1. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Focus on Respiratory Failure (Relates to Chapter 68, “Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome,” in the textbook)

2. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Results from inadequate gas exchange Results from inadequate gas exchange Insufficient O 2 transferred to the blood Hypoxemia Inadequate CO 2 removal Hypercapnia

3. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gas Exchange Unit Fig. 68-1

4. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Not a disease but a condition Not a disease but a condition Result of one or more diseases involving the lungs or other body systems Result of one or more diseases involving the lungs or other body systems

5. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Classification Classification Hypoxemic respiratory failure Hypercapnic respiratory failure

6. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification of Respiratory Failure Fig. 68-2

7. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Hypoxemic respiratory failure Hypoxemic respiratory failure PaO 2 60%

8. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Hypercapnic respiratory failure Hypercapnic respiratory failure PaCO 2 above normal ( >45 mm Hg) Acidemia (pH <7.35)

9. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Range of V/Q Relationships Fig. 68-4

10. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypoxemic Respiratory Failure Etiology and Pathophysiology Causes Causes Ventilation-perfusion (V/Q) mismatch COPD Pneumonia Asthma Atelectasis Pulmonary embolus

11. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypoxemic Respiratory Failure Etiology and Pathophysiology Causes Causes Shunt Anatomic shunt Intrapulmonary shunt An extreme V/Q mismatch

12. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypoxemic Respiratory Failure Etiology and Pathophysiology Causes Causes Diffusion limitation Severe emphysema Recurrent pulmonary emboli Pulmonary fibrosis Hypoxemia present during exercise

13. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diffusion Limitation Fig. 68-5

14. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypoxemic Respiratory Failure Etiology and Pathophysiology Causes Causes Alveolar hypoventilation Restrictive lung disease CNS disease Chest wall dysfunction Neuromuscular disease

15. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypoxemic Respiratory Failure Etiology and Pathophysiology Interrelationship of mechanisms Interrelationship of mechanisms Combination of two or more physiologic mechanisms

16. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercapnic Respiratory Failure Etiology and Pathophysiology Imbalance between ventilatory supply and demand Imbalance between ventilatory supply and demand

17. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercapnic Respiratory Failure Etiology and Pathophysiology Airways and alveoli Airways and alveoli Asthma Emphysema Chronic bronchitis Cystic fibrosis

18. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercapnic Respiratory Failure Etiology and Pathophysiology Central nervous system Central nervous system Drug overdose Brainstem infarction Spinal chord injuries

19. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercapnic Respiratory Failure Etiology and Pathophysiology Chest wall Chest wall Flail chest Fractures Mechanical restriction Muscle spasm

20. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercapnic Respiratory Failure Etiology and Pathophysiology Neuromuscular conditions Neuromuscular conditions Muscular dystrophy Multiple sclerosis

21. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Respiratory Failure Tissue Organ Needs Major threat is the inability of the lungs to meet the oxygen demands of the tissues Major threat is the inability of the lungs to meet the oxygen demands of the tissues

22. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Respiratory Failure Clinical Manifestations Sudden or gradual onset Sudden or gradual onset A sudden decrease in PaO 2 or rapid increase in PaCO 2 indicates a serious condition A sudden decrease in PaO 2 or rapid increase in PaCO 2 indicates a serious condition

23. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Respiratory Failure Clinical Manifestations When compensatory mechanisms fail, respiratory failure occurs When compensatory mechanisms fail, respiratory failure occurs Signs may be specific or nonspecific Signs may be specific or nonspecific

24. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Respiratory Failure Clinical Manifestations Severe morning headache Severe morning headache Cyanosis Cyanosis Late sign Tachycardia and mild hypertension Tachycardia and mild hypertension Early signs

25. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Respiratory Failure Clinical Manifestations Consequences of hypoxemia and hypoxia Consequences of hypoxemia and hypoxia Metabolic acidosis and cell death Decreased cardiac output Impaired renal function

26. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Respiratory Failure Clinical Manifestations Specific clinical manifestations Specific clinical manifestations Rapid, shallow breathing pattern Tripod position Dyspnea

27. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Respiratory Failure Clinical Manifestations Specific clinical manifestations Specific clinical manifestations Pursed-lip breathing Retractions Change in I:E ratio

28. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Respiratory Failure Diagnostic Studies History and physical assessment History and physical assessment ABG analysis ABG analysis Chest x-ray Chest x-ray CBC, sputum/blood cultures, electrolytes CBC, sputum/blood cultures, electrolytes ECG ECG Urinalysis Urinalysis V/Q lung scan V/Q lung scan Pulmonary artery catheter (severe cases) Pulmonary artery catheter (severe cases)

29. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Nursing Assessment Nursing Assessment Health information Health history Medications Surgery

30. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Nursing Assessment Nursing Assessment Functional health patterns Health perception–health management Nutritional-metabolic Activity-exercise Sleep-rest Cognitive-perceptual Coping–stress tolerance

31. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Nursing Assessment Nursing Assessment Physical assessment General Integumentary Respiratory Cardiovascular Gastrointestinal Neurologic Laboratory findings

32. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Nursing Diagnoses Nursing Diagnoses Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Risk for fluid volume imbalance Anxiety Imbalanced nutrition: Less than body requirements

33. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Planning: Overall goals Planning: Overall goals ABG values within patient’s baseline Breath sounds within patient’s baseline No dyspnea or breathing patterns within patient’s baseline Effective cough and ability to clear secretions

34. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Prevention Prevention Thorough history and physical assessment to identify at-risk patients Early recognition of respiratory distress

35. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Respiratory therapy Respiratory therapy Oxygen therapy: Delivery system should Be tolerated by the patient Maintain PaO 2 at 55 to 60 mm Hg or more and SaO 2 at 90% or more at the lowest O 2 concentration possible

36. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Respiratory therapy Respiratory therapy Mobilization of secretions Hydration and humidification Chest physical therapy Airway suctioning Effective coughing and positioning

37. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

38. Augmented Cough Fig. 68-6

39. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Respiratory therapy Respiratory therapy Positive pressure ventilation (PPV) Noninvasive PPV BiPAP CPAP

40. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Noninvasive PPV Fig. 68-7

41. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Drug Therapy Drug Therapy Relief of bronchospasm Bronchodilators Reduction of airway inflammation Corticosteroids Reduction of pulmonary congestion Diuretics, nitrates if heart failure present

42. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Drug Therapy Drug Therapy Treatment of pulmonary infections IV antibiotics Reduction of severe anxiety, pain, and agitation Benzodiazepines Narcotics

43. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Nutritional Therapy Nutritional Therapy Maintain protein and energy stores Enteral or parenteral nutrition Nutritional supplements

44. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Nursing and Collaborative Management Medical Supportive Therapy Medical Supportive Therapy Treat the underlying cause Maintain adequate cardiac output and hemoglobin concentration

45. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Gerontologic Considerations Physiologic aging results in 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

46. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Respiratory Failure Gerontologic Considerations Lifelong smoking Lifelong smoking Poor nutritional status Poor nutritional status Less available physiologic reserve Less available physiologic reserve Cardiovascular Respiratory Autonomic nervous system