Critical Care of Patients with Acute Respiratory Disorders

Acute Respiratory Distress Syndrome

• acute lung injury

• from an acute insult at the level of the alveoli, causing severe hypoxemia and decreased compliance of the lungs

1. Shock

2. Aspiration

3. Sepsis

Precipitating Factors of Acute Respiratory Distress Syndrome

1. Pneumonia

2. Aspiration

Direct Etiologic/Risk Factors related to ARDS

1. Sepsis

2. Severe Trauma

3. Severe Burns

Indirect Etiologic/Risk Factors related to ARDS

1. Major Surgery

2. Hematologic Disorder

Other Etiologic/Risk Factors related to ARDS

1. Macrophages

2. Neutrophils

Cellular mediators that are released in ARDS causing injury to the alveolar capillary membrane

1. Cytokines

2. Enzymes

Chemical mediators that are released in ARDS causing injury to the alveolar capillary membrane

stiff lungs

In ARDS, lung compliance becomes markedly decreased

1. decrease in functional residual capacity

2. severe hypoxemia

The result of ARDS

severe refractory hypoxemia

In ARDS, . the blood returning to the lung for gas exchange is pumped through the nonventilated, nonfunctioning areas of the lung, causing a shunt to develop. This means that blood is interfacing with nonfunctioning alveoli & gas exchange is markedly impaired, resulting in

Crackles

Is heard in ARDS as fluid begins to leak into the alveolar interstitial space

Fibrosing alveolitis

in ARDS, Acute lung injury then progresses to X with persistent severe hypoxemia

4 to 12 mmHg

(ARDS) Normal reading of pulmonary artery wedge pressure reading:

>15 mmHg

Elevated reading of Pulmonary artery wedge pressure which suggest increased left-sided heart failure/cardiogenic pulmonary edema

1. hypovolemia

2. reduced preload

In Pulmonary artery wedge pressure reading the “low“ indicates

1. Mechanical Ventilation

Medical Management of Acute Respiratory Distress Syndrome

35 cm

In ARDS, Protective ventilation, maximum inspiratory pressure of X should be instituted

Positive End-Expiratory Pressure

In ARDS, this should be used to improve PaO2 to keep the alveoli open, thereby improving gas exchange

1. bronchodilators

2. corticosteroids

3. neutrophil inhibitors

Drugs used in Acute Respiratory Distress Syndrome for Medical Intervention

Antibiotics

What drug to use if is it already in the late course of ARDS?

Impaired gas exchange related to fluid in lungs

Acute Respiratory Distress Syndrome Nursing Diagnosis

1. O2

2. Teach slow, pursed lip breathing

3. CPT

Nursing Management in Acute Respiratory Distress Syndrome

1. 60 mmHg

2. >90 %

in ARDS, Maintain PaO2 of X mmHg or Sao2 X

intubation & initiation of mech vent

In ARDS, Assist with X if patient becomes increasingly lethargic, cannot cough or expectorate secretions, cannot cooperate with therapy, or if pH falls below 7.30

1. Pneumococcal vaccine

2. Flu vaccine

Preventive measure of Acute Respiratory Distress Syndrome

Pulmonary Embolism

Obstruction of one or more pulmonary arteries by a thrombus (or thrombi) which becomes dislodged and is carried to the pulmonary vasculature

1. deep vein of the legs

2. right side of the heart

3. upper extremity

Usual origin of Pulmonary Embolism

Pulmonary Infarction

Refers to necrosis of lung tissue that can result from interference with the blood supply

1. venous stasis

2. concurrent phlebitis

3. heart failure, stroke

Predisposing Factors of Pulmonary Embolism

1. immobilization

2. obesity

3. MI

Risk Factors of Pulmonary Embolism

increase in pulmonary vascular resistance

This reaction compounds the ventilation-perfusion imbalance

1. syncope

2. sharp & stabbing chest pain

3. hypocapnia

4. hypoxemia

Results in Pulmonary Embolism

impending doom

Chest pain with apprehension and a sense of X occurs when most of the pulmonary artery is obstructed

heart gallop

Clinical manifestation of pulmonary embolism: there is a loud pulmonic component of S2 (Split S2)

palpable cord

In Pulmonary Embolism, signs of suggestive deep ein thrombosis is

1. Thoracic imaging

2. Pulmonary angiography

3. venography

4. D-dimer assay

5. ABG/Electrolytes levels

6. CXR

Diagnostic Evaluation of Pulmonary Embolism

Ventilation/Perfusion Scan

V/Q Scan is a test of choice for suspected PE (possibly using single-photon emission computed tomography) or helical contrast-enhanced CT scan

Pulmonary Angiography

if noninvasive testing is inconclusive or not a candidate for noninvasive testing

Contrast studies

should be avoided in persons who are pregnant or have advanced renal failure

Venography

test results confirm or exclude the diagnosis of PE)

D dimer assay

for low to intermediate probability of pulmonary embolism

ABG/Electrolyte levels

• decreased PaO2 is usually found in Pulmonary Embolism, due to perfusion abnormality of the lung

• respiratory alkalosis

CXR

normal or possible wedge-shaped infiltrate; usually shows sinus tachycardia, PR interval depression, and nonspecific T-wave change

1. nasal oxygen

2. perfusion scan

3. dobutamine or dopamine

4. digitalis glycosides

5. continuous ECG monitoring

6. IV morphine or sedatives

Massive PE is a life-threatening emergency. The immediate objective is to stabilize the cardiopulmonary system:

dabigatran (Pradaxa)

Non-vitamin K antagonist oral anticoagulants for Pulmonary Embolism

Warfarin (Coumadin)

Anticoagulation therapy for pulmonary embolism

urokinase (Kinlytic)

Thrombolytic Therapy for Pulmonary Embolism

IV Morphine

may be given to relieve anxiety, alleviate chest discomfort (which improves ventilation).

4 to 6 hours

In Pulmonary Embolism, IV loading dose usually followed by continuous pump or drip infusion or given intermittently every

1 1/2 to 2

Dosage adjusted to maintain the partial thromboplastin time (PTT) at X times the pretreatment value (if the value was normal)

Protamine sulfate

IV heparin in PE. this may be given to neutralize heparin in event of severe bleeding

1. Ligation

2. Plication

3. clipping of the inferior vena cava

Surgical Management in PE: Interruption of vena cava-reduces channel size to prevent lower extremity emboli from reaching lungs and it is accomplished by

femoral or jugular

Placement of transvenously inserted Intraluminal Filter in inferior vena cava to prevent migration of emboli; inserted through X vein by way of catheter.

Pulmonary Embolectomy

A surgical management in pulmonary embolism that requires a thoracotomy with cardiopulmonary bypass technique

Transvenous catheter embolectomy

a technique in which a vacuum-cupped catheter is introduced transvenously into the affected pulmonary artery. Suction is applied to the end of the embolus and the embolus is aspirated into the cup

Ineffective Tissue Perfusion (Pulmonary) related to decreased blood circulation

Nursing Diagnosis of Pulmonary Embolism

Correcting Breathing Pattern

Nursing Management of Pulmonary Embolism

1. IV fluids

2. Vasopressors

In PE, Monitor patient’s response to

Hypoxemia

In PE, This is due to abnormalities of V/Q mismatch

Respiratory Failure

an alteration in the function of the respiratory gas exchange system in either O, (hypoxic respiratory failure) and/or CO, elimination (hypercapnic respiratory failure)

hypoxic respiratory failure

alteration in the function of the respiratory gas exchange system in Oxygen

hypercapnic respiratory failure

alteration in the function of the respiratory gas exchange system in carbon dioxide

Hypoxemic respiratory failure (type 1)

is characterized by arterial oxygen (PaO2 ) level to fall below 60 mmHg (hypoxemia) with a normal or low arterial CO2 tension (PaCO2)

Hypoxemic respiratory failure (type 1)

it is the most common form of respiratory failure, usually associated with acute diseases of the lung

Hypercapnic respiratory failure (type 2)

• is characterized by an arterial CO2 (PaCO2) level of 50 mmHg.

• Hypoxemia is common while breathing room air.

• pH depends on the bicarbonate level, which, in turn, is dependent on the duration of hypercapnia.

1. acute

2. chronic

3. combined acute and chronic

Respiratory failure is classified as

Acute Respiratory Failure

• Characterized by hypoxemia (PaO2 <50 mmHg) and/or hypercapnia (PaCO2 >50 mm Hg) and acidosis (pH less than 7.35).

• Occurs rapidly, usually in minutes to hours or days

Chronic Respiratory Failure

• Characterized by hypoxemia (decreased PaO2) and/or hypercapnia (increased PaCO2) with a normal pH (7.35 to 7.45).

• Occurs over a period of days to months to years, allowing for activation of compensatory mechanisms, including bicarbonate retention with normalization of pH

1. Hypoxemia

2. Hypercapnia

3. Tachypnea then bradypnea

4. Accessory muscles use

5. Asynchronous resiprations

Clinical Manifestation of Respiratory Failure

Hypoxemia

restlessness, agitation, dyspnea, disorientation, confusion, delirium, loss of consciousness

hypercapnia

headache, somnolence, dizziness, confusion

ABG levels

Nursing Alert in Respiratory Failure

Obtain X whenever the history or signs and symptoms suggest the patient is at risk for developing respiratory failure

oximeter

The need for ABG analysis can be decreased by using an X to continuously monitor oxygen saturation (SaO2

ABG Analysis

shows changes in PaO2, PaCO2, pH, and possibly HCO3 from the patient's normal

<50 mmHg

PaO2 normal value

35 to 45 mmHg

PaCO2 normal value

7.35

pH normal value

elevated

in Respiratory Failure the end tidal CO2 monitoring is elevated or decreased?

decreasing

in Respiratory Failure the pulse oximetry is increasing or decreasing?

1. CBC

2. CXR

3. ECG

to determine underlying cause and patient’s condition in Respiratory Failure

oxygen therapy

how to correct hypoxemia?

1. bronchodilators

2. corticosteroid

to reduce bronchospasm and inflammation in RF

Diuretics

For Pulmonary vascular congestion or pulmonary edema in RF

Noninvasive positive pressure ventilation

X using a face mask may be a successful option for short-term support of ventilation

fraction of inspired oxygen

Nursing Alert in patients with Respiratory Failure:
Avoid administration of X (FiO2) of 100% for COPD Patients

Impaired Gas Exchange related to fluid in the lungs

Nursing Diagnosis of Patients with Respiratory Failure

administer O2

Nursing Management of Respiratory Failure

1. incentive spirometer

2. nebulization

3. HOB 30

In respiratory failure, provide measures to prevent atelectasis and promote chest expansion and secretion clearance, as ordered

1. SpO2

2. ABG levels

3. RR

4. VC

in Respiratory Failure, Monitor adequacy of alveolar ventilation by frequent measurement of

Chest Physiotherapy

is considered for retained secretions in Respiratory Failure

Pneumococcal vaccine

protects against Streptococcus pneumoniac bacteria in Respiratory Failure

Pneumothorax

• air in the pleural space

• in patients with chest trauma, it is usually the result of a laceration to the lung parenchyma, tracheobronchial tree, or esophagus

• the patient's clinical status depends on the rate of air leakage and size of wound

Spontaneous pneumothorax

sudden onset of air in the pleural space with deflation of the affected lung in the absence of trauma

Tension pneumothorax

buildup of air under pressure in the pleural space resulting in interference with filling of both the heart and lungs

Open pneumothorax

sucking wound of chest which implies an opening in the chest wall large enough to allow air to pass freely in and out of thoracic cavity with each attempted respiration

Hemothorax

• presence of blood in the pleural space as a result of penetrating or blunt chest trauma

• it accompanies a high percentage of chest injuries.

• patient may be asymptomatic, dyspneic, hypoxemic, hypotensive, apprehensive, or in shock.

empyema

in hemothorax, can result in hidden blood loss, increased risk of

empyema

collection of thick, infected pus inside the pleural cavity

1. absent breath sounds

2. tracheal deviation

diminished or X of affected side, X to unaffected side

Hyperresonance

There is X and diminished breath sounds on the affected side in pneumothorax