Acute Respiratory Failure Respiratory failure is a sudden and lifethreatening deterioration of the gas exchange function of the lung.

It exists when the exchange of oxygen for carbon dioxide in the lungs cannot keep up with the rate of oxygen consumption and carbon dioxide production by the cells of the body. Acute respiratory failure (ARF) is defined as a fall in arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and a rise in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. In ARF, the ventilation or perfusion mechanisms in the lung are impaired. Respiratory system mechanisms leading to ARF include: Alveolar hypoventilation Diffusion abnormalities Ventilationperfusion mismatching Shunting It is important to distinguish between ARF and chronic respiratory failure. Chronic respiratory failure is defined as a deterioration in the gas exchange function of the lung that has developed insidiously or has persisted for a long period after an episode of ARF. The absence of acute symptoms and the presence of a chronic respiratory acidosis suggest the chronicity of the respiratory failure. Two causes of chronic respiratory failure are

COPD (discussed in Chap. 24) and neuromuscular diseases (discussed in Chap. 65). Patients with these disorders develop a tolerance to the gradually worsening hypoxemia and hypercapnia. However, a patient with chronic respiratory failure may develop ARF. This is seen in the COPD patient who develops an exacerbation or infection that causes additional deterioration of the gas exchange mechanism. The principles of management of acute versus chronic respiratory failure are different; the following discussion will be limited to ARF. Pathophysiology Common causes of ARF can be classified into four categories: decreased respiratory drive, dysfunction of the chest wall, dysfunction of the lung parenchyma, and other causes. DECREASED RESPIRATORY DRIVE Decreased respiratory drive may occur with severe brain injury, large lesions of the brain stem (multiple sclerosis), use of sedative medications, and metabolic disorders such as hypothyroidism. These disorders impair the normal response of chemoreceptors in the brain to normal respiratory stimulation. DYSFUNCTION OF THE CHEST WALL The impulses arising in the respiratory center travel through nerves that extend from the brain stem down the spinal cord to

receptors in the muscles of respiration. Thus, any disease or disorder of the nerves, spinal cord, muscles, or neuromuscular junction involved in respiration seriously affects ventilation and may ultimately lead to ARF. These include musculoskeletal disorders (muscular dystrophy, polymyositis), neuromuscular junction disorders (myasthenia gravis, poliomyelitis), some peripheral nerve disorders, and spinal cord disorders (amyotrophic lateral sclerosis, Guillain-Barr syndrome, and cervical spinal cord injuries). DYSFUNCTION OF LUNG PARENCHYMA Pleural effusion, hemothorax, pneumothorax, and upper airway obstruction are conditions that interfere with ventilation by preventing expansion of the lung. These conditions, which may cause respiratory failure, usually are produced by an underlying lung disease, pleural disease, or trauma and injury. Other diseases and conditions of the lung that lead to ARF include pneumonia, status asthmaticus, lobar atelectasis, pulmonary embolism, and pulmonary edema. OTHER CAUSES In the postoperative period, especially after major thoracic or abdominal surgery, inadequate ventilation and respiratory failure may occur because of several factors. During this period, for

example, ARF may be caused by the effects of anesthetic agents, analgesics, and sedatives, which may depress respiration as described earlier or enhance the effects of opioids and lead to hypoventilation. Pain may interfere with deep breathing and coughing. A mismatch of ventilation to perfusion is the usual cause of respiratory failure after major abdominal, cardiac, or thoracic surgery. Clinical Manifestations Early signs are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and finally respiratory arrest. Physical findings are those of acute respiratory distress, including use of accessory muscles, decreased breath sounds if the patient cannot adequately ventilate, and other findings related specifically to the underlying disease process and cause of ARF. Medical Management The objectives of treatment are to correct the underlying cause and to restore adequate gas exchange in the lung. Intubation and mechanical ventilation may be required to maintain adequate

ventilation and oxygenation while the underlying cause is corrected. Nursing Management Nursing management of the patient with ARF includes assisting with intubation and maintaining mechanical ventilation (described in Chap. 25). The nurse assesses the patients respiratory status by monitoring the patients level of response, arterial blood gases, pulse oximetry, and vital signs and assessing the respiratory system. The nurse implements strategies (eg, turning schedule, mouth care, skin care, range of motion of extremities) to prevent complications. The nurse also assesses the patients understanding of the management strategies that are used and initiates some form of communication to enable the patient to express his or her needs to the health care team. Nursing care also addresses the problems