respiratory failure
TRANSCRIPT
Respiratory FailureArtificial Airways
Mechanical Ventilation
Respiratory FailureArtificial Airways
Mechanical Ventilation
Learning OutcomesLearning Outcomes
Describe respiratory failureDescribe artificial airwaysDescribe mechanical ventilationApply nursing management across
life span
Describe respiratory failureDescribe artificial airwaysDescribe mechanical ventilationApply nursing management across
life span
Respiratory FailureRespiratory Failure
Sudden, life threatening deterioration of the gas exchange function of the lung
Patient can not eliminate CO2 from the alveoli
CO2 retention results in hypoxemiaO2 reaches the alveoli but can not
be absorbed or used properly.
Sudden, life threatening deterioration of the gas exchange function of the lung
Patient can not eliminate CO2 from the alveoli
CO2 retention results in hypoxemiaO2 reaches the alveoli but can not
be absorbed or used properly.
Respiratory failure Continued
Respiratory failure Continued
Lung can move air sufficiently but cannot oxygenate the pulmonary blood properly
Respiratory failure occurs as a result of:mechanical abnormality of the lungs
or chest walldefect in the respiratory control
center in the brain orImpairment in the function of the
respiratory muscles
Lung can move air sufficiently but cannot oxygenate the pulmonary blood properly
Respiratory failure occurs as a result of:mechanical abnormality of the lungs
or chest walldefect in the respiratory control
center in the brain orImpairment in the function of the
respiratory muscles
Acute Respiratory Failure (ARF)
Acute Respiratory Failure (ARF)
Defined as:PaO2 < 50 mm Hg (hypoxemia)PaCO2 > 50 mm Hg (hypercapnia)Arterial pH < 7.35
Defined as:PaO2 < 50 mm Hg (hypoxemia)PaCO2 > 50 mm Hg (hypercapnia)Arterial pH < 7.35
Chronic Respiratory Failure(CRF)
Chronic Respiratory Failure(CRF)
Defined as:Deterioration in gas exchange that has
occurred over a long period of time after an episode of ARF
Absence of acute symptoms and presence of chronic respiratory acidosis
Patient develop tolerance to gradual worsening hypoxemia and hypercapnia
COPD and neuromuscular diseases
Defined as:Deterioration in gas exchange that has
occurred over a long period of time after an episode of ARF
Absence of acute symptoms and presence of chronic respiratory acidosis
Patient develop tolerance to gradual worsening hypoxemia and hypercapnia
COPD and neuromuscular diseases
PathophysiologyARF
PathophysiologyARF
Ventilation or perfusion mechanism impairedAlveolar hypoventilationDiffusion abnormalitiesVentilation-perfusion mismatchingshunting
Ventilation or perfusion mechanism impairedAlveolar hypoventilationDiffusion abnormalitiesVentilation-perfusion mismatchingshunting
ARF CausesARF Causes
Decreased respiratory driveDysfunction of the chest wallDysfunction of the lung
parenchymaPost op after major thoracic or
abdominal surgery
Decreased respiratory driveDysfunction of the chest wallDysfunction of the lung
parenchymaPost op after major thoracic or
abdominal surgery
Decreased Respiratory Drive
Decreased Respiratory Drive
Severe brain injuryLesions of the brain stem (MS)Use of sedative medicationsMetabolic disorders (hypothyroidism)
Theory: These disorders impair chemoreceptors in the brain to normal respiratory stimulation
Severe brain injuryLesions of the brain stem (MS)Use of sedative medicationsMetabolic disorders (hypothyroidism)
Theory: These disorders impair chemoreceptors in the brain to normal respiratory stimulation
Dysfunction of Chest WallDysfunction of Chest Wall
Any disease of the nerves, spinal cord, muscles or neuromuscular junction involved in respiration seriously affects ventilation e.g. Muscular dystrophy, Polymyositis, Myasthenia gravis, ALS
Theory: impulses arising in the respiratory center travel through nerves that extend from the brainstem down the spinal cord to receptors in the muscles of respiration
Any disease of the nerves, spinal cord, muscles or neuromuscular junction involved in respiration seriously affects ventilation e.g. Muscular dystrophy, Polymyositis, Myasthenia gravis, ALS
Theory: impulses arising in the respiratory center travel through nerves that extend from the brainstem down the spinal cord to receptors in the muscles of respiration
Dysfunction of Lung Parenchyma
Dysfunction of Lung Parenchyma
Pleural effusionHemothoraxUpper airway obstructionPneumoniaPE
Pleural effusionHemothoraxUpper airway obstructionPneumoniaPE
AssessmentAssessment
DyspneaHeadacheRestlessnessConfusionTachycardiaCyanosisDysrhythmiasDecreased LOCAlterations in respirations and breath
sounds
DyspneaHeadacheRestlessnessConfusionTachycardiaCyanosisDysrhythmiasDecreased LOCAlterations in respirations and breath
sounds
Nursing ManagementNursing ManagementIdentify and treat the cause of respiratory
failureAdminister O2 to maintain PaO2 level
above 60 to 70 mm HgHigh fowlersEncourage deep breathingBronchodilatorsPrepare patient for mechanical
ventilation if supplemental O2 cannot maintain acceptable PaO2 levels
Identify and treat the cause of respiratory failure
Administer O2 to maintain PaO2 level above 60 to 70 mm Hg
High fowlersEncourage deep breathingBronchodilatorsPrepare patient for mechanical
ventilation if supplemental O2 cannot maintain acceptable PaO2 levels
Acute respiratory Distress Syndrome (ARDS)
Acute respiratory Distress Syndrome (ARDS)
Form of ARF caused by diffuse lung injury leading to extravascular lung fluid
Major site of injury is the alveolar capillary membrane
Interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance
Form of ARF caused by diffuse lung injury leading to extravascular lung fluid
Major site of injury is the alveolar capillary membrane
Interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance
ARDS ContinuedARDS Continued
ABG’s identify respiratory acidosis and hypoxemia that does not respond to an increased percentage of O2
Chest x-ray shows interstitial edemaSepsis, fluid overload, shock, trauma,
neurological injuries, burns, aspiration amongst some of the causes
ABG’s identify respiratory acidosis and hypoxemia that does not respond to an increased percentage of O2
Chest x-ray shows interstitial edemaSepsis, fluid overload, shock, trauma,
neurological injuries, burns, aspiration amongst some of the causes
AssessmentAssessment
One of the earliest signs, tachypneaDyspneaDecreased breath soundsDeteriorating blood gas levelsHypoxemia despite high concentrations
of delivered O2Decreased pulmonary complianceDecreased infiltrates
One of the earliest signs, tachypneaDyspneaDecreased breath soundsDeteriorating blood gas levelsHypoxemia despite high concentrations
of delivered O2Decreased pulmonary complianceDecreased infiltrates
Nursing ManagementNursing Management
Administer O2High FowlersRestrict fluidRespiratory treatmentsDiuretics, anticoagulants, corticosteroidsPrepare patient for intubation and
mechanical ventilation, using positive end-expiratory pressure (PEEP)
Administer O2High FowlersRestrict fluidRespiratory treatmentsDiuretics, anticoagulants, corticosteroidsPrepare patient for intubation and
mechanical ventilation, using positive end-expiratory pressure (PEEP)
Artificial AirwaysArtificial Airways
Adequate ventilation dependent on free movement of air through the upper and lower airways.
Many disorders either narrow or block as a result of disease.
Foreign bodies or secretions can also impede ventilation
Adequate ventilation dependent on free movement of air through the upper and lower airways.
Many disorders either narrow or block as a result of disease.
Foreign bodies or secretions can also impede ventilation
Endotracheal IntubationEndotracheal Intubation
Involves passing endotracheal tube through mouth or note into the trachea with aide of a laryngoscope
Once passed a cuff is inflated to prevent air from leaking around the outer part of the tube, to minimize the possibility of aspiration and movement of tube
Provides a patent airway Method of choice in emergency care
Involves passing endotracheal tube through mouth or note into the trachea with aide of a laryngoscope
Once passed a cuff is inflated to prevent air from leaking around the outer part of the tube, to minimize the possibility of aspiration and movement of tube
Provides a patent airway Method of choice in emergency care
Nursing ManagementNursing Management
Assess chest expansion for symmetryAuscultate breath soundsObtain chest x-rayCheck cuff pressure every 8-12 hoursMonitor for signs of aspirationSecure tube to patients face with
tape and mark proximal end for position
Assess chest expansion for symmetryAuscultate breath soundsObtain chest x-rayCheck cuff pressure every 8-12 hoursMonitor for signs of aspirationSecure tube to patients face with
tape and mark proximal end for position
Nursing ManagementNursing Management
Provide for oral care, usually need two professionals as tube needs to be moved from side to side of mouth
Suction prnExcessive suctioning, speaking can
dislodge tubeMaintain cuff inflationAdminister O2 as orderedEnsure high humidity
Provide for oral care, usually need two professionals as tube needs to be moved from side to side of mouth
Suction prnExcessive suctioning, speaking can
dislodge tubeMaintain cuff inflationAdminister O2 as orderedEnsure high humidity
Nursing Management Continued
Nursing Management Continued
Prevent premature removal of tube.
Explain to patient and family purpose of tube
Last resort is use of soft wrist restraints.
Maintain skin integrity
Prevent premature removal of tube.
Explain to patient and family purpose of tube
Last resort is use of soft wrist restraints.
Maintain skin integrity
ExtubationExtubation
Usually respiratory therapist at hospital does this.
Semifowlers positionCuff is deflatedMonitor for respiratory difficulty e.g.
stridorO2 as prescribedInform patient may experience
hoarseness or sore throat.
Usually respiratory therapist at hospital does this.
Semifowlers positionCuff is deflatedMonitor for respiratory difficulty e.g.
stridorO2 as prescribedInform patient may experience
hoarseness or sore throat.
TracheostomyTracheostomy
Surgical incision into the trachea for the purpose of establishing an airway
Tracheostomy is the stoma or opening that results from the tracheotomy
Can be permanent or temporary
Surgical incision into the trachea for the purpose of establishing an airway
Tracheostomy is the stoma or opening that results from the tracheotomy
Can be permanent or temporary
Types (See table 20-1)Types (See table 20-1)
Double LumenSingle LumenCuffed TubeCuffless tubeFenestrated tubeCuffed fenestrated tubeMetal tracheostomy tubeTalking tracheostomy tube
Double LumenSingle LumenCuffed TubeCuffless tubeFenestrated tubeCuffed fenestrated tubeMetal tracheostomy tubeTalking tracheostomy tube
Double LumenDouble Lumen
Outer cannula: fits into stoma and keeps airway open
Inner cannual: fits into outer cannula and locks into place. Some can e removed and cleaned and reused.
Obturator: stylet with a blunt end used to facilitate direction of tube when inserting. Removed after tube placement
Outer cannula: fits into stoma and keeps airway open
Inner cannual: fits into outer cannula and locks into place. Some can e removed and cleaned and reused.
Obturator: stylet with a blunt end used to facilitate direction of tube when inserting. Removed after tube placement
FenestratedFenestrated
Used to wean patient from a tracheostomy
Allows patient to speakCuffed used with spinal cord
paralysis: can facilitate mechanical ventilation and speech.
Used to wean patient from a tracheostomy
Allows patient to speakCuffed used with spinal cord
paralysis: can facilitate mechanical ventilation and speech.
Nursing ManagementNursing Management
Assess respirations for bilateral breath sounds Monitor ABGs and pulse ox Encourage deep breathing and coughing Maintain semi to high fowlers position Monitor for bleeding Suction prn Assess stoma If tube dislodges, initial nursing action is to
grasp the retention sutures to spread the opening
Assess respirations for bilateral breath sounds Monitor ABGs and pulse ox Encourage deep breathing and coughing Maintain semi to high fowlers position Monitor for bleeding Suction prn Assess stoma If tube dislodges, initial nursing action is to
grasp the retention sutures to spread the opening
Mechanical VentilationMechanical Ventilation
Controls patients respirations during surgery or during treatment of severe head injury
Oxygenate the blood when patients ventilator efforts are inadequate
Rest the respiratory musclesPositive or negative pressure device
that maintains ventilation and oxygen delivery for a prolonged period of time
Controls patients respirations during surgery or during treatment of severe head injury
Oxygenate the blood when patients ventilator efforts are inadequate
Rest the respiratory musclesPositive or negative pressure device
that maintains ventilation and oxygen delivery for a prolonged period of time
IndicationsIndications
PaO2 < 50 mm Hg with pH < 7.25Vital capacity < 2 times the tidal
volumeNegative inspiratory force <25 cm
H2ORespiratory rate >35/min
PaO2 < 50 mm Hg with pH < 7.25Vital capacity < 2 times the tidal
volumeNegative inspiratory force <25 cm
H2ORespiratory rate >35/min
Classification of Ventilators
Classification of Ventilators
Negative-pressureSimple and do not require intubation of
the airwayThe iron lung, also known as the Drinker
and Shaw tank, was one of the first negative-pressure machines used for long-term ventilation.
The machine is a large elongated tank, which encases the patient up to the neck.
Negative-pressureSimple and do not require intubation of
the airwayThe iron lung, also known as the Drinker
and Shaw tank, was one of the first negative-pressure machines used for long-term ventilation.
The machine is a large elongated tank, which encases the patient up to the neck.
Positive Pressure Ventilators
Positive Pressure Ventilators
Work by increasing the patient's airway pressure through an endotracheal or tracheostomy tube.
The positive pressure allows air to flow into the airway until the ventilator breath is terminated
Subsequently, the airway pressure drops to zero, and the elastic recoil of the chest wall and lungs push the tidal volume, the breath out through passive exhalation
Work by increasing the patient's airway pressure through an endotracheal or tracheostomy tube.
The positive pressure allows air to flow into the airway until the ventilator breath is terminated
Subsequently, the airway pressure drops to zero, and the elastic recoil of the chest wall and lungs push the tidal volume, the breath out through passive exhalation
TypesTypes
Pressured Cycled Delivers a flow of air (inspiration)
until it reaches a preset pressure and then cycles off
Expiration occurs passively Intended only for short term Most common type IPPB machine
Pressured Cycled Delivers a flow of air (inspiration)
until it reaches a preset pressure and then cycles off
Expiration occurs passively Intended only for short term Most common type IPPB machine
Types continuedTypes continued
Timed CycledPushes air into lungs until a preset
time has elapsedUsed in newborns or neonatal client
Timed CycledPushes air into lungs until a preset
time has elapsedUsed in newborns or neonatal client
Types ContinuedTypes Continued
Volume-cycledPushes air into the lungs until a
preset volume is deliveredA constant tidal volume is delivered
regardless of changing compliance of the lungs and chest wall or the airway resistance in the client or ventilator
Volume-cycledPushes air into the lungs until a
preset volume is deliveredA constant tidal volume is delivered
regardless of changing compliance of the lungs and chest wall or the airway resistance in the client or ventilator
Types ContinuedTypes Continued
Noninvasive positive pressureGiven via face mask cover nose and mouth,
nasal maskCPAP: continuous positive airway pressureBPAP: bi-level positive airway pressureUsed for sleep apnea, positive pressure act
as a splint keeping the upper airway and trachea open during sleep.
Noninvasive positive pressureGiven via face mask cover nose and mouth,
nasal maskCPAP: continuous positive airway pressureBPAP: bi-level positive airway pressureUsed for sleep apnea, positive pressure act
as a splint keeping the upper airway and trachea open during sleep.
Modes of VentilationModes of Ventilation
ControlledSet tidal volume at set rateUsed for patients who can not initial
respirationLeast used mode because if patient
tries to initiate a breath, the efforts are blocked by the ventilator
ControlledSet tidal volume at set rateUsed for patients who can not initial
respirationLeast used mode because if patient
tries to initiate a breath, the efforts are blocked by the ventilator
Modes continuedModes continued
Assist control (AC)Most commonly usedTidal volume and ventilator rate are
preset Ventilator takes over the work of
breathing for clientProgrammed to respond should the
patient initiate a breath
Assist control (AC)Most commonly usedTidal volume and ventilator rate are
preset Ventilator takes over the work of
breathing for clientProgrammed to respond should the
patient initiate a breath
Modes ContinuedModes Continued
Synchronized intermittent mandatory ventilation (SIMV)Similar to AC however allows patient to
breath spontaneously at their own rateCan be used as primary or weaning
mode.When used in weaning mode, the
number of SIMV breaths is gradually decreased and the patient gradually resumes spontaneous breathing
Synchronized intermittent mandatory ventilation (SIMV)Similar to AC however allows patient to
breath spontaneously at their own rateCan be used as primary or weaning
mode.When used in weaning mode, the
number of SIMV breaths is gradually decreased and the patient gradually resumes spontaneous breathing
Ventilator controls and settings
Ventilator controls and settings
Tidal volume: volume of air that the client receives with each breath
Rate: number of ventilator breaths delivered per minute
Fraction of inspired oxygen (FiO2): concentration of oxygen delivered to patient. Determined by ABG
Tidal volume: volume of air that the client receives with each breath
Rate: number of ventilator breaths delivered per minute
Fraction of inspired oxygen (FiO2): concentration of oxygen delivered to patient. Determined by ABG
Controls and settingsControls and settings
Sighs: volumes of air that are 1.5 to 2 times the set tidal volume, delivered 6 to 10 times per hour
PIP: peak airway inspiratory pressure: pressure needed by ventilator to deliver a set tidal volume at a given compliance
Sighs: volumes of air that are 1.5 to 2 times the set tidal volume, delivered 6 to 10 times per hour
PIP: peak airway inspiratory pressure: pressure needed by ventilator to deliver a set tidal volume at a given compliance
Positive End Expiratory Pressure (PEEP)
Positive End Expiratory Pressure (PEEP)
Positive pressure exerted during the expiratory phase of ventilation
Improved oxygenation by enhancing gas exchange and preventing adelectasis
Need indicates a severe gas exchange disturbance
Positive pressure exerted during the expiratory phase of ventilation
Improved oxygenation by enhancing gas exchange and preventing adelectasis
Need indicates a severe gas exchange disturbance
Nursing managementNursing management
Assess patient first, ventilator second VS, lung sounds, respiratory status and
breathing pattern Monitor skin color, lips and nail beds Monitor chest for bilateral expansion Assess ventilator settings Ensure alarms are set Empty ventilator tubing when moisture
collects T&P client at least every 2 hours
Assess patient first, ventilator second VS, lung sounds, respiratory status and
breathing pattern Monitor skin color, lips and nail beds Monitor chest for bilateral expansion Assess ventilator settings Ensure alarms are set Empty ventilator tubing when moisture
collects T&P client at least every 2 hours