Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome Chapter 68 Overview Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Fig. 68-1. Normal gas exchange unit in the lung. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Fig. 68-2. Classification of respiratory failure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Etiology and Pathophysiology Hypoxemic respiratory failure Ventilation-perfusion mismatch Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Fig. 68-3. Regional V/Q differences in the normal lung. At the lung apex, the V/Q ratio is 3.3, at the midpoint 1.0, and at the base 0.63. This difference causes the PaO2 to be higher at the apex of the lung and lower at the base. Values for PaCO2 are the opposite (i.e., lower at the apex and higher at the base). Blood that exits the lung is a mixture of these values. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Fig. 68-4. Range of ventilation to perfusion (V/Q) relationships. A, Absolute shunt, no ventilation due to fluid filling the alveoli. B, V/Q mismatch, ventilation partially compromised by secretions in the airway. C, Normal lung unit. D, V/Q mismatch, perfusion partially compromised by emboli obstructing blood flow. E, Dead space, no perfusion due to obstruction of the pulmonary capillary. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Etiology and Pathophysiology Hypoxemic respiratory failure, continued Shunt Diffusion limitation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Fig. 68-5. Diffusion limitation. Exchange of CO2 and O2 cannot occur because of the thickened alveolar-capillary membrane. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Etiology and Pathophysiology Hypoxemic respiratory failure, continued Alveolar hypoventilation Interrelationship of mechanisms Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Etiology and Pathophysiology, continued Hypercapnic respiratory failure Airways and alveoli Central nervous system Chest wall Neuromuscular conditions Tissue oxygen needs Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Failure Clinical Manifestations Consequences of hypoxemia and hypoxia Specific clinical manifestations Diagnostic Studies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing and Collaborative Management: Acute Respiratory Failure Nursing Assessment Nursing Diagnoses Planning Prevention Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing and Collaborative Management: Acute Respiratory Failure Respiratory Therapy Oxygen therapy Mobilization of secretions Effective coughing and positioning Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing and Collaborative Management: Acute Respiratory Failure Fig. 68-6. Augmented coughing is performed by placing the palm of the hand on the abdominal musculature below the xiphoid process. As the patient ends a deep inspiration and begins the expiration, the hand should be moved forcefully downward, increasing abdominal pressure, resulting in a forceful cough. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing and Collaborative Management: Acute Respiratory Failure Respiratory Therapy Mobilization of secretions, continued Hydration and humidification Chest physical therapy Airway suctioning Positive pressure ventilation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing and Collaborative Management: Acute Respiratory Failure Fig. 68-7. Noninvasive bilevel positive pressure ventilation. A mask is placed over the nose or nose and mouth. Positive pressure from a mechanical ventilator assists the patient’s breathing efforts, decreasing the work of breathing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing and Collaborative Management: Acute Respiratory Failure Drug Therapy Relief of bronchospasm Reduction of airway inflammation Reduction of pulmonary congestion Treatment of pulmonary infections Reduction of severe anxiety, pain, and agitation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing and Collaborative Management: Acute Respiratory Failure Medical Supportive Therapy Treating the underlying cause Maintaining adequate cardiac output Maintaining adequate hemoglobin concentration Nutritional Therapy Evaluation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Gerontologic Considerations: Respiratory Failure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Fig. 68-8. Stages of edema formation in acute respiratory distress syndrome. A, Normal alveolus and pulmonary capillary. B, Interstitial edema occurs with increased flow of fluid into the interstitial space. C, Alveolar edema occurs when the fluid crosses the blood-gas barrier. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Etiology and Pathophysiology Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Fig. 68-9. Pathophysiology of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Etiology and Pathophysiology, continued Injury or exudative phase Reparative or proliferative phase Fibrotic phase Clinical Progression Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Clinical Manifestations and Diagnostic Studies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Fig. 68-10. Chest x-ray of a patient with acute respiratory distress syndrome (ARDS). The x-ray shows new, bilateral, diffuse, homogeneous pulmonary infiltrates without cardiac failure, fluid overload, chest infection, or chronic lung disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Table 68-7. Diagnostic Findings in Acute Lung Injury/Acute Respiratory Distress Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Complications Ventilator-associated pneumonia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Table 68-8. Key Components of Ventilator Bundle Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Respiratory Distress Syndrome Complications, continued Barotrauma Volutrauma Stress ulcers Renal failure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing and Collaborative Management: Acute Respiratory Distress Syndrome Nursing Assessment Nursing Diagnoses Planning Oxygen administration Positive pressure ventilation Positioning strategies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing and Collaborative Management: Acute Respiratory Distress Syndrome Fig. 68-11. A, Turning patient prone on Vollman Prone Positioner. B, Patient lying prone on Vollman Prone Positioner. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing and Collaborative Management: Acute Respiratory Distress Syndrome Fig. 68-12. TotalCare SpO2RT® Bed System offers continuous lateral rotation therapy and percussion and vibration therapies. Patients can easily and quickly be repositioned. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing and Collaborative Management: Acute Respiratory Distress Syndrome Medical Supportive Therapy Maintenance of cardiac output and tissue perfusion Maintenance of nutrition and fluid balance Evaluation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.