Acute Respiratory Failure

Respiratory System
Consists of two parts:
Gas exchange organ (lung): responsible for
OXYGENATION
Pump (respiratory muscles and respiratory control
mechanism): responsible for VENTILATION
NB: Alteration in function of gas exchange unit
(oxygenation) OR of the pump mechanism (ventilation)
can result in respiratory failure

Normal Lung

Lung Anatomy

Normal Alveoli

Gas Exchange Unit

Fig. 66-1

Normal ABGs

pH = 7.35-7.45
CO2 = 35-45
HCO3= 23-27

Respiratory and Metabolic

Acidosis and Alkalosis
CO2 is an acid and is controlled by the
Respiratory (Lung) system
HCO3 is an alkali and is controlled by the
Metabolic (Renal) system
Respiratory response is immediate; Metabolic
response can take up to 72 hours to respond
(except in patients with COPD who are in a
constant state of Compensation!)

ABG Interpretation
Step 1:
Check the pH: Is it acidotic or alkalotic or
normal? pH below 7.35 is acidotic; pH
above 7.45 is alkalotic
If pH is normal, then the ABG is
compensated; if pH not normal, then the
ABG is uncompensated

ABG Interpretation (contd)

Step 2.
Check the CO2 and HCO3:

If the CO2 (acid) is above 45, the pt is

acidotic; if the CO2 is below 35, the pt is
alkalotic

If the HCO3 is above 27, the patient is

alkalotic; if the HCO3 is below 23, the patient
is acidotic

ABG Interpretation (contd)

Step 3
If the CO2 is high (above 45), then the patient is in
Respiratory Acidosis; if the CO2 is low (below
35), then the patients is in Respiratory Alkalosis.
If the HCO3 is high (above 27), then the patient is in
Metabolic Alkalosis; if the HCO3 is low (below
23), then the patient is in Metabolic Acidosis.

ABG Example #1
pH = 7.36
CO2 = 41
HCO3 = 27
Diagnosis: ?

ABG Example #2
pH = 7.49
CO2 = 37
HCO3 = 32

Diagnosis: ?

ABG Example #3
pH = 7.29
CO2 = 50
HCO3 = 26

Diagnosis: ?

ABG Example #4
pH = 7.40
CO2 = 32
HCO3 = 30

Diagnosis: ?

Acute Respiratory Failure

Results from inadequate gas exchange
Insufficient O2 transferred to the blood
Hypoxemia
Inadequate CO2 removal
Hypercapnia

Acute Respiratory Failure

with Diffuse Bilateral
Infiltrates

Acute Respiratory Failure

Not a disease but a condition
Result of one or more diseases involving
the lungs or other body systems
NB: Acute Respiratory Failure: when
oxygenation and/or ventilation is
inadequate to meet the bodys needs

Acute Respiratory Failure

Classification:
Hypoxemic respiratory failure (Failure
of oxygenation)
Hypercapnic respiratory failure
(Failure of ventilation)

Classification of Respiratory Failure

Fig. 66-2

Acute Respiratory Failure

Hypoxemic Respiratory Failure
PaO2 of 60 mm Hg or less
(Normal = 80 - 100 mm Hg)
Inspired O2 concentration of 60% or
greater

Acute Respiratory Failure

Hypercapnic Respiratory Failure
PaCO2 above normal (>45 mm Hg)
Acidemia (pH <7.35)

Hypoxemic Respiratory Failure

Etiology and Pathophysiology
Causes:
Ventilation-perfusion (V/Q) mismatch
Shunt
Diffusion limitation
Alveolar hypoventilation

V-Q Mismatching
I) V/Q

mismatch

Normal ventilation of alveoli is comparable to

amount of perfusion
Normal V/Q ratio is 0.8 (more perfusion than
ventilation)
Mismatch d/t:
Inadequate ventilation
Poor perfusion

Range of V/Q Relationships

Fig. 66-4

Hypoxemic Respiratory Failure

Etiology and Pathophysiology
Causes V/Q mismatch

COPD
Pneumonia
Asthma
Atelectasis
Pulmonary embolus

Hypoxemic Respiratory Failure

Etiology and Pathophysiology
II) Shunt
An extreme V/Q mismatch
Blood passes through parts of respiratory
system that receives no ventilation
d/t obstruction OR fluid accumulation
Not Correctable with 100% O2

Diffusion Limitations
III) Diffusion Limitations
Distance between alveoli and pulmonary
capillary is one- two cells thick
With diffusion abnormalities: there is an
increased distance between alveoli (may
be d/t fluid)
Correctable with 100% O2

Hypoxemic Respiratory Failure

Etiology and Pathophysiology
Causes Diffusion limitations
Severe emphysema
Recurrent pulmonary emboli
Pulmonary fibrosis
Hypoxemia present during exercise

Diffusion Limitation

Fig. 66-5

Alveolar Hypoventilation
IV) Alveolar Hypoventilation
Is a generalized decrease in
ventilation of lungs and resultant
buildup of CO2

Hypoxemic Respiratory Failure

Etiology and Pathophysiology
Causes Alveolar hypoventilation
Restrictive lung disease
CNS disease
Chest wall dysfunction
Neuromuscular disease

Hypoxemic Respiratory Failure

Etiology and Pathophysiology
Interrelationship of mechanisms
Hypoxemic respiratory failure is frequently caused
by a combination of two or more of these four
mechanisms
Effects of hypoxemia

Build up of lactic acid metabolic acidosis cell death

CNS depression
Heart tries to compensate HR and CO
If no compensation: O2, acid, heart fails, shock, multisystem organ failure

Hypercapnic Respiratory Failure

Etiology and Pathophysiology
Imbalance between ventilatory supply
and demand
Occurs when CO2 is increased

Causes Hypercapnic
Respiratory Failure
I) Alveolar Hypoventilation and VQ
Mismatch:
Ventilation not adequate to eliminate CO2
Leads to respiratory acidosis
Eg. Narcotic OD; Guillian-Barre, ALS, COPD,
asthma

Causes Hypercapnic
Respiratory Failure
II) VQ Mismatch:
- Leads to increased work of breathing
- Insufficient energy to overcome
resistance; ventilation falls; PCO2;
respiratory acidosis

Hypercapnic Respiratory Failure

Categories of Causative
Conditions
I) Airways and alveoli
Asthma
Emphysema
Chronic bronchitis
Cystic fibrosis

Hypercapnic Respiratory Failure

Categories of Causative
Conditions
II) Central nervous system
Drug overdose
Brainstem infarction
Spinal cord injuries

Hypercapnic Respiratory Failure

Categories of Causative
Conditions
III) Chest wall
Flail chest
Fractures
Mechanical restriction
Muscle spasm

Hypercapnic Respiratory Failure

Categories of Causative
Conditions
IV) Neuromuscular conditions
Muscular dystrophy
Multiple sclerosis

Respiratory Failure
Tissue Oxygen Needs

Major threat is the inability of the lungs

to meet the oxygen demands of the tissues

Respiratory Failure
Clinical Manifestations
Sudden or gradual onset
A sudden in PaO2 or rapid in PaCO2
is a serious condition

Respiratory Failure
Clinical Manifestations
When compensatory mechanisms fail,
respiratory failure occurs
Signs may be specific or nonspecific

Respiratory Failure
Clinical Manifestations
Severe morning headache
Cyanosis
Late sign
Tachycardia and mild hypertension
Early signs

Respiratory Failure
Clinical Manifestations
Consequences of hypoxemia and hypoxia
Metabolic acidosis and cell death
Cardiac output
Impaired renal function

Respiratory Failure
Clinical Manifestations
Specific clinical manifestations
Rapid, shallow breathing pattern
Sitting upright
Dyspnea

Respiratory Failure
Clinical Manifestations
Specific clinical manifestations
Pursed-lip breathing
Retractions
Change in Inspiratory:Expiratory
ratio

Respiratory Failure
Diagnostic Studies

Physical assessment
ABG analysis
Chest x-ray
CBC
ECG

Respiratory Failure
Diagnostic Studies

Serum electrolytes
Urinalysis
V/Q lung scan
Pulmonary artery catheter (severe cases)

Acute Respiratory Failure

Nursing and Collaborative
Management
Nursing Assessment
Past health history
Medications
Surgery
Tachycardia

Acute Respiratory Failure

Nursing and Collaborative
Management
Nursing Assessment
Fatigue
Sleep pattern changes
Headache
Restlessness

Acute Respiratory Failure

Nursing and Collaborative
Management
Nursing Diagnoses
Ineffective airway clearance
Ineffective breathing pattern
Risk for imbalanced fluid volume
Anxiety

Acute Respiratory Failure

Nursing and Collaborative
Management
Nursing Diagnoses
Impaired gas exchange
Imbalanced nutrition: less than body
requirements

Acute Respiratory Failure

Nursing and Collaborative
Management
Planning
Overall goals:
ABGs and breath sounds within
baseline
No dyspnea
Effective cough

Acute Respiratory Failure

Nursing and Collaborative
Management
Prevention
Thorough physical assessment
History

Acute Respiratory Failure

Nursing and Collaborative
Management
Respiratory Therapy
Oxygen therapy
Mobilization of secretions
Effective coughing and positioning

Acute Respiratory Failure

Nursing and Collaborative
Management
Respiratory Therapy
Mobilization of secretions
Hydration and humidification
Chest physical therapy
Airway suctioning

Acute Respiratory Failure

Nursing and Collaborative
Management
Respiratory Therapy
Positive pressure ventilation (PPV)

Acute Respiratory Failure

Nursing and Collaborative
Management
Drug Therapy
Relief of bronchospasm
Bronchodilators

Acute Respiratory Failure

Nursing and Collaborative
Management
Drug Therapy
Reduction of airway inflammation
Corticosteroids

Acute Respiratory Failure

Nursing and Collaborative
Management
Drug Therapy
Reduction of pulmonary congestion
IV diuretics

Acute Respiratory Failure

Nursing and Collaborative
Management
Drug Therapy
Treatment of pulmonary infections
IV antibiotics

Acute Respiratory Failure

Nursing and Collaborative
Management
Drug Therapy
Reduction of severe anxiety, pain, and
agitation
Benzodiazepines
Narcotics

Acute Respiratory Failure

Nursing and Collaborative
Management
Medical Supportive Therapy
Treat the underlying cause
Maintain adequate cardiac output and
hemoglobin concentration
Monitor BP, O2 saturation, urine
output

Acute Respiratory Failure

Nursing and Collaborative
Management
Nutritional Therapy
Maintain protein and energy stores
Enteral or parenteral nutrition
Supplements