Acute Respiratory Failure

DEFINITION y y Life threatening deterioration of gas exchange function of the lung Decrease in arterial pressure oxygen tension to < 50mmHg and an increase in arterial carbon dioxide tension to > than 50mmHg. With an arterial carbon dioxide < 7.35.(Brunner and Suddarth) A condition in which the respiratory system fails in one or both of its gas exchange function. Occurs previously healthy person as a result of acute disease or truma invovling the respiratory system or it may develop in the course of a chronic neuromuscular or respiratory disease( Bullock,Heuze) A condition in which the lungs fail to oxygenate blood adequately and prevent carbon dioxide retention. Not a specific disease, but a result of a number of conditions that impair ventilation, compromise the matching of ventilation and perfusion or disrupt the blood flow in the lung.(Porth) A broad , non specific clinical diagnosis indicating that the respiratory system is unable to supply the oxygen necessary to maintain metabolism or cannot eliminate sufficient carbon dioxide.

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Two general types of Respiratory Failure(Black) 1. Hypoxemic Respiratory Failure- diffuse problems such as pulmonary edema,near drowning, or ARDS, localized problems such as pneumonia, bleeding into the chest or lung tumors. 2. Ventilatory Failure- CNS depression, inadequate neuromuscular ability to sustain breathing or excessive respiratory system load. ETIOLOGY y y y y y y Impaired ventilation Upper Airway Obstruction-infection,foreign bodies, larygospasm,tumors Weakness or paralysis of respiratory muscles-brain injury, drug overdose, guillain barres syndrome, muscular dystrophy Chest wall injury Impaired Matching of Ventilation and Perfusion-COPD,Restrictive lung disease,Atelectasis Impaired Diffusion-pulmonary edema,ARDS

SIGNS and SYMPTOMS Hallmark Sign- Varying degrees of hypoxemia and hypercapnia 1. HYPOXIA Arterial PO2<50mmHg Tachycardia Mild increase in BP Cool and Moist skin Confusion Delirium Difficulty in Problem solving Bradycardia(Late) Loss of judgement Euphoria untruly combative behavior sensory impairement Mental fatigue Drowsiness Stridor and Coma(late) Hypotension(late)

2. HYPERCAPNIA Increase Pco2 Headache Conjuctual Hyperemia Flushed Skin Increased Sedation Tachycardia Diaphoresis Mild to Moderate increase in BP

DIAGNOSTIC PROCEDURE y y MRI and CT SCAN for clearly view of Lung and Lung components. CHEST X-RAY(Radiohgraphy)- most frequently used radiograph.

Normal values: appearing and normally positioned chest,bony thorax (all bones present, aligned,symmentrical, and normally shaped), soft tissue, mediastinum,lungs, pleura,heart, and aortic arch. y SPIROMETRY,Forced Expiratory Maneuver Volume-Time spirogram(V-T tracing); Flow-Volume Spirogram(F-V Loop)

-this mechanical device is clinically used to measure lung capacities, voulmes,and flow rates. This mechanical signal is converted to an electric signal, which records the amount of gas breath in and out and produces a Spirogram. -determines the effectiveness of the various mechanical forces involved in lung and chest wall movement. -the forced expiratory volumes exhaled within 1, 2, or 3 seconds are sometimes referred to timed vital capacities(FEV ; FEV :FEV respectively) this measurement are useful for evaluating a patient s response to bronchodilators. Two categories of Spirometry o o Normal Values y y y FVC: >80% (>0.80%) of predicted value FEV ; FEV ; FEV : FEV ,> 80% (>0.80) of predicted value FEV /FVC: FEV , 80%-85% (0.80-0.85) of FVC FEV , 90%-94% (0.90-0.94) of FVC FEV , 95%-97% (0.95-0.97) of FVC Predicted values are based on the patient s age,gender,height,and ethnicity. The mechanical or volume-displacement types(water filled, dry rolling seal, wedge, or bellows) The electronic or flow-sensing types (pneumotachometer or hotwire anemometer)

MEDICAL MANANGENT Management for Acute respiratory Failure consist of two simultaneous process 1. Maintaining oxygenation and ventilation 2. Treatment of infection, removal of secretion,a nd reversal of any airways constriction present.

Correcting Hypoxemia Patient need oxygen when they are severly hypoxic. High FiO levels and may require a mechanical ventilation or continuos positive airway pressure (CPAP)

Reducing Preload Patient is in an upright position. Diuretics are prescribed to promote fluid excretion. Nitrates, such as nitroglycerine are used for their vasodilative properties. Phlebotmoy can be used to remove excess blood,-rare

Reducing Afterload Antihypertensive agents, including potent agents such a s nitoprusside are prescribed. Morphine is prescribed to reduce the sympathetic nervous system response and reduce anxiety form dyspnea.

Supprting Refusion Inotropic medication such a s dobutamine. UO is monitored closely to determine whether renal perfusion is adequate. An intra-aortic baloon pump (IAMP) may be needed.

Endotracheal Intubation and Mechanical Ventilation For patient who fail to respond to conservative management and who have hypercapnia with evidence of obtundation.

Control of Infection,Brochonstriction and Secretion

Removal of secretion is accomplished by urging the patient to cough or by passing suction catheters into the trachea which in addition to removing secretion that are present. Postural drainage and chest percusiion often-used adjuncts that have been shown, especially when secretion are voluminous, to improve tracheobronchial clearance to increase sputum volume beyond that produced by cough. Broad Spectrum Antibiotics if no single agent is suspected or isolated. Or erythromycin, if legionallae or mycoplasm are suspected, should be added to regimen.

Reference: Textbook of Medical-Surgical Nursing Brunner and Suddarth