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Acute Respiratory Failure/ARDS

Terms in this set (92)

What is acute respiratory failure?
A medical emergency that can develop rapidly over hours to days.
How does acute respiratory failure happen?
Happens when there is inability of the cardiopulmonary system to provide adequate oxygenation and/or CO2 removal to meet tissue needs.
What is the "general rule" for ABGs in a patient with respiratory failure?
CO2 greater than 50 and oxygen less than 50. pH is also less than 7.35.
What do you have to remember about your patient with COPD who is in acute respiratory failure?
COPD patients can live "normally" with higher levels of CO2 and lower levels of oxygen. For instance, a pt. with COPD can have a CO2 level of 50 and an oxygen level of 84 and that is their "normal" because they are have chronic respiratory failure just like pt. with C-spine injury or pt. with ALS.
What is the normal CO2 (carbon dioxide/bicarb/HCO3) level?

(90% of CO2 exists in the blood as bicarb, therefor your CO2 level is really a measure of your blood bicarb level).
23-29 mEq/L
What is chronic respiratory failure?
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 acute respiratory failure.
What suggests chronic respiratory failure?
Absent of acute symptoms and the presence of chronic respiratory acidosis.
What are the two causes of chronic respiratory failure and why?
COPD and neuromuscular disease such as Guilliane Barre, myasthenia gravis, polio, and spinal cord injury. These disorders cause a dysfunction of the chest wall.
What can cause failure of oxygenation or ventilation and further cause acute respiratory failure?
-Decreased respiratory drive--> narcotics, anesthesia, sedatives
-Dysfunction of chest wall--> neuromuscular disorders
-Dysfunction of the lung parenchyma-->alveoli of the lungs (COPD, asbestosis, atelectatsis)

Others include: asthma, CHF, pulmonary edema, ARDS, near drowning, CVA, IICP, PE, pleural effusion, pneumothorax, fx ribs (lungs can't expand), morbid obesity (chest wall is difficult to move)
What is the main hallmark symptom of acute respiratory failure?
Dyspnea/Tachypnea-->increased depth then rate.
What are the symptoms of acute respiratory failure?
Dyspnea, tachypnea, nasal flaring, grunting, pursed lips, orthopnea, hypoxemia, hypercarbia, accessory muscle use.
What are the symptoms of hypoxemia?
HARAT: hypoxemia-->anxiety, restlessness, agitation, tachycardia
What are the symptoms of hypercarbia?
Somnolence (sleepiness), lethargy, sedation, flushing, slight drop in BP, coma as CO2 increases because it is sedating and flushing from the vasodilation.
Which of these patients does the nurse recognize is at highest risk for acute respiratory failure?
A. 40 yo female, smoker, taking oral contraceptives
B. 22 yo male, paraplegic
C. 50 yo male, post hemicolectomy, receiving PCA
D. 79 yo female with rapid atrial fibrillation, receiving heparin therapy


C: Because the patient is post-op, he may experience pain that may worsen with taking deep breaths. The PCA can cause his RR to decrease which puts him at further risk for respiratory failure. Anyone post-op is at high risk for resp. failure!
What are some examples of ventilatory failure?
Impaired function of CNS (C-spine injury, drug OD, hemorrhage, sleep apnea), neuromuscular dysfunction (SCI, ALS), musculoskeletal dysfunction (chest trauma, malnutrition), pulmonary dysfunction (CF, asthma)
What are some examples of oxygenation failure?
Pneumonia, ARDS, heart failure, COPD, PE, restrictive lung diseases.
True or false: Patients post-op from thoracic surgery or abdominal surgery are at a very high risk for developing acute respiratory failure? Why or why not?
True. During this period of post-op, acute respiratory failure may be caused by the effects of anesthetics, analgesics and sedative agents, which may depress respirations or enhance the effects of opioids and lead to hypoventilation. Pain may also interfere with coughing & deep breathing.
The nurse notices that her patient is experiencing dyspnea and tachypnea with increased depth and then an increased rate. She suspects acute respiratory failure. What is her priority action for this patient?
Give O2!!!! Should give via ambu bag.
What is usually the cause of acute respiratory failure in a patient post-op thoracic or abdominal surgery?
Ventilation-perfusion mismatch is the usual cause of respiratory failure after major abdominal, cardiac or thoracic surgery.
What is Acute Respiratory Distress Syndrome (ARDS) and what are the characteristics?
A severe form of acute lung injury characterized by a sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, PCWP of less than 18mmHg, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.
When does ARDS usually occur?
After an acute traumatic event such as direct injury to the lungs like prolonged smoke inhalation, or indirect injury to the lungs such as shock.
What is the major cause of death in ARDS?
Non-pulmonary MODS (multiple organ dysfunction), often with sepsis. Mortality rate is very high at 36-44%!!!
What are some signs and symptoms of respiratory failure?
Accessory muscle use, initial hypertension then hypotension, if respiratory arrest there is 4 minutes until brain damage and 6 minutes until brain death,

*restlessness-->anxiety-->coma*
Etiology of ARDS: Inflammatory Responses
Shock, severe trauma, sepsis/SIRS (systemic inflammatory response syndrome), penumonia, acute pancreatitis, aspiration, PE (especially fat or amniotic fluid), drug ingestion/OD, hematologic disorders (DIC), multiple/massive blood transfusions-->TRALI (transfusion related acute lung injury), major surgery (bypass/cardio-pulmonary surgery).
What are the three cardinal symptoms of ARDS?
-Hypoxemia: despite supplemental oxygen and regardless of the amount of PEEP

-Reduced lung compliance: damage type II pneumocytes which produce surfactant.

-Bilateral infiltrates: on CXR ("white out" or ground glass appearance
What are some more signs and symptoms of ARDS?
Restlessness, tachycardia, tachypnea/extreme dyspnea & SOB, accessory muscle use, intercostal and substernal retractions, increased WOB, diaphoresis, grunting respiration, cyanosis.
Describe the pathophysiology of ARDS.
-Injury reduces normal blood flow to lungs
-Platelets aggregate
-Platelets release substances: histamine, serotonin, and bradykinin that inflame and damage the alveolar capillary membrane
-The inflammatory substances above, especially histamine, increases capillary permeability which allows fluid to shift into interstitial spaces
-As capillary permeability increases, proteins and more fluid leak out
-This increases interstitial osmotic pressure and results in pulmonary edema
-Because of the pulmonary edema, alveoli fill with fluid causing decreased blood flow and damage surfactant production.
-It interferes with further surfactant production and without surfactant, alveoli collapse causing impaired gas exchange.
-Patients RR increases but the sufficient oxygen cannot cross alveolar capillary membrane because of the damage
-Carbon dioxide crosses more easily and is lost with every exhalation: O2 and CO2 levels decrease.
-Pulmonary edema worsens and the inflammation leads to fibrosis which further impedes gas exchange.
-The end result is hypoxemia leading to METABOLIC ACIDOSIS.
How can you remember the progression of ARDS?
A: Assault to te pulmonary system
R: Respiratory distress
D: Decreased lung compliance
S: Severe respiratory failure
What is the treatment for ARDS?
#1: TREAT UNDERLYING CAUSE
-Mechanical ventilation
-Hemodynamic support
-Inotropics such as Norepinephrine (vasopressor) to vasoconstrictor blood vessels to help raise blood pressure (in shock)
-Fluid balance
-Nutrition support
-Abx if needed
-Dialysis if needed r/t decreased renal perfusion (increased waste in blood=decreased blood flow to kidneys=kidney failure), metabolic acidosis and fluid overload
What are the main complications of ARDS?
-Pulmonary fibrosis
-Pulmonary artery hypertension
-Right heart failure
-MODS

*Remember, ARDS frequently occurs as a complication of sepsis and SIRS as well as other morbidities.*
What is the purpose of mechanical ventilation?
To assist patient with gas exchange.
What are the types of non-invasive positive pressure ventilation?
BiPAP and CPAP
In what circumstances should the nurse avoid giving a patient CPAP or BiPAP?
Avoid in respiratory or cardiac arrest, somnolence, copious (abundant) secretions.
How does Positive Pressure Ventilation work?
Inflates lung by exerting positive pressure on the airway, pushes air in, forces the alveoli to expand during inspiration.
What are the hemodynamic effects that both invasive and non-invasive positive pressure ventilation has on the body?
Decreased venous return causes decreased BP, decreased cardiac output.
What are the simple differences between CPAP and BiPAP?
CPAP can be worn at home and BiPAP must me worn at the hospital.
Describe the ventilatory mode Assist Control (AC).
Internal positive pressure ventilation that has a set FiO2, set tidal volume (based on body weight), set breaths which the patient can trigger the ventilator with spontaneous breaths between mandatory breaths-also called "breathing over the vent" - when this happens the RR may increase from the set RR, but the tidal volume with stay the same as what the vent is set on.
True or false: endotracheal intubation or tracheostomy is usually necessary to use positive-pressure ventilators.
True.
What are the three types of invasive positive-pressure ventilators and how are they classified?
Pressure-cycled ventilator
Volume-cycled ventilator
High-Frequency Oscillator (really a mode of ventilation)

**These types of positive pressure vents are classified by the method of ending the inspiratory phase of respiration.
Describe a Pressure-Cycled positive pressure ventilator.
This type of positive pressure vent delivers a flow of air (inspiration) until it reaches a preset pressure and then cycles off, and expiration occurs passively.

*Limitations: volume or air or oxygen can change when patient's airway resistance or compliance changes therefore the tidal volume may be inconstant and may compromise ventilation so its only used for short-term.
Describe a Volume-Cycled positive pressure ventilator.
This type of positive pressure vent delivers a preset amount of air with each inspiration, once the preset volume is delivered to the patient, the vent cycles off and exhalation occurs passively. This allows a relatively constant, consistent adequate amount of oxygen with each breath despite varying airway pressures.

*This is most commonly used because of the consistent amount of pressure delivered.
Describe the ventilator mode High-Frequency Oscillator.
This mode can deliver high respiratory rates that are accompanied by very low tidal volumes and high airway. Can get up to 300BPM in which you would just document that "patient has positive chest wiggle."
What kind of patients are candidates for noninvasive positive pressure vents like CPAP and BiPAP?
-COPD
-Sleep apnea
-Acute/Chronic Respiratory Failure
-Acute Pulmonary Edema
What lab is extremely important to check before your patient gets intubated and why?
Potassium! Must check potassium before intubation because Succinylcholine is given to relax respiratory muscles prior to intubation and this made can raise potassium..

Therefore, check your patients potassium level before giving Succinylcholine--if their potassium level is high or on the verge of being high, you don't want to give this med, you can get a different med ordered.
In order to use CPAP, the patient must be able to do what?
Patient must be able to breathe indecently in order to use this kind of ventilation.
What is CPAP?
Continuous Positive Airway Pressure provides positive pressure to the airways throughout the respiratory cycle.

It can be used as adjunct to mechanical ventilation. The positive pressure us used with a leak-proof mask to keep the alveoli open, thereby preventing respiratory failure.
What is BiPAP and what patients is it mostly used for?
Bilevel Positive Airway Pressure offers independent control of inspiratory and expiratory pressures while providing pressure support ventilation. Each inspiration can be initiated either by the patient or by the machine if it is programmed with a backup rate which ensures that the patient receives a set number of breaths per minute.

*BiPAP is mostly used for patients who require ventilatory assistance at night (severe COPD/sleep apnea)
How does Pressure Support Ventilation (PSV) work?
This type of ventilatory mode is used to assist spontaneous breathing in a ventilated patient. The patient triggers the ventilator-the vent delivers a flow up to a preset limit depending on the desired minute volume, the patient continues breath for as long as they wish, and the flow is cycled off when a certain peak inspiratory flow (usually 25%) has been reached.
Do tidal volumes vary in Pressure Support Ventilation? What happens to the pressure when patient gets stronger with this mode?
Tidal volumes with this vent mode may vary just as they do with normal breathing. Pressure decreases as patient gets stronger.
How does Pressure Regulated Volume Control (PRVC) and Adaptive Pressure Ventilation (APV) work?
Volume is controlled by the ventilator and the pressure is regulated, set tidal volume delivered-but pressure is adjusted from breath to breath based on changes in airway resistance and compliance and WOB.

*For example, if volume is too low, pressure will increase on next breath. If pressure is too high, the pressure decreases on the next breath.*
How does PEEP (Positive End Expiratory Pressure) work?
This vent mode holds end of expiration and hold alveoli open to allow more time and surface area for oxygen diffusion.

*The idea of PEEP is similar to blowing up a balloon and not letting it completely deflate before blowing it back up again--think about how the alveoli are forced open for a longer time with PEEP to allow for more oxygen diffusion.*
What problems is PEEP especially useful for?
PEEP is especially useful for severe hypoxemia (atelectasis and ARDS) to keep alveoli open because alveoli are closed with ARDS r/t surfactant damage and collapsed with atelectasis.
If patient is on 100% oxygen, using PEEP can help decrease what?
PEEP can decrease the % of oxygen that patients needs, especially if it's a really high percentage like 100% oxygen.
What hemodynamic consequences can PEEP have?
This mode can cause hypotension and decreased cardiac output.
Although all usual modes of ventilation can be used for weaning, which are the most common that are used?
CPAP and Pressure Support.
What does CPAP do during weaning?
This weaning mode allows the patient to breathe spontaneously while applying positive pressure throughout the respiratory cycle to keep the alveoli open and promote oxygenation.

*CPAP is often used in conjunction with PSV for weaning*
The nurse should assess for what when patient is on a CPAP/PSV wean?
Nurse should assess for...
-Tachypnea
-Tachycardia
-Reduced tidal volumes
-Decreasing oxygen saturations
-Increasing carbon dioxide levels
What are some complications of mechanical ventilation?
-Impaired communication r/t intubation

-Bucking/fighting the vent: Happens when patient attempts to breathe out during ventilator's mechanical inspiratory phase or when there is an increased abdominal muscle effort from patient.

-Barotrauma: Excessive positive pressure can cause lung damage which may result in a spontaneous pneumothorax

-Volutrauma: Excessive tidal volumes can cause lung damage

-Infection: (VAP!!) Report high temp or change in color or odor of sputum to physician for follow up

-Atelectasis: Clear patient's secretions

-GI complications: Usually on Protonix to decrease risk of stress ulcers)

-Immobility: Can lead to DVTS-make sure your patient has SCDs that work!!

-Tracheoesophageal fistula

-Aspiration
A pO2 of 40 on 80% FiO2 suggests what?
ARDS
Describe the mode SIMV (Synchronized Intermittent Mandatory Ventilation) that is sometimes used for weaning?
SIMV has set mandatory breaths but between breaths the patient can breath spontaneously and it helps with strengthening and reconditioning.
Nursing management for ARF/ARDS
-Suctioning/clearing the airway: if patient is coughing, if you can hear secretions, if high pressure alarm goes off.

-Position: A client in respiratory failure should be at semi-fowlers (30-45 degrees_)

-Percussion PT if available with specialty beds

-VAP prevention
How should patient in respiratory failure be positioned during suctioning?
Minimum of 40-45 degrees
Excessive ventilation can cause what? Underventilation can cause what?
Excessive ventilation: pO2 high (resp alkalosis)

Underventilation: pCO2 high (resp acidosis)
How can you as the nurse prevent Ventilator Associated Pneumonia (VAP)?
ZAP the VAP by proper hand washing, HOB elevated 30 degrees, oral care q4-6h, tooth brush q8-12h, moisturize lips, verify feeding tube placement with CXR, change ventilator circuits if visibly soiled, intubation with tube to facilitate subglottic secretion removal, "bundle" to prevent VAP.
How do you use "bundle" to prevent VAP?
The Ventilator Bundle contains four components, elevation of the head of the bed to 30-45 degrees, daily 'sedation vacation' and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis.
What is the purpose of sedation for patients on a vent?
To decrease oxygen demand and promote compliance with ventilator.
What medications are often used for sedation?
-Versed
-Propofol/Diprivan
-Lorazepam/Ativan
-Dexmedetomidine/Precedex
What is a sedation vacation and how often is it performed?
Sedation is turned off daily (usually in the morning) and the patient is assessed to see if we can extubate.
What is the reversal agent for benzodiazepine overdose?
Romazicon.

(Narcan is for opioids)
Why is Diprivan (propofol) a milky white color?
It is this color because it has lipids present in the solution.
What medications can be added to sedation if patient is experiencing pain?
Morphine or Fentanyl
True or false: Sedation may be given via OGT if the patient has a functional gut.
True. But sedation via OGT with a functional gut can only be given in acute situations
What is the mechanism of action of a neuromuscular blockade?
Blocks the effects of acetycholine at the myoneural junction to reduce oxygen demand. Patient cannot contract any muscles including the diaphragm (they can't breath on their own).
What are some paralyzing agents/drugs that are given?
-Vecuronium (Norcuron)
-Atracurium (Tracrium)
-Rocuromium (Zemeron)
What is the proper nursing action before administering a paralyzing agent?
Give the patient sedation (versed, proposal) before giving the paralytic agent because although all of their muscles are paralyzed, they still have sensation and can feel pain, and may become overly anxious. If patient is having pain, can also give analgesic.
How does the nurse monitor a patient who is paralyzed from a drug that she administered?
BIS monitoring-BiSpectral brain wave analysis, the higher the number, the more awake the patient is. 100%=most awake.
What are some additional interventions for respiratory failure?
Hypothermia to decrease oxygen demands on the body.

Pharmacologic management.

Assessing/teaching to prevent recurrence or exacerbation.
What devices are necessary to provide nutritional support via enteral feedings for your vented patient?
Tubing, x-ray to verify placement, irrigation set, feeding "jevity".

Different devices include
-Dobhoff
-NG
-J-tube
-PEG tube

**PPN can go thru peripheral line
**TPN needs central line
What devices are necessary to provide nutritional support via parenteral feedings for your vented patient?
IV (PICC/Central line), saline flushes

**PPN can go thru peripheral line
**TPN needs central line
What are the requirements that patient must have to consider beginning their wean?
-Afebrile
-Clear CXR
- -25cm pressure inspiratory
-Able to clear secretions on their own
-H/H stable
-Pt needs equal or less than 50% FiO2 (if they need anything higher, they cannot begin wean)
What are the methods of wean used?
CPAP and PS.
Nursing interventions during wean
-VS q15min
-Emotional support, hold patients hand
-Elevate HOB
Why would you return patient to ventilator?
Increase in temp
Hyper or hypotension
Tachycardia
Overly anxious
Low oxygen saturations (low pulse ox)
What is an appropriate drug of choice to promote comfort during terminal wean?
Morphine drip
How does nursing care continute with terminal wean?
Still give mouth care, turn patient, don't change a painful dressing if patient is on a terminal wean--whats the point? YOU WANT TO MAKE PATIENT COMFORTABLE.
The mechanical ventilator high pressure alarm sounds continuously. What should the nurse do?
Assess for breath sounds and suction.
The vents low pressure alarm is going off, what should the nurse check?
Check to see if there are any air leaks in the tubing.
A patient has been receiving mechanical ventilation for three days, he opens his eyes to commands and assists vent. Do you think he is ready to begin weaning?
Yes because he is assisting the vent and breathing on his own, he is awake and alert because he obeys command.
Your patient has been on a vent for three days, is awake and oriented and on an FiO2 of 80%. Do you think he is ready to begin weaning?
No, because he is still on an FiO2 greater than 50%. If FiO2 is greater than 50% patient is not a candidate to begin weaning off vent.
Your patient has been on a vent for a few days, is on AC, 100% and 15 PEEP. Are they ready for wean?
No!! In order to initiate wean, PEEP must be 5 or less and FiO2 must be less than 50%. This patient still has a ways to go.
Your patient has been on a vent for three days because of an acute MI. Are they ready for wean after three days?
No because the MI was acute-it will take a longer time for pt. to be stable.
A client who has had a lung resection is receiving mechanical ventilation and intravenous vecuronium (Norcuron). What additional medication can the nurse anticipate administering?
Lorazepam. Never paralyze without sedation first!!!!!
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