RESPIRATORY FAILURE hydrostatic pressure

-is a syndrome of inadequate gas exchange due to 3. Non - cardiogenic pulmonary edema
dysfunction of one or more essential components Pulmonary edema due to increased
of the respiratory system. permeability.
Acute lung injury (ALI)
 Chest wall (including pleura and 4. Acute respiratory distress syndrome
diaphragm) (ARDS)
 Airways 5. Pulmonary embolism
 Alveolar – capillary unit 6. Atelectasis 7. Pulmonary fibrosis
 Pulmonary circulation
 Nerves
 CNS or Brain Stem Type II respiratory failure
-lungs are unable to
Epidemiology effectively get rid of carbon
dioxide (CO2), leading to a
Incidence: about 360,000 cases per year in the dangerous buildup of CO2 in
United States the blood.
 36% die during hospitalization
 Morbidity and mortality rates increase 1. Central hypoventilation
with age and presence of comorbidities. 2. Asthma
3. Chronic obstructive pulmonary disease
CLASSIFICATION (COPD)
Respiratory failure may be: ( Hypoxemia and hypercapnia often occur
 Acute together)
 Chronic 4. Neuromuscular and chest wall disorders
 Acute on chronic.:  Myopathies
E. g. acute exacerbation of advanced COPD  Neuropathies
 Kyphoscoliosis
CAUSES  Myasthenia gravis
5. Obesity Hypoventilation Syndrome
Type I Respiratory Failure
-also known as 'hypoxemic respiratory Type III respiratory failure
failure', occurs when the lungs are unable to - peri-operative respiratory
provide sufficient failure, is a form of lung
oxygen to the failure that occurs after
blood, leading to a surgery.
dangerously low
level of oxygen 1. Inadequate post -
(hypoxemia). operative analgesia,
upper abdominal incision
1. Pneumonia 2. Obesity, ascites
2. Cardiogenic pulmonary edema 3. Pre - operative tobacco smoking
-Pulmonary edema due to increased 4. Excessive airway secretions
Type IV respiratory failure DIAGNOSIS: LABORATORY WORKUP
-respiratory failure due to shock, is a  ABG
condition where the body's metabolic demands  Complete blood count
for oxygen exceed the cardiopulmonary  Cardiac serologic markers
system's ability to provide it.  Microbiology

1. Cardiogenic DIAGNOSTIC INVESTIGATIONS

shock  Pulmonary function tests/bedside
2. Septic shock spirometry
3. Hypovolemic  Bronchoscopy
shock  Chest radiography
 Electrocardiogram
 Echocardiography
DIAGNOSIS: HISTORY
 Sepsis MANAGEMENT
 Pneumonia 1. ABC’s
 Pulmonary embolus suggested by sudden  Ensure airway is adequate
onset of shortness of breath or chest pain  Ensure adequate supplemental oxygen
 COPD exacerbation suggested by history and assisted ventilation, if indicated
of heavy smoking, cough, sputum  Support circulation as needed
production 2. Treatment of a specific cause when
 Cardiogenic pulmonary edema suggested possible
by chest pain, paroxysmal nocturnal  Infection
dyspnea, and orthopnea.  Antimicrobials, source control .
 Airway obstruction
DIAGNOSIS: PHYSICAL FINDINGS  Bronchodilators, glucocorticoids.
 Hypotension usually with signs of poor  Improve cardiac function
perfusion suggests severe sepsis or  Positive airway pressure, diuretics,
massive pulmonary embolus. vasodilators, morphine, inotropes .
 Hypertension usually with signs of poor 3. Mechanical ventilation
perfusion suggests cardiogenic  Non - invasive
pulmonary edema. # Mask: usually orofacial to start
 Wheezing suggests airway obstruction:  Invasive
-Bronchospasm # Endotracheal tube (ETT)
-Secretions # Tracheostomy – if upper airway is
-Pulmonary edema obstructed
 Stridor suggests upper airway obstruction
 Elevated jugular venous pressure suggests Indications for Mechanical Ventilation
right ventricular dysfunction due to 1. Cardiac or respiratory arrest.
accompanying pulmonary hypertension 2. Tachypnea or bradypnea with respiratory
 Tachycardia and arrhythmias may be the fatigue.
cause of cardiogenic pulmonary edema 3. Acute respiratory acidosis.
4. Inability to protect the airway associated
with depressed level of consciousness
5. Shock associated with excessive Nursing Diagnosis
respiratory work 1. Anxiety related to oxygen deprivation.
6. Inability to clear secretions with impaired 2. Impaired gas exchange related to loss of
gas exchange functioning lung tissue and inadequate
7. Short term adjunct in management of ventilation/perfusion ratio.
acutely increased intracranial pressure 3. Risk of infection related to microbial
(ICP) invasion.
4. Fatigue related to oxygen deprivation.
A. Non-Invasive Mechanical Vetnilation 5. Fear related to air hunger and mechanical
Consider Non invasive ventilation particularly ventilation.
in the following settings:
 COPD exacerbation Nursing Plan and Interventions
 Cardiogenic pulmonary edema
 Obesity hypoventilation syndrome Goals
1. Prevent avoidable injury.
Nursing management: 2. Maintain effective airway clearance and gas
 Assess the patient’s tissue oxygenation exchange.
status regularly. 3. Increase comfort.
 Evaluate ABG results 4. Reduce anxiety.
 To enhance V/Q matching, turn the 5. Maintain adequate nutritional status.
patient on a regular and timely basis to 6. Increase understanding of the disease
rotate and maximize lung zones. process, its treatment, and prevention
 Regular, effective use of incentive
spirometry Interventions
 Regular patient turning and repositioning 1. Provide a quiet, supportive environment.
enhances diffusion by promoting a 2. Assess, record, and report all deviations
healthy, well-perfused alveolar surface. from baseline evaluation and document
 These actions, as well as suctioning, help complaints of increased discomfort and
mobilize sputum or secretions. difficulty breathing.
3. Encourage bed rest in semi to high Fowler
Nursing Approach to the Client position, allow frequent uninterrupted rest
with Acute Respiratory Failure periods in between therapeutic interventions.
4. Monitor vital signs, breath sounds, heart
Nursing Assessment sounds, neurological status, and signs of
1. Obtain history from the client as to the onset hypoxia every 1 to 2 hours depending on status
and progression of symptoms. acuity.
2. Assess respirations for dyspnea and pain that 5. Monitor need for suctioning secretions when
increases with inspiration. client is unable to clear on his own.
3. Assess for headache, confusion, restlessness, 6. Administer prescribed bronchodilators, be
and increased heart rate. alert for potential side effects.
4. Assess sputum for quantity and 7. Prepare the client and family for intubation
characteristics. and mechanical ventilation.
8. Monitor arterial blood gases (ABGs).
9. Stabilize the endotracheal (ET) tube for
comfort and assess skin integrity around mouth
for irritation.
10. Suction via ET tube as needed, evaluate
lung sounds and quality of mechanical
ventilation.
11. Monitor renal status for fluid imbalance,
assess intake and output with quality and
quantity of urine.
12. Assure that the client maintains adequate
nutritional status, whether by parenteral
nutrition (TPN) or tube feedings as prescribed
by physician.
13. Turn every 2 hours to prevent skin
breakdown, hemostasis, and pooling of
pulmonary secretions.
14. Provide emotional support to the client and
family members.
15. Provide teaching in order to provide
sufficient care at home and to prevent future
incidence.

Evaluation
1. Maintains adequate gas exchange.
2. Alleviation of pain and discomfort.
3. Maintains adequate airway clearance and
effective breathing patterns.
4. Maintains adequate nutritional status.
5. Absence of infection and complications.
 Acute Respiratory Distress • Decreased pulmonary compliance
Syndrome (ARDS) • Pulmonary infiltrates
• A form of acute respiratory failure that • Anxiety, restlessness
occurs as a complication of some other
condition; it is caused by a diffuse lung injury
and leads to extravascular lung fluid.
• The major site of injury is the alveolar
capillary membrane.
• The interstitial edema causes compression
and obliteration of the terminal airways and
leads to reduced lung volume and compliance.

• The ABG levels identify respiratory acidosis

and hypoxemia that do not respond to an
increased percentage of oxygen. Diagnostic Evaluation:
• The chest x-ray shows bilateral interstitial • The hallmark sign for ARDS is a shunt;
and alveolar infiltrates; interstitial edema may hypoxemia remains despite
not be noted until there is a 30% increase in increasing oxygen therapy.
fluid content. • Decreased lung compliance; increasing
• Causes include sepsis, fluid overload, shock, pressure required to ventilate patient on
trauma, neurological injuries, burns, mechanical ventilation
disseminated intravascular coagulation, drug • Chest X-ray exhibits bilateral infiltrates
ingestion, aspiration, and inhalation of toxic (early stages). Lung fields with a ground-glass
substances. appearance and, with irreversible hypoxemia,
massive consolidation (“white-outs”) of both
lung fields (in later stages).
• Sputum reveals the infectious organism.
• Pulmonary artery catheter readings:
pulmonary artery wedge pressure >
18mmHg.
• ABG analysis on room air initially shows a
decreased PaO2 (less than 60mmHg) and a
decreased PaCO2 (less than 35mmHg). The
resulting pH reflects respiratory alkalosis.
• Blood culture reveals the infectious
Assessment Findings: organism.
• Tachypnea
• Severe Dyspnea, use of accessory muscle
• Decreased breath sounds
• Severe crackles and rhonchi heard on
auscultation
• Deteriorating ABG levels
• Hypoxemia despite high concentrations of
delivered oxygen
 • Intubation and mechanical ventilation using
PEEP or pressure-controlled inverse ratio
ventilation.
• Oxygen therapy.
• Transfusion therapy: platelets, packed RBCs.

Treatment: Drug therapy

options

• Analgesics: morphine sulfate

• Antacids: aluminum hydroxide
• Antibiotics: according to susceptibility of
infecting organism
• Anticoagulants: heparin
• Diuretic: furosemide
Nursing Diagnosis: • Exogenous surfactant: beractant
• Anxiety • Histamine-2 blockers: cimetidine,
• Impaired gas exchange famotidine, ranitidine
• Ineffective breathing pattern • Mucosal barrier fortifier: sucralfate
• Ineffective tissue perfusion • Neuromuscular blockers:
(cardiopulmonary) pancuroniumbromide, vecuroniumbromide
• Proton pump inhibitor: pantoprazole
Planning and Goals: sodium
• Demonstrate improved oxygenation • Steroids: hydrocortisone sodium succinate
• Demonstrate adequate breathing pattern solu-cortef), methylprednisolone sodium
• Exhibit decreased anxiety succinate (solu-Medrol)

Nursing Evaluation: Expected Nursing Interventions:

Outcomes
• Adequate oxygenation • Identify and treat the cause of the acute
• Breathing without difficulty respiratory distress
• Decreased anxiety syndrome.
• Administer oxygen as prescribed.
Treatment: • Place the client in a Fowler’s position.
• Bed rest with prone position, if possible, and • Restrict fluid intake as prescribed.
passive ROM • Provide respiratory treatments as prescribed.
exercises. • Administer diuretics, anticoagulants, or
• Rotating bed therapy. corticosteroids as prescribed.
• Chest physiotherapy, postural drainage, and • Prepare the client for intubation and
suction. mechanical ventilation using positive
• Restricted fluid intake or, if intubated, end-expiratory pressure (PEEP).
nothing by mouth.
• Extracorporeal membrane oxygenation, if
available.