Respiratory Failure

Description #

Patients are admitted to hospital for various reasons, from trauma, acute medical/surgical events or exacerbations of chronic medical conditions to neurological or psychiatric diagnoses. Sudden, or even expected, deterioration of respiratory status is very distressing to the patient and anxiety-ridden for nursing staff. Almost any patient admitted to hospital can have an event of respiratory failure. The purpose of this module is to provide an overview of respiratory failure (RF) and the clinical interventions necessary to prevent deterioration to refractory respiratory failure.

Learning Objectives #

Upon completion of this module the learner should be able to:

1. Demonstrate the etiology and pathophysiology of respiratory failure

2. Identify early indicators of impending or developing RF

3. Relate diagnostic indicators to clinical indicators for RF

4. Establish a systematic approach to report RF appropriately to the health team

5. Initiate and implement appropriate early interventions for RF to minimize further deterioration

6. Implement appropriate emergency responses and contribute effectively to the resuscitation of a respiratory patient as a member of the health care team

Etiology and Pathophysiology of Respiratory Failure #

Respiratory failure (RF) is a common and serious condition for hospitalized patients. It occurs when the lungs fail in the exchange of oxygen and/or elimination of carbon dioxide. RF is classified as hypoxemia and hypercapnia respiratory failure. The hypoxemia (type I) respiratory failure is defined as PaO2 <60mmHg on room air. The hypercapnia (type II) respiratory failure is defined as PaCO2 >45mmHg with uncompensated acidosis. RF is further classified as acute, chronic or acute on chronic. The most frequent form of RF in hospitalized patients is acute hypoxemia and hypercapnia RF or acute on chronic RF in patients with pre-existing pulmonary disease. 

The process of respiration involves movement of air from the atmosphere to the alveoli, exchange of gases from alveoli and pulmonary capillaries, transport of oxygenated blood to the tissue and exchange of oxygen and carbon dioxide between capillaries and tissue.

In order for these processes to occur there must be:

• A patent airway
• An intact chest wall
• Normal lung parenchyma and pulmonary circulation
• An intact respiratory centre and peripheral nervous system
• Intact respiratory muscles
• Normal cardiac function and normal tissue for oxygen extraction 

Therefore, airway obstruction, lung parenchyma diseases, pulmonary circulation abnormalities, ventilatory pump failure, chest wall abnormalities, and cardiac failure may cause RF. Table 1 describes the effects that each of these abnormalities have on the respiratory system and its effects on gas exchange .

Contributing factors to RF and its mechanisms #

Airway obstruction

Lung parenchyma disease with ventilation/diffusion abnormalities

Pulmonary vessels disorder

CNS and peripheral nervous system disorders

Disorder of respiratory muscle

Chest wall integrity

Other conditions

Mechanisms of Respiratory Failure

Pathophysiology of airway obstruction

Pathophysiology of hypercapnia and hypoxemia respiratory failure

Airway Obstruction #

Lung parenchyma disease with ventilation/diffusion abnormalities #

Pulmonary vessels disorder #

CNS and peripheral nervious system disorders #

Disorder of respiratory muscle #

Chest wall integrity #

Other conditions #

Mechanisms of Respiratory Failure #

Pathophysiology of Airway Obstruction #

Pathophysiology of hypercapnia and hypoxemia respiratory failure #

Refractory Respiratory Failure #

Fig 3 shows the initiation and progression of respiratory failure. The flow diagram is self-explanatory showing the end result of hypercapnia and hypoxemia respiratory failure with mixed acidosis. Progression to refractory respiratory failure will occur if early interventions are not provided for the patient.  

Identify early indicators of impending or developing RF #

High-risk patients for RF often have a precarious health status with minimal respiratory reserve; any acute disease or condition discussed above can initiate the cycle of RF. The presenting clinical signs and symptoms of RF in these patients are dependent on the underlying pathology, and acute or chronic event. However, the usual patient complaints can be non-specific and vague. The most common and earliest complaint from these patients is dyspnea. Therefore, it is important to understand dyspnea (Appendix A: Understanding dyspnea). When interventions are not given during the subjective complaint of breathlessness, the patient will progress to manifest ventilatory fatigue. Table 1 describes the early and late signs and symptoms of RF.

Table 2. Early and Late Signs and Symptoms of Acute RF 

Relate diagnostic indicators to clinical indicators for RF #

The diagnosis of RF begins with a complete medical history with clinical suspicions for the presence of RF. For example, if an unrestrained driver of a single motor vehicle crashed against a power pole they will likely sustain rib fractures, pulmonary contusions, pneumothorax and/or hemothorax, decreased LOC. These injuries will put this patient at risk of developing RF.

Physical assessment is the next step to the diagnosis RF. The assessment should be conducted systematically using A, B, C, & D format and as comprehensive as the situation permits (Table 3). Sometimes, respiratory failure is so advanced the complete assessment needs to be held until the patient is stabilized and respiratory status improved.

Table 3: The ABCD of assessment

Once the physical assessment is completed, then laboratory and imaging studies will be done to confirm the presence and the cause of RF. However, treatment is often initiated before any diagnostic tests. Table 4 shows the different laboratory and imaging studies for RF diagnosis.

Table 4 Laboratory and Imaging Studies for RF

Establish a systematic approach to report RF to appropriate health team #

In order to communicate effectively with the resident and/or physician, one must use a systematic approach to report changes in the patient’s condition. The SBAR is one such communication tool. Table 4 demonstrate an example of the SBAR system using a patient with respiratory complaints.

Table 5 The SBAR Communication Tool

Initiate and implement appropriate early interventions for RF to minimize further deterioration #

Hypoxemia can cause organ dysfunction but hypercapnia by itself without acidosis and hypoxemia is well tolerated without a threat to organ function. Therefore, the priority in the immediate management of RF is to prevent tissue hypoxia. Table 6 shows the appropriate early nursing interventions for RF after the doctor has been notified.

Table 6. Early Nursing Interventions for RF

Hypoxemia RF

Hypercapnia RF

Participate in the emergency response to the resuscitation of a RF patient #

When the patient progresses to (refractory hypoxemia and/or hypercapnia respiratory failure) a code blue situation, the role of the primary nurse is to call for help, activate the code button at the bedside, get other staff to bring the ward crash cart to the bedside and stay with the patient to ensure ABCs are maintained. 

Airway (A)         

• Inspect oral cavity and suction or clear obstruction if present
• Open patient’s airway using either the head-tilt or jaw-thrust maneuver
• When no cervical spine injury is suspected and if tolerated by the patient, insert an oropharyngeal airway 

Breathing (B)         

• Ensure resuscitation ambu bag is attached to the oxygen outlet and/or tank
• Ensure oxygen flowmeter is turned up as far as possible ensuring a delivery concentration of 100% oxygen
• Assist with ventilation if patient is not breathing or having difficulty breathing or the respiratory rate is too slow

Circulation (C)         

• Check patient’s HR and pulse, if there isn’t peripheral palpable pulses check the carotid pulses before starting chest compressions
• Perform a manual (cuff) blood pressure on the patient 
• Ensure that there is an ACCESS IV line established to administer medications
• Delegate duties to other staff such as recording the code, gathering supplies and calling the admitting service/doctor.
• Prepare the patient’s chart to be available to the code team. 
• Provide the code team with a brief overview of the patient’s history and the event that led to the code and any interventions rendered.
• Assist the code team to get supplies and send laboratory specimens.
• Prepare and assist the code team to move the patient to ICU. 

Notify the family of the event and/or the patients transfer to ICU.

Appendix A: Understanding Dyspnea #

Dyspnea #

• A subjective feeling of breathlessness
• Shortness of breath
• Distressing sensation associated with breathing
• Means different things to each patient
• Cannot be equated with objective signs 

Difference Between Breathlessness And Dyspnea

• Breathlessness may not be perceived as unpleasant, e.g., with excitement or exercise
• Dyspnea is usually perceived as discomfort, and laboured
• Usually, the terms are used interchangeably

Mechanisms Of Dyspnea:

• Stimulation of Chemoreceptors
• In carotid and aortic bodies, responding to hypoxia: eg. High altitudes
• In the medulla, responding to a) CO2 and b) pH
• Mechanoreceptors:
• Upper airways and the trigeminal nerve, vagus nerve stretch receptors in bronchial smooth muscles, epithelium of the airways, alveolar interstitium, intercostal muscles.
• Stimulated by environmental temperature, dust, chemicals, and gases.
• Large and sudden changes of lung volume, smoke, pulmonary congestion, asthma, embolism, COPD etc.

Assessment Of Dyspnea #

• Timing:
• Chronic dyspnea (COPD) – progressive, insidious, variable, persistent 
• Acute dyspnea (asthma, or PE) – is sudden, high intensity, and frightening.
• Paroxysmal nocturnal dyspnea (COPD, CHF- at night with patient lying flat
• Find out if occurs at rest or with exercise
• End of life
• Precipitating Factors
• Inhalation of smoke, antigens, fumes (COPD, asthma)
• Orthopnea (COPD, CHF)- assessed by asking patient how many pillows they need at night
• Platypnea (Cirrhosis, pneumonectomy)
• Associated Symptoms
• Cough, with or without sputum- note colour, amount, odor, consistency, time of day, haemoptysis
• Weight loss- Chronic (COPD); sudden weight loss (Cancer, AIDS)
• Chest pain- crushing (MI); pleuritic (Pneumonia or pneumothorax)
• Confusion, restlessness, ßLOC 
• Alleviating Factors
• Position change (Tachypnea or platypnea)
• Medication- Nitroglycerine (MI); Beta-agonists
• Quality
•       How does the patient describe the dyspnea?
• Tightness (bronchospasm, asthma)
• Increase effort to breathe (COPD)
• “Air hunger” “suffocation”- (CHF)
• Intensity 

Borg dyspnea tool- 0-10 rating scale:

• 0- Nothing at all
• 1- very slight
• 5- severe
• 7- very severe
• 10- worst imaginable

Appendix B: Land-marking for Auscultation of the Chest #

Appendix C: Arterial Blood Gas Analysis #

Normal values: 

                       pH         7.35 – 7.45

                      PaCO2   35 – 45 mm Hg

                      PaO2     80 – 95 mm Hg

                       HCO3    21 – 28 mEq/L

Cyber Patient contains animated interactive material for e-education.Select a Cyber Patient Module from the list below to enter

Cyber Patient contains animated interactive material for e-education.

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References #

Beers, M. H., Porter, R.S., Jones, T.V., Kaplan, J. L., & Berkwits, M. (Eds.). (2006). The Merck Manual of Diagnosis and Therapy, 18th edition, Section 5 pp351-511. Division of Merck & Co., Inc. whitehouse Station, NJ.

Markou, N. K., Myrianthefs, P. M., & Baltopoulos, G. J., (Oct-Dec 2004). Respiratory Failure-An Overview. Critical Care Nursing Quarterly, Vol. 27(4), pp. 353-379.

Sharma, S., (June 29, 2006). Respiratory Failure. eMedicine from WebMD, Retrieved on 8/26/2006, from, http://www.emedicine.com/med/topic2011.htm

Sibernagl, S. & Lang, F.,(Eds.). (2000) Color Atlas of pathophysiology, pp 62-91. Thieme, Stuttgart, New York.