Chapter 27: Respiratory Failure

Chapter 27: Respiratory Failure  

Overview

• Includes:

  • Acute Respiratory Failure (ARF)

  • Acute Respiratory Distress Syndrome (ARDS)

  • Severe Acute Respiratory Syndrome (SARS)

• Older adults are at higher risk due to:

  • Decreased lung elasticity

  • Thickened alveoli

  • Reduced pulmonary reserve (faster decompensation)

Acute Respiratory Failure (ARF)

Failure to adequately ventilate and or oxygenate

Leads to ventilation–perfusion (V/Q) mismatch

Types and Causes

• Ventilatory failure (impaired CO₂ removal)

  • Mechanical lung or chest wall problems

  • Respiratory muscle dysfunction (especially diaphragm)

  • CNS respiratory control dysfunction

• Oxygenation failure (impaired O₂ uptake)

  • Decreased pulmonary perfusion (pulmonary embolism)

  • Altered gas exchange medium (pulmonary edema, pneumonia)

• Combined ventilatory and oxygenation failure

  • Diseased lungs (asthma, emphysema, cystic fibrosis)

  • Leads to ↑ work of breathing, muscle fatigue, severe hypoxemia

Diagnosis

• Based on arterial blood gas (ABG) values

Acute Respiratory Distress Syndrome (ARDS)

Cause

• Lung injury from:

  • Sepsis

  • Trauma

  • Burns

  • Aspiration

  • Blood transfusions

• Results in fluid accumulation in alveoli → impaired gas exchange

Pathophysiology

• Systemic inflammatory response damages alveolar–capillary membrane

• Increased permeability → protein-rich fluid fills alveoli

• Decreased surfactant → alveolar collapse

• Worsening edema compresses and destroys airways

Severe Acute Respiratory Syndrome (SARS)

Cause

• Viral infection from mutated coronavirus (e.g., SARS-CoV-2)

Key Features

• Virus invades pulmonary tissue → inflammatory response

• Spread via airborne droplets (coughing, sneezing, talking)

A nurse is reviewing the health records of five clients. Which of the following clients should the nurse identify as being at risk for developing acute respiratory distress syndrome?

Select all that apply.

a

A client who experienced a near-drowning incident

b

A client following coronary artery bypass graft surgery

c

A client who has a hemoglobin of 15.1 mg/dL

d

A client who has dysphagia

e

A client who experienced acute drug toxicity

a

A client who experienced a near-drowning incident

b

A client following coronary artery bypass graft surgery

d

A client who has dysphagia

e

A client who experienced acute drug toxicity

---

ARDS develops after a client experiences an acute lung injury that stimulates the inflammatory process within the lungs.

Acute Respiratory Failure Risk Factors

Ventilatory Failure

• COPD

• Pulmonary embolism

• Pneumothorax

• Flail chest

• ARDS

• Asthma

• Pulmonary edema

• Pulmonary fibrosis

• Neuromuscular disorders (multiple sclerosis, Guillain-Barré syndrome)

• Spinal cord injury

• Stroke impairing respiratory drive

• Elevated intracranial pressure

Oxygenation Failure

• Pneumonia

• Hypoventilation

• Hypovolemic shock

• Pulmonary edema

• Pulmonary embolism

• ARDS

• Low hemoglobin (anemia)

• Low environmental oxygen:

  • Carbon monoxide poisoning

  • High altitude

  • Smoke inhalation

Combined Ventilatory and Oxygenation Failure

• Hypoventilation

• Chronic bronchitis

• Acute asthma attack

• Emphysema

• Cardiac failure

Acute respiratory distress syndrome (ARDS) Risk Factors

Shock

Disseminated intravascular coagulation (DIC)

Aspiration

Pulmonary emboli (fat, amniotic fluid)

Pneumonia and pulmonary infections

Sepsis

Near-drowning

Trauma

Multiple blood transfusions

CNS damage

Smoke or toxic gas inhalation

Drug toxicity (opioids, heroin, salicylates)

SARS-CoV-2 infection

Severe acute respiratory syndrome (SARS) Risk Factors

Exposure to infected individual

Immunocompromised state (chemotherapy, AIDS)

Age ≥ 65 years

Chronic kidney, liver, or lung disease

Smoking or substance use disorder

Obesity

Cardiovascular disease

Diabetes mellitus type 1 or 2

Pregnancy

Vitamin D deficiency

Acute Respiratory Failure Expected Findings

Dyspnea

Orthopnea

Cyanosis

Hypoxemia

Tachycardia

Confusion

Irritability or agitation

Restlessness

Hypercarbia (elevated CO₂)

ARDS Expected Findings

Severe dyspnea

Bilateral noncardiogenic pulmonary edema

Decreased lung compliance

Patchy bilateral infiltrates on chest x-ray

Severe hypoxemia despite 100% oxygen

Cyanosis

Pallor

Intercostal and substernal retractions

SARS-CoV-2 Expected Findings

Mild to Moderate

• Dyspnea

• Sore throat

• Loss of taste and smell

• Cough

• Fatigue

• Myalgia

• Headache

Severe

• Chest pressure or pain

• Cyanosis

• Altered level of consciousness

• ARDS

• Sepsis (may progress to septic shock)

• Kidney damage

• Cardiomyopathy

• Pneumonia

• Irregular heartbeat

ARF Labs

ABGs

• PaO₂ < 60 mm Hg or SaO₂ < 90% on room air (hypoxemia)

• PaCO₂ > 50 mm Hg with pH < 7.35 (ventilatory failure)

• SaO₂ < 90%

Combined Ventilatory and Oxygenation Failure

• Room air PaO₂ < 60 mm Hg (oxygenation failure)

• OR PaCO₂ > 50 mm Hg with pH < 7.35 (ventilatory failure)

• SaO₂ < 90% in both

ARDS Labs

ABGs

• PaO₂ < 60 mm Hg or SaO₂ < 90% on room air (hypoxemia)

• PaCO₂ > 50 mm Hg with pH < 7.35 (ventilatory failure)

• SaO₂ < 90%

Brain natriuretic peptide (BNP) (helps rule out cardiac cause)

SARS Labs

ABGs

• PaO₂ < 60 mm Hg or SaO₂ < 90% on room air (hypoxemia)

• PaCO₂ > 50 mm Hg with pH < 7.35 (ventilatory failure)

• SaO₂ < 90%

SARS

• CBC with differential

• Aminotransferases

• D-dimer

• C-reactive protein

• Ferritin

• Lactate dehydrogenase

SARS-CoV-2 Diagnostic Testing

• Rapid antigen test

  • Positive = high likelihood of infection

  • Negative = low likelihood

• NAAT (PCR)

  • Preferred test

  • Detects viral RNA

  • High sensitivity

Respiratory Failure Diagnostics

Chest X-ray

• Pulmonary edema (ARF, ARDS)

• Cardiomegaly (ARF)

• Diffuse infiltrates or ground-glass appearance (ARDS, SARS)

• Pulmonary infiltrates (SARS)

CT Scan

• Scattered ground-glass opacities (SARS)

Nursing Actions

• Assist with positioning before and after imaging

• Report results promptly

Electrocardiogram (ECG)

• Used to rule out cardiac involvement

Hemodynamic Monitoring

• Pulmonary capillary wedge pressure in ARDS:

  • Normal or low (4–12 mm Hg)

• Used for fluid management

Nursing Actions

• Monitor ECG during central venous catheter placement

• Keep resuscitation equipment available

• Monitor hemodynamic waveforms and values

• Confirm catheter placement with chest x-ray

Respiratory Failure Care

Maintain patent airway and assess respiratory status at least hourly.

Mechanical ventilation often required:

• Use PEEP or CPAP to prevent alveolar collapse during expiration.

• Follow facility protocol for ventilator monitoring and documentation.

Oxygenate before suctioning to prevent worsening hypoxemia.

Suction as needed:

• Common indicator: coarse crackles over trachea.

Assess and document sputum color, amount, and consistency.

Monitor:

• Vital signs

• Breathing patterns

• Lung sounds

• Continuous SaO₂

• Pain level

Monitor ABGs as prescribed and after ventilator setting changes.

Continuous ECG monitoring:

• Watch for dysrhythmias related to hypoxemia, especially during repositioning or suctioning.

Monitor for pneumothorax:

• High PEEP increases risk.

Positioning:

• Optimize ventilation and perfusion.

• Prone positioning as prescribed for ARDS or SARS.

Infection prevention:

• Strict hand hygiene.

• Proper suctioning technique.

• Oral care every 2 hr and as needed.

• Use PPE appropriately.

• Droplet and contact precautions for SARS-CoV-2.

• Airborne precautions during aerosol-generating procedures.

Nutrition support:

• Monitor bowel sounds and elimination.

• Daily weights.

• Monitor intake and output.

• Administer enteral or parenteral nutrition as prescribed.

• Elevate HOB 30°–45° during tube feedings (aspiration prevention).

• Verify NG tube placement before feedings.

Provide emotional support:

• Encourage expression of feelings.

• Provide alternative communication methods (dry erase board, pen and paper).

Interprofessional Care

Respiratory Therapy

• Manages ventilator settings.

• Provides chest physiotherapy.

• Performs endotracheal suctioning.

• Administers inhaled medications.

Physical Therapy

• Supports rehabilitation after prolonged ventilation.

Nutritional Therapy

• Enteral or parenteral feeding.

• Nutritional support after extubation.

Respiratory Failure Meds

Benzodiazepines

• Examples:

  • Lorazepam

  • Midazolam

• Action:

  • Decrease anxiety and resistance to ventilation

  • Reduce oxygen consumption

• Nursing Actions:

  • Monitor respirations in non-ventilated clients.

  • Monitor blood pressure and SaO₂.

  • Use cautiously with opioids.

General Anesthesia

• Example:

  • Propofol

• Actions:

  • Induces and maintains anesthesia

  • Sedates for mechanical ventilation

• Nursing Actions:

  • Contraindicated in egg allergy or hyperlipidemia.

  • Administer only to intubated, ventilated clients.

  • Monitor ECG, blood pressure, sedation level.

  • Slow IV rate to assess neurologic status per protocol.

  • Monitor for hypotension.

  • Titrate to ordered sedation level.

  • No analgesic effect. Assess pain and give analgesics as prescribed.

Corticosteroids

• Examples:

  • Cortisone acetate

  • Methylprednisolone sodium succinate

  • Dexamethasone sodium phosphate

• Indication:

  • Hospitalized SARS-CoV-2 clients requiring supplemental oxygen

• Action:

  • Decrease inflammation and WBC migration

• Nursing Actions:

  • Taper gradually.

  • Administer with antiulcer medication.

  • Monitor weight and blood pressure.

  • Monitor glucose and electrolytes.

• Client Education:

  • Take oral doses with food.

  • Do not stop abruptly.

Opioid Analgesics

• Examples:

  • Morphine sulfate

  • Fentanyl

• Action:

  • Pain control

• Nursing Actions:

  • Monitor respirations in non-ventilated clients.

  • Monitor blood pressure, heart rate, SaO₂.

  • Monitor ABGs (risk of hypercapnia).

  • Use cautiously with sedatives.

  • Assess pain and response.

  • Keep naloxone and resuscitation equipment available.

Neuromuscular Blocking Agents

• Examples:

  • Vecuronium

  • Atracurium

  • Rocuronium

• Actions:

  • Facilitate ventilation

  • Decrease oxygen consumption

  • Used with high PEEP or inverse ratio ventilation

• Nursing Actions:

  • Use only in intubated, ventilated clients.

  • Monitor ECG, blood pressure, muscle strength.

  • Always administer sedatives and analgesics concurrently.

  • Do not provide sedation or pain relief alone.

  • Have neostigmine and atropine available for reversal.

  • Have resuscitation equipment available.

  • Explain procedures.

• Client Education:

  • Paralysis is medication-induced.

Antibiotics (Culture-Sensitive)

• Example:

  • Vancomycin

• Action:

  • Treat identified organisms

• Nursing Actions:

  • Obtain sputum culture before first dose.

  • Monitor for hypersensitivity reactions.

  • Infuse IV dose over at least 60 min (prevent red man syndrome).

  • Monitor IV site for infiltration.

  • Do not mix with other medications.

  • Monitor renal function and coagulation.

• Client Education:

  • Take oral doses with food.

  • Complete full course.

Antivirals (SARS-CoV-2)

• Example:

  • Remdesivir

• Action:

  • Slows viral replication

• Nursing Actions:

  • Obtain GFR, liver enzymes, PT, and INR before and during therapy.

  • Monitor for hypersensitivity.

  • Monitor IV site.

  • Monitor renal function and coagulation.

  • Monitor for GI side effects.

Antirheumatics (SARS-CoV-2)

• Examples:

  • Baricitinib

  • Tocilizumab

• Action:

  • Suppress inflammatory response

• Nursing Actions:

  • Monitor for hypersensitivity.

  • Monitor for arterial and deep vein thrombosis.

  • Monitor liver and kidney function.

  • Obtain CBC with differential and absolute neutrophil count.

Anticoagulants (SARS-CoV-2)

• Examples:

  • Dalteparin

  • Enoxaparin

• Action:

  • Prevent clot formation

• Nursing Actions:

  • Monitor for hypersensitivity.

  • Inspect injection sites for bruising.

  • Monitor for bleeding.

  • Obtain CBC with differential and absolute neutrophil count.

Immunizations (SARS-CoV-2)

• Follow current CDC guidelines for age and risk group.

Respiratory Failure Procedures

Intubation and Mechanical Ventilation

• Artificial airway placement with ventilator support

Nursing Actions

• Monitor ECG, SaO₂, lung sounds, skin color.

• Sedate as needed.

• Explain procedure and provide reassurance.

• Keep suction, bag-valve mask, and oxygen available.

• Suction as needed.

Preintubation

• Preoxygenate with 100% oxygen.

• Assist ventilation with bag-mask.

• Ensure emergency equipment is ready.

Postintubation

• Confirm placement:

  • End-tidal CO₂

  • Bilateral breath sounds

  • Symmetrical chest movement

  • Chest x-ray

• Secure tube per protocol.

• Monitor cuff pressure:

  • Maintain 20–30 cm H₂O (prevent tracheal injury).

PEEP

• Maintains alveolar expansion during expiration.

• Improves gas exchange and prevents atelectasis.

Client Education

• Alternative communication methods are required while intubated.

Kinetic Therapy

• Rotational bed therapy to reduce atelectasis and improve ventilation

Nursing Actions

• Start slowly and increase rotation as tolerated.

• Monitor ECG, SaO₂, breath sounds, blood pressure.

• Stop if distress occurs.

• Provide skin care.

• Sedate as needed.

Respiratory Failure Complications

Endotracheal Tube Trauma

• Tracheal or vocal cord injury.

• Possible need for tracheostomy with long-term ventilation.

Altered Endotracheal Tube Position

• Nursing Actions:

  • Check tube position every 1–2 hr.

  • Monitor cuff pressure (20–30 cm H₂O).

  • Assess lung sounds, SaO₂, chest movement with repositioning.

  • Secure tube and document depth.

Aspiration Pneumonia

• Nursing Actions:

  • Check cuff for leaks.

  • Assess suction contents for gastric material.

  • Verify NG tube placement.

Infection

• Nursing Actions:

  • Strict hand hygiene.

  • Proper suctioning technique.

  • Meticulous oral care.

  • Monitor secretion color, amount, and consistency.

Blocked Endotracheal Tube

• Indicated by high-pressure ventilator alarm.

• Nursing Actions:

  • Suction secretions.

  • Insert oral airway to prevent tube biting.

Mechanical Ventilation Complications

Increased Intrathoracic Pressure

• Effects:

  • Decreased venous return

  • Decreased cardiac output

  • Hypotension

  • RAAS activation → fluid retention, ↓ urine output

• Nursing Actions:

  • Monitor intake and output.

  • Daily weights.

  • Assess hydration.

• Client Education:

  • Avoid Valsalva maneuver.

Barotrauma

• Causes:

  • Pneumothorax

  • Subcutaneous emphysema

• Nursing Actions:

  • Monitor oxygenation and ABGs.

  • Assess for crepitus.

  • Monitor for high-pressure alarms.

Immobilization

• Risks:

  • Muscle atrophy

  • Pneumonia

  • Pressure injuries

• Nursing Actions:

  • Reposition and suction every 2 hr.

  • Provide skin care.

  • Perform range-of-motion exercises.

SARS-CoV-2 Infection

Post-Acute Coronavirus Syndrome

• Symptoms lasting ≥ 4 weeks:

  • Dizziness

  • Myalgia

  • Persistent loss of taste or smell

  • Brain fog

  • Depression

  • Dyspnea

  • Headache

  • Fatigue

• Nursing Actions:

  • Educate clients on symptoms.

  • Assess at follow-up visits.

  • Refer as needed.

Patient Education: SARS-CoV-2

• Hand hygiene.

• Maintain ≥ 6 ft distance when indicated.

• Wear a mask when indicated.

• Avoid touching face.

• Obtain COVID-19 vaccination per CDC guidelines.

A nurse is planning care for a client who has severe acute respiratory distress syndrome (ARDS). Which of the following actions should the nurse include in the plan of care?

Select all that apply.

a

Administer antibiotics.

b

Provide supplemental oxygen.

c

Administer enteral nutrition.

d

Administer of bronchodilators.

e

Maintain ventilatory support.

b

Provide supplemental oxygen.

c

Administer enteral nutrition.

e

Maintain ventilatory support.

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

a

“This medication is given to treat infection.”

b

“This medication is given to facilitate ventilation.”

c

“This medication is given to decrease inflammation.”

d

“This medication is given to reduce anxiety.”

b

“This medication is given to facilitate ventilation.”

Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and SaO₂ 91% on room air. Which of the following actions should the nurse take first?

a

Obtain a chest x-ray.

b

Prepare for chest tube insertion.

c

Administer oxygen via a high-flow mask.

d

Initiate IV access.

c

Administer oxygen via a high-flow mask.

A nurse is planning care for a client in the ICU who has a SARS-CoV-2 infection that has progressed to ARDS. In which of the following positions should the nurse plan to place the client to promote ventilation.

a

Supine

b

Dorsal recumbent

c

Prone

d

Left lateral

c

Prone