Chapter 35

Pulmonary Disorders & Acute Respiratory Failure Chabot College N60B Spring 2015

Objectives1. Describe etiology, pathophysiology, assessment findings & interventions for a client with acute respiratory failure.2. Differentiate acute & chronic respiratory failure & pathophysiology of each.3. Identify therapies utilized in the client with respiratory failure to improve gas exchange.4. Identify risk factors, clinical manifestations of pulmonary embolism.5. Explain the collaborative management of the client who has developed pulmonary embolism an acute respiratory failure P.E.6. Compare the features of respiratory failure of ventilatory origin with those of oxygenation origin7. Utilize laboratory data and other diagnostic tests to determine the adequacy of ventilatory interventions.8. Discuss collaborative management of the client who has ARDS. 9. Identify common causes of ARDS, and symptoms of the condition10.Describe the following conditions to include causes, symptoms and collaborative management:11. Discuss the collaborative management of the client who has had chest trauma, to include pulmonary contusions, rib fracture, flail chest and hemo-/pneumothorax

23Physiology of Gas Exchange (Respiration)

Respiration is the process by which O2 is transferred from the air to tissues and CO2 is excreted in the expired air3 Step ProcessVentilationDiffusionTransport

43 Basic Respiratory FunctionsAlveolar Ventilation: Supplies O2 and removes CO2Arterial Blood Oxygenation: Maintain PaO2 Tissue Oxygenation: Oxygen delivery and tissue utilizationMain FunctionPhysiologic ComponentClinical AssessmentAlveolar VentilationAlveolar OxygenationRemoval of CO2PaCO2

Blood OxygenationArterial O2 Tension

PaO2Hgb; SaO2Tissue OxygenationOxygen Delivery (DO2)Tissue O2 UtilizationCO5Acute Respiratory Failure (ARF)Classified by blood gas abnormalityPressure of arterial oxygen PaO2 50 mm HgpH < 7.305Phipps pg 592Causes of Acute Respiratory FailureThe patient is always hypoxemic due to:Ventilatory failureOxygenation failureCombination of ventilatory and oxygenation failure

6Ventilatory FailureExtrapulmonary causes perfusion is normal, ventilation is inadequateNeuromuscular disordersSpinal cord injuryCentral nervous system dysfunction: CVAChemical depressionStructural disorders: kyphosis, obesity, apnea7Ventilatory FailureIntrapulmonary causesAirway disease: COPD, asthmaVentilation perfusion V/Q mismatchPulmonary embolismPneumothoraxARDS (acute respiratory distress syndrome)AmyloidosisInterstitial fibrosis89Oxygenation FailureVentilation is normal but lung perfusion is decreased.Low atmospheric oxygen concentration High altitudes, closed spaces, smoke inhalation, CO poisoningPneumonia, CHF, Pulmonary embolismInterstitial pneumonitis-fibrosisAbnormal hemoglobinHypovolemic shockHypoventilationNitroprusside therapy10Combined Ventilation and Oxygenation FailureHypoventilation R/T inadequate respiratory effortsRespiratory arrestMore profound hypoxemia than either of previous conditionsGas exchange at the alveolar-capillary membrane is inadequatetoo little O2 reaches the blood and CO2 is retained.Chronic emphysema, bronchitis, asthma

Acute Respiratory FailureRapidly developing dyspnea is an emergency situationPulse oximeter is less than 90% and partial pressure of oxygen less than 60 mm HgPartial pressure of arterial carbon dioxide more than 50 mm Hg leading to acidemiaPosition patient in upright position, call a Rapid Response Team, administer oxygen1112Clinical Presentation ARFConditionSymptomsPhysical FindingsHypoxemiaDyspnea, OrthopneaRestlessnessAgitationDisorientationConfusionDelirium Labored breathingCyanosisTachypneaCardiac arrhythmiasTachycardia

HypercapniaHeadache, somnolenceDizzinessComa, confusionHypertension, tachycardiaMuscle twitchingDiaphoresisPapilledemaAcidosisComaCardiac arrhythmias13Causes of Acute Respiratory FailureCOPDPneumoniaSepsisPulmonary edemaTraumaOverdose

AnesthesiaSurgeryNeurological insultsCancerPulmonary embolism

14Management of ARF

Chronic Respiratory FailureChronic Respiratory Failure develops over time as a result of conditions affecting muscles, nerves, bones, or tissues support breathingCOPD (chronic obstructive pulmonary disease)spinal cord injuriesnerve damage (involving the nerves that controls breathing)chronic alcohol abuse suppresses the respiratory center

15Symptoms of Chronic Respiratory Failuredifficulty breathing-dyspneabluish tint to the skin or lips (due to oxygen deprivation)bluish fingernailsrapid breathingfatigueagitation, anxiety, confusion or sleepinessproductive cough

16Treatment of Chronic Respiratory Failure (COPD)Oxygen therapy 2-4 L/min by nasal cannula to maintain SPO2 88%Positioning in upright positionPursed lip BreathingMedications: Inhalers: atrovent, proventil, floventMucolytics mucomyst, guaifenesin, dextromethorphanLong acting control with Spiriva and Vrovana 1718Acute Respiratory Distress Syndrome (ARDS)Persistent hypoxia despite 100% FiO2 Decreased pulmonary complianceDyspneaPulmonary edemaDense pulmonary infiltrates seen on x-rayMortality for 60

18Stiff lungs, difficult to ventilateEasy to pop blebsARDS Signs and SymptomsInflammatory response to lung injury: sepsis and trauma most common causesRapid shallow respirationsInspiratory crackles Respiratory alkalosisLab work: ABGs, brain natriuretic peptide (BNP), tumor necrosis factor (TNF) and interleukin 1 (IL-1)1920Etiologies of ARDS

21Causes of Lung Injury in ARDSSystemic inflammatory response (SIRS)Intrinsically the alveolar-capillary membrane is injured sepsis and shock.Extrinsically the alveolar-capillary membrane is injured aspiration or inhalation injury.Pathophysiology of ARDS

2223Synonyms for ARDS

24Collaborative Management ARDSDiagnostic TestsABG, chest x-ray, sputum culture, serum electrolytes, complete blood countMedicationsBronchodilators, mucolyticsTreatmentsOxygen therapy, mechanical ventilation, PEEPDietNPO or high calorieActivityBR, cluster nursing interventions

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2526Management of ARDS

27ABG ReviewpH normal is 7.35 - 7.45pH 50PaO2 80 to 100 mm HgPoorly oxygenating PaO2