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Acute Respiratory Failure Cheat Sheet by

Adult Health 2

Acute Resp. Failur­e/Acute Lung Injury

ARF: sudden deteri­oration in pulmonary gas exchange = CO2 retention & inadequate oxygen­ation
paO2 < 60 mmHg
(should be 80-100)
paCO2 60 mmHg
(should be 35-45)
arterial pH < 7.35
(pts usually acidotic)


Upper airway
Toxic inhalation
Drug reacti­on/OD
Cardio­pulm. bypass
Multiple fractures
Lung/bone marrow tx

Stages of ARF

Stage 1: inc. SOB, RR, few CXR changes... within 24 hr signs of ARDS (CXR changes)
- Tachyp­neic, dyspneic
Stage 2 (Exuda­tive): vent. required
- Address underlying issues
Stage 3 (Proli­fer­ative): hemody­nam­ically unstable
- Can't maintain BP, tachy, compen. mechan­isms, inflam­mation & cascade of events
Stage 4 (Fibrotic): lung fibrosis issues; vent. management issues
- Dec. compli­ance, stiffness

Types of Respir­atory Failure

Type 1 - Acute Hypoxemic: abnl. transport of O2 w/ resultant inadequate oxygen­ation
Type 2 - Hyperc­apnic: inadequate alveolar ventil­ation; marked elevation in paCO2
Type 3 - Mixed Hypoxe­mic­-Hy­per­capnic: inadequate alveolar ventil­ation & abnormal O2 transport
- Often most common type

Management of ARF

Warrants immediate interv­ention!
Correct the cause
Alleviate hypoxemia & hyperc­apnia

Indica­tions for Intubation

Altered mental status or coma
Severe respir­atory distress
Extremely low or agonal RR (gasping)
- Cerebral issue r/t O2
Obvious respir­atory muscle fatigue - r/t inc. work of breathing = mechanical vent.
Peripheral cyanosis - fingers, lips dusky
Impending cardio­pulm. arrest - heart starts to compensate (tachy, arryth­mias) cardiac arrest
Better to intubate electively rather than emerge­ntly!
Mechanical vent. - helps to breathe, protects airway

Systemic Inflam­matory Response Syndrome (SIRS)

2+ of...
Temp. > 100.4oF (38oC) or 98.6oF (36oC)
HR > 90 bpm
RR > 20 breath­s/min or paCO2 < 32
WBC > 12,000 or < 4,000 or/ >10% bands
Older adults - inc. risk for MODS w/ less chance of recovery from ARDS

Acute Respir­atory Distress Syndrome (ARDS)

Severe end of continuum
Complex syndrome w/ high mortality risk
Precip­itated by direct or indirect lung injury
Lung injury Dec. blood flow to lungs (inflamm. mediators thin lung lining) Alveolar membrane damage (membranes thicken, gases can't exchange)
Inc. membrane protein permea­bility ("Leak syndro­me"; changes osmotic pressure) Inters­titial & intra-­alv­eolar edema (alveolar area flooded = pulm. edema) Further impaired oxygen­ation Pulm. edema Inflamm. changes can lead to fibrosis (may cause permanent lung change)
Surfactant gets lost & makes process worse...
- Dec. gas exchange
- Dec. lung compliance (resis­tance, pressure)

ARDS (cont.)

Symptoms can develop very quickly after lung insult
- Accessory muscle use
- Tachypneic
- Tachyc­ardia
- Restless, air hunger = change in O2
- Confusion
- New/wo­rsening lung sounds (crackles, wheezes) steroids
- Change in SpO2
- Lethargy (lose ability to protect airway)
- Dyspnea
- At risk for arrythmias
- Change in renal status
Bolded are the earliest signs

ARDS Diagnostic Criteria

paO2-FiO2 ratio < 200 - shunt formula; normally > 300
B/L infilt­rates on CXR - white out
Elevated serum lactate levels - indicates anaerobic metabo­lism, tissue hypoxia
No cariac etiology for pulm. edema
Deteri­oration of ABG's despite interv­ention - resistant to O2

ARDS Management

- Correct the cause
- Prevent further damage
- Supportive care
Care bundles to improve outcomes
5 P's of ARDS:
- Perfusion (max O2 transport)
- Position
- Protective lung vent.
- Protocol weaning
- Prevent compli­cations
Mechanical ventil­ation
Fluid status: RA/CVP, JVD, BP, urinary output

Mechanical Ventil­ation

Improves O2, figures out CO2, buys time
Lowest FiO2 possible, smallest TV possible
Modes of MV:
- Volume cycled: pushes air in until preset volume delivered
- Time cycled: pushes air in until preset time reached
- Assist modes: pt can assist but vent can take over work of breathing
- Pressure support: weaning mode; depends on pt's breathing (used for weaning)
- Pressure control: preset volume (based on age, sex, height)
- Airway Pressu­re-­Release Ventil­ation (APRV)
Weaning ASAP!
- Infection
- Dependent on machine
- Muscles dependent
- Vent may cause trauma (barot­rauma, pressure trauma)
Positive End Expiratory Pressure (PEEP): back pressure prevents alveolar collapse; helps to keep fluid out of alveoli
- Inc. PEEP = inc. intrat­horacic pressure dec. perfusion = dec. CO
- Affected intrat­horacic pressure = organ failure

Management of Ventilated Patients

3 Priori­ties:
1) Monitor & evaluate pt response
- Vent setting, trach approp­riately
- Assess s/s of distress (lung sounds, chest expansion, ABC & disync­hrony r/t proper setting [change vent settings])
2) Manage vent safely
- Not alone, daily CXR for placement
3) Prevent compli­cations
- Oral care (dec. bacteria), turn & repo. (changes lung perfusion), VAP protocol (elevate HOB >30o, aspiration precau­tions), DVT prophy­laxis, skin care
- Breath sounds should be equal & symm.
- Document safety, measur­ement
Proning: no shock, inc. ICP, unstable spine
- Antibi­otics (if known microo­rga­nism)
- Bronch­odi­lators (airway patency)
- Surfac­tant? (not really used, expensive)
- Cortic­ost­eroids? (immun­osu­ppr­essed, glycemic control)
- Diuretics (dec. lung/g­eneral edema, watch electr­olytes)
- Neurom­uscular blocking agents (paralytic agents, sedatives = dec. work of breathing)
- Flolan? (new; inc. flow, V/Q mismatch)
- Epinep­hrine
- Low dose dopamine
Ex. Neurom­uscular Blocking Agents - propophol, Nimbex, + inotropes
+ Inotropes: dilate vascular bed = inc. CO (dibut­amine, watch for dec. BP - r/t dose; vasopr­essors)
- Dec. mortality, days of not eating prophy­lactic enzyme release
- Avoid inc. carb feeds
Prevent compli­cations - VAP, SIRS, MODS, DVT, infection, skin breakdown

Nursing Diagnoses

Mechanical Vent
Impaired gas exchange
Risk for infection
Dec. tissue perfusion
Risk for injury - r/t airway
Airway clearance
Risk for injury - r/t immobility
NO ineffe­ctive breathing pattern


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