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Acute Respiratory Failure

Mechanical Ventilation
Acute Respiratory Failure
• Characterized by
– PaO2 < 60
– O2 Sat < 90
– PaCO2 > 50
– pH < 7.30
Types of Failure
• Ventilatory Failure
• Oxygenation Failure
• Combined Ventilatory/Oxygenation Failure
Ventilatory Failure
• V/Q • Caused by
• Adequate Perfusion – Mechanical
abnormality of lungs or
• Inadequate ventilation chest wall
– Insufficient air – Defect in respiratory
movement control center
↓ O2 to alveoli – Impaired function of
– CO2 retention respiratory muscles
Oxygenation Failure
• Adequate ventilation
• Decreased perfusion
• Inadequate oxygenation of pulmonary
blood
• Caused by
– Pulmonary Embolism
– Inadequate hemoglobin
Combined
Ventilatory/Oxygenation Failure

• Hypoventilation
• Inadequate gas exchange
• Occurs in clients with abnormal lungs
• Cardiac failure
– Cannot compensate for ↓ O2
Assessment
• Signs of Hypoxemia • Signs of Hypercapnia
• Decreased PO2 • Increased PCO2
– Dyspnea, tachypnea – Dyspnea → resp.
– Cyanosis depression
– Restlessness – Headache
– Apprehension – Tachycardia
– Confusion – Coma
– Tachycardia – Systemic vasodialation
– Dysrhythmias – Heart failure
– Metabolic acidosis – Respiratory acidosis
Interventions
• Correct underlying cause
• Support ventilation
∀ ↑ PO2 and ↓PCO2
– O2 therapy
– Positioning
↓ anxiety
– Energy conservation
– Bronchodialators
Mechanical Ventilation
• Unresponsive to interventions
• Hypoxemia
• Progressive alveolar hypoventilation with
respiratory acidosis
• Respiratory support after surgery
Endotracheal Intubation
• Short term (10-14 days)
• Maintain patent airway
∀ ↓ work of breathing
• Remove secretions
• Provide ventilation & O2
Types of Ventilators
• Negative Pressure (Mimic spontaneous breaths)
– Iron Lung
• Positive Pressure (Push air into lungs)
– Pressure cycled
• Air delivered until preset pressure reached
– Time cycled (Pediatrics/Neonates)
• Push air in with preset time
• Tidal volume & pressure variable
– Volume cycled
• Push air in until preset volume reached
• Constant tidal volume
• Variable pressure
Modes of ventilation
• Controlled ventilation
• Assist-control (A/C)
• Synchronized Intermittent Mandatory
Ventilation (SIMV)
Controlled ventilation
• Least used
• All breaths delivered at preset tidal
volume, pressure & rate
• Client with no spontaneous effort
– Severe ICP
– Brain death
– Voluntary paralysis of muscles
Assist-Control Ventilation
• Most commonly used
• Tidal volume & rate preset
• Client does not trigger breath, ventilator
will deliver breath
• Advantage- client controls rate of
breathing
• Disadvantage - ↑ respiratory rate →
hyperventilation → respiratory alkalosis
SIMV
• Similar to A/C ventilation
• Spontaneous breathing between ventilator
breaths at clients own rate & tidal volume
• Used as primary ventilator mode or
weaning mode
Ventilator Settings
• Tidal Volume (VT)
– Volume of air delivered each breath
– 7-10 cc/kg body wt.
• 75 kg = 750 cc

• Rate
– # of breath/minute
– 10-14 BPM

• Fraction of inspired O2 (FIO2)


– Oxygen concentration
– 21% (room air) to 100%
Ventilator Settings
• Peak Airway (Inspiratory) Pressure (PIP)
– Pressure needed to deliver set tidal volume
– Highest pressure indicated during
inspiration
↑ airway resistance
• Bronchospasms
∀ ↑ secretions
• Pulmonary edema
∀ ↓ pulmonary compliance
– Prevents barotrauma
• Lung damage from excessive pressure
Ventilatory Settings
• Continuous Positive Airway Pressure
(CPAP)
– Spontaneous respirations
– Intubation or tight fitting mask
– Positive pressure during the entire respiratory
cycle (5-15 cm H2O)
– Keeps alveoli open during inspiration
– Prevents alveoli collapse during expiration
– Improves gas exchange & oxygenation
– Used during weaning
– Nasal CPAP, BIPAP
Ventilatory Settings
• Positive End-Expiratory Pressure
(PEEP)
– Must be intubated
– Positive pressure exerted during expiration
(+5 to +15 cm H2O)
– Keeps alveoli open between breaths
– Improves oxygenation
– Enhances gas exchange
– Treatment for persistent hypoxemia
Ventilatory Settings
• Pressure Support Ventilation (PSV)
– Client’s inspiratory effort is assisted to a
certain level of pressure
↓ work of breathing & ↑ comfort through ↑
control by client
– PSV 5-20
Management
• Anxiety
– Education
– Communication
– Alarms
• Treat client first, then ventilator
Management
• Assessment
– Client response to treatment
– Continuous O2 saturation
– Vital signs
– Lung Sounds
– Ventilator settings & alarms
– Management of secretions
• Closed suction system
Prevent Complications
• Cardiac
– Hypotension
• Application of positive pressure →↑
intrathoracic pressure → ↓ venous return to
heart → ↓ cardiac output
• Dehydration
• Requires high PIP
– Fluid retention
∀ ↓ cardiac output → stimulation of renin-
angiotensin-aldosterone response → fluid
retention
Prevent Complications
• Lungs
– Barotrauma
• COPD
• Pneumothorax, subq emphysema
– Volutrauma
– Acid-base abnormalities
• Infection
– Within 48 hrs of intubation, bacteria
colonization
Prevent Complications
• Electrolyte Imbalances
– Monitor K+, Ca++, Mg++, phosphate levels
– Efficiency of respiratory muscle function
• Muscular
– Immobility
↑ muscle tone & strength
– Facilitates gas exchange
Prevent Complications
• Ventilator Dependence
– Respiratory muscle fatigue
– Client unable to resume independent
breathing
• Extubation
– Monitor respiratory effort
– Supplemental O2
– Monitor O2 saturation
Weaning from Ventilator
• Parameters set for PaO2, O2 Sat, PaCO2 &
pH
∀ ↓ FIO2 →↑spontaneous effort by client
• Remain on T-piece after ventilator before
extubation → aerosol mask
• Minimal sedation while weaning
• Monitor respiratory effort & rate, vital signs

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