Respiratory Failure & Acute Respiratory Distress Syndrome

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct?

"PEEP prevents the lung air sacs from collapsing during exhalation." rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

respiratory failure treatment

1. O2 administration 2. mobilzation of secretions (effective coughing, incentive spirometry, hydration, airway suctioning) 3. positive pressure ventilation (non invasive or intubation) 4. drug therapy relief of bronchospasm (albuterol) reduction of airway inflammation (corticosteroids) reduction of pulmonary congestion (lasix) treatment of pulmonary infection (antibiotics) reduction of severe anxiety/pain (benzos and opioids) 5. treatment of underlying cause

ARDS treatment

1. O2 administration 2. prone position 3. lateral rotation therapy 4. positive pressure ventilation with PEEP 5. permissive hypercapnia 6. alternative modes of mechanical ventilation 7. treatment of underlying cause 8. hemodynamic monitoring 9. medications: inotropic/vasopressor meds (dopamine, dobutamine, norepinephrine), diuretics, IV fluids, sedation/analgesia, neuromuscular blockade

acute respiratory failure assessment

1. level of consciousness (first signs: restlessness, anxiety, confusion) 2. distress with labored, irregular breathing 3. chest wall retractions 4. tachypnea leading to increased pH (alkalosis) 5. dyspnea 6. crackles/wheezes 7. unable to lie flat 8. increased sputum, cough, wet lung sounds 9. cyanosis (late sign) 10. decreased blood pressure 11. tachycardia 12. anxiety-fear of suffocation and lack of control

Perfusion, Positioning, Protect lung ventilation, Protocol weaning, Prevent complications

5 Ps of ARDS therapy

V/Q Mismatch

A defect which occurs in the lungs whereby ventilation and perfusion are not equally matched

remember that pulse ox has limitations

A patient can be hypoxic without being hypoxemic and pulse ox only measures the blood saturation of O2 to hemoglobin. Post-op hypoxia is typically caused by a pneumothorax or pulmonary embolism. When a patient suddenly becomes agitated, uncooperative, or behaves differenet from baseline suspect hypoxia.

After receiving change-of-shift report, which patient will the nurse assess first?

A patient with septicemia who has intercostal and suprasternal retractions rationale: This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

Arterial Blood Gases

ABG; Gold standard for testing respiratory function; a test done on arterial blood to determine levels of O2, CO2, and other gases present. Data should be interpreted along with physical assessment and clients baseline. Ex: COPD pts will have a higher than normal PaCO2 as their "normal" due to the air trapping

What is the usual course of ventilation settings?

AC-assist control, Wean to SIMV, Decrease rate, Trial of CPAP with pressure support, Get baseline ABG's and another set on CPAP if patient is tolerating well, Extubate with respiratory therapist, Place on cool mist mask, then nasal cannula.

ECMO

ARDS intervention oxygenating blood outside of the body

Low Tidal Volume

ARDS intervention r/t mechanical ventilations (vent. setting)

High Frequency Ventilation

ARDS intervention r/t mechanical ventilations which combines very high respiratory rates (>60 breaths per minute) with tidal volumes that are smaller than the volume of anatomic dead space

Direct Trauma

ARDS lung injury cause ie. inhalation of toxins/smoke/chem, aspiration GI, near drowning, PE

Indirect Trauma

ARDS lung injury cause ie. shock, burns, severe trauma, ETOH, smoking

What is Acute respiratory distress syndrome (ARDS)?

ARDS: High mortality rate 50 - 60%, Many precipitating events may cause ARDS. Aspiration, DIC, Inhalation of smoke or chemical irritants, Shock, Trauma, Major surgery, Fat or air embolism.

ARDS

Acute lung injury, most severe form of ARF

What is the pathophysiology of ARDS?

Alveolar‐capillary membrane injury. Decreased surfactant production-From damage to alveolar type II cells. Leakage of fluid into alveoli- Causing fibrotic changes of the lung parenchema (tissue), Shunting, V/Q mismatch.

hypoxia

An insufficiency of oxygen in the body's tissues.

To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse?

Arterial blood gas (ABG) analysis rationale: ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests also may be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?

Assess oxygenation using pulse oximetry. rationale: Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take?

Assist the patient with staged coughing. rationale: The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

What are complications of mechanical ventilation?

Barotrauma: Presence of extra alveolar air. PTX - air in pleural space, Subcutaneous emphysema (crepitus). Signs and symptoms: Decreased breath sounds, Tracheal deviation, Hypoxemia. Cardiovascular: Decreased cardiac output. Tension Pneumothorax, Pressurized air enters pleural space, Disconnect from vent, manually ventilate with bag-valve (ambu bag), prepare for chest tube insertion. Fluid Retention‐ Caused by decreased CO; renin‐angiotensin‐aldosterone system; vent humidification. Oxygen Toxicity‐ Prolonged FIO2 > 50%.

ABGs

Blood test necessary for Dx of Resp Failure

Early (1-24 hrs)

CMS (early/late) of ARDS: increased RR, respiratory alkalosis, refractory hypoxemia, crackles, "white out" P/F ratio poor

Late

CMS (early/late) of ARDS: severe hypoxemia, acidosis, hypercapnea, tissue hypoxia

ARDS

CMs: increased RR, resp alkalosis, refractory hypoxemia, crackles, CXR (diffuse bilateral infiltrates -> white out), P/F ratio poor

What do you do if low pressure alarm sounds?

Check exhaled tidal volume, Check connections, Cuff leak, Check to see that chest is rising/falling.

shift to the right

Decreased Hgb affinity to O2, occurs with decreased pH, increased pCO2, temp and 2,3 DPG.

What is acute respiratory failure?

Defined as sudden and life‐threatening deterioration of gas exchange function of the lungs.

What are defining characteristics of acute respiratory failure?

Defining characteristics (ABG's on room air): PaO2 < 60 mm Hg, PaCO2 > 50 mm Hg, pH < 7.30. How would you interpret this state?

What are causes of respiratory acidosis?

Drug overdose, Pneumonia, Pulmonary edema, Pneumothorax. These conditions are caused by hypoventilation.

Late

Early/Late stage ARDS: alveolar cell damage, decrease surfactant production, diffuse infiltrates

Early

Early/Late stage ARDS: fibrin, blood, fluid, protein exude into interstitial space around alveoli, increase distance across capp. membrane

To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation?

Elevate head of bed to 30 to 45 degrees. rationale: Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs.

what is the Ventilator associated pneumonia (VAP) bundle?

Elevation of the head of the bed, Daily "sedation vacation"-take them off sedation and see if they are ready to wean off ventilator, Peptic ulcer prophylaxis, DVT prophylaxis, Oral care with chlorhexidine.

What are causes of metabolic alkalosis?

Excess ingestion of antacids, Excessive administration of NaHCO3, Loss of metabolic acids as with. Vomiting, Lavage (purging), Excessive diuretics.

Shunt

Extreme V/Q mismatch resulting in the blood exiting the heart without O2.

Acute respiratory failure results from?

Failure of oxygenation. Hypoventilation: Alveolar and arterial O2 is decreased because amount of gas entering alveoli per minute is reduced, Caused by shallow breathing. Shunting: Occurs when areas of lung are not adequately ventilated so Hgb is not picking up O2, Perfusion is adequate, but gas exchange does not take place.

2-3 weeks

Fibrotic phase occurs this many weeks after initial insult/injury in ARDS

Hypercapnic Respiratory Failure

INCREASED CO2 (greater than 45mm Hg) and DECREASED pH (less than 7.35), Telling us it's a VENTILATION problem, pt either not breathing enough or has an airtrapping diagnosis such as asthma or COPD

shift to the left

Increased Hgb affinity to O2, occurs with increased pH, decreased pCO2, temp and 2,3 DPG.

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit?

Insert a retention catheter rationale: Insertion of retention catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

What is treatment for ARDS?

Intubation. Supplemental O2 via mechanical ventilation to maintain PaO2. Suctioning/turning/prone positioning. Treatment for shock (fluids). Nutritional support- Require 35 - 45 kcal/kg/day. Need increased calories to meet metabolic demands. Need to start nutrition immediately: TPN and tube feeding, Sedation/analgesics. What medications will you expect? May need neuromuscular blockade (medication induced induced paralysis). Pharmacologic agents: Dopamine/Dobutamine/Norepinephrine, Antibiotics, Steroids ‐ maybe, Bronchodilators - usually inline breathing treatments. Pain medication: versed, morphine drip, dilaudid, propofol.

What are late signs of acute respiratory failure?

Lethargy, Kussmal breathing pattern, Diaphoresis, Use of accessory muscles, Decreased breath sounds.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a pneumothorax. Which action will the nurse anticipate taking?

Lower the positive end-expiratory pressure (PEEP). rationale: Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax.

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?

Obtain oxygen saturation using pulse oximetry. rationale: The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developing ARDS.

Acute Respiratory Failure

Occurs when gas exchanging functions are inadequate. Ex: insufficient O2 is transferred to the blood or inadequate CO2 is removed from the lungs -A sudden decrease in PaO2 or rapid rise in PaCO2 can quicly become life threatening - ex: bronchospasm in asthma. -Gradual changes are tolerated better by the body Ex: COPD where the body can compensate.

A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care?

Offer the patient fluids at frequent intervals. rationale: Since the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. The use of the incentive spirometer should be more frequent in order to facilitate the clearance of the secretions. The other actions also may be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?

Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask. rationale: The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

A patient with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FIO2) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

Oxygen saturation 99% rationale: The FIO2 of 80% increases the risk for oxygen toxicity. Since the patient's O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not need to be urgently reported to the health care provider.

shift to the left

Oxyhemoglobin Shift CMs: rapid breathing, becoming fatigued, previously agitated

shift to the right

Oxyhemoglobin Shift CMs: shallow breathing, barely responsive, low O2 sat

hypercapnia

PaCO2 > 50 mmHg

What is the indicator of failure to ventilate?

PaCO2. Decrease ventilation increases Co2, Increase CO2 causes vasodilation & neurologic changes.

Hypoxemic Respiratory Failure

PaO2 60mm Hg or less even with supplemental oxygen Ex: Pneumonia, Pulmonary emboli, Pulomary edema, alveoli disease, low CO conditions

hypoxemia

PaO2 < 50 mmHg

What are indications for intubation and mechanical ventilation?

PaO2 < 50 mmHg with FiO2 > 60%. What do we call this? oxyhemoglobin dissociation. PaCO2 > 50 with pH < 7.25. What is this condition? respiratory acidosis. Respiratory rate > 35/bpm, What do we call this? Hyperventilation. Worsening chest x‐rays. PaO2 = PaCO2

<200

PaO2:FiO2 ratio (Acute Lung Injury calculation) indicating severe hypoxemia

What are causes of respiratory alkalosis?

Pain, Anxiety, Fever, Asthma, ARDS. These conditions result from hyperventilation. too little CO2

What is continuous positive airway pressure (CPAP)?

Positive pressure during spontaneous breaths. Mode used when patient is being weaned from the ventilator. Delivers a preset FiO2. Rate and tidal volume are determined by the patient. Often used with pressure support. Patient is still intubated and on the ventilator.

Lungs (& chest)

Primary Function = get O2 from the air that is inhaled into the bloodstream, simultaneously eliminating CO2 from the blood through exhaled air.

7-10 days

Proliferative phase occurs this many days after initial insult/injury in ARDS

What are failed weaning parameters?

RR > 30 or < 8 bpm, Changes in HR and BP, Declining O2 Sat, Dysrhythmias, Decrease in spontaneous tidal volume, Labored respirations, Decreased LOC. If these symptoms occur, place back on previous ventilator settings. Sometimes patients are weaned during the day and placed back on vent to rest during the night.

What are causes of metabolic acidosis?

Renal failure, DKA, Salicylate drug overdose. These conditions result from acid gain.

What are clinical manifestations of respiratory arrest?

Respiratory arrest: Bradypnea, Obtundation-minimal if no response, Bradycardia, Hypotension or no BP. What will the ABG's look like for this patient?

signs and symptoms of hypercapnia

Respiratory: dyspnea, decreased respiratory rate or increased rapid rate with shallow respirations cerebral: morning headache, disorientation, progressive somnolence, coma (late) cardiac: dysrhythmias, hypertension, tachycardia, bounding pulse Neuromuscular: muscle weakness, decreased deep tendon reflexes, tremor, seizures (late) other: pursed lip breathing, use of tripod position

signs and symptoms of hypoxemia

Respiratory: dyspnea, tachypnea, prolonged expiration (i:e; 1:3 normal is 1:2), use of excessory muscles, decreased SpO2 (<80%), cyanosis (late) Cerebral: agitation, disorientation, delirium, restless, confusion, decreased LOC, coma (late) Cardiac: tachycardia, hypertension, skin cool clammy and diaphoretic, dysrhythmias and hypotension (late) Other: fatigue, unable to speak in full sentences

What are early signs of acute respiratory failure?

Restlessness, Irritability, Fatigue, Headache, Dyspnea, Tachycardia, Adventitious breath sound.

severe acute respiratory syndrome

SARS; acute resp infection caused by coronavirus (CoV). Spread by close contact via droplets Symptoms: fever, sore throat, rhinorhea, chills, rigors, diarrhea, HA, body aches, progressive resp changes (dry cough advances to difficulty breathing) Treatment: isolation, antiviral, corticosteriods

Nursing care...

Safeguard the Patient: Ambu bag; functioning suction; check settings/functioning of vent. Psychological Aspects/ Patient Teaching. Physical Activity. Nutrition: 35‐45 kcal/kg/day. Evaluate Bowel Sounds/Record BM. Pain Medication/Sedation. VAP Bundle.

What do you do if high pressure alarm sounds?

Suction if rhonchi auscultated, Reposition head/neck, Check for tube biting, Auscultate breath sounds; check for pneumothorax. Empty water in tubing.

What are clinical manifestations of ARDS?

Sudden and progressive pulmonary edema (non cardiogenic), Increasing bilateral infiltrates ("white‐out" on chest x‐ray). Severe dyspnea, accessory muscles, retractions. Hypoxemia refractory to supplemental O2. Reduced lung compliance (stiff lungs). Change in mentation (agitation, restless), Tachypnea, tachycardia.

Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased?

The patient has subcutaneous emphysema. rationale: The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not indications that PEEP should be reduced.

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse?

The patient is somnolent. rationale: Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse?

The patient's PaO2 is 45 mm Hg. rationale: The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.

When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective?

The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. rationale: The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most important to report to the health care provider?

The patient's respiratory rate has decreased from 30 to 10 breaths/min. rationale: A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

acute respiratory distress syndrome (ARDS)

This is a sudden and progressive form of acute respiratory failure caused by damage to alveolar capillary membranes, allowing fluid to leak into lungs. Gas exchange impaired by damage to pulmonary capillary membrane and presence of fluid in alveoli. Surfactant rendered inactive, results in collapse of alveoli. Life threatening condition characterized by severe dyspnea, hypoxemia, & diffuse pulmonary edema. Causes are: trauma, SEPSIS, severe pulmonary infections, inhalation lung injuries. Keep in prone position. TPN feedings.

Methylprednisone

Tx of ARDS which reduces systemic inflammation, increases pulmonary function, decreases duration of mechanical ventilation and SAVES LIVES

What are parameters for weaning a patient off a ventilator?

Underline problem is starting to resolve, Improved CXR, Normal breath sounds, Clear secretions, Hemodynamic stability: RR < 25 bpm, Spontaneous tidal volume 4 - 5ml/kg. Adequate ABG's: PaO2 > 60 mmHg on FiO2 < 50%, PaCO2 < 45 mmHg, PEEP < 5 cm H2O. Assess LOC: Stop sedation, paralytics. Assess nutritional status-albumin, prealbumin. Determine patients readiness to wean. Do you want to check the Hgb?

Mechanical Ventilation

Used to improve oxygen delivery, relieve upper airway obstruction, remove secretions, minimize work of breathing or promote rest of an injured lung

What is mechanical ventilation?

Using a machine to do the work of breathing when the patient is unable to adequately ventililate on their own. Cannot maintain a patent airway. requires supplemental O2 under pressure to maintain oxygenation.

How does acute respiratory failure happen?

V/Q mismatch: Most common cause of low O2, Ratio is about 1 : 1»Ventilation is 4L/min »Perfusion is 5L/min 5L/min. Low V/Q ratio produces shunting. High V/Q ratio produces increased dead space.Diffusion defects Movement of O2 and CO2 across the alveoli‐capillary membrane is impaired.

What is a pressure-targeted ventilator?

Ventilator allows air to flow into lungs until a preset pressure is achieved. Tidal volumes may vary with each breath. Increased risk of hypoventilation.

What is a volume targeted ventilator?

Ventilator is set to allow air to flow until a preset tidal volume is delivered. Commonly used in ICU today.

Acute Respiratory Failure

broad, non-specific dx; respiratory system is unable to supply the oxygen necessary to maintain tissue metabolism OR cannot sufficiently eliminate CO2.

Non-cardiogenic

cause of pulmonary edema not associated with cardiac factors. Ie. lung tumors, near drowning, pneumonia, aspiration, sepsis, inhalation smoke/toxins

Alveolar Hypoventilation

cause of ventilatory failure characterized by decreased CNS drive or mechanical disruptions

respiratory distress

clinical manifestation, not a diagnosis, r/t difficulty breathing

PE

common cause of poor perfusion/good ventilation

Pneumonia, Asthma

common causes (2) of poor ventilation/good perfusion

ARDS

consists of three phases: exudative, proliferative, fibrotic

hypoxemia

deficient amount of oxygen in the blood; leads to hypoxia if not treated

respiratory failure

diagnosis r/t difficulty breathing, not a single disease but a combination of a variety of problems

early

early?/late? CMs of hypoxemia: O2 sat drop, restlessness, HTN, dyspnea, Tachypnea, Tachycardia, Mild resp. alkalosis

late

early?/late? CMs of hypoxemia: cyanosis, bradycardia, slow RR, metabolic acidosis, respiratory acidosis

A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with _______________

endotracheal intubation and positive pressure ventilation. rationale: The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration?

gentamicin (Garamycin) 60 mg IV rationale: Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will ______________

increase the oxygen flow rate. rationale: Increasing oxygen flow rate usually will improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

Intubation

indications include: refractory hypoxemia, upper airway obstruction and insufficient spontaneous respiratory effort

A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with ____________

inserting a pulmonary artery catheter. rationale: Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

Cardiogenic

most common cause of pulmonary edema r/t cardiac factors -> fluid back up

ARDS

most common causes = sepsis (capillary basement membrane damage), GI aspiration (alveolar endothelial damage)

ventilation

movement of air in and out of the lungs

Ventilation Perfusion mismatch

occurs in conditions during which either the flow of oxygen is limited in the alveoli or the circulation through the pulmonary capillary is compromised

Shunt

occurs when blood exits the heart without having participated in gas exchange. A shunt can be viewed as an extreme ventilation perfusion mismatch. There are two types of shunts: anatomical and intrapulmonary

When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned _______________

on the right side. rationale: The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

2,3 DPG

organic phosphate (diphosphoglycerate) in the RBC that alters the affinity of Hgb for O2

1

phase of ARDS (1,2,3): endothelial changes, inflammatory changes in alveloi, pt may be asymptomatic except for underlying cause

3

phase of ARDS (1,2,3): full pulmonary edema, massive inflammatory response, damage to basement membrane and alveolar epithelium, increased chasm between capp membrane and alveoli

2

phase of ARDS (1,2,3): increased capillary permeability, increased fluid in interstitial spaces (not alveoli), pt becoming symptomatic (anxious, reports of dyspnea)

Proliferative

phase of ARDS: damage of alveolar cells (type I and II), decreased surfactant (atelectasis), hypoxemia, intrapulmonary shunting, V/Q mismatch

Fibrotic

phase of ARDS: irreversible deposition of fibrin into lungs (pulm fibrosis, decreased lung compliance), worsening hypoxemia, V/Q imbalance, profound arterial hypoxemia

what is Positive end expiratory pressure (PEEP)?

positive End Expiratory Pressure (PEEP): Positive airway pressure throughout exhalation. Keeps airways open at end of expiration. Use to decrease amount of FiO2 needed. Benefits: decreased shunt; improved oxygenation. Complications: barotrauma; decreased cardiac output. PEEP increases intrathorasic pressure and can impinge on the heart, decreasing cardiac output, BP will go down may need vasopressors.

diffusion limitation

process that occurs when gas exchange across the alveolar-capillary membrane is compromised by a process that thickens or destroys the membrane. Ex: pulmonary fibrosis, ARDS

hypoxemia

reduced oxygenation of arterial blood

hypoxia

reduced oxygenation of tissues

Shunts

refractory to supplemental O2

Ventilatory Failure

resp failure characterized by a rise in Paco2 (hypercapnia) that occurs when the respiratory load can no longer be supported by the strength or activity of the system

Hypoxemic

resp failure characterized by diffusion abnormalities (ie. pneumonia, secretions, atelectasis, pulmonary edema).

sedation

resp pharm: low dose used in specific cases, used for severe anxiety and restlessness (decrease O2 demand) *must stay with pt

diuretics

resp pharm: maintain fluid balance

narcotic antagonist

resp pharm: reverses resp depression effect of specific medications (narcan, romazicon, verced)

antibiotics

resp pharm: treat infx, help reduce swelling and exudate clogging up airways

respiration

the exchange of O2 and CO2 at the alveolar-capillary level and at the tissue-cellular level

hypercapnia

the presence of an abnormally high level of carbon dioxide in the circulating blood

morphine

tx of pulm edema to decreas anxiety

nitrates

tx of pulm edema to reduce preload and afterload

inotropics

tx of pulm edema to support perfusion by increasing CO