ARF: An Exploration

Denise Nunes

Chief Complaint
JB 68yo female found unresponsive on 10/11
Noted by husband to be increasingly lethargic week prior

to admission.
Transported JB to the Swedish ER where she presented

with agonal breathing and coarse crackles in the right upper lobe.

Initial History
JB presents with history of COPD, hyperthyroidism
Past surgeries: Caesarean section Home Medications: Propylthiouracil, 3L NC

Review of Systems
Information obtained from Medical Record

Physical Assessment
General Appearance: supine HOB elevated to 30, intubated tube

at 21cm right side , legs edematous, under light sedation 0.5 mg Ativan via R 20 gauge IV port, opens eyes on commands. Left IV port receiving 0.9 NS at 83cc/hr. Left hand tremors on arousal. Soft wrist restraints on arms.
Skin: warm to touch, skin is scaly, bruising near IV insertion site.

Left hand 20 gauge IV peripheral access, Right hand 20 gauge main IV port. Mucus membranes are dry r/t intubation and feeding tube. Oral care ordered. No rashes or breaks in skin.
Head and Neck: head is normocephalic atraumatic. Neck free of

ecchymosis or other signs of trauma. Supple and movable.

Physical Assessment
Lungs: crackles present on auscultation of right upper lobe. Scant

secretions on suctioning. On ventilator CMV at 12, FiO2 at 40, PEEP at 5, Tidal 450, tubing inserted at 21cm right side, Sat 99% Chest x ray shows proper placement of ET tube at the carina
Heart: telemetry, ECG sinus tachy, HR 80s-90s, Normal S1, S2, No

additional heart sounds, no S3, S4, no murmurs, bruits, or thrills. Capillary refill <2 sec. Peripheral pulses palpable and normal 2+/4+, PR Interval 0.12, QRS <0.12, Regular rhythm, HR 90. 10/13/2011, received 2D echo, results are still pending.
Abdomen/Gastrointestinal (GI): abdomen non-distended, bowel

sounds presents, evening nurse reported melena, DHT placed 10/13/2011, KUB shows ileus, nutrition held, remains NPO.

Physical Assessment
Genitourinary (GU): Foley inserted, I/Os monitored Q 1hr. Urine clear,

dark amber in color, low output between 13- 20 ccs/hr.

Neurological (include mental status and pain assessment): Light

sedation, 0.5 mg/hr Ativan. Pupils Round and sluggishly reactive to light. No facial asymmetry. EEG findings 10/13/2011: severe anoxic encephalopathy. Left hand tremors extremities.

Extremities: Weakness in all extremities. 3+ pitting edema in lower Reproductive History: Gravida 1 Para 1 Immunity: (include immunizations): Last Pnemovaccine 07/2007, all

other immunizations up to date

Pertinent Lab Work

Laboratory Test
RBC

Normal Range
3.7-5.0 x 106/L

Results
2.99L

Possible Reasons
Low RBCs related to decreased oxygenation and hypercapnia Related to low RBC, Hgb levels Related to low RBC, Hgb levels Acid-base Kidneys may not be able to filter the increased amount of urea created by state of acidosis. Inability to filter results in increased serum levels Reserves released because of malnutrition Hypercapnia r/t COPD Partial compensation of respiratory acidosis Respiratory acidosis

HGB HCT Ca BUN

11.0-15.0 g/dL 33.0-45.0% 8.7-10.7 mg/dL 7-22 mg/dL

9.3L 30.8L 8.4L 24 H

Glucose PaCO2 HCO3 pH

70-99 mg/dL 35-45 mmHg 22-26 7.35-7.45

107 H 71.9H 36.7H 7.33L

Diagnostic Exams
Chest X-ray revealed lung fields consistent with COPD,

hyperdistended alevoli
Kidneys, Ureter and Bladder x-ray ordered to ensure

proper placement DHT.

EEG- severe anoxic encephalopathy 2D Echo- rule out endocarditis EKG: Sinus Rhythm

Patient and Family Considerations

Caucasian
Retired since 1968 Patient lives at home with husband who is primary care

giver

ARF Differential Diagnosis

Disease/Condition

Differentiating Signs/Symptoms
People suffering diabetic ketoacidosis and acidosis from other causes (e.g., aspirin toxicity) have labored (Kussmaul) breathing. People with acute panic attack and other forms of anxiety often present with marked respiratory distress characterized by "air hunger" or a feeling of dyspnea.

Differentiating Tests Arterial blood gas analysis shows metabolic acidosis (low pH, low bicarbonate) and hyperventilation (decreased PaCO2). Pulse oximetry shows normal oxygen saturation.

Hyperventilation secondary to metabolic acidosis

Hyperventilation secondary to anxiety

Arterial blood gas analysis shows respiratory alkalosis with an elevated pH and decreased PaCO2. Pulse oximetry shows normal oxygen saturation.

ARF Differential Diagnosis

Disease/Condition

Differentiating Signs/Symptoms
People with marked sleep apnea may present with hypoventilation and prolonged apneic spells while sleeping.

Differentiating Tests ABGs may show decreased PaO2 and elevated PaCO2, and pulse oximetry shows hypoxia. When awake and ABGs are often normal. Sleep apnea is diagnosed by a formal sleep study. During apnea spells, ABGs show decreased PaO2 and elevated PaCO2, and pulse oximetry shows hypoxia. When awake gases are often normal.

Sleep apnea

Obesity

People with marked obesity may present with hypoventilation and prolonged apneic spells while sleeping.

COPD Differential Diagnosis

Symptoms such as shortness of breath, chest tightness, wheezing, and coughing may be caused by conditions other than chronic obstructive pulmonary disease (COPD) and must be considered in the differential diagnosis of COPD. These conditions include: Asthma Bronchiectasis - chronic widening of the bronchial tubes that can lead to respiratory tract infections and make it very difficult for the patient to breathe Congestive heart failure Interstitial lung disease - scarring of the lung tissue or the lining of the air sacs that results in breathing difficulty Lung infections (e.g., pneumonia; tuberculosis)

Working Diagnosis

ARF results from acute or chronic malfunctions in gas exchange between the lungs and the blood causing hypoxia with or without hypercapnia.

Patients may present with SOB, anxiety, confusion, tachypnea, cardiac dysfunction, and cardiac arrest. Central nervous system depression can occur as a result of lack of oxygenation of the blood and vital organs or excessive accumulation of carbon dioxide.
Pulse oximetry, chest x-rays, blood gas, labs, sputum, blood cultures analysis are key diagnostic tests.

Initial management involves ensuring that the upper airway is patent and clear of obstructions. Subsequent management involves supplemental oxygenation and ventilatory support with immediate attention to the underlying cause or causes for respiratory failure.
Endotracheal intubation and mechanical ventilation are employed when other less invasive maneuvers have failed.

Pathophysiology

ARF - respiratory system is not able to maintain adequate gas exchange.

The two functions of gas exchange: oxygenation and carbon dioxide elimination. When the respiratory system fails in one or both of these processes, ARF results. There are two types of ARF. Type 1 is characterized by a lack of oxygen in the blood, or hypoxemia. ABG results for Type 1 ARF would present low PaO2 levels and normal PaCO2 levels. Type 1 is the most common form of respiratory failure and can be associated with acute diseases of the lung that involve fluid filling or collapse of the aleveolar.. Type 2 ARF ABG results would show increased PaCO2 levels, or hypercapnia and hypoxemia. Oxygenation is need to sustain tissues and remove carbon dioxide metabolic waste from cells. Without proper oxygenation acid-base equilibrium is affected and the body is forced to compensate. The pathophysiologic mechanisms that account for the hypoxemia observed in a wide variety of diseases are Type 1: V/Q mismatch and shunt and Type 2: hypoventilation of the alveoli. These 2 mechanisms lead to widening of the alveolar-arterial PO2 gradient

 Complications Ischemic-anoxic encephalopathy Cardiac

dysrhythmias Venous thromobembolism Gastrointestinal bleeding Artificial airway complications Mechanical ventilation complications Enteral and parenteral nutrition complications Peripheral arterial cannulation complications Complications Ischemic-anoxic encephalopathy Cardiac dysrhythmias Venous thromobembolism Gastrointestinal bleeding Artificial airway complications Mechanical ventilation complications Enteral and parenteral nutrition complications Peripheral arterial cannulation complications

Treatment and Rationales

Ventilator and Settings: invasive ventilation at pre-

determined setting allows for proper oxygenation to correct ARF

Foley: measure I/Os to ensure proper fluid balance Sedation: allow the body to rest, vent takes over work of

breathing

Medication
DVT Prophylaxis: Heparin
Antibiotic: Levoquin GI Prophylaxis: Nexium Anti-inflammatory: Solu-medrol Bronchodilator: Combivent

Diuretic: Diamox

NAME OF MEDICATION

DOSAGE AND TIME

CLASSIFICATION AND ACTION

MAJOR SIDE EFFECTS

CONTRAINDICATIO NS

Heparin Sodium

5,000 Unit/1ML SubQ, Every 12 hours

Levaquin

500 mg IVPB Q24hrs

Nexium

40 mg IVP Q12

Ativan

0.5mg IVP, Q4hr PRN

Solumedrol

40mg, IVP Q6H

Antithrombolitic, Anticoagulant Heparin works by thinning the blood to prevent clots. This patient is prescribed Heparin as a prophylaxis of DVT and PE, post surgery. Anti-infective, fluoroquinolones, used to treat pneumonia Proton Pump Inhibitor, used to treat GERD and as GI prophylaxis in hospital settings Benzodiazepine used an anxiolytic, amnesic, sedative/hypnotic, anticonvulsant and muscle relaxant. Glucocorticoid, used as an anti-inflammatory Prevent wheezing and shortness of breath in COPD patients by relaxing the airways. Carbonic anhydrase inhibitor, prescribed as a diuretic.

Spinal/epidural hematoma - Increased Risk of hemorrhage -thrombocytopenia

Administered subcutaneously Notify provider if receiving spinal or epidural anesthesiainteraction may cause paralysis

Increased risk of tendon Myasthenia Gravis, rupture, hepatotoxicity epilepsy and liver disease Increased risk of PNA in Hypersensitivity hospitalized patients, n/v/d

Respiratory depression, sedation

Respiratory diseases, sleep apnea, pregnancy, breast feeding

ITP, clotting issues.

Combivent

MDI, 8 Puffs INH Q4H

Hypersensitivity, may decrease carbohydrate and glucose tolerance Headache, nausea, diarrhea. Increased heart rate, cough. Upset stomach, vomiting, and loss of appetite.

Soy and Peanut allergies, and allergies to atropine.

Contraindicated in people with sickle cell, sulfa allergies.

Diamox

20mg, IV Q8H

Non-Pharmalogical Interventions
Pressure Ulcer Prevention: Q2hrs turning
Edematous extremities: Prop w/ pillow VAP, PNA prevention: Oral care Aspiration Prevention: PRN suctioning

Health Education

Referrals

Proposed Evaluation of Care

Patient and Family Management of Care