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Acute Respiratory Failure Cheat Sheet by

Adult Health 2
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Acute Resp. Failur­e/Acute Lung Injury

ARF: sudden deteri­oration in pulmonary gas exchange = CO2 retention & inadequate oxygen­ation
paO2 < 60 mmHg
(should be 80-100)
paCO2 60 mmHg
(should be 35-45)
arterial pH < 7.35
(pts usually acidotic)

Causes

Direct
Indi­rect
Aspiration
Sepsis
Pneumonia
Burns
Contus­ion­s/t­rauma
Truama
Upper airway
obstru­ction
TRALI
Toxic inhalation
Drug reacti­on/OD
SARS
Cardio­pulm. bypass
 
Pancre­atitis
 
Multiple fractures
 
Lung/bone marrow tx

Stages of ARF

Stage 1: inc. SOB, RR, few CXR changes... within 24 hr signs of ARDS (CXR changes)
- Tachyp­neic, dyspneic
Stage 2 (Exuda­tiv­e): vent. required
- Address underlying issues
Stage 3 (Proli­fer­ati­ve): hemod­yna­mically unstable
- Can't maintain BP, tachy, compen. mechan­isms, inflam­mation & cascade of events
Stage 4 (Fibro­tic): lung fibrosis issues; vent. management issues
- Dec. compli­ance, stiffness

Types of Respir­atory Failure

Type 1 - Acute Hypoxe­mic: abnl. transport of O2 w/ resultant inadequate oxygen­ation
Type 2 - Hyperc­apn­ic: inade­quate alveolar ventil­ation; marked elevation in paCO2
Type 3 - Mixed Hypoxe­mic­-Hy­per­cap­nic: inade­quate alveolar ventil­ation & abnormal O2 transport
- Often most common type

Management of ARF

Warrants immediate interv­ent­ion!
GOALS:
Correct the cause
Alleviate hypoxemia & hyperc­apnia

Indica­tions for Intubation

Altered mental status or coma
Severe respir­atory distress
Extr­emely low or agonal RR (gasping)
- Cerebral issue r/t O2
Obvious respir­atory muscle fatigue - r/t inc. work of breathing = mechanical vent.
Peri­pheral cyanosis - fingers, lips dusky
Impe­nding cardio­pulm. arrest - heart starts to compensate (tachy, arryth­mias) cardiac arrest
Better to intubate electively rather than emerge­ntly!
Mechanical vent. - helps to breathe, protects airway
 

Systemic Inflam­matory Response Syndrome (SIRS)

2+ of...
Temp. > 100.4oF (38oC) or 98.6oF (36oC)
HR > 90 bpm
RR > 20 breath­s/min or paCO2 < 32
WBC > 12,000 or < 4,000 or/ >10% bands
Older adults - inc. risk for MODS w/ less chance of recovery from ARDS

Acute Respir­atory Distress Syndrome (ARDS)

Severe end of continuum
Complex syndrome w/ high mortality risk
Precip­itated by direct or indirect lung injury
Pathop­hys­iology:
Lung injury Dec. blood flow to lungs (inflamm. mediators thin lung lining) Alveolar membrane damage (memb­ranes thicken, gases can't exchange)
Inc. membrane protein permea­bil­ity ("Leak syndro­me"; changes osmotic pressure) Inte­rst­itial & intra-­alv­eolar edema (alveolar area flooded = pulm. edema) Further impaired oxygen­ation Pulm. edema Inflamm. changes can lead to fibrosis (may cause permanent lung change)
Surfactant gets lost & makes process worse...
- Dec. gas exchange
- Dec. lung compliance (resis­tance, pressure)

ARDS (cont.)

Symptoms can develop very quickly after lung insult
Asse­ssm­ent:
- Accessory muscle use
- Tach­ypn­eic
- Tach­yca­rdia
- Restless, air hunger = change in O2
- Confusion
- New/wo­rsening lung sounds (crackles, wheezes) steroids
- Change in SpO2
- Lethargy (lose ability to protect airway)
- Dysp­nea
- At risk for arrythmias
- Change in renal status
Bolded are the earliest signs

ARDS Diagnostic Criteria

paO­2-­FiO2 ratio < 200 - shunt formula; normally > 300
B/L infilt­rates on CXR - white out
Elevated serum lactate levels - indicates anaerobic metabo­lism, tissue hypoxia
No cariac etiology for pulm. edema
Dete­rio­ration of ABG's despite interv­ent­ion - resistant to O2

ARDS Management

GOALS:
- Correct the cause
- Prevent further damage
- Suppo­rtive care
Care bundles to improve outcomes
5 P's of ARDS:
- Perf­usion (max O2 transport)
- Posi­tion
- Prot­ect­ive lung vent.
- Prot­ocol weaning
- Prev­ent compli­cations
Mechanical ventil­ation
Fluid status: RA/CVP, JVD, BP, urinary output
 

Mechanical Ventil­ation

Improves O2, figures out CO2, buys time
Lowest FiO2 possible, smallest TV possible
Modes of MV:
- Volume cycled: pushes air in until preset volume delivered
- Time cycled: pushes air in until preset time reached
- Assist modes: pt can assist but vent can take over work of breathing
- Pressure support: weaning mode; depends on pt's breathing (used for weaning)
- Pressure control: preset volume (based on age, sex, height)
- Airway Pressu­re-­Release Ventil­ation (APRV)
Weaning ASAP!
- Infection
- Dependent on machine
- Muscles dependent
- Vent may cause trauma (barot­rauma, pressure trauma)
Positive End Expiratory Pressure (PEEP): back pressure prevents alveolar collapse; helps to keep fluid out of alveoli
- Inc. PEEP = inc. intrat­horacic pressure dec. perfusion = dec. CO
- Affected intrat­horacic pressure = organ failure

Management of Ventilated Patients

3 Priori­ties:
1) Monitor & evaluate pt response
- Vent setting, trach approp­riately
- Assess s/s of distress (lung sounds, chest expansion, ABC & disync­hrony r/t proper setting [change vent settin­gs])
2) Manage vent safely
- Not alone, daily CXR for placement
3) Prevent compli­cat­ions
- Oral care (dec. bacter­ia), turn & repo. (changes lung perfus­ion), VAP protocol (elevate HOB >30o, aspiration precau­tio­ns), DVT prophy­laxis, skin care
Note:
- Breath sounds should be equal & symm.
- Document safety, measur­ement
Pron­ing: no shock, inc. ICP, unstable spine
Pharma­cot­herapy:
- Anti­bio­tics (if known microo­rga­nism)
- Bron­cho­dil­ators (airway patency)
- Surf­act­ant? (not really used, expens­ive)
- Cort­ico­ste­roi­ds? (immu­nos­upp­ressed, glycemic control)
- Diur­etics (dec. lung/g­eneral edema, watch electr­oly­tes)
- Neur­omu­scular blocking agents (para­lytic agents, sedatives = dec. work of breath­ing)
- Flol­an? (new; inc. flow, V/Q mismatch)
- Epin­eph­rine
- Low dose dopamine
Ex. Neurom­uscular Blocking Agents - propophol, Nimbex, + inotropes
+ Inotropes: dilate vascular bed = inc. CO (dibut­amine, watch for dec. BP - r/t dose; vasopr­ess­ors)
Nutr­iti­on:
- Dec. mortality, days of not eating prophy­lactic enzyme release
- Avoid inc. carb feeds
Prevent compli­cat­ions - VAP, SIRS, MODS, DVT, infection, skin breakdown

Nursing Diagnoses

ARDS
Mech­anical Vent
Impaired gas exchange
Risk for infection
Dec. tissue perfusion
Risk for injury - r/t airway
Airway clearance
Risk for injury - r/t immobility
NO ineffe­ctive breathing pattern

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