Respiratory Failure

Artificial Airways
Mechanical Ventilation
 Learning Outcomes
Describe respiratory failure
Describe artificial airways
Describe mechanical ventilation
Apply nursing management across
life span
 Respiratory Failure
Sudden, life threatening
deterioration of the gas exchange
function of the lung
Patient can not eliminate CO2 from
the alveoli
CO2 retention results in
hypoxemia
O2 reaches the alveoli but can not
be absorbed or used properly.
 Respiratory failure
Continued
 Lung can move air sufficiently but
cannot oxygenate the pulmonary blood
properly
 Respiratory failure occurs as a result of:
mechanical abnormality of the lungs
or chest wall
defect in the respiratory control
center in the brain or
Impairment in the function of the
respiratory muscles
 Acute Respiratory Failure
(ARF)
Defined as:
PaO2 < 50 mm Hg (hypoxemia)
PaCO2 > 50 mm Hg (hypercapnia)
Arterial pH < 7.35
 Chronic Respiratory
Failure
Defined as:
(CRF)
Deterioration in gas exchange that
has occurred over a long period of
time after an episode of ARF
Absence of acute symptoms and
presence of chronic respiratory
acidosis
Patient develop tolerance to gradual
worsening hypoxemia and
hypercapnia
COPD and neuromuscular diseases
 Pathophysiology
ARF
Ventilation or perfusion
mechanism impaired
Alveolar hypoventilation
Diffusion abnormalities
Ventilation-perfusion mismatching
shunting
 ARF Causes
Decreased respiratory drive
Dysfunction of the chest wall
Dysfunction of the lung
parenchyma
Post op after major thoracic or
abdominal surgery
 Decreased Respiratory
Drive
Severe brain injury
Lesions of the brain stem (MS)
Use of sedative medications
Metabolic disorders
(hypothyroidism)

Theory: These disorders impair

chemoreceptors in the brain to
normal respiratory stimulation
 Dysfunction of Chest Wall
 Any disease of the nerves, spinal cord,
muscles or neuromuscular junction
involved in respiration seriously affects
ventilation e.g. Muscular dystrophy,
Polymyositis, Myasthenia gravis, ALS

Theory: impulses arising in the respiratory

center travel through nerves that
extend from the brainstem down the
spinal cord to receptors in the muscles
of respiration
 Dysfunction of Lung
Parenchyma
Pleural effusion
Hemothorax
Upper airway obstruction
Pneumonia
PE
 Assessment
 Dyspnea
 Headache
 Restlessness
 Confusion
 Tachycardia
 Cyanosis
 Dysrhythmias
 Decreased LOC
 Alterations in respirations and breath
sounds
 Nursing Management
 Identify and treat the cause of
respiratory failure
 Administer O2 to maintain PaO2 level
above 60 to 70 mm Hg
 High fowlers
 Encourage deep breathing
 Bronchodilators
 Prepare patient for mechanical
ventilation if supplemental O2 cannot
maintain acceptable PaO2 levels
Acute respiratory Distress
Syndrome (ARDS)
Form of ARF caused by diffuse
lung injury leading to extravascular
lung fluid
Major site of injury is the alveolar
capillary membrane
Interstitial edema causes
compression and obliteration of
the terminal airways and leads to
reduced lung volume and
compliance
 ARDS Continued
ABG’s identify respiratory acidosis
and hypoxemia that does not
respond to an increased
percentage of O2
Chest x-ray shows interstitial
edema
Sepsis, fluid overload, shock,
trauma, neurological injuries,
burns, aspiration amongst some of
 Assessment
 One of the earliest signs, tachypnea
 Dyspnea
 Decreased breath sounds
 Deteriorating blood gas levels
 Hypoxemia despite high concentrations
of delivered O2
 Decreased pulmonary compliance
 Decreased infiltrates
 Nursing Management
 Administer O2
 High Fowlers
 Restrict fluid
 Respiratory treatments
 Diuretics, anticoagulants,
corticosteroids
 Prepare patient for intubation and
mechanical ventilation, using positive
end-expiratory pressure (PEEP)
 Artificial Airways
Adequate ventilation dependent
on free movement of air through
the upper and lower airways.
Many disorders either narrow or
block as a result of disease.
Foreign bodies or secretions can
also impede ventilation
 Endotracheal Intubation
 Involves passing endotracheal tube
through mouth or note into the trachea
with aide of a laryngoscope
 Once passed a cuff is inflated to prevent
air from leaking around the outer part of
the tube, to minimize the possibility of
aspiration and movement of tube
 Provides a patent airway
 Method of choice in emergency care
 Nursing Management
Assess chest expansion for
symmetry
Auscultate breath sounds
Obtain chest x-ray
Check cuff pressure every 8-12
hours
Monitor for signs of aspiration
Secure tube to patients face with
tape and mark proximal end for
 Nursing Management
 Provide for oral care, usually need two
professionals as tube needs to be
moved from side to side of mouth
 Suction prn
 Excessive suctioning, speaking can
dislodge tube
 Maintain cuff inflation
 Administer O2 as ordered
 Ensure high humidity
 Nursing Management
Continued
Prevent premature removal of
tube.
Explain to patient and family
purpose of tube
Last resort is use of soft wrist
restraints.
Maintain skin integrity
 Extubation
 Usually respiratory therapist at hospital
does this.
 Semifowlers position
 Cuff is deflated
 Monitor for respiratory difficulty e.g.
stridor
 O2 as prescribed
 Inform patient may experience
hoarseness or sore throat.
 Tracheostomy
Surgical incision into the trachea
for the purpose of establishing an
airway
Tracheostomy is the stoma or
opening that results from the
tracheotomy
Can be permanent or temporary
 Types (See table 20-1)
 Double Lumen
 Single Lumen
 Cuffed Tube
 Cuffless tube
 Fenestrated tube
 Cuffed fenestrated tube
 Metal tracheostomy tube
 Talking tracheostomy tube
 Double Lumen
 Outer cannula: fits into stoma and
keeps airway open
 Inner cannual: fits into outer cannula
and locks into place. Some can e
removed and cleaned and reused.
 Obturator: stylet with a blunt end used
to facilitate direction of tube when
inserting. Removed after tube
placement
 Fenestrated
Used to wean patient from a
tracheostomy
Allows patient to speak
Cuffed used with spinal cord
paralysis: can facilitate mechanical
ventilation and speech.
 Nursing Management
 Assess respirations for bilateral breath sounds
 Monitor ABGs and pulse ox
 Encourage deep breathing and coughing
 Maintain semi to high fowlers position
 Monitor for bleeding
 Suction prn
 Assess stoma
 If tube dislodges, initial nursing action is to
grasp the retention sutures to spread the
opening
 Mechanical Ventilation
 Controls patients respirations during
surgery or during treatment of severe
head injury
 Oxygenate the blood when patients
ventilator efforts are inadequate
 Rest the respiratory muscles
 Positive or negative pressure device
that maintains ventilation and oxygen
delivery for a prolonged period of time
 Indications
PaO2 < 50 mm Hg with pH < 7.25
Vital capacity < 2 times the tidal
volume
Negative inspiratory force <25 cm
H2O
Respiratory rate >35/min
 Classification of
Ventilators
 Negative-pressure
Simple and do not require intubation
of the airway
The iron lung, also known as the
Drinker and Shaw tank, was one of
the first negative-pressure machines
used for long-term ventilation.
The machine is a large elongated
tank, which encases the patient up to
the neck.
 Positive Pressure
Ventilators
 Work by increasing the patient's airway
pressure through an endotracheal or
tracheostomy tube.
 The positive pressure allows air to flow
into the airway until the ventilator
breath is terminated
 Subsequently, the airway pressure
drops to zero, and the elastic recoil of
the chest wall and lungs push the tidal
volume, the breath out through passive
exhalation
 Types
Pressured Cycled
 Delivers a flow of air (inspiration)
until it reaches a preset pressure
and then cycles off
 Expiration occurs passively
 Intended only for short term
 Most common type IPPB machine
 Types continued
Timed Cycled
Pushes air into lungs until a preset
time has elapsed
Used in newborns or neonatal client
 Types Continued
Volume-cycled
Pushes air into the lungs until a
preset volume is delivered
A constant tidal volume is delivered
regardless of changing compliance of
the lungs and chest wall or the airway
resistance in the client or ventilator
 Types Continued
 Noninvasive positive pressure
Given via face mask cover nose and mouth,
nasal mask
CPAP: continuous positive airway pressure
BPAP: bi-level positive airway pressure
Used for sleep apnea, positive pressure act
as a splint keeping the upper airway and
trachea open during sleep.
 Modes of Ventilation
Controlled
Set tidal volume at set rate
Used for patients who can not initial
respiration
Least used mode because if patient
tries to initiate a breath, the efforts
are blocked by the ventilator
 Modes continued
Assist control (AC)
Most commonly used
Tidal volume and ventilator rate are
preset
Ventilator takes over the work of
breathing for client
Programmed to respond should the
patient initiate a breath
 Modes Continued
Synchronized intermittent
mandatory ventilation (SIMV)
Similar to AC however allows patient
to breath spontaneously at their own
rate
Can be used as primary or weaning
mode.
When used in weaning mode, the
number of SIMV breaths is gradually
decreased and the patient gradually
resumes spontaneous breathing
 Ventilator controls and
settings
Tidal volume: volume of air that
the client receives with each
breath
Rate: number of ventilator breaths
delivered per minute
Fraction of inspired oxygen (FiO2):
concentration of oxygen delivered
to patient. Determined by ABG
 Controls and settings
Sighs: volumes of air that are 1.5
to 2 times the set tidal volume,
delivered 6 to 10 times per hour
PIP: peak airway inspiratory
pressure: pressure needed by
ventilator to deliver a set tidal
volume at a given compliance
 Positive End Expiratory
Pressure (PEEP)
Positive pressure exerted during
the expiratory phase of ventilation
Improved oxygenation by
enhancing gas exchange and
preventing adelectasis
Need indicates a severe gas
exchange disturbance
 Nursing management
 Assess patient first, ventilator second
 VS, lung sounds, respiratory status and
breathing pattern
 Monitor skin color, lips and nail beds
 Monitor chest for bilateral expansion
 Assess ventilator settings
 Ensure alarms are set
 Empty ventilator tubing when moisture
collects
 T&P client at least every 2 hours