Acute Pulmonary Failure

Respiratory System
Consists

of two parts:

Gas exchange organ (lung): responsible for OXYGENATION Pump (respiratory muscles and respiratory control mechanism): responsible for VENTILATION

Alteration in function of gas exchange unit (oxygenation) OR of the pump mechanism (ventilation) can result in respiratory failure

Acute Respiratory Failure

Respiratory

failure is a syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and ventilation.

Failure

of gas exchange due to inadequate function of one or more essential components of respiratory system

Gas Exchange Unit

Fig. 68-1

Acute Respiratory Failure

0 Classification: 0 Hypoxemic Respiratory Failure (Failure of Oxygenation) -Insufficient O2 transferred to the blood
0 Hypercapnic Respiratory Failure(Failure of

Ventilation) - Inadequate CO2 removal

Classification of Respiratory Failure

Diagnosis
History Taking Physical Exam

Etiology

Causes of Acute Respiratory Failure

Type 1 respiratory failure Type 2 respiratory failure

Parenchymal process Pneumonia Pulmonary edema cadiogenic noncardiogenic Pulmonary hemorrhage Progressive interstitial process Pulmonary vascular Pulmonary embolism Pulmonary hypertension

Increased load Upper airway obstruction Asthma COPD Neurological etiology Central respiratory depression Spinal cord injury Peripheral nerve Neuromuscular junction

Hypoxemic Respiratory Failure

-Insufficient

O2 transferred to the blood

Causes:
Ventilation-perfusion Shunt Diffusion

(V/Q) mismatch

limitation Alveolar hypoventilation

 II)

Shunt An extreme V/Q mismatch Blood passes through parts of respiratory system that receives no ventilation

d/t obstruction OR fluid accumulation Not Correctable with 100% O2

 III)

Diffusion Limitations

Distance between alveoli and pulmonary capillary is one- two cells thick With diffusion abnormalities: there is an increased distance between alveoli (may be d/t fluid) Correctable with 100% O2

Diffusion Limitation

Fig. 68-5

 Causes

Diffusion limitations Severe emphysema Recurrent pulmonary emboli Pulmonary fibrosis Hypoxemia present during exercise

Alveolar Hypoventilation -- Is a generalized decrease in ventilation of lungs and resultant buildup of CO2

IV)

 Causes

Alveolar hypoventilation Restrictive lung disease CNS disease Chest wall dysfunction Neuromuscular disease

Interrelationship of mechanisms Hypoxemic respiratory failure is frequently caused by a combination of two or more of these four mechanisms Effects of hypoxemia Build up of lactic acid metabolic acidosis cell death CNS depression Heart tries to compensate HR and CO If no compensation: O2, acid, heart fails, shock, multi-system organ failure

Hypercapnic Respiratory Failure

-Insufficient

CO2 removal

 Imbalance

between ventilatory supply and demand Occurs when CO2 is increased

Causes Hypercapnic Respiratory Failure

I) Alveolar Hypoventilation and VQ Mismatch:

Ventilation not adequate to eliminate CO2 Leads to respiratory acidosis Eg. Narcotic OD; Guillian-Barre, ALS, COPD, asthma

Causes Hypercapnic Respiratory Failure

II) VQ Mismatch: - Leads to increased work of breathing

- Insufficient energy to overcome resistance; ventilation falls; PCO2; respiratory acidosis

Hypercapnic Respiratory Failure Categories of Causative Conditions

I) Airways and alveoli Asthma Emphysema Chronic bronchitis Cystic fibrosis

Hypercapnic Respiratory Failure Categories of Causative Conditions

II)

Central nervous system Drug overdose Brainstem infarction Spinal cord injuries

Hypercapnic Respiratory Failure Categories of Causative Conditions

III)

Chest wall Flail chest Fractures Mechanical restriction Muscle spasm

Hypercapnic Respiratory Failure Categories of Causative Conditions

IV)

Neuromuscular conditions Muscular dystrophy Multiple sclerosis

Respiratory Failure Tissue Organ Needs

Major threat is the inability of the lungs to meet the oxygen demands of the tissues

Clinical Manifestations

Severe morning headache Cyanosis - Late sign Tachycardia and mild hypertension - Early signs Consequences of hypoxemia and hypoxia Metabolic acidosis and cell death Cardiac output Impaired renal function

 Specific

clinical manifestations Rapid, shallow breathing pattern Sitting upright Dyspnea Pursed-lip breathing Retractions Change in Inspiratory:Expiratory ratio

 Disease

Process-Pathophysiology

Diagnostic Procedure

Diagnosis: Laboratory Workup

ABG

Quantifies magnitude of gas exchange abnormality Identifies type and chronicity of respiratory failure
Anemia may cause cardiogenic pulmonary edema Polycythemia suggests may chronic hypoxemia Leukocytosis, a left shift, or leukopenia suggestive of infection Thrombocytopenia may suggest sepsis as a cause

Complete blood count

Diagnosis: Laboratory Workup

Cardiac

serologic markers

Troponin, Creatine kinase- MB fraction (CKMB) B-type natriuretic peptide (BNP) Respiratory cultures: sputum/tracheal aspirate/broncheoalveolar lavage (BAL) Blood, urine and body fluid (e.g. pleural) cultures

Microbiology

Laboratory Investigations

Chest radiography

Identify chest wall, pleural and lung parenchymal pathology; and distinguish disorders that cause primarily V/Q mismatch (clear lungs) vs. Shunt (intra- pulmonary shunt; with opacities present) Identify arrhythmias, ischemia, ventricular dysfunction Identify right and/or left ventricular dysfunction

Electrocardiogram

Echocardiography

Laboratory Investigations

Pulmonary function tests/bedside spirometry

Identify obstruction, restriction, gas diffusion abnormalities May be difficult to perform if critically ill
Obtain biopsies, brushings and BAL for histology, cytology and microbiology Results may not be available quickly enough to avert respiratory failure Bronchoscopy may not be safe if critically ill

Bronchoscopy

Nursing Diagnoses
Ineffective

airway clearance Ineffective breathing pattern Risk for imbalanced fluid volume Anxiety Impaired gas exchange Imbalanced nutrition: less than body requirements

Acute Respiratory Failure

Planning:

Nursing and Collaborative Management Overall goals

ABG

values within patients baseline Breath sounds within patients baseline No dyspnea or breathing patterns within patients baseline Effective cough and ability to clear secretions

Acute Respiratory Failure

Nursing and Collaborative Management
Prevention

Thorough history and physical assessment to identify at-risk patients Early recognition of respiratory distress

Respiratory Failure: Management

 ABC

Ensure

airway is adequate Ensure adequate supplemental oxygen and assisted ventilation, if indicated Support circulation as needed

Acute Respiratory Failure

Nursing and Collaborative Management

Respiratory 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

Acute Respiratory Failure

Nursing and Collaborative Management
Respiratory

therapy

Mobilization of secretions

Hydration and humidification Chest physical therapy Airway suctioning Effective coughing and positioning

Augmented Cough

Fig. 68-6

Management
Mechanical

ventilation

Non-invasive (if patient can protect airway and is hemodynamically stable)

Mask:

usually orofacial to start

Invasive
Endotracheal

tube (ETT) Tracheostomy if upper airway is obstructed

Indications for Mechanical Ventilation

Cardiac

or respiratory arrest Tachypnea or bradypnea with respiratory fatigue orimpending arrest Acute respiratory acidosis Refractory hypoxemia (when the P aO 2 could not be maintained above 60 mm Hg with inspired O 2 fraction (F I O 2 )>1.0) Inability to protect the airway associated with depressed levels of consciousness

Indications contd
Shock

associated with excessive respiratory work Inability to clear secretions with impaired gas exchange or excessive respiratory work Newly diagnosed neuromuscular disease with a vital capacity <10-15 mL/kg Short term adjunct in management of acutely increased intracranial pressure (ICP)

Non-invasive ventilatory support

The application of ventilatory support through a nasal prong or full face mask in lieu of ETT is being used increasingly for patients with acute or chronic mild to moderate respiratory failure Conscious Intact airway Intact airway reflexes

Non-invasive ventilatory support

Has proven beneficial in
acute

exacerbations of COPD and asthma, decompensated CHF with mild-tomoderate pulmonary edema, pulmonary edema from hypervolemia obesity hypoventilation syndrome

Noninvasive PPV

Fig. 68-7

Invasive ventilatory support

Useful

when pt does not respond to non invasive methods of ventilation

Invasive ventilatory support

Indications

Apnea or bradypnea ALI & ARDS

Severe cardiogenic shock

Traumatic brain injury Brain injury

Follow up
Complications
Pulmonary

embolism, barotrauma, fibrosis, cx secondary to use of mechanical devices, VILI, oxygen toxicity hypotension, reduced cardiac output, arrhythmia, pericarditis, and acute myocardial infarction.

Cardiovascular-

 Gastrointestinal-

hemorrhage, gastric distention, ileus, diarrhea, and pneumoperitoneum. pneumonia, urinary tract infections, and catheter-related sepsis

Infectious-

Renal

- Acute renal failure and abnormalities of electrolytes and acid-base homeostasis malnutrition, hypoglycemia, abd distension, etc

Nutritional

Invasive vs. Non- invasive Ventilation

Consider

non- invasive ventilation particularly in the following settings:

COPD exacerbation Cardiogenic pulmonary edema Obesity hypoventilation syndrome Noninvasive ventilation may be tried in selected patients with asthma or noncardiogenic hypoxemic respiratory failure

Acute Respiratory Failure

Nursing and Collaborative Management
Drug

Therapy

Relief of bronchospasm
Bronchodilators

Reduction of airway inflammation

Corticosteroids

Reduction of pulmonary congestion

Diuretics,

nitrates if heart failure present

Acute Respiratory Failure

Nursing and Collaborative Management
Drug

Therapy
antibiotics

Treatment of pulmonary infections

IV

Reduction of severe anxiety, pain, and agitation

Benzodiazepines Narcotics

Acute Respiratory Failure

Nursing and Collaborative Management
Nutritional

Therapy

Maintain protein and energy stores Enteral or parenteral nutrition Nutritional supplements

Acute Respiratory Failure

Nursing and Collaborative Management
Medical

Supportive Therapy

Treat the underlying cause Maintain adequate cardiac output and hemoglobin concentration

Acute Respiratory Failure Gerontologic Considerations

Physiologic

aging results in

Ventilatory capacity Alveolar dilation Larger air spaces Loss of surface area Diminished elastic recoil Decreased respiratory muscle strength Chest wall compliance

Acute Respiratory Failure Gerontologic Considerations

Lifelong

smoking Poor nutritional status Less available physiologic reserve

Cardiovascular Respiratory Autonomic nervous system