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Acute Respiratory Failure

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
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
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
7. To review the
complications Resulting From Acute Respiratory
8. To review the management of Acute Respiratory Failure and Chest
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 &
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).
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
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. 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
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:
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
subsequent to respiratory failure
severe respiratory
distress or profound shock requiring emergent resuscitation.
Pulmonary: pulmonary embolism, pulmonary fibrosis, complications
secondary to the use of mechanical ventilator
Cardiovascular: hypotension, reduced cardiac output, cor pulmonale,
arrhythmias, pericarditis and acute myocardial infarction
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
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
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
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
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
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
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
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
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
Impaired gas
exchange related to
Decreased lung
compliance, Low
amount of
Increased breathing
rate, Any primary
medical problem
Check for the use of
accessory muscles.
Objectives plan
Assess the rate,
rhythm, and depth of
Nursing intervention
Reassure the patient and
reduce the anxiety during
acute episodes of respiratory
Rational on scientific principle
Change in rate and depth of respiration
is the early sign of respiratory difficulty.
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
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
Schedule daily activities in
such a way that it will provide
rest periods between
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
Assess for any sign
of cyanosis.
Assess for any sign of
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
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
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
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.
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.
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