Acute respiratory failure

introduction
Acute respiratory failure (ARF) occurs in many disease states.It may be the patient’s
primary problem or a complicating
factor in other conditions. This chapter reviews the pathophysiology of ARF, several
common causes, and the nursingcare involved in the treatment of these patients.
• Definition
• ARF is defined as a state of altered gas exchange in which the respiratory
system fails in either oxygenation or carbon dioxide (CO2) elimination.
These failures are classified into one of two categories: type 1 hypoxemic
or oxygenation failure, or type II hypercapnic or ventilatory failure.
Hypoxemic or oxygenation failure is characterized by an abnormal
arterial blood gas (ABG) value obtained with the patient breathing room
air; partial pressure of oxygen (O2) in arterial blood (PaO2) is less than 60
mm Hg, and the partial pressure of carbon dioxide (CO2) level (PaCO2) is
normal or low. Hypercapnic or ventilatory failure is characterized by a
PaCO2 of greater than 50 mm Hg with a pH of less than 7.30.4 ARF differs
from chronic respiratory failure in the length of time necessary for it to
develop. ARF occurs rapidly over minutes to hours, with little time for
physiological compensation. Chronic respiratory failure develops over
time and allows the body’s compensatory mechanisms to activate. ARF
and chronic respiratory failure are not mutually exclusive.
ARF may occur when a person who has chronic respiratory failure
develops a sudden respiratory infection or is exposed to other types of
stressors. This is referred to as acute-on-chronic respiratory failure.
Obese individuals may also be at a greater risk for respiratory failure

Pathophysiology
1-Failure of Oxygenation: is present when the PaO2 cannot be
adequately maintained. Five generally accepted mechanisms
that reduce PaO2 and create a state of hypoxemia are (1)
hypoventilation, (2) intrapulmonary shunting, (3) ventilation perfusion
mismatching, (4) diffusion defects, and (5) decreased barometric
pressure (Figure 14-1). Decreased barometric pressure,which occurs at
high altitudes, is not addressed in this text.Nonpulmonary conditions
such as decreased cardiac output and low hemoglobin level may also
result in tissue hypoxia.
• 2-Hypoventilation: In the normal lung, the partial pressure of alveolar O2
(PAO2) is approximately equal to the arterial O2(PaO2). Alveolar
ventilation refers to the amount of gas that enters the alveoli per minute.
If the alveolar ventilation is reduced because of hypoventilation, the
PAO2 and the PaO2 are reduced. Factors that may lead to hypoventilation
include a drug overdose that causes central nervous system depression,
neurological disorders that cause a decrease in the rate or depth of
respirations, and abdominal or thoracic surgery leading to shall low
breathing patterns secondary to pain on inspiration.
Hypoventilation also produces an increase in the alveolar CO2 level
because the CO2 that is produced in the tissues is delivered to the lungs
but is not released from the body.
• 3-Intrapulmonary shunting: In normally functioning lungs, a small amount of
blood returns to the left side of the heart without engaging in alveolar gas
exchange. This is referred to as the physiological shunt. If, however, a larger
amount of blood returns to the left side of the heart without participating in gas
exchange, the shunt becomes pathological and a decrease in the PaO2 occurs.4
The condition exists when areas of the lung that are inadequately ventilated are
adequately perfused The blood, therefore, is shunted past the lung and returns
unoxygenated to the left side of the heart. Causes of shunting include atrial or
ventricular septal defects, at electasis, pneumonia, and pulmonary edema.
• 4-Ventilation-perfusion mismatch: Gas exchange in thelungs is dependent upon
the balance between ventilated areas of the lung (ventilation) receiving blood
flow (perfusion).The rate of ventilation (V.) usually equals the rate of perfusion
(Q.), resulting in a ventilation-to-perfusion (V./Q) ratio of 1.0. If ventilation
exceeds blood flow, the V/Q. ratio is greater than 1.0; if ventilation is less than
blood flow, the V/Q ratio is less than 1. Both of these conditions are examples of
V/Q. mismatch. In respiratory failure, V/Q . mis- match is the most common
cause of hypoxemia and can often be corrected by increasing the FiO2.
• 5-Diffusion defects:Diffusion is the movement of gas from an area of
high concentration to an area of low concentration.In the lungs, O2
and CO2 move between the alveoli and the blood by diffusing across
the alveolar-capillary membrane.The alveolar-capillary membrane has
six barriers to the diffusion of O2 and CO2. In respiratory failure, the
distance between the alveoli and the capillaries may be increased by
the accumulation of fluid in the interstitial space Changes in capillary
perfusion pressure, leakage of plasma proteins into the interstitial
space, and destruction of the capillary membrane contribute to the
buildup of fluids around the alveolus. Fibrotic changes in the lung tissue
itself, such as those seen in chronic obstructive pulmonary disease
(COPD), may also contribute to a reduction in the diffusion capacity of
the lung.
• 6-Low cardiac output:A normal cardiac output results in the delivery
of 600 to 1000 mL/min.If the cardiac output decreases, less
oxygenated blood is delivered. To maintain normal aerobic
metabolism in low cardiac output states, the tissues must extract
increasing amounts of O2 from the blood. When this increase in
extraction can no longer compensate for the decreased cardiac
output, the cells convert to anaerobic metabolism. This results in the
production of lactic acid, which depresses the function of the
myocardium and further lowers cardiac output.
• 7- Low hemoglobin level: Approximately 95% of the body’s O2 is
transported to the tissues bound to hemoglobin. If a patient’s
hemoglobin level is less than normal, the O2 supply to the tissues may
be impaired and tissue hypoxia can occur. An alteration in hemoglobin
function.
• 8-Tissue hypoxia: The final step in oxygenation is the use of O2 by the
tissues. Anaerobic metabolism occurs when the tissues cannot obtain
adequate O2 to meet metabolic needs In addition, some conditions
such as cyanide poisoning may leave the tissues unable to use O2
despite normal O2 delivery.26 Anaerobic metabolism is inefficient and
results in the accumulation of lactic acid. The effects of tissue hypoxia
vary with the severity of the hypoxia but may result in cellular death
and subsequent organ failure.
• 9-Hypoventilation: Hypoventilation is the cause of respiratory failure
that occurs in patients with central nervous system abnormalities,
neuromuscular disorders, drug overdoses, and chest wall
abnormalities. In hypoventilation, CO2 accumulates in the alveoli and
is not blown off. Respiratory acidosis occurs rapidly before renal
compensation can occur. Mechanical ventilation may be necessary to
support the patient until the initial cause of the hypoventilation can
be corrected.
• Assessment: production are noted. A thorough cardiac assessment
provides information about the heart’s ability to deliver O2 to the tissues.
The patient must be closely monitored for changes in blood pressure,
heart rate, and cardiac rhythm. ARF initially causes tachycardia and
increased blood pressure. As ARF progresses, it may lead to dysrhythmias,
angina, bradycardia, hypotension, and cardiac arrest. The nurse should
evaluate peripheral perfusion by assessing pulses for strength and bilateral
equality. The skin is assessed for a decrease in temperature and the
presence of cyanosis or pallor, which are additional indicators of poor
perfusion. Serial chest x-rays and pulmonary function tests provide
important assessment information. ABG measurements to assess gas
exchange and acid-base balance. Noninvasive monitoring such as pulse
oximetry (SpO2) provides information about the patient’s oxygenation,
whereas continuous end-tidal CO2 monitoring provides information about
the patient’s ventilation
• Interventions:1-Maintaining a Patent Airway Some causes of acute respiratory
failure such as COPD, cardiogenic pulmonary edema, pulmonary infiltrates in
immunocompromised patients, and palliation in the terminally ill may be
effectively treated with noninvasive positive-pressure ventilation (NPPV).49
However, if a patient is unable to maintain a patent airway, intubation and
mechanical ventilation may be required for treatment.
• 2-Minimizing O2 Demand: Decreasing the patient’s O2 demand begins with
providing adequate rest. Unnecessary physical activity is avoided in patients
with ARF. Agitation, restlessness, fever, sepsis, and patient-ventilator
dyssynchrony must be addressed because they all contribute to increased O2
demand and consumption.
• 3-Treating the Cause of ARF: While the patient’s hypoxia is being treated,
efforts must be made to identify and reverse the cause of the ARF. Specific
interventions for acute respiratory distress syndrome (ARDS), COPD, asthma,
pneumonia, and pulmonary embolism are detailed later in this chapter.
• 4-Preventing Complications:Finally, the critical care nurse must be alert to the potential
complications that the patient with ARF may encounter. Preventive measures must be
taken to prevent the complications of immobility, adverse effects from medications, fluid
and electrolyte imbalances, development of gastric ulcers, and the hazards of mechanical
ventilation.
• 5-Optimizing O2 Delivery :Optimizing O2 delivery can be achieved in many ways,
depending on the needs of the patient. The first is to provide supplemental O2 via nasal
cannula or face mask to maintain the PaO2 above 60 mm Hg or the SaO2 above 90%.4
Higher PaO2 values are indicated in cases of severe tissue hypoxia, low flow states, or
deficiencies in O2 carrying capacity. If supplemental O2 is ineffective in raising PaO2 levels,
non-invasive or invasive mechanical ventilation is indicated. Patients are positioned for
comfort and to enhance V/Q matching. Some patients who are alert and dyspneic are able
to oxygenate more effectively in the semi-Fowler to high Fowler position. Patients with
unilateral lung disease should be positioned on their side with the better functioning
“good” lung down. This allows gravity to perfuse the lung that has the best ventilation.
Other methods to optimize O2 delivery include red blood cell transfusion to ensure
adequate hemoglobin levels to transport O2, and enhancing cardiac output and blood
pressure to deliver sufficient O2 to the tissues.
• Nursing Diagnoses:
• Several nursing diagnoses must be considered in the care of a patient
with ARF and are discussed in the “Nursing Care Plan for a Patient with
Acute Respiratory Failure.” Expected outcomes include adequate organ
and tissue oxygenation, effective breathing, and adequate gas exchange.
‫اشرف غسان شكري عابد •‬
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‫يزيد باسم ابو غوش •‬
‫‪• 11941703‬‬
‫رامز سامر سعيد حجازي •‬
‫‪• 11941607‬‬
‫هيثم عنتر خليل اغبارية •‬
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‫عبد الرحمن سميح رجا •‬
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‫‪• For : D.Fatima Hirzallah‬‬