Hala Ayyash

EGH-N8G.ForumPalestine.com
#0spiratory Failur0 (#F)
&
A#$
10/12/2011
Hala Ayyash
Hala Ayyash
(1)
Respiratory Failure Respiratory Failure
(RF) (RF)
Hala Ayyash
#espiratory Failure #espiratory Failure
{#F_ {#F_
01inition
Classi1ication o1 #F
istinction b0tw00n Acut0 and Chronic #F
iagnosis o1 #F
Caus0s
Clinical pr0s0ntation
Inv0stigations
Manag020nt o1 #F
Co2plications o1 A#F
efinitions #F efinitions #F
efinition
#0spiration is gas 0chang0 b0tw00n th0 organis2 and
its 0nviron20nt. Function o1 r0spiratory syst02 is to
trans10r O
2
1ro2 at2osph0r0 to blood and r02ov0 CO
2
1ro2 blood.
Clinically
#0spiratory 1ailur0 is d01in0d as PaO
2
60 22Hg whil0
br0athing air, or a PaCO
2
~50 22Hg.
-Acut0 and chronic
Hala Ayyash
lassification of #F lassification of #F
Hala Ayyash
lassification of #F lassification of #F
%yp0 1
Hypo02ic #F **
PaO2 60 22Hg with
nor2al or PaCO2
Associat0d with acut0
dis0as0s o1 th0 lung
Pul2onary 0d02a
(Cardiog0nic,
noncardiog0nic (A#$),
pn0u2onia, pul2onary
h02orrhag0, and collaps0
%yp0 2
Hyp0rcapnic #F
PaCO2 ~ 45 22Hg
Hypo02ia is co22on
rug ov0rdos0,
n0uro2uscular dis0as0,
ch0st wall d01or2ity,
COP, and Bronchial
asth2a
Hala Ayyash
istinction between Acute and istinction between Acute and
ronic #F ronic #F
Acut0 #F
0v0lops ov0r 2inut0s to
hours
pH quickly to 7.2
Ea2pl0 Pn0u2onia
Chronic #F
0v0lops ov0r days
in HCO3
pH slightly
Polycyth02ia, Corpul2onal0
Ea2pl0 COP
Hala Ayyash
iagnosis of #F iagnosis of #F
1 1 -- linical {symptoms, signs_ linical {symptoms, signs_
ypoxemia
yspn0a, Cyanosis
Con1usion, so2nol0nc0, 1its
%achycardia, arrhyth2ia
%achypn0a (good sign)
Us0 o1 acc0ssory 2s
Nasal 1laring
#0c0ssion o1 int0rcostal 2s
Polycyth02ia
Pul2onary H%N,
Corpul2onal0, #t. HF
ypercapnia
C0r0bral blood 1low, and
C$F Pr0ssur0
H0adach0
Ast0riis
Papillo0d02a
War2 0tr02iti0s,
collapsing puls0
Acidosis (r0spiratory, and
20tabolic)
pH, lactic acid
Hala Ayyash
iagnosis of #F iagnosis of #F
2 2 -- auses auses
1 CN$
0pr0ssion o1 th0 n0ural
driv0 to br0ath
Brain st02 tu2ors or vascular
abnor2ality
Ov0rdos0 o1 a narcotic, s0dativ0
My0d02a, chronic 20tabolic
alkalosis
Acut0 or chronic hypov0ntilation
and hyp0rcapnia
Hala Ayyash
iagnosis of #F iagnosis of #F
2 2 -- auses auses
2 - isord0rs o1 p0riph0ral
n0rvous syst02, #0spiratory 2s,
and Ch0st wall
Inability to 2aintain a l0v0l o1
2inut0 v0ntilation appropriat0 1or
th0 rat0 o1 CO2 production
Guillian-Barr0 syndro20, 2uscular
dystrophy, 2yasth0nia gravis,
2orbid ob0sity
Hypo02ia and hyp0rcapnia
Hala Ayyash
iagnosis of #F iagnosis of #F
2 2 -- auses auses
3 - Abnor2iti0s o1 th0
airways
Upp0r airways
Acut0 0piglotitis
%rach0al tu2ors
Low0r airway
COP, Asth2a, cystic
1ibrosis
Acut0 and chronic
hyp0rcapnia
Hala Ayyash
iagnosis of #F iagnosis of #F
2 2 -- auses auses
4 - Abnor2iti0s o1 th0 alv0oli
i11us0 alv0olar 1illing
hypo02ic #F
Cardiog0nic and
noncardiog0nic pul2onary
0d02a
Aspiration pn0u2onia
Pul2onary h02orrhag0
Associat0 with Intrapul2onary
shunt and incr0as0 work o1
br0athing
Hala Ayyash
iagnosis of #F iagnosis of #F
3 3 -- ommon causes ommon causes
ypoxemic RF ypoxemic RF
Chronic bronchitis, 02phys02a
Pn0u2onia, pul2onary 0d02a
Pul2onary 1ibrosis
Asth2a, pn0u2othora
Pul2onary 02bolis2,
Pul2onary hyp0rt0nsion
Bronchi0ctasis, A#$
Fat 02bolis2, Ob0sity
Cyanotic cong0nital h0art dis0as0
Granulo2atous lung dis0as0
ypercapnic ypercapnic RF RF
Chronic bronchitis,02phys02a
$0v0r0 asth2a, drug ov0rdos0
Poisonings, Myasth0nia gravis
Polyn0uropathy, Polio2y0litis
Pri2ary 2s disord0rs
1ry alv0olar hypov0ntilation
Ob0sity hypov0ntilation synd.
Pul2onary 0d02a, A#$
My0d02a, h0ad and c0rvical
cord injury
Hala Ayyash
iagnosis of #F iagnosis of #F
3 3 - - nvestigations nvestigations
ABG
CBC, Hb
An02ia tissu0 hypo02ia
Polycyth02ia chronic #F
Ur0a, Cr0atinin0
LF% clu0s to #F or
its co2plications
El0ctrolyt0s (K, Mg, Ph) Aggravat0 #F
CPK, %roponin 1 MI
CPK, nor2al %roponin 1 Myositis
%$H Hypothyroidis2
Hala Ayyash
iagnosis of #F iagnosis of #F
3 3 - - nvestigations nvestigations
Ch0st ray Pul2onary 0d02a
A#$
Echocardiography Cardiog0nic pul2onary
0d02a
A#$
PAP, #t v0ntricular
hyp0rtrophy in C#F
Hala Ayyash
iagnosis of #F iagnosis of #F
3 3 - - nvestigations nvestigations
ECG cardiac caus0 o1 #F
Arrhyth2ia du0 to hypo02ia and
s0v0r0 acidosis
u #ight h0art cath0t0rization to 20asur0
Pul2onary capillary w0dg0 pr0ssur0 (PCWP)
Nor2al A#$ (18 22Hg)
Incr0as0d Cardiog0nic pul2onary
0d02a
Hala Ayyash
anagement of A#F anagement of A#F
ICU ad2ition
1 -Airway 2anag020nt
Endotrach0al intubation:
Indications
$0v0r0 Hypo02ia
Alt0r0d 20ntal status
I2portanc0
pr0cis0 O2 d0liv0ry to th0 lungs
r02ov0 s0cr0tion
0nsur0s ad0quat0 v0ntilation
Hala Ayyash
anagement of A#F anagement of A#F
2 -Corr0ction o1 hypo02ia
O2 ad2inistration via
nasal prongs, 1ac0 2ask,
intubation and M0chanical
v0ntilation
Goal: Ad0quat0 O2
d0liv0ry to tissu0s
PaO2 ~ 60 22Hg
Art0rial O2 saturation
~90
Hala Ayyash
anagement of A#F anagement of A#F
3- Corr0ction o1 hyp0rcapnia
Control th0 und0rlying caus0
Controll0d O2 supply
1 -3 lit/2in, titrat0 according
O2 saturation
O2 supply to k00p th0 O2
saturation ~90 but 93 to
avoid inducing hyp0rcapnia
COP-chronic bronchitis,
02phys02a
Hala Ayyash
anagement of A#F anagement of A#F
4 M0chanical v0ntilation
Indications
P0rsist0nc0 hypo02ia
d0spit0 O2supply
0cr0as0d l0v0l o1
consciousn0ss
Hyp0rcapnia with s0v0r0
acidosis (pH 7.2)
Hala Ayyash
anagement of A# anagement of A#
4 - M0chanical v0ntilation
Incr0as0 PaO2
Low0r PaCO2
#0st r0spiratory 2s
(r0spiratory 2s 1atigu0)
'0ntilator
Assists or controls th0
pati0nt br0athing
%h0 low0st FIO2 that
produc0s $aO2 ~90 and
PO2 ~60 22Hg should b0
giv0n to avoid O2 toicity Hala Ayyash
anagement of A#F anagement of A#F
5 -PEEP (positiv0 End-
Epiratory pr0ssur0
Us0d with 20chanical v0ntilation
Incr0as0 intrathoracic pr0ssur0
K00ps th0 alv0oli op0n
0cr0as0 shunting
I2prov0 gas 0chang0
Hypo02ic #F (typ0 1)
A#$
Pn0u2onias
Hala Ayyash
anagement of A#F anagement of A#F
6 - Noninvasiv0 '0ntilatory
support (IPP')
Mild to 2od0rat0 #F
Pati0nt should hav0
Intact airway,
Al0rt, nor2al airway prot0ctiv0
r01l00s
Nasal or 1ull 1ac0 2ask
I2prov0 oyg0nation,
#0duc0 work o1 br0athing
Incr0as0 cardiac output
COP, asth2a, CHF
Hala Ayyash
anagement of A#F anagement of A#F
7 - %r0at20nt o1 th0
und0rlying caus0s
A1t0r corr0ction o1 hypo02ia,
h02odyna2ic stability
Antibiotics
Pn0u2onia
In10ction
Bronchodilators (COP, BA)
$albuta2ol
r0duc0 bronchospas2
airway r0sistanc0
Hala Ayyash
anagement of A#F anagement of A#F
7 - %r0at20nt o1 th0 und0rlying caus0s
Anticholin0rgics (COP,BA)
Ibratropiu2 bro2id0
inhibit vagal ton0
r0la s2ooth 2s
%h0ophyllin0 (COP, BA)
i2prov0 diaphrag2atic contraction
r0la s2ooth 2s
iur0tics (pul2onary 0d02a)
Frus02id0, M0talzon0
Hala Ayyash
anagement of A#F anagement of A#F
7 - %r0at20nt o1 th0 und0rlying caus0s
M0thyl pr0dnison0 (COP, BA, acut0 0sinophilic pn)
#0v0rs0 bronchospas2, in1la22ation
Fluids and 0l0ctrolyt0s
Maintain 1luid balanc0 and avoid 1luid ov0rload
I' nutritional support
%o r0stor0 str0ngth, loss o1 2s 2ass
Fat, carbohydrat0, prot0in
Hala Ayyash
anagement of A#F anagement of A#F
7 - %r0at20nt o1 th0 und0rlying
caus0s
Physioth0rapy
Ch0st p0rcussion to loos0n
s0cr0tion
$uction o1 airways
H0lp to drain s0cr0tion
Maintain alv0olar in1lation
Pr0v0nt at0l0ctasis, h0lp lung
0pansion
Hala Ayyash
omplications of A#F omplications of A#F
Pul2onary
Pul2onary 02bolis2
barotrau2a
pul2onary 1ibrosis (A#$)
Nosoco2ial pn0u2onia
Cardiovascular
Hypot0nsion,
Arrhyth2ia
MI, p0ricarditis
GI%
$tr0ss ulc0r, il0us, diarrh0a,
h02orrhag0
In10ctions
Nosoco2ial in10ction
Pn0u2onia, U%I,
cath0t0r r0lat0d s0psis
#0nal
A#F (hypop0r1usion,
n0phrotoic drugs)
Poor prognosis
Nutritional
Malnutrition, diarrh0a
hypoglyc02ia,
0l0ctrolyt0 disturbanc0s
Hala Ayyash
{2_
A#8
A#8
Also known as A
{diffuse alveolar disease_
or AL {acute lung in]ury_
a vari0ty o1 acut0 and di11us0 in1iltrativ0
l0sions which caus0 s0v0r0 r01ractory
art0rial hypo02ia and li10-thr0at0ning
arrhyth2ias
emory Jogger
Assault to th0 pul2onary syst02
#0spiratory distr0ss
0cr0as0d lung co2plianc0
$0v0r0 r0spiratory 1ailur0
irect auses {nflammatory
process is involved in all_
Pn0u2onia*
Aspiration o1 gastric cont0nts*
Pul2onary contusion
N0ar drowning
Inhalation injury
ndirect auses {Inflammatory
process is involved)
$0psis* (2ost co22on) g2 -
$0v0r0 trau2a with shock stat0 that r0quir0s
2ultipl0 blood trans1usions*
rug ov0rdos0
Acut0 pancr0atitis
Patopysiology of Patopysiology of
A#8 A#8
a2ag0 to alv0olar-capillary 202bran0
Incr0as0d capillary hydrostatic pr0ssur0
0cr0as0d colloidal os2otic pr0ssur0
Int0rstitial 0d02a
Alv0olar 0d02a or pul2onary 0d02a
Loss o1 sur1actant
Patopysiologic 8tages Patopysiologic 8tages
in A#8 in A#8
Injury or Eudativ0- 1-7 days
Int0rstitial and alv0olar 0d02a and at0l0ctasis
#01ractory hypo02ia and sti11 lungs
#0parativ0 or Proli10rativ0-1-2 w00ks a1t0r
0ns0 1ibrous tissu0, incr0as0d pul2onary hyp0rt0nsion
occurs
Fibrotic-2-3 w00k a1t0r
i11us0 scarring and 1ibrosis, d0cr0as0d sur1ac0 ar0a,
d0cr0as0d co2plianc0 and pul2onary hyp0rt0nsion
%e essential %e essential
disturbances of A#8 disturbances of A#8
**int0rstitial and alv0olar 0d02a and
at0l0ctasis
linical anifestations:
Early
yspn0a-(al2ost always pr0s0nt),
tachypn0a, cough, r0stl0ssn0ss
Ch0st auscultation 2ay b0 nor2al or
r0v0al 1in0, scatt0r0d crackl0s
ABGs
**Mild hypo02ia and r0spiratory
alkalosis caus0d by hyp0rv0ntilation
linical anifestations:
Early
Ch0st -ray 2ay b0 nor2al or show
2ini2al scatt0r0d int0rstitial in1iltrat0s
Ed02a 2ay not show until 30
incr0as0 in lung 1luid cont0nt
linical anifestations:
Late
$y2pto2s wors0n with progr0ssion o1 1luid
accu2ulation and d0cr0as0d lung
co2plianc0
Pul2onary 1unction t0sts r0v0al d0cr0as0d
co2plianc0 and lung volu20
Evid0nt disco21ort and incr0as0d WOB
linical anifestations:
Late
$uprast0rnal r0tractions
%achycardia, diaphor0sis, chang0s in s0nsoriu2
with d0cr0as0d 20ntation, cyanosis, and pallor
Hypo02ia and a PaO
2
/FIO
2
ratio 200 d0spit0
incr0as0d FIO
2
( 0: 80/.8100)
linical anifestations
As A#$ progr0ss0s, pro1ound
r0spiratory distr0ss r0quir0s
0ndotrach0al intubation and positiv0
pr0ssur0 v0ntilation
Ch0st -ray t0r20d whit0out or whit0
lung b0caus0 o1 consolidation and
wid0spr0ad in1iltrat0s throughout
lungs
est X est X- -#ay of A#8 #ay of A#8
linical anifestations
I1 pro2pt th0rapy not initiat0d, s0v0r0
hypo02ia, hyp0rcapnia, and 20tabolic
acidosis 2ay 0nsu0
Nursing iagnoses
In0110ctiv0 airway cl0aranc0
In0110ctiv0 br0athing patt0rn
#isk 1or 1luid volu20 i2balanc0
Ani0ty
I2pair0d gas 0chang0
I2balanc0d nutrition: L0ss than body
r0quir020nts
Planning
Following r0cov0ry
PaO
2
within nor2al li2its or at
bas0lin0
$aO
2
~ 90
Pat0nt airway
Cl0ar lungs or auscultation
yspnea and %acypnea
%h0 Auscultation Assistant - Br0ath $ounds
Nursing Assessment
Lung sounds
ABG`s
CX#
Capillary r01ill
N0uro ass0ss20nt
'ital signs
O2 sats
H02odyna2ic 2onitoring valu0s
iagnostic %ests
ABG-r0vi0w
CX#
Pul2onary Function %0sts- d0c. co2plianc0
and d0c vital capacity - (2a 0hal0d
a1t0r 2a inhal0)
H02odyna2ic Monitoring- (Pul2onary
art0ry pr0ssur0s) to rul0 out pul2onary
0d02a
8evere A#8 8evere A#8
Goal of %reatment for
A#8
Maintain ad0quat0 v0ntilation and r0spirations.
Pr0v0nt injury
Manag0 ani0ty
%reatment
M0chanical '0ntilation-goal PO2~60 and 02 sat
90 with FIO2 50
PEEP- can caus0 d0c. CO, B/P and barotrau2a
Positioning- pron0, continuous lat0ral rotation
th0rapy
H02odyna2ic Monitoring- 1luid r0plac020nt or
diur0tics
Ent0ral or Par0nt0ral F00ding- high calori0, high
1at. #0s0arch shows that 1or2ulas 0nrich0d with
o20ga -3 1atty acids 2ay i2prov0 th0 outco20s o1
thos0 with A#$
ont.
Crystalloids v0rsus colloids
Mild 1luid r0striction and diur0tics
Proning
Proning typically r0s0rv0d 1or
r01ractory hypo02ia not
r0sponding to oth0r th0rapi0s
Plan 1or i220diat0 r0positioning
1or cardiopul2onary r0suscitation
Proning-Principles
Positioning strat0gi0s
M0diastinal and h0art cont0nts plac0 2or0
pr0ssur0 on lungs wh0n in supin0 position than
wh0n in pron0
Pr0dispos0s to at0l0ctasis
%urn 1ro2 supin0 to pron0 position
May b0 su11ici0nt to r0duc0 inspir0d O
2
or
PEEP
Fluid pools in d0p0nd0nt r0gions o1 lung
ffect of prone position on ventilation distribution. In th0 supin0 position, th0 distribution
o1 v0ntilation is pr010r0ntially distribut0d to th0 v0ntral r0gions. Wh0n th0 pati0nt is pron0,
th0 sti11n0ss o1 th0 dorsal ch0st wall 1avors th0 distribution o1 v0ntilation to th0 dorsal
r0gions, 1acilitating r0in1lation in this ar0a.
Prone evice Prone evice
*Pron0 positioning
With position chang0 to pron0, pr0viously
nond0p0nd0nt air-1ill0d alv0oli b0co20
d0p0nd0nt, p0r1usion b0co20s gr0at0r to
air-1ill0d alv0oli oppos0d to pr0viously
1luid-1ill0d d0p0nd0nt alv0oli, th0r0by
i2proving v0ntilation-p0r1usion 2atching.
No benefit in mortality No benefit in mortality
enefits to Proning
B01or0 proning
A1t0r proning
Positioning
Oth0r positioning strat0gi0s
Continuous lat0ral rotation th0rapy
ontinuous Lateral
#otation
ygen %erapy
Oyg0n
High 1low syst02s us0d to
2ai2iz0 O
2
d0liv0ry
$aO
2
continuously 2onitor0d,
Usually hav0 art0rial lin0 1or
1r0qu0nt ABG`s
Giv0 low0st conc0ntration that
r0sults in PaO
2
60 22 Hg or
gr0at0r
#espiratory %erapy
#isk 1or O
2
toicity incr0as0s
wh0n FIO
2
0c00ds 60 1or 2or0
than 48 hours
Pati0nts will co22only n00d
intubation with 20chanical
v0ntilation b0caus0 PaO
2
cannot
b0 2aintain0d at acc0ptabl0
l0v0ls
ecanical ventilation
PEEP
High0r l0v0ls o1 PEEP ar0 o1t0n n00d0d to
2aintain PaO
2
at 60 22 Hg or gr0at0r
**High l0v0ls o1 PEEP can co2pro2is0
v0nous r0turn
Pr0load, CO, and BP
edical 8upportive edical 8upportive
%erapy %erapy
Maint0nanc0 o1 cardiac output and
tissu0 p0r1usion
Continuous h02odyna2ic
2onitoring
Continuous BP 20asur020nt
via art0rial cath0t0r
edical 8upportive
%erapy
Pul2onary art0ry cath0t0r to 2onitor
pul2onary art0ry pr0ssur0,
pul2onary art0ry w0dg0 pr0ssur0s,
and CO
Ad2inistration o1 crystalloid
1luids or colloid 1luids, or low0r
PEEP i1 CO 1alls
edical 8upportive
%erapy
Us0 o1 inotropic drugs 2ay b0
n0c0ssary
H02oglobin usually k0pt at l0v0ls
gr0at0r than 9 or 10 with
$aO
2
_90
Pack0d #BCs
Maint0nanc0 o1 1luid balanc0
edical 8upportive
%erapy
May b0 volu20 d0pl0t0d and pron0
to hypot0nsion and d0cr0as0d CO
1ro2 20chanical v0ntilation and
PEEP
Monitor PAWP, daily w0ights, and
I and O`s to ass0ss 1luid status
edications edications
Inhal0d Nitric Oid0
$ur1actant th0rapy
corticost0roids
Hala Ayyash
%HANK Y& %HANK Y&