2 greater
than 45 mm Hg arterial and pH less than 7.35.
b. There is an imbalance between ventilatory supply (maximum
ventilation without developing respiratory muscle fatigue) and
ventilatory demand (amount of ventilation needed to keep the
PaCO2 within normal limits)
c. Normally supply exceeds demand- so that one can increase
exercise which increases CO2 production without an elevation
PaCO2
d. With preexisting lung disease, as COPD, do not have this ability
and cannot increase lung ventilation in response to exercise or
metabolic demands.
e. When ventilator demand does exceed ventilator supply, the
PaCO2 can no longer be sustained within normal limits and
hypercapnia occurs.
f. Hpercapnia respiratory failure is sometimes called ventilatory
failure because primary problem is the inability of the
respiratory system to ventilate out sufficient CO2 to maintain
normal PaCO2
g. Four categories of causes (Lewis p 1745 Table 68-1)
1) Abnormalities of the airways and alveoli (asthma, COPD,
cystic fibrosis)
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b.
c.
d.
e.
f.
g.
Integumentary
Respiratory
Cardiovascular
Gastrointestinal
Neurologic
Other findings- labs, chest X-ray, wedge pressure changes
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