Acute Respiratory failure
What is it
Lungs not able to maintain adequate gas exchange
Causes
Intrapulmonary
Extra-pulmonary
Damage to the brain, spinal cord, neuromuscular, thorax, pleura, and upper airways
lower airways and alveoli, pulmonary circulation and the alveolar capillary membrane
S/S
Hallmark = hypoxemia (PaO2 <60)
Causes of hypoxemia:
V/Q mismatch
Intrapulmonary shunting
Alveolar hypoventilation
Hypercapnia (PaCO2 >50) may be present but not required
Can lead to
Multiple organ dysfunction syndrome
due to lack of o2 in vital organs
early sign of hypoxia = RAT: restlessness, anxiety, tachycardia
Later signs: confusion, chest pain, tachypnea, hyperventilation, dyspnea, decreased urinary output, polycythemia, cyanosis
headache, drowsiness, flushed skin (vessels dilate with high CO2), change in LOC
Acidosis: decreased LOC, dysrhythmia (brady), cool, clammy, pale skin
Diagnostic studies
ABGs with a PaO2 less than 60 mmhg
In patients with chronically high CO2 levels (COPD) the pH must also be less than 7.35 to be considered respiratory failure
if ventilation issue present PaCO2 greater than 50 mmHg
Desired outcomes
Adequate oxygenation: PaO2 60-1000 mmhg and SaO2 >90%
Adequate ventilation: pH 7.35-7.45 and PaCo2 35-45 mmhg (or patients baseline)
Treat the underlying cause
Management
Control any shock or multiple organ dysfuntinon
Decreased risk of infection
Rest respiratory muscles by mechanically ventilating
Maintain nutritional support
Bronchodilator
positioning of patient to increase oxygen saturation
Mechanically ventilate and sedate
Prevention of desaturation
Administer o2
Management for specific causes of respiratory dysfunction
Maintain an adequate airway with an endotracheal tube
If not caught and treated, respiratory dysfunction may lead to respiratory failure
Correct hypoxia and acidosis
enteral nutrition if possible but if not parenteral nutrition
if unilateral lung problem
if bilateral lung problem
frequent repositioning (q2 minimum)
Good lung down
right is bigger so put right down
Prioritize and bundle nursing care
Monitor saturation
Administer sedation and or paralytic as ordered
Ventilation/perfusion problems
Pneumonia
Head trauma
Supportive treatments
Respiratory depression
find cause and correct: discontinue medications (ex: reverse narcotics)
Reduce ICP, elevate HOB, head and neck in neutral position
PE: thrombolytic therapy, embolectomy
low CO: improve CO
ABX
o2, peep, mechanical ventilation
Acute Respiratory Distress Syndrome
What is it
Diagnosis
Systemic process that is considered to be the pulmonary manifesation of MODS
Referred to as non cardiogenic pulmonary edema because wedge pressure remains less than 18 mmhg
Ratio of PaO2 to FiO2 less than or equal to 300 mm Hg that does not respond to supplemental oxygen
Bilateral infiltrates on CXR leading to a white out appearance
Acute onset
Rule out cardiac cause: PAOP (pulmonary aclussive) less than 18 mmhg
Divide the patients PaO2 by the patients FiO2
Less than 300 is indicative of ARDS (<100 is severe)
Causes (anything)
Direct
Indirect
pulmonary contusion
pneumonia
near drowning
inhalation burns
Aspiration
shock states
DIC
embolism
burns
Sepsis
3 phases
Proliferative
Fibrotic
Exudative
Occurs within 24-48 hours in insult
damage to the alveolar capillary membrane occurs
further alveolar capillary damage, V/Q mismathc worsens
Lungs become stiff and noncompliant
diffuse fibrosis and scarring, compliance very poor
refractory hypoxemia due to severe V/Q mismatch and intrapulmonary shunting
Medical management
Inhaled nitric oxide
ECMO (extracorporeal membrane oxygenation)
Low tidal volume to prevent lung barotrauma due to decreased compliance
Hydration
Mechanically ventilate
hyperoxygenate
PEEP: Open up the alveoli and keep them open (need a lot) (decrease when you can)
leads to hypercapnia which causes vasodilation
vasodilation which will help get more hgb to the pulmonary area
Keep patient hydrated without causing pulmonary edema due to fluid overload
Do not routinely administer fluid boluses (can increase pulmonary edema
Medications
Neuromuscular blocking agents
sedatives
Bronchodilators
positive inotrope ( heart squeeze harder)
Ipratropium (anticholinergic)
Albuterol (beta adrenergic agonist)
chemically paralyze to decrease o2 requirement)
Position
Prone
may be able to turn PEEP down (prevents vent associated lung injury)
prone fro 12-18 hours at a time
more effective during the early phases
use P/F ration to determine need and effectiveness
improves the perfusion to the less damaged areas of the lungs
special attention to skin breakdown risk and prevention
Investigational studies
corticosteroids for inflammation
conflicting results, may depend on the cause of ARDS
Pneumonia
what is it
acute inflammation of the lung parenchyma that is caused by an infections agent that can lead to alveolar consolidation
Common in ICU
Aspiration pneumonia
sedation
ventilation: due to bacterial organisms being introduced into the lower airways via the ETT
Tube feedings
Prevention of aspiration/ventilation associated pneumonia
oral care - brush teeth at least every 12 hours, cleanse mouth q2
Chlorhexidine swabs q12
ensure that balloon on artificial airway is adequately inflated
suction subglottic secretions
all HOB should be kept at > 30 ' unless contraindicated
ensure feeding tube placement is correct
symptoms
fever
high WBC count
increased production of secretions/change in secretions
signs of respiratory distress
decreased Sp02
crackles/coarse lung sounds
suctioning tube feed or gastric contents from the ET tube
tachycardia, coughing, retractions
Dx
sputum culture
CXR
treatment
fluid management for hydration
nutrition
ABX
aspiration: stop NG feedings, may place NG tube to decompress stomach, may feed with duodenal tube
Oxygen/ventilation/PEEP
Pulmonary Embolism
what is it
A clot that occurs in the body and travels through the venous circulation to the pulmonary circulation
partially or completely occludes a pulmonary artery
Massive PE= 50% or more of the pulmonary bed is occluded
Predispositioning factors
Birth control medications
Recent trauma
Dehydration
Type A blood group
Infection
AFIB
Decreased CO
Surgery (especially orthopedic)
Pregnancy
Smoking
Bed rest/ immobility
History of DVT
Virchow's triad: damage to vessels, venous stasis, hypercoagulability
S/S
Crackles
Apprehension
Tachypnea
Hemoptysis = cough up blood
Cough with pink, frothy sputum
Syncope
Pleuritic chest pain (sudden, sharp)
Tachycardia
Dyspnea
Dx
CXR: cannot detect PE
D-dimer: strong negative predictive value only (if normal, no clot) (elevated means theres a clot somewhere) (not specific) (screening tool)
EKG: not specific, sinus tachycardia, T wave inversion
CTPA (computed tomography pulmonary angiography): current standard of care for DX (CT with contract to see where it is)
ABG: low PaO2, low PaCO2, high pH
V/Q scan: must be combine with assessment and other fundings. Used if patient can't have contrast (bad if they can't stay still)
Treatment
Heparin (monitor with aPTT or heparin assay (anti xa)
Oral anticoagulants
Reverse clot with thrombolytics
Surgery
Oxygenation (may need intubation to deliver high o2 concentrations)
Reduce risk for additional clots with heparin grr, then switch to oral anticoagulant
therapeutic aptt: 1.5-2.5 x control (60-80 seconds)
Therapeutic heparin assay: 0.3-0/7 U/ml
Factor Xa inhibitors = rivaroxaban (xarelto), apixaban (eliquis)
Direct thrombin inhibitors = dabigatran (pradaxa)
Vitamin K antagonist = warfarin (coumadin)
Vena cava filter placement
Embolectomy for massive or decompensating patient
Prevention
compression devices
anticoagulants (enoxaparin/lovenox)
elevate legs
active/passive ROM
early ambulation
Adequate hydration
Status asthmaticus
what is it
a severe asthma attach that does not respond to conventional treatment with bronchodilators
Bronchial constriction with air trapping and excessive mucous obstruction
IgE -> mast cell release -> histamine release -> causes bronchoconstriction
Common causes
Non compliance with medications
Respiratory infections
Triggers (allergens, exercise, environmental)
Other risk factors
Overuse of bronchodilator agents
NSAIDs/ASA
S/S
extremely dyspneic
cough - if they are moving enough air
wheezing (expiatory) (inspiratory and expiratory is bad sign)
tachycardia
diaphoresis
prolonged expiratory phase
increased accessory muscle use
Difficulty speaking*
Decreased LOC*
Diminished or absent lung sounds*
sudden disappearance of wheezing * (ominous sign)
Inability to lie supine*
- = patient worsening
Assessment
PaO2 < 60 on room air
SaO2 <91%
PEFR (peak expiratory flow rate) usually <40% normal values based on gender, age and height
PaCO2 may be lower or normal initially as fatigue and air trapping progresses may become elevated
Dx
ABGs: normal to low PaCO2, initially, later increased with decreased O2
CXR: hyperinflated lung
Desired patient outcomes
CO2 normal
control airway secretions
pH normal and PaO2 >60
spontaneous ventilation
Patent airway
reversal of bronchospasm
Patient management
supplemental o2 to keep o2 stats >92%
Intubation and mechanical ventilation (use >8 mm tube to decrease airway resistance)
Support of ventilation
If intubated, low PEEP to keep bronchioles open so that exhalation can occur (leads to less air trapping). high PEEP should be avoided
Sedation and neuromuscular paralysis may be needed
Pharm
Xanthines have not shown to be useful
Antibiotics if bacterial infection is suspected
Corticosteroids
Bronchodilators
Short acting anticholinergics (inhibit bronchoconstriction) when used with B2 have a synergistic effect
Short acting B2 adrenergic agonist promotes bronchodilation
MDI, nebulizer, and continuous nebulization
Ex: albuterol, levalbuterol
Ex: ipratropium
Systemic used to treat status asthmaticus, anti inflammatory effects decrease edema, decrease mucous production and potentiate B2 agonist
Monitor for complications
Respiratory acidosis
Death
Hypoxia
Pneumothorax
Thoracic trauma
Who gets them
Usually serous in elderly, obese, and patients with cardiac or pulmonary disease
Occurs in 6/10 motor vehicle collisions
Common in patients with multiple trauma injuries
Types
Pneumothorax
Diaphragmatic rupture
Flail chest
Cardiac contusion - mimics MI (aortic tears and rupture)
Fractured ribs
Pulmonary contusion (most common visceral injury)
Management
Evaluate need for supplemental O2
Ensure patient airway
Cardiac monitoring
Frequent resp assessments
Continuous SpO2 monitoring
Fractured Ribs
Patient management
Pain control
intercostal nerve blocks
Most effective and does not interfere with coughing sighing and deep breathing
prevent pneumonia
bronchial hygiene
coughing
IS
Deep breathing
Stabilization of fracture
Binders no longer recommended
Sternal fractures
Unstable
Stable
NSAIDs and rest
surgical fixation, ETT, and mech vent
Flail chest
What is it
Section of the chest wall (3+ ribs) becomes detached from the thoracic cage
paradoxical movement of the thoracic wall when patient breaths
S/S
Shock
Bony crepitation at the site of the fracture
Severe chest wall pain
Paradoxical chest movement
Cyanosis
Hypotension, tachycardia, and hemoptysis may also be present
Rapid shallow respirations
patient management
Neuromuscular blocking agent
Adequate sedation
Intubation and PEEP
Pain control
Surgical stabilization of flail segment
Hemothorax
What is it
An accumulation of blood in the thorax and is often accompanied by a pneumothorax
Causes
Thoracic surgery
Anticoagulation therapy
Blunt or penetrating thoaxix trauma
Dissecting thoracic aneurysm
S/S
400 Ml or < minimal symptoms
400 ml signs of shock, diminished or absent breath sounds on side on hemothorax
Dx
CVP or PAP low
bloody thoracentesis
Hgb and Hct decreased
CXR fluid in base of chest cavity
ABGs: decreased PaO2 and increased PaCO2 and falling pH
Patient management
Inserted between 5th and 6th intercostal space at mid or anterior axillary line
Connected to water sealed drainage system
Chest tubes
Autotransfusion may be used for loss of 1 liter or more
Thoracentesis
May need surgery to correct the problem
Pneumothorax
What is it
air leaks from lungs or chest wall
Causes
Rupture or bleb or emphysematous area
PEEP at high pressure or with lungs that have lost elasticity
Blunt or penetrating traumas
Spontaneous rupture: especially in tall lean people
Types
Open: penetrating injuries
Tension: one way valve system is created - air can enter pleural space but cannot escape
Closed: air enters space from airways
S/S of tension pneumothorax
Diminished or absent breath sounds on affected side
Chest pain
Progressive cyanosis
Tracheal shift toward unaffected side
Asymmetrical chest wall movement
Mediastinal shift
Dyspnea and restlessness
Dx
CXR
Ultrasound
ABGs
CT
Patient management
Thoracentesis
Small catheter with flutter valve
Needle aspiration: 2nd intercostal space on anterior chest
Chest tube insertion with use of low suction (10-20 cm H2O)
Sucking chest wound
What is it
special type of open pneumothorax where air is sucked into the thoracic cavity through the chest wall instead of into the lungs during inspiration
Treatment
emergency management
Cover wound with 3 sided dressing
prepare for chest tube placement
Chest tubes
Use
negative pressure in order to re-expand collapsed lung or to remove excess blood from cavity
3 chambers
Suction: amount ordered by provider, wall suction set to at least 80, ordered suction set on collection chamber
Water seal: allows fluid to drain but keeps air from returning into cavity
Drainage: monitor for amount, color consistency, and any odor
Tidaling
normal change in suction pressure due to breathing
Never
clamp a chest tube without a providers worder
May cause more damage to lung
Exception: may clamp for short time if changing out collection device
If chest tube comes apart form collection device
submerge chest tube into cup/container of sterile water
If chest tube falls out of patient
Cover site with occlusive dressing
Call provider
Supplies to keep at bedside
Large hemostats x 2
Sterile water
Pharm for lower respiratory
Bronchodilators
Beta 2 adrenergic agonists
Long acting
Fast acting
Proventil (abluberol)
Levalbuterol (xopenex)
Alupent (metaproterenol)
Serevent (salmeterol)
Systemic effects can produce many undesirable or potentially harmful side effects
Nervousness, irritability, tachycardia, and cardiac dysrhythmias
Xanthines
(bronchodilators for long term use, not acute problems)
Theophylline/aminophylline
Administer orally and parenterally
Anticholinergics
Bronchodilator and decrease respiratory secretions
Ipratropium (Atrovent)
Have fewer side effects than atropine
Leukotriene antagonists
Decrease inflammatory process that is a part of asthma and also stops further bronchoconstriction and mucous secretions
Montelukasat (singulair)
Not used to treat an acute asthma attack but can be continued during acute treatment
Glucosteriords
Anti-inflammatories = prevention and treating acute episodes
Systemic anti inflammatory
Inhalation
Azmacort (triamcinolone)
Decadron Phosphate Respihaler (dexamethasone sodium phosphate)
Vanceril (beclomethasone)
Methylprednisolone
Prednisone
Some side effects with systemic use: weight gain, electrolyte disturbances, osteoporosis, mood swings, and yeast infection (if using inhaled)
Diuretics
treat pulmonary edema
Furosemide (Lasix)
Antibiotics
pulmonary infections
orally, IV, IM, or inhaled
cause acidosis
TPN only if gut not functioning
Clots
Remove/despove
Low CO
depends on cardiac problem (fluid? inotrope?)
KNOW HOW TO CALCULATE P/F RATIO (fio2 in decimals)
takes blood from a vein and delivers it back to a vein
Works as your lung (dialysis for your lungs)
not better mortality
Propofol, midazolam, fentanyl
For mechanical ventilation and because of paralytic
increase CO if needed
Corticosteroids
Dexamethasone for COVID
When to prone
EARLY
if P/F ration <150
Saddle embolism = so big it wraps around
KNOW HEPARIN NOMOGRAM FOR EXAM
increase RR to to compensate
Get glucose less than 180