Acute Respiratory Failure

Intrapulmonary Shunting : causes ?

(hypoxemia) atrial or ventricular septal defect, atelectasis, pneumonia, pulmonary edema

Arterial blood gas alterations in pneumonia include which of the following? Hypoxemia and respiratory alkalosis Normal oxygen and respiratory acidosis Hypoxemia and metabolic acidosis Normal values

A

Treatment for PE

ABCs; oxygen Thrombolytics (dissolve the clots) Heparin Monitor laboratory results for - Bleeding - Thrombocytopenia Surgical procedures - Embolectomy - Vena cava umbrella (prevention)

If the PaO2 is 60 mm Hg and the FiO2 is 0.6, the PaO2/FiO2 ratio is: 100 1000 360 3600

ANS: A. 100 Show the math: 60/0.6 = 100. This patient would be in ARDS.

ARF is defined as? ARF is classified as? result in?

ARF is defined as an inability of the respiratory system to provide oxygenation and/or remove carbon dioxide from the body. ARF is classified as oxygenation failure resulting in hypoxemia without a rise in carbon dioxide levels, or ventilation failure resulting in hypercapnia and hypoxemia

Why does administration of higher levels of oxygen not help in shunt disorders?

As the shunt worsens, the PaO2 continues to decrease. This cause of hypoxemia cannot be effectively treated by solely increasing the fraction of inspired O2 (FiO2) because the increased oxygen is unable to reach the alveoli. Treatment is directed toward opening the alveoli and improving ventilation.

The nurse suspects respiratory failure secondary to hypoventilation in a patient with: Anxiety Neuromuscular disease Pulmonary embolism Volume A/C ventilation at rate of 20 breaths/min

B

Treatment of VAP med?

Bacteria-specific antibiotic therapy Patients with early-onset VAP may be placed on narrow-spectrum monotherapy of either ceftriaxone, fluoroquinolones, ampicillin-sulbactam, or ertapenem. Patients at risk for MDR pathogens require broad-spectrum therapy to include antipseudomonal cephalosporin, antipseudomonal carbapenem, beta-lactam/beta-lactamase inhibitor with antipseudomonal fluoroquinolone or aminoglycoside plus linezolid or vancomycin. Antibiotics are subsequently adjusted based on culture results, but initial treatment should not be delayed while awaiting culture results.

Mrs. J.'s condition continues to worsen. A decision is made to try the oscillator ventilator. Why is this decision made? What is the related nursing care? As Mrs. J. gets worse, what other complications can occur with ARDS?

Because Mrs. J. was unable to be oxygenated with high levels of FiO2 and PEEP, a new ventilatory strategy is needed. The oscillator may successfully recruit alveoli in cases of severe ARDS. Review text for nursing care, which includes sedation, neuromuscular blockade, and prevention of complications of bed rest. Psychological support for the family is also critical (and has been given throughout).

Meds for ARF in COPD

Beta2 agonists (bronchodilators) Corticosteroids Antibiotics (depends on cause) Cautious administration of sedatives

Exacerbation of Asthma: causes ? x2 effect? x2

Bronchodilators no longer working Noncompliance with medications effect- Hyperventilation with air trapping results in respiratory acidosis Severe hypoxemia

To prevent VAP, it is recommended that the head of bed be elevated to at least: 15 degrees 20 degrees 30 degrees 45 degrees

C

O2 decr if CO decr bc? Normal delivery of o2?

Cardiac output must be adequate to maintain tissue perfusion Normal delivery is 600 to 1000 mL/min of oxygen

Medical Management of ARF in COPD: correct hypoxemia? O2 should be administered to achieve a SaO2 of ? what types of mask? -----is often used in management of the patient with ARF in COPD. This is done to prevent the need for?

Cautious administration of O2 Noninvasive positive-pressure ventilation Ventilatory assistance O2 should be administered to achieve a SaO2 of 88% to 92%. A Venturi mask will deliver more precise oxygen concentrations than nasal prongs but may not be tolerated as well. NPPV is often used in management of the patient with ARF in COPD. This is done to prevent the need for intubation and possible prolonged mechanical ventilation.

Diagnosis of PE

Clinical signs and symptoms d-dimer assay (positive) V/Q scan with high probability of PE Duplex ultrasound (DVT) High-resolution multidetector computed tomography angiography (MDCTA; spiral CT) Pulmonary angiogram

Treatment of ARDS: comfort? position ? other tx?

Comfort - Sedation - Pain relief - Neuromuscular blockade Decrease O2 consumption Positioning - Prone positioning

Pneumonia types

Community-acquired Health care-acquired Hospital-acquired Ventilator-associated

Cornerstones of care for a patient with CF? most common pathogen found in adult patients with CF ? Tx sometimes seen?

Cornerstones of care for a patient with CF Antibiotic therapy Airway clearance Nutritional support Ventilatory support Pseudomonas aeruginosa is the most common pathogen found in adult patients with CF tx- lung transplant

A nursing intervention to maximize airway clearance is which of the following? Administer supplemental oxygen. Elevate the head of bed. Provide oral care every 4 hours. Reposition patient every 2 hours.

D

Diffusion is? n the lungs, O2 and CO2 move between the-----and the blood by diffusing across the-------membrane. ? Diffusion defects impair ? first parameter to alter (hypoxemia)? late sign of diffusion defect.? why?

Diffusion is the movement of gas from an area of high concentration to an area of lower concentration. In the lungs, O2 and CO2 move between the alveoli and the blood by diffusing across the alveolar-capillary membrane. Diffusion defects impair gas exchange. Poor oxygen exchange is the first parameter to alter (hypoxemia); CO2 is more readily diffusible, so hypercapnia is a late sign of diffusion defect.

assessment?

Dyspnea Chronic cough Sputum production Postbronchodilator spirometry limitations Pulmonary function studies Chest wall changes (barrel chest) Accessory muscles used for breathing Clubbing of the fingers Wheezing and crackles ABG (hypoxemia and hypercapnia)

Symptoms of ARDS

Dyspnea and tachypnea Hyperventilation with normal breath sounds Respiratory alkalosis Increased temperature and pulse Worsening chest x-rays that progress to "white out" Increased PIP on ventilation Eventual severe hypoxemia disorientation

VAP Bundle?

Elevate head of bed 30 to 45 degrees Awaken daily and assess readiness to wean and extubate Stress ulcer disease prophylaxis Venous thromboembolism (VTE) prophylaxis Oral care

Presentation of Pneumonia

Fever Cough Purulent sputum Hemoptysis Dyspnea/tachypnea Chest pain (pleuritic) Adventitious breath sounds

Tx ARDS?

Fluid and electrolyte balance Adequate nutrition Pharmacologic intervention Psychosocial support

Diffusion of O2 and CO2 does not occur if x2?

Fluid in alveoli Pulmonary fibrosis

Cystic Fibrosis patho? effects? can cause?

Genetic disorder Mutation in chloride transport results in "sticky" mucus that obstructs glands: Lungs (greatest effect) Pancreas Liver Salivary glands Testes Thick mucus in lungs is medium for infection, chronic bronchitis, and ARF

Prevention of VAP?

Hand washing and standard precautions Surveillance Ventilator bundle Prevent transmission - Sterile water in circuit - Drain condensate AWAY from patient - Avoid normal saline during suctioning

Complications of PE

Heart failure Obstructive shock Death

Hemoglobin necessary to ? Oxygen saturation (SaO2) refers to the percentage of ? normal?

Hemoglobin is necessary for transport of oxygen. Oxygen saturation (SaO2) refers to the percentage of O2 binding sites on each hemoglobin molecule that are filled with O2, and the normal value is 96% to 100%. Many critically ill patients have low hemoglobin levels secondary to a variety of factors.

Prevention of PE med

Heparin, low-molecular weight heparin Treatment of atrial dysrhythmias Prophylactic anticoagulant therapy Warfarin; long-term prevention

When ventilation is impaired, PaCO2 increases, resulting in ? can result from?

Hypercapnia Related to: Alveolar hypoventilation—decrease in ventilation and hypoxemia V/Q mismatch

Oxygenation failure occurs when the PaO2 cannot be adequately maintained and is the most commonly occurring type of ARF. Five generally accepted mechanisms that reduce PaO2 and create a state of hypoxemia are ?

Hypoventilation Intrapulmonary shunting Ventilation-perfusion mismatch Diffusion defects Decreased barometric pressure Low cardiac output (nonpulmonary hypoxemia) Low hemoglobin level (nonpulmonary hypoxemia)

Increased risk: for pneumonia ?

Increased risk: elderly, alcoholic, smokers, chronic diseases, head injury, immunosuppression

Prevention of Pneumonia? who should get it? when? what it contain?

Influenza vaccine All persons over 6 months People at high risk for complications of influenza People in contact with those at high risk Health care providers At age 65, pneumococcal vaccination to prevent Streptococcus or pneumococcus Conjugate dose Polysaccharide dose

ARDS Pathophysiology?

Insult—systemic inflammatory response syndrome (SIRS) Release of inflammatory mediators Damage to alveolar-capillary membrane Increased capillary permeability Pulmonary edema (noncardiogenic Microatelectasis (poped aveoli) Decreased compliance (stiff lungs) Decreased surfactant (damage to type II pneumocytes) Impaired gas exchange V/Q mismatch

Within 2 hours of NPPV, Mrs. J. is getting worse. Her SpO2 remains at 85%, and the oxygen via NPPV was 80%. Her chest x-ray shows bilateral "white out." What treatment is indicated?

Intubation and mechanical ventilation are urgently needed.

How can you alleviate anxiety in the patient with status asthmaticus? What positioning will facilitate gas exchange? What discharge teaching is essential to prevent future episodes?

Keep the patient in a position that maximizes respiration, often high-Fowler position. Must reinforce adherence to the prescribed medical therapy and monitoring for early signs and symptoms of exacerbation.

Interventions resp failure x5

Maintain a patent airway Optimize O2 delivery Minimize O2 demand Identify and treat the cause of ARF Prevent complications (most importance is to optimize oxygen delivery and minimize oxygen demand. )

Mrs. J. is placed on noninvasive positive-pressure ventilation (NPPV). Why is this decision made?

Mrs. J. is in respiratory failure. A trial of NPPV may be done to avoid the need for intubation and mechanical ventilation.

Mrs. J. is placed on volume assist/control (V-A/C) ventilation: rate 16 breaths/min, VT 8 mL/kg, FiO2 0.80, and PEEP 10 cm. What is the rationale for these settings, including PEEP?

Mrs. J. needs adequate oxygenation and ventilation. The V-A/C mode will provide ventilation. Since she is severely hypoxemic, a high level of oxygen is required. The PEEP is used to maximize oxygenation by increasing the FRC.

Mrs. J. is a 31-year-old female admitted to the critical care unit with respiratory distress after getting the "flu." Her condition worsens; SpO2 is 85% on Venturi mask at 0.50. ABGs show a PaO2 of 50 mm Hg. Her chest x-ray is showing infiltrates. Calculate Mrs. J.'s PaO2/FiO2 ratio, and interpret the findings.

Mrs. J.'s PaO2/FiO2 ratio is 100, indicating ARDS. Find PaO2/FiO2 ratio by dividing.

What is a possible etiology of ARDS in Mrs. J.?

Mrs. J.'s history indicated flu-like symptoms. She likely developed these symptoms from an acute viral infection, such as H1N1 infection.

Be alert for complications: like?

Multiple organ dysfunction syndrome (MODS) Renal failure Disseminated intravascular coagulation Long-term pulmonary effects associated with high oxygen and other therapies

Ventilatory Assistance

NPPV Intubation End-of-life issues Advance directives

NPPV is indicated for ? Intubation and invasive mechanical ventilation are indicated in ?

NPPV is indicated for dyspnea with respiratory muscle fatigue or respiratory acidosis, and assists the patient's respiratory efforts by delivering positive airway pressure through a nasal, oronasal, or full face mask Intubation and invasive mechanical ventilation are indicated in those patients who fail trials of NPPV or have persistent or worsening hypoxemia, respiratory arrest, cardiac arrest, decreased level of consciousness, aspiration, inability to remove own secretions, hemodynamic instability, or life-threatening ventricular dysrhythmias.

monitor for ARDS? once diagnosis?

Need to monitor ABGs and serial chest x-rays. Calculate PaO2/FiO2 ratio daily to trend the value. Once ARDS is diagnosed, important assessment data that are used to guide treatment include hemodynamic measurements, ABGs, mixed venous blood gases, breath sounds, serial chest x-ray studies, computerized tomography (CT), complete blood cell count with differential, blood and sputum cultures, and fluid and electrolyte values. Metabolic and nutritional needs must also be assessed, as well as the psychosocial needs of the patient and family.

Assessment of Respiratory Failure:x10 shows earliest signs of hypoxemia and hypercapnia?

Neurological—shows earliest signs of hypoxemia and hypercapnia Respiratory Cardiovascular Nutrition Psychosocial Chest x-ray Pulmonary function tests Laboratory studies Arterial blood gases (ABGs) Pulse oximetry and end-tidal CO2

ARDS is ? criteria ? x3

Noncardiogenic pulmonary edema (cardiogenic CHF) Diagnostic criteria 1) acute onset within one week of clinical insult; 2) bilateral pulmonary opacities not explained by other conditions; 3) altered PaO2/FiO2 ratio . (box pg. 397)

V/Q mismatch : normal V? normal P? normal VQ? ratio? causes? x3

Normal ventilation (V) is 4 L/min Normal perfusion (Q) is 5 L/min Normal V/Q ratio is 4/5 or 0.8 pneumonia, pulmonary edema, or pulmonary embolism

Pathophysiology Pneumonia ? cause? leads to?

Organisms in lower respiratory tract to overwhelm defense mechanisms Causes Aspiration Inhalation Spread from another infected area Impaired mucociliary clearance -This inflammatory response leads to a ventilation perfusion mismatch, resulting in dyspnea, hypoxemia, fever, and leukocytosis.

Medical Management?

Oxygen Bronchodilators Corticosteroids Sedation Transfusions Therapeutic paralysis Nutritional support Hemodynamic monitoring

Medical Management of asthma

Oxygen; ventilation in severe cases IV corticosteroids Inhaled bronchodilators; rapid-acting beta2-agonists Teaching

Oxygenation failure, also known as ? characterized by: PaO2 of less than? with normal to decreased levels of?

Oxygenation failure, also known as Type 1, is characterized by a PaO2 of less than 60 mm Hg with normal to decreased levels of carbon dioxide.

Diagnostic criteria ARDS? x3 Severity is determined by the PaO2/FiO2 ? x2 requirement of? levels- mild? mod? severe?

PaO2/FiO2 ratio of less than 200 Bilateral infiltrates Pulmonary capillary wedge pressure < 18 mm Hg Severity is determined by the PaO2/FiO2 ratio, and PEEP or CPAP requirements of ≥ 5 cm H2O: 1) Mild ARDS—201 to 300 mm Hg; 2) Moderate—101 to 200 mm Hg; and 3) Severe—≤ 100 mm Hg.

Intrapulmonary Shunting : what is it?

Pathological shunt exists when areas of the lung that are inadequately ventilated are adequately perfused the blood, therefore, is shunted past the lung and returns unoxygenated to the left side of the heart.

What patients would you identify as having a high risk of developing ARDS? Why is hyperventilation an early sign seen in patients developing ARDS? What related ABG abnormality will be seen?

Patients hyperventilate early in the course of the disease as an attempt to increase oxygen delivery. Early cases will have respiratory alkalosis. (CO2_+) ---to much of it increases the base

Prevention of VAP cont.

Prevent infection and aspiration Avoid reintubation Oral intubation ETT with continuous aspiration of subglottic secretions Sedation and weaning protocols Aseptic suctioning of endotracheal tube (ETT) Nutrition Mobilization

Prevention of PE ?

Sequential compression devices Foot pumps Compression stockings Position changes

What is the likely rationale for the drop in Mrs. J.'s blood pressure? What is the significance of the bilateral breath sounds?

Several complications can occur from high levels of PEEP, including pneumothorax and tension pneumothorax. The bilateral breath sounds would likely rule out a pneumothorax. At high levels, PEEP decreases venous return and can reduce cardiac output. Optimum PEEP that maximizes oxygenation without decreasing cardiac output must be determined. Mrs. J. is in critical condition.

Pharmacologic Therapy

Short-acting inhaled beta2-agonists Long-acting beta2-agonists Corticosteroids (prednisone) Antibiotics

Short-acting inhaled beta2-agonists. Adverse effect? Long-acting beta2-agonists are effective in controlling? recommended regimen of predisone?mmon adverse effects of steroid therapy include ?

Short-acting inhaled beta2-agonists. Adverse effects include tachycardia, dysrhythmias, tremors, hypokalemia, anxiety, bronchospasm, and dyspnea. Long-acting beta2-agonists are effective in controlling stable chronic COPD. Prednisone 40 mg per day for five days is the recommended regimen. Common adverse effects of steroid therapy include hyperglycemia and an increased risk of infection.

PE S/S?

Symptoms of deep venous thrombosis Chest pain (worse on inspiration) Dyspnea Tachycardia Tachypnea Cough; hemoptysis Crackles, wheezes Hypoxemia (Classic" signs of dyspnea, hemoptysis, and chest pain)

the final step in oxygenation is use ? If tissues are hypoxic results? he effects of tissue hypoxia vary with the severity of the hypoxia but may result in?

The final step in oxygenation is use of oxygen at the tissue level. If tissues are hypoxic, anaerobic metabolism and lactic acidosis result. The effects of tissue hypoxia vary with the severity of the hypoxia but may result in cellular death and subsequent organ failure. (Cyanide poisoning prevent tissue from using o2)

Treatment of ARDS? O2 x4?

Treat the cause Oxygenation and ventilation Positive end-expiratory pressure (PEEP) Possible nontraditional modes of ventilation: high-frequency, pressure-control, and inverse-ratio

Ventilator-Associated Pneumonia (VAP): associated with? patho? Controversies about best way to?

VAP is pneumonia associated with intubation and mechanical ventilation. Aspiration of bacteria from oropharynx or gastrointestinal tract Many potential causes Controversies about best way to diagnose—no "gold standard"

Ventilation failure, also known as? characterized by a PaCO2 greater than ?

Ventilation failure, also known as Type II, is characterized by a PaCO2 greater than 45 mm Hg. Altered gas exchange with failure of oxygenation, ventilation, or both.

Ventilation-perfusion mismatch occurs if? V/Q ratio is greater than 1.0 when? the V/Q ratio is less than 1. when?

Ventilation-perfusion mismatch occurs if either ventilation or perfusion is decreased. If ventilation exceeds blood flow, the V/Q ratio is greater than 1.0; if ventilation is less than blood flow, the V/Q ratio is less than 1.

ARF: Pulmonary Embolus (PE): Virchow's triad? Embolus results in?

Virchow's triad Venous stasis Altered coagulability Damage to vessel wall Embolus results in a lack of perfusion to ventilated alveoli (V/Q mismatch)

Exacerbation of Asthma

Wheezing Dyspnea Chest tightness Use of accessory muscles Nonproductive cough Hyperventilation initially Peak expiratory flow reading is less than 50% of normal values

ARF in Chronic Obstructive Pulmonary Disease (COPD): Worsening ? cause?

Worsening V/Q mismatch (e.g., secretions and bronchoconstriction can lead to ARF) acute exacerbations, CHF/ pulmonary edema, dysrhythmias, pneumonia, dehydration, and electrolyte imbalances

Many factors can result in hypoventilation and decreased oxygenation and ventilation. Factors that can lead to hypoventilation include ?

a drug overdose that causes central nervous system depression, neurological disorders that cause a decrease in the rate and/or depth of respirations, abdominal or thoracic surgery leading to shallow breathing patterns secondary to pain on inspiration

additional assessment Wheezing indicates?

anxiety, wheezing, chest tightness, tachypnea, t achycardia, fatigue, malaise, confusion, fever, sleeping difficulties. Wheezing indicates narrowing of the airways. Retraction of intercostal muscles may occur with inspiration, and exhalation is prolonged through pursed lips. The patient is generally more comfortable in the upright position. Tachycardia and hypotension may result from reduced cardiac output.

Pulmonary Causes of Hypoxemia?

hypoventilation shunt P/Q mismatch result in PE diffusion defect due to incr interstitial fluid

PaO2 / FiO2 when should you be concerned ?

less than 100