RESPIRATORY FAILURE

BY :
AAN NURAENI
CRITICAL CARE NURSING
FACULTY OF NURSING
UNPAD
2013
 Description

Respiratory failure is impairement of the lungs

ability to maintain adequate oxygen and
carbondioxide homeostatis.
It usually occurs secondary to another disorder, in
such a way as to decrease the ventilatory drive,
decrease muscle strength, dec chest wall elasticity,
dec lung capacity for gas exchange, increase airway
resistance, or increase metabolic O2 requirements
 Classification

Acute respiratory failure (ARF) :

It occurs over hours to days

Urgency

Chronic Respiratory failure (CRF) :

It develops over months to years

Allowing compensatory mechanism (improve oxygen transport

and buffer respiratory acidemia)
Acute on chronic repiratory failure (AOCF) :
AOCF is ARF superimposed on CRF
 Classification

Hypoxemic respiratory failure :

Low PaO2 (< 50 mmHg)
Normal or low PaCO2
V/Q mismatch ARDS

Hypoxemic hipercapnic respiratory failure :

Low PaO2 (< 50 mmHg)

Elevation of PaCO2 (> 50 mmHg).

 Etiology

Extrapulmonary Intrapulmonary

Brain : Drug overdose, central Upper airways : sleep

alveolar hypoventilation
sindrome, Brain trauma, post-
apnea, tracheal
op anesthesia deppression obstruction
Spinal cord : GBS, Poliomyelitis Lower airways alveoli :
etc
COPD
Neuromuscular : Myasthenia
gravis, MS, Organophosphate Pulmonary emboli
poisoning
Inhalation of toxic gases
Thorax : Massive obesity, chest
trauma etc
Pleura : Pleural effusion,
Pneumothorax
 Pathophysiologi

Respiratory system is made up of two basic parts :

Gas exchange organ (Lung) Alteration
The pump (the respiratory
control mechanism)
Respiratory insufficiency &/
Respiratory failure

Inadekuat ventilasi hipoxic dec pH resp acidosis

 Pathophysiology

RF Hipoxemia, the main causes of hypoxemia

are :
Alveolar hypoventilation
The O2 being brought into the alveoli is insufficient to meet
metabolic needs of body
Metabolic needs
Ventilation
Ventilation / Perfusion mismatching
Ventilation and blood flow mismatched
Alveoli partially collapsed or partially filled with fluid
Intrapulmonary shunting
Blood reaches the arterial system without participating in gas
exchange
 Acute Respiratory Failure

Defined by predetermined criteria :

PaO2 of 50 mmHg or less (measured on room air)

PaCO2 of 50 mmHg or more

pH of 7,35 or less

Hypercapnia and hypoxemia are present in CRF with pH ussually stay within
range of 7,35 7,45
AOCF : Secondary insult to the respiratory functin of CRF patients the
individual can no longer compensate for the altered lung function.
Because CO2 retention preexist in patients with CRF , PaCO2 is less relevant than
pH and PaO2 in determining respiratory status
 Clinical Manifestation

Secondary to Hypercapnia, Hipoxemia, and

Respiratory Acidosis
Headache
Irritability
Confusion
Increasing somnolence, coma
Asterixis (flapping tremor)
Cardiac dysrhytmia
Tachycardia
Hipotension
Cyanosis
 Clinical Manifestation

Secondary to increased work of breathing :

Dyspnea

Exhaustion

Secondary to pressure on right side of heart

Peripheral edema

Neck vein distension

Hepatomegaly
 Assesment and Diagnosis

Hypoxemia : ABG analysis

PaCO2 > 50 mmHg
PaO2 < 50 mmHg

Hipercapnia
Acidosis
pH < 7.35

Additional tests : Bronchoscopy, chest radiography,

thoracic ultrasound, CT scan
Spirometry
Sputum for culture and sensitivity
 Medical management

Oxygenation :
To correct hypoxemia keeping the arterial Hb oxygen saturation > 90
%
Supplemental oxygen administration and positive airway pressure

Ventilation : non invasive and invassive ventilation

Pharmacology :
To facilitate dilation of airways, such as Bronchodilators (beta 2 agonist
and anticholinergic agents). Aminophiline have negative side effects.
Steroids to decrease airway inflamation and enhance the beta2agonists
effect. Sedation (assist maintaining adequate ventilation), analgesics
Acidosis :
Correction of hypoxemia and sodium bicarbonate
Nutrition support
Prevention of complications
 Nursing Management

Health history :
History of past or present associated disorder, recent change in
respiratory status, change in sputum (color, viscosity, odor),
increase dyspnea, change in mental status, complaints of chest
tightness or pain.
Current medications and any recent changes in medication
regimen
Self care modalities used

A family memberor friend who maybe able to provide objective

information about changes in the patients.
 Nursing Management

Physical Examination :
Abnormalities of general appearance, breathing dificulty,
postural change
Variation in mental status, which may range from agitation to
somnolence
Changes in vital signs to identify tachycardia, tachypnea,
bradypnea, or apnea, hypotension, and other abnormalities.
Respiratory status abnormalities

Relevant laboratory studies, including ABGs, sputum culture

and sensitivity, and bedside spirometry
Nursing Diagnoses, Outcomes, and Intervention

Nursing Diagnosis : Impaired Gas Exchange

Outcomes :
Demonstrate improve ventilation and oxygenation

Have PaO2, PCO2 and pH within acceptable baseline limits.

Demonstrate mental status at prerespiratory failure level

Exhibit respiratory rate within or near normal levels, with

moderate tidal volume
Have no dyspnea or preacute illness level of dyspnea
 Nursing Intervention :
Oxygen therapy rapidly evaluated with ABG, pulse oximetry

Frequent assesment of respiratory status, vital signs, level of

conciousness, tolerance of ventilatory support, ventilator
setting
Facillitation of use of controlled breathing tecniques

Review of lab data, especially electrolytes, hematocrite

Pain evaluation (collaboration analgesia especially opiates)

 Nursing diagnosis

Ineffective airway clearance

Decrease cardiac output
Imbalanced nutrition : less than body requirements
 Nursing Management

Nursing care is directed by the specific etiology of ARF. Common

interventions :
Positioning
Preventing desaturation :
Performing procedures only as needed
Hyperoxygenating the patient before suctioning
Providing adequate rest and recovery time between various procedures
Minimizing oxygen consumption
Deep breathing after extubation
Promoting secretion clearance :
Adequate systemic hydration
Hummidifying supplemental oxygen
Coughing and suctioning
Chest physiotherapy
Patient Education
Adequate nutrition