1 TERM PAPER ON ACUTE RESPIRATORY FAILURE AND CHEST TRAUMA BY NWANNA CHIDINMA MAT NO. SUBMITTED TO THE DEPARTMENT OF NURSING SCIENCE FACULTY OF HEALTH SCIENCE IMO STATE UNIVERSITY, OWERRI IN PARTIAL FULFILLMENT OF ADVANCED CONCEPT OF CRITICAL CARE NURSING NSC 723 LECTURER DR. VINCENT CHINELO FEBRUARY, 2022 2 Introduction Acute respiratory failure and chest trauma is a potentially fatal medical condition caused by fluid buildup in the lung’s air sacs. This buildup interferes with critical pulmonary functions in two ways (Cherian, Kumar, & Akasapu, 2016). First, the lungs are blocked from transmitting oxygen to the bloodstream, leading to the gradual starvation of the body’s organs. Secondly, the lungs are prevented from removing carbon dioxide, a waste product of cellular respiration. This results in high levels of bloodstream toxins (Brodie & Bacchetta 2016). Despite many technical advances in diagnosis, monitoring and therapeutic intervention, acute respiratory failure continues to be a major cause of morbidity and mortality in intensive care unit (ICU) setting (Brodie & Bacchetta 2016). Respiratory failure (RF) is diagnosed when the patient loses the ability to ventilate adequately or to provide sufficient oxygen to the blood and systemic organs. Clinically respiratory failure is diagnosed when PaO2 is less than 60mm of Hg with or without elevated CO2 level, while breathing room air. High mortality rates are common for patients with acute respiratory failure, even in ICUs specializing in modern critical care techniques. In an International multicenter study, only 55.6% patients with acute respiratory failure survived their hospitalization whereas 44.4% died in 3 the hospital (Zambon, and Vincent, 2014). Urgent resuscitation of the patient requires airway control, ventilator management, and stabilization of the circulation. At the same time patient should be evaluated for the cause of respiratory failure and therapeutic plan should be derived from an informed clinical and laboratory examination supplemented by the results of special intensive care unit (ICU) interventions. Recent advances in the ICU management and monitoring technology facilitates early detection of the pathophysiology of vital functions, with the potential for prevention and early titration of therapy for the patients with acute respiratory failure which improves the outcome (Shrestha, Khanal, Sharma, and Nepal 2020). Aim and Objectives The aim of this seminar paper is to review the Acute Respiratory Failure and chest trauma. The specific objectives:1. To review the concept of Acute Respiratory Failure 2. To review the concept of Acute Respiratory Failure and Chest Trauma 3. To review the classification of Acute Respiratory Failure 4. To review the signs or symptoms Acute Respiratory Failure and Chest Trauma 5. To review the causes of Acute Respiratory Failure and Chest Trauma 6. To review the diagnosis of Acute Respiratory Failure 4 7. To review the complications Resulting From Acute Respiratory Failure 8. To review the management of Acute Respiratory Failure and Chest Trauma Concept of Acute Respiratory Failure The loss of the ability to ventilate adequately or to provide sufficient oxygen to the blood and systemic organs (Brodie & Bacchetta 2016). The pulmonary system is no longer able to meet the metabolic demands of the body with respect to oxygenation of the blood and/or CO2 elimination. Respiratory failure is classified as type 1 respiratory failure or type 2 respiratory failure. 2 Type 1 respiratory failure is defined by a PaO2 of <60mmHg with a normal or low PaCO2. Type 2 respiratory failure is defined by a PaO2 of <60mHg and a PaCO2 of >45mHg. Respiratory failure is also classified as acute, acute on chronic or chronic. This distinction is important in deciding on whether the patient needs to be treated in intensive care unit (ICU) or can be managed in general medical ward and most appropriate treatment strategy, particularly in type 2 respiratory failure (Rawal, Yadav and Kumar2021). 5 Concept of Acute Respiratory Failure and Chest Trauma The thoracic cavity contains three major anatomical systems: the airway, lungs, and the cardiovascular system. As such, any blunt or penetrating trauma can cause significant disruption to each of these systems that can quickly prove to be life threatening unless rapidly identified and treated. Chest trauma accounts for approximately 25% of mortality in trauma patients. This rate is much higher in patients with polytraumatic injuries and acute respiratory failure. 85-90% of chest trauma patients can be rapidly stabilized and resuscitated by a handful of critical procedures. Unlike other disease entities, trauma patients often present with a known traumatic mechanism such as a car collision, fall, gunshot or stab wound. In rare cases, a patient may present in a state of significant altered mental status and be unable to provide any significant history. In these situations, certain physical examination clues to the presence of trauma include findings such as contusions, lacerations, or deformities. Palpation of crepitus over the chest wall may also be appreciated (Prescott, and Sjoding 2021). Classification of Acute Respiratory Failure Type 1 (Hypoxemic ) - PO2 < 50 mmHg on room air. Usually seen in patients with acute pulmonary edema or acute lung injury. These disorders 6 interfere with the lung's ability to oxygenate blood as it flows through the pulmonary vasculature. Type 2 (Hypercapnic/ Ventilatory ) - PCO2 > 50 mmHg (if not a chronic CO2 retainer). This is usually seen in patients with an increased work of breathing due to airflow obstruction or decreased respiratory system compliance, with decreased respiratory muscle power due to neuromuscular disease, or with central respiratory failure and decreased respiratory drive. 1. Type 3 (Peri-operative). This is generally a subset of type 1 failure but is sometimes considered separately because it is so common. 2. Type 4 (Shock) - secondary to cardiovascular instability. Signs or Symptoms Acute Respiratory Failure and Chest Trauma Kress and Hall (2011) noted trouble breathing and chest trauma is the main symptom of acute respiratory failure. Symptoms may also include: 1. Severe shortness of breath 2. Labored and unusually rapid breathing 3. Low blood pressure 4. Confusion and extreme tiredness 5. Rapid breathing. 6. Restlessness or anxiety. 7 7. Skin, lips, or fingernails that appear blue (cyanosis). 8. Rapid heart rate. 9. Abnormal heart rhythms (arrhythmias). 10.Confusion or changes in behavior. 11.Tiredness or loss of energy. 12.Feeling sleepy or having a loss of consciousness. 13. Difficulty breathing, 14. Failure of the chest to expand normally, Causes of Acute Respiratory Failure and Chest Trauma Guzman (2016) noted acute respiratory failure and chest trauma has wideranging and disparate causes: Acute respiratory distress syndrome (ARDS): ARDS is a medical condition marked by low levels of oxygenated blood. It often results from a prior medical problem, such as pneumonia, pancreatitis, or septic infection, and, in turn, proceeds the onset of respiratory failure. Alcohol or drug abuse: Excessive alcohol or drug consumption can reduce the brain’s ability to properly regulate breathing. Breathing obstructions: Windpipe injuries or foreign objects lodged in the throat can impede the flow of oxygen to the lungs. Narrowing 8 of the bronchial tubes by asthma, chronic obstructive pulmonary disorder (COPD), or cystic fibrosis can have a similar effect. Cardiac failure: The heart and lungs work in tandem to respirate and nourish the body. Heart failure can therefore have a catastrophic effect on pulmonary functions. Chemical inhalation: Breathing in heavy smoke, harsh fumes, or toxic chemicals can initiate respiratory failure. Infections: Infections, including pneumonia, are frequently behind cases of respiratory failure. Physical injury: The neurological system plays a key role in the healthy functioning of the respiratory system. Injuries to the brain or spinal column can greatly weaken the pulmonary function. Scoliosis, an excessive curvature of the spine, can also be an issue. Stroke: A stroke is the death of brain tissue, leading to a loss of physiological function. Since the brain is involved in breathing, a major stroke can result in respiratory failure. Diagnosis of Acute Respiratory Failure Kress and Hall (2011) acute respiratory failure is a medical emergency requiring immediate action. To confirm a diagnosis, the physician may: 9 Document medical history: This will include general information about the health, as well as questions about the nature and severity of the current symptoms. Conduct a physical exam: A stethoscope will allow the doctor to listen for abnormal breathing patterns or behaviors, including evidence of infected or fluid-filled lungs. Order a chest X-ray or CT scan: X-rays and CT scans provide noninvasive, visual evidence of lung injury or inflammation. Conduct pulse oximetry: A pulse oximeter is a non-invasive means of measuring the lung’s effectiveness in oxygenating the blood. Poorly oxygenated blood is indicative of a respiratory disorder. An arterial blood gas test is similar, but requires a blood draw. Complications Resulting From Acute Respiratory Failure Guzman (2016) noted that multiple organ-system complications involving the cardiovascular, pulmonary, gastrointestinal system may occur subsequent to respiratory failure Chest Trauma. Unstable chest trauma, severe respiratory distress or profound shock requiring emergent resuscitation. Pulmonary: pulmonary embolism, pulmonary fibrosis, complications secondary to the use of mechanical ventilator 10 Cardiovascular: hypotension, reduced cardiac output, cor pulmonale, arrhythmias, pericarditis and acute myocardial infarction Gastrointestinal: haemorrhage, gastric distention, ileus, diarrhoea, pneumoperitoneum and duodenal ulceration- caused by stress is common in patients with acute respiratory failure Infectious: noscomial- pneumonia, urinary tract infection and catheterrelated sepsis. Usually occurs with use of mechanical devices. Renal: acute renal failure, abnormalities of electrolytes and acid-base balance. Nutritional: malnutrition and complications relating to parenteral or enteral nutrition and complications associated with NG tube- abdominal distention and diarrhea Management of Acute Respiratory Failure and Chest Trauma According to Gehlbach and Hall (2011) the management of acute respiratory failure can be divided into an urgent resuscitation this includes supportive measures and treatment of the underlying cause. Supportive measures which depend on depending on airways management to maintain adequate ventilation and correction of the blood gases abnormalities 11 1. Correction of Hypoxemia The goal is to maintain adequate tissue oxygenation, generally achieved with an arterial oxygen tension (PaO2) of 60 mm Hg or arterial oxygen saturation (SaO2), about 90%. Un-controlled oxygen supplementation can result in oxygen toxicity and CO2 (carbon dioxide) narcosis. Inspired oxygen concentration should be adjusted at the lowest level, which is sufficient for tissue oxygenation. Oxygen can be delivered by several routes depending on the clinical situations in which we may use a nasal cannula, simple face mask nonrebreathing mask, or high flow nasal cannula. Extracorporeal membrane oxygenation may be needed in refractory cases 2. Correction of hypercapnia and respiratory acidosis This may be achieved by treating the underlying cause or providing ventilatory support. 3. Ventilatory support for the patient with respiratory failure The goals of ventilatory support in respiratory failure are: Correct hypoxemia Correct acute respiratory acidosis 12 Resting of ventilatory muscles Non-invasive respiratory support: is ventilatory support without tracheal intubation/ via upper airway. Considered in patients with mild to moderate respiratory failure. Patients should be conscious, have an intact airway and airway protective reflexes. Noninvasive positive pressure ventilation (NIPPV) has been shown to reduce complications, duration of ICU stay and mortality (Guzman, 2016). It has been suggested that NIPPV is more effective in preventing endotracheal intubation in acute respiratory failure due to COPD than other causes. The etiology of respiratory failure is an important predictor of NIPPV failure (Cremer, and Schultz, 2012). Invasive respiratory support: indicated in persistent hypoxemia despite receiving maximum oxygen therapy, hypercapnia with impairment of conscious level. Intubation is associated with complications such as aspiration of gastric content, trauma to the teeth, barotraumas, trauma to the trachea etc Permissive hypercapnia - A ventilatory strategy that allows arterial carbon dioxide(PaCO2) to rise by accepting a lower alveolar minute ventilation to avoid the risk of ventilator-associated lung injury in patients with ALI and minimize intrinsic positive end-expiratory pressure (auto PEEP) in patients with COPD thereby protecting the lungs from barotrauma. Permissive 13 hypercapnia could increase survival in immunocompromised children with severe ARDS (Cherian Kumar & Akasapu 2016). Physiotherapy Management Cooke & Erikson (2017) noted that physio-therapeutic interventions aim to maximize function in pump and ventilatory systems and improve quality of life. In mechanically ventilated patients, early physiotherapy has been shown to improve quality of life and to prevent ICU-associated complications like de-conditioning, ventilator dependency and respiratory conditions. Main indications for physiotherapy are excessive pulmonary secretions and atelectasis. Timely physical therapy interventions may improve gas exchange and reverse pathological progression thereby avoiding ventilation. Nurse management Nursing management of a patient with Acute Respiratory Failure using nursing processes 14 The key role of the nurse is to identify the patents as high risk for Acute Respiratory Failure in all patients Nursing management using the nursing process e.g. nursing assessment, nursing diagnosis, planning, implementation and evaluation Nursing assessment for acute respiratory failure and chest trauma Nursing diagnosis-1: Ineffective breathing pattern Expected outcomes The patient takes relaxed breathing at a normal rate and depth. There is the absence of dyspnea and blood gas analysis shows normal parameters. The patient verbalizes his/her comfort without any sign of dyspnea. Nursing care plane for acute respiratory failure and chest trauma 15 Date Diagnosis Impaired gas exchange related to Decreased lung compliance, Low amount of surfactant, Increased breathing rate, Any primary medical problem Check for the use of accessory muscles. Objectives plan Assess the rate, rhythm, and depth of respiration Nursing intervention Reassure the patient and reduce the anxiety during acute episodes of respiratory distress. Rational on scientific principle Change in rate and depth of respiration is the early sign of respiratory difficulty. Evaluation Take cardiac output measurements after a change in positive pressure ventilation. Check for the use of accessory muscles. Provide proper position to the client. A prone position is recommended. When lung compliance decreases, it impacts the work of breathing and it increases significantly. Assess the breath sound of the lungs. Assess the breath sound of the lungs. An increase in pulmonary oedema cause fluid to move into alveoli, as a result, a crackles sound is heard. Check for any sign of dyspnea. Check for any sign of dyspnea. Schedule daily activities in such a way that it will provide rest periods between activities. Maintain oxygen saturation at 90% or above. Check vital signs and level of consciousness in each half an hour with changes in positive pressure ventilation and inotrope administration. Check peripheral pulses, capillary refill and skin temperature. Assess for any sign of cyanosis. Assess for any sign of cyanosis. Dyspnea causes an increase in anxiety in the patient. Anxiety leads to increase oxygen demand of the body and breathing pattern is altered. Bluish discolourisation of the tongue, mucus membrane and skin indicates a decrease in oxygen concentration in the blood. Check the fluid balance by maintaining an intake output chart, and taking the daily weight of the patient. Administer drugs as per physicians prescription and observe for the response of the drug. Check oxygen concentration in pulse oximeter and do an arterial blood gas analysis. Check oxygen concentration in pulse oximeter and do an arterial blood gas analysis. Pulse oxymetry and ABG analysis help to interpret the current oxygen status in the blood. In ARDS, oxygen saturation decreases. Administer fluid to maintain fluid status. Assess for any cough]tcykf. Check for the energy level of the patient. An increase in pulmonary oedema and fibrin build up stimulate cough reflex and it leads to an increase in cough. Check the ventilator setting. Ensure the alarms of the ventilator are on. Administer medications according to the physician’s prescriptions. (e.g., antibiotics, bronchodilators, steroids, and antianxiety medications). Do suction if required. All the team members who are involved in the care of the patient must be informed about the patients respiratory status. 16 Conclusions Despite advances in critical care, ARF still has high morbidity and mortality. Even those who survive can have a poorer quality of life. While many risk factors are known for ARF, there is no way to prevent the condition. Besides the restriction of fluids in high-risk patients, close monitoring for hypoxia by the team is vital. The earlier the hypoxia is identified, the better the outcome. Those who survive have a long recovery period to regain functional status. Many continue to have dyspnea even with mild exertion and thus are dependent on care from others. Even though many risk factors for ARF are known, there is no way of preventing ARF. However, careful management of fluid in high-risk patients can be helpful. Steps should be taken to prevent aspiration by keeping the head of the bed elevated before feeding. Discharge planning should include medication reconciliation, detailed home care planning (whether by family members or in-home/visiting nursing), and plans for follow-up visits and evaluations. Patients and caregivers must be counseled on signs of when to contact the clinician in the event of exacerbation or deterioration of the patient's condition. 17 References Brodie D, Bacchetta M. (2016). Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med.365(20):190-514. Cherian SV, Kumar A, Akasapu K, (2016). Salvage therapies for refractory hypoxemia in ARDS. Respir Med. 14(1):150-158. Cooke C.R, and Erikson S.E, (2017). Trends in the incidence of noncardiogenic acute respiratory failure: the role of race. Crit Care Med. 2012;40(5):1532-8. Cremer OL, and Schultz M.J. 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