Acute Respiratory Failure (ARF)

A sudden and life-threatening deterioration of the gas exchange function of the lung. Exists when the exchange of oxygen for carbon dioxide in the lungs cannot keep up with the rate of oxygen consumption carbon dioxide production by the cells of the body. Defined as a decrease in arterial oxygen tension (PaO2) to less than 50 mmhg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mmhg (hypercarpnia), with an arterial pH of less than 7.35. It is important to distinguish Chronic respiratory failure (CRF) between ARF, CRF is defined as a deterioration in the gas exchange function of the lung that has developed insidiously or has persisted for a long period after an episode of ARF. 2 causes of chronic respiratory failure are COPD and neuromuscular diseases. Patients with these disorders develop a tolerance to the gradually worsening hypoxemia and hypercarpnia. However, patients with CRF can develop ARF. For example, a patient with COPD may develop an exacerbation or infection that causes additional deterioration of gas exchange. The principles of management of acute versus CRF are different.

Pathophysiology In ARF, the ventilation or perfusion mechanisms in the lung are impaired. Impaired respiratory system mechanisms leading to ARF include: Alveolar hypoventilation Diffusion abnormalities Ventilation-perfusion mismatching Shunting Common causes of ARF can be classifiedinto 4 categories: decreased respiratory drive, dysfunction of the chest wall, dysfunction of the lung parenchyma and other causes. Decreased Respiratory Drive Decreased respiratory drive may occur with severe brain injury, large lesions of the brainstem (multiple sclerosis), use of sedative medications and metabolic disorders such

as severe hypothyroidism. These disorders impair the response of chemoreceptors in the brain to normal respiratory stimulation. Dysfunction of the Chest Wall The impulses arising in the respiratory center travel through nerves that extend from the brainstem down the spinal cord to receptors in the muscles of respirations. Any disease or disorder of the nerves, spinal cord, muscles, or neuromuscular junction involved in respiration seriously affects ventilation and may ultimately lead to ARF. These include musculoskeletal disorders (muscular dystrophy, polymyositis), neuromuscular junction disorders (myasthenia gravis, poliomyletis), some peripheral nerve disorders and spinal corddisorders (anatrophic lateral sclerosis, Guillain-Barre syndrome, and cervical spinal cord injuries.) Dysfunction of Lung Parenchyma Pleural effusion, hemothorax , pneumothorax and upper airway obstruction are conditions that interfere with ventilation by preventing expansion of the lung. These conditions, which may cause respiratory failure, usually are produced by an underlying lung disease, pleural disease, or trauma and injury. Other diseases and conditions of lung parenchyma that lead to ARF include pneumonia, status asthmaticus, lobar atelectasis, PE and pulmonary edema. Other Causes In the postoperative period, especially after major thoracic or abdominal surgery, inadequate ventilation and respiratory failure may occur because of several factors. During this period, for example, ARF may be caused by the effects of anesthetic agents, analgesics, and sedatives which may depress respiration (as described earlier) or enhance the effect of opiods and lead to hypoventilation . Pain may interfere with deep breathing and coughing. A ventilation perfusion mismatch is the usual cause of respiratory failure after major abdominal, cardiac, or thoracic surgery. Clinical manifestation Early signs are those associated with impaired oxygenation and may include: Restlessness Fatigue Headache Dyspnea Air hunger Tachycardia Increased blood pressure As the hypoxemia progresses, more obvious signs may be present, including : Confusion Lethargy

Tachycardia Tachypnea Central cyanosis Diaphoresis Respiratory arrest

Physical findings are : Use of accessory mucles Decreased breath sounds if the patient cant adequately ventilate

Medical management The objectives of treatment are to correct the underlying cause and to restore adequate gas exchange in the lung. Intubation and mechanical ventilation and oxygenation while the underlying cause is corrected. Nursing Management Assist with intubation and maintaining mechanical ventilation Assess patients respiratory status by monitoring the level of responsiveness, arterial blood gases, pulse oximetry and vital signs Assess entire respiratory system and implement strategies (turning schedule, mouth care, skin care, range of motion of extremities) to prevent complications. Assess the patients understanding of management strategies that are used and initiates some form of communication to enable the patient to express concerns and needsto the health care team Patient teaching Mechanical Ventilator Is a positive or negative pressure breathing device that can maintain ventilation and oxygen delivery for a prolonged period. Indication If a patient has a continuous decrease in oxygenation (PaO2) an increase in arterial carbon dioxide levels (PaCO2) Persistent acidosis (decreased pH) Conditions such as: thoracic or abdominal surgery, drug overdose, neuromuscular disorders, inhalation injury, COPD, multiple trauma, shock, multi system failure and coma

Classification of Ventilators Negative pressure ventilators -Negative pressure ventilators exert a negative pressure on the external chest, Decreasing the intrathoracic pressure during inspiration allows air to flow into the lung, filing its volume.

-it is mainly used in chronic respiratory failure associated with neuromuscular conditions, such as poliomyelitis , muscular dystrophy, amyotrophic lateral sclerosis, and myasthenia gravis. Types of Negative pressure ventilators

Iron lung (drinker respirator tank) o Negative pressure chamber used for ventilation o Used extensively during polio epidemics in the past and currently is used by a few polio survivors survivors and patients with other neuromuscular disorders. Body wrap (pneumo-wrap) and Chest Cuirass (tortoise shell) o Are portable devices that require a rigid cage or shell to create a negative-pressure chamber around the thorax and abdomen.

Positive Pressure Ventilators -Positive pressure ventilators inflate the lungs by exerting positive pressure on the airway, pushing air in, similar to a bellows mechanism, forcing the alveoli to expand during inspiration. Expiration occurs passively. Types of positive pressure ventilators Pressure cycled ventilators o When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.

Time-cycled ventilators o Time-cycled ventilators terminate or control inspiration after a preset time o Used in newborns and infants

Volume-cycled ventilators o Most commonly used positive-pressure ventilators today o The volume of air is delivered with each inspiration is preset.

Noninvasive Positive-Pressure Ventilation (NIPPV) -Is a method of positive-pressure ventilation that can begiven via face mask that cover the nose and mouth, nasal masks, or other oral or nasal devices such as the nasal pillow ( a small nasal canula that seals around the nares to maintain the prescribed pressure) -It eliminates the need for endotracheal intubation or tracheostomy and decreases the risk of nosocomial infections such as pneumonia. Ventilator modes `Refers to how breathes are delivered to the patient. Assist-control (A/C) ventilation Provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent Mandatory Ventilation (IMV) Provides a combination of mechanically assisted breaths and spontaneous breaths. Synchronized intermittent mandatory ventilation (SIMV) Also delivers a preset tidal volum3 and number of breaths per minute. Pressure Ventilation (PSV) Applies a pressure plateau to the airway throughout the patient-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing. Airway pressure release ventilation (APRV) is a time triggered , pressure-limited, time cycled mode of mechanical ventilation that allows unrestricted, spontaneous breathing throughout the ventilatory cycle. Proportional Assist Ventilation (PAV) Provides partial ventilator support in which the ventilator generates pressure in proportion to the patients inspiratory efforts.

Results The goal of ventilation management is to wean the patient from mechanical support and to reestablish spontaneous respiration.