Pulmonary Disorders &

Acute Respiratory Failure

Chabot College
N60B
Spring 2015

Objectives
1. 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
origin
7. 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 condition
10.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
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Physiology 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 air

3 Step Process

1.Ventilation
2.Diffusion
3.Transport
3

3 Basic Respiratory Functions

1.

Alveolar Ventilation: Supplies O2 and removes CO2

2.

Arterial Blood Oxygenation: Maintain PaO2

3.

Tissue Oxygenation: Oxygen delivery and tissue utilization

Main Function

Physiologic Component

Clinical Assessment

Alveolar Ventilation

Alveolar Oxygenation
Removal of CO2

PaCO2

Blood Oxygenation

Arterial O2 Tension

PaO2
Hgb; SaO2

Tissue Oxygenation

Oxygen Delivery (DO2)

Tissue O2 Utilization

CO

Acute Respiratory Failure (ARF)

Classified by blood gas abnormality
Pressure of arterial oxygen PaO2 <60 mm Hg
Oxygen saturation SaO2 < 90%
Pressure of arterial carbon dioxide PaCO2 > 50
mm Hg
pH < 7.30

Causes of
Acute Respiratory Failure
The patient is always hypoxemic due to:
Ventilatory failure
Oxygenation failure
Combination of ventilatory and oxygenation
failure

Ventilatory Failure
Extrapulmonary causes perfusion is normal,
ventilation is inadequate
Neuromuscular disorders
Spinal cord injury
Central nervous system dysfunction: CVA
Chemical depression
Structural disorders: kyphosis, obesity, apnea
7

Ventilatory Failure
Intrapulmonary causes
Airway disease: COPD, asthma
Ventilation perfusion V/Q mismatch

Pulmonary embolism
Pneumothorax
ARDS (acute respiratory distress syndrome)
Amyloidosis
Interstitial fibrosis
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Oxygenation Failure
Ventilation is normal but lung perfusion is
decreased.

Low atmospheric oxygen concentration

High altitudes, closed spaces, smoke inhalation, CO
poisoning
Pneumonia, CHF, Pulmonary embolism
Interstitial pneumonitis-fibrosis
Abnormal hemoglobin
Hypovolemic shock
Hypoventilation
Nitroprusside therapy
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Combined Ventilation and

Oxygenation Failure

Hypoventilation R/T inadequate respiratory

efforts

Respiratory arrest

More profound hypoxemia than either of

previous conditions
Gas exchange at the alveolar-capillary
membrane is inadequatetoo little O2
reaches the blood and CO2 is retained.

Chronic emphysema, bronchitis, asthma

10

Acute Respiratory Failure

Rapidly developing dyspnea is an emergency

situation
Pulse oximeter is less than 90% and partial
pressure of oxygen less than 60 mm Hg
Partial pressure of arterial carbon dioxide
more than 50 mm Hg leading to acidemia
Position patient in upright position, call a
Rapid Response Team, administer oxygen
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Clinical Presentation ARF

Condition

Symptoms

Physical Findings

Hypoxemia

Dyspnea, Orthopnea
Restlessness
Agitation
Disorientation
Confusion
Delirium

Labored breathing
Cyanosis
Tachypnea
Cardiac arrhythmias
Tachycardia

Hypercapnia

Headache, somnolence
Dizziness
Coma, confusion

Hypertension, tachycardia
Muscle twitching
Diaphoresis
Papilledema

Acidosis

Coma

Cardiac arrhythmias
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Causes of Acute Respiratory

Failure

COPD
Pneumonia
Sepsis
Pulmonary edema
Trauma
Overdose

Anesthesia
Surgery
Neurological
insults
Cancer
Pulmonary
embolism
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Management of ARF

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Chronic Respiratory Failure

Chronic Respiratory Failure develops over time

as a result of conditions affecting muscles,
nerves, bones, or tissues support breathing

COPD (chronic obstructive pulmonary disease)

spinal cord injuries
nerve damage (involving the nerves that controls
breathing)
chronic alcohol abuse suppresses the respiratory
center
15

Symptoms of Chronic Respiratory

Failure

difficulty breathing-dyspnea
bluish tint to the skin or lips (due to oxygen
deprivation)
bluish fingernails
rapid breathing
fatigue
agitation, anxiety, confusion or sleepiness
productive cough
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Treatment of Chronic Respiratory

Failure (COPD)

Oxygen therapy 2-4 L/min by nasal cannula

to maintain SPO2 88%
Positioning in upright position
Pursed lip Breathing
Medications:

Inhalers: atrovent, proventil, flovent

Mucolytics mucomyst, guaifenesin,
dextromethorphan
Long acting control with Spiriva and Vrovana
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Acute Respiratory Distress

Syndrome (ARDS)

Persistent hypoxia despite

100% FiO2
Decreased pulmonary
compliance
Dyspnea
Pulmonary edema
Dense pulmonary infiltrates
seen on x-ray
Mortality for <60 years is 40
percent, higher if >60

18

ARDS Signs and Symptoms

Inflammatory response to lung injury: sepsis

and trauma most common causes
Rapid shallow respirations
Inspiratory crackles
Respiratory alkalosis
Lab work: ABGs, brain natriuretic peptide
(BNP), tumor necrosis factor (TNF) and
interleukin 1 (IL-1)
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Etiologies of ARDS

20

Causes of Lung Injury in ARDS

Systemic inflammatory response (SIRS)

Intrinsically the alveolar-capillary
membrane is injured

sepsis and shock.

Extrinsically the alveolar-capillary

membrane is injured

aspiration or inhalation injury.

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Pathophysiology of ARDS

22

Synonyms for ARDS

23

Collaborative Management ARDS

Diagnostic Tests

Medications

Oxygen therapy, mechanical ventilation, PEEP

Diet

Bronchodilators, mucolytics

Treatments

ABG, chest x-ray, sputum culture, serum electrolytes,

complete blood count

NPO or high calorie

Activity

BR, cluster nursing interventions

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Management of ARDS

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ABG Review

pH normal is 7.35 - 7.45

PaCO2 35-45 mm Hg

Poorly oxygenating

PaO2 <50

SaO2 90%-100%

Retaining carbon dioxide PCO2 >50

PaO2 80 to 100 mm Hg

pH <7.35 is Acidosis

<90% Poorly perfusing

HCO3 normal is 22 to 26 mEq/liter

>27 Compensation for acidosis

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Blood Gas interpretation

Disorder

pH

Primary problem

Compensation

Metabolic acidosis

in HCO3-

in PaCO2

Metabolic alkalosis

in HCO3-

in PaCO2

Respiratory acidosis

in PaCO2

in [HCO3-]

Respiratory
alkalosis

in PaCO2

in [HCO3-]

28

Oxyhemoglobin Dissociation
Curve
Venous point: pO2 40 mmHg with SaO2 = 75%

pO2 100 mmHg with SaO2 = 97.5%

P50 is Partial pressure of oxygen at which

the oxygen carrying protein is 50%
saturated Normal 26.6 mmHg

P50
29

Oxyhemoglobin Dissociation
Curve

One molecule of hemoglobin binds with 4

molecules of oxygen in the alveoli and
unloads oxygen or dissociates oxygen in the
tissues
A right shift indicates decreased oxygen
affinity (oxygen easily moves to tissues).
When the oxygen needs are lower due to
decreased metabolism there is a shift to the
left (oxygen remains on hemoglobin)
30

Oxyhemoglobin Dissociation
Curve

A shift to the right (oxygen moves to tissues)

can be caused by an increase in 4 factors:

high temperature
increased pH (high hydrogen ion concentration
increased pCO2
increased breakdown products of RBC
(glycolosis) red cell 2, 3 DPG level

31

Oxyhemoglobin Dissociation
Curve

A shift to the left (oxygen remains on

hemoglobin) can result from
Decreased tissue temperature
Decreased pCO2
Decreased glucose breakdown
Higher pH or alkalosis
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Clinical Example

Myocardial infarction patient has increased

anaerobic metabolism, increasing CO2.
Oxygen will dissociate quickly to the hypoxic
tissues
If patient takes antacids believing they have
heartburn, alkalosis results
Shift to the left from alkalosis decreases
oxygen delivery to the hypoxic tissue
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Origin of Pulmonary Embolism

34

Pulmonary Embolism

Collection of particulate matter-solids, liquids, or

gases-enters venous circulation & lodges in the
pulmonary vessels.
A deep vein thrombosis
breaks loose from one
of the veins in the legs or
pelvis.

35

Etiology
Prolonged immobilization
Central venous catheters
Surgery
Obesity
Advancing age
Hypercoagulability
History of thromboembolism
Cancer diagnosis

36

Pulmonary Health Promotion and

Illness Prevention

Stop smoking.
Reduce weight.
Increase physical activity.
If traveling or sitting for long periods,
exercise, get up frequently and drink plenty of
fluids.
Refrain from massaging or compressing leg
muscles.
Hospitalized patients: VTE prophylaxis
37

Clinical Manifestations
Assess the client for:
Respiratory manifestations: dyspnea, tachypnea,
tachycardia, pleuritic chest pain, dry cough,
hemoptysis
Cardiac manifestations: distended neck veins,
syncope, cyanosis, hypotension, abnormal heart
sounds, abnormal electrocardiogram findings
Low-grade fever, petechiae, symptoms of flu

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Interventions
Evaluate

chest

pain
Auscultate breath
sounds
Encourage good
ventilation and
relaxation
Surgery

Monitor the
following:

respiratory pattern
tissue oxygenation
laboratory values
effects of
anticoagulant
medications
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Pulmonary Embolism Pathway

41

Pulmonary Embolism In Situ

42

Pleural Conditions
Pleurisy:

inflammation of both layers of

pleurae

Inflamed surfaces rub together with respirations,

cause sharp pain intensified with inspiration

Pleural

effusion: collection fluid in pleural

space usually secondary to another disease
process

Large effusions impair lung expansion, cause

dyspnea
43

Pleural Effusion Illustrated

44

Pleural Conditions (contd)

Empyema: accumulation of thick, purulent fluid
in pleural space.
Caused from pulmonary infection, lung
abscess or infected pleural effusion
Pneumonia or lung abscess spread across
pleura
Chest surgery or trauma introduces bacteria
into the pleural space
45

Empyema Illustrated

46

Empyema

Recent febrile illness, chest pain dyspnea, cough,

trauma
Patient usually acutely ill; febrile, night sweats,
chills fluid
Fibrin development, abnormal breath sounds,
decreased fremitus, impaired lung expansion
Resolution is a prolonged process
Thoracentesis to diagnosis, culture
Treat by collapsing lung, draining empyema,
chest tube(s) and appropriate antibiotics
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Chest Trauma

Chest injuries are responsible for 25% of traumatic

deaths in United states
Pulmonary Contusion most frequently from rapid
deceleration from car crashes

Respiratory failure develops over time

Hemorrhage and edema in and between alveoli
Hypoxemia, dyspnea and secretions develop
Goal: maintenance of ventilation and oxygenation
May need ventilatory support with PEEP
Often leads to ARDS
48

Rib Fractures
Fractures of the ribs result from blunt trauma
Bone ends of the ribs may be driven into the
chest and may cause:

pulmonary contusion
hemothorax
pneumothorax

Pain on inspiration results in splinting, possibly to pneumonia and atelectasis

Ribs will reunite spontaneously
Treatment focuses on controlling pain
Intercostal block if pain is severe
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Flail Chest
Flail Chest

is paradoxic

chest movement resulting from

multiple rib fractures usually from car accidents

The chest sucks inward during inspiration and

puffs out during expiration

Treatment includes

Humidified oxygen
Respiratory care to clear secretions
Monitoring ABGs for respiratory failure

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Pneumothorax

Collapsed lung

A pneumothorax is an injury to the chest that

allows
air to enter pleural space and collapse the lung
Symptoms include decreased breath sounds, tracheal deviation
toward open on affected side, subcutaneous emphysema,
pleuritic pain
May occur from trauma, medical procedures (central line
insertion) or
Treatment is with chest tube(s) closed chest drainage
Spontaneous tension pneumothorax: may need emergency
decompression with a large bore needle to 2nd intercostal space
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Hemothorax

Hemothorax is bleeding into the lung

following blunt trauma or penetrating injuries

May occur after rib or sternum fractures

Breath sounds are reduced on auscultation
Percussion is dull, breath sounds reduced on involved side
Blood in the pleural space may be
removed by
thoracentesis and chest tube(s)
Thoracotomy needed to remove 15001500
-2000 mL from chest
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Questions?

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