Acute respiratory Failure ARF - Inadequate Co2 removal > Hypercapnia -> Inc. PaCO2 - - - - airwaylalveoli problem: Obstruct/trapping COPD asthma Cystic Fibrosis = PaO2 -160mmhg , 160 % 02 PaO2 less 60 - when pt greater/equal to 60 % - , , . = - · L Kidney don't use right away Both types of ARF acute on Chronic : ↳ Changes In PaO2/PaCO2 = develop hour/days COPD then have Pneumonia- hemodynamic unstable - ↳ Inc HR/RR . Chronic - Four . - 1: 1 , - Treat : - · - - Oxygen Therapy - continously Inc PaOz - - . gas exchange Capillary Shunt : pass thro Capillarles who gas exchange - more . W/ high FiOz hypoxemic than short patients = - - 2-3 word dsypnea pursed-lip breath = Inc. exhale , prevent bronchial collapse L diaphoretic from Inc. WoB - - ↳ Pneumothorax 02 alone ineffective Physiologic Mechanisms - = - - - - = High F,02 long time . 02 Toxic (> 60% for > 48hrs) Inc permeability , dec surfact . , Fibrotic change in alveoli (stiff) , absorpt at electasis . mobilize secretions : limit exchange lead to ARF = position , cough, suction , humid/hydrate - Position: HOB 30 D , Side-lying(aspiration) , Unilateral = lateral/side - - Chronic hypercapnia : Provide 02 low flow , mech vent. W/ Inadequate response - - Collapsed - dc. Ventilation Inc. Paco2 - . causes: Cns conditions , acute asthma , chest wall = . Causes : Pulm Fibrosis , ARDS , PE hypoxemia exercise , - ° good long down = Improve V/Q by drain Secretion remove (bad lung side UP Bilateral = reposition regular interval both sides Tripod: Inc anterior-posterior Chest (expand) - Sit wI arms propped overbed . . WOB table = dec dsyfunction consequence of hypoxemia leads to HYPOXIA SEVERE : Cell Shift aerobic-Panaerobic : use more fuel ↳produce less . Frequent assess high risk patients prevent pneumonia , immobile - -due to mechanism of hypercapnic contributes to hypoxemia - C/DB , IS , ambulate , pain/pulm Hygiene , treat underlying Observe response/monitor changes In Mental , RR , abgs = maintain Pa02 55-60 Hypoxemic Thicker - slows gas exchange Alveolar hypoventilation : , apply 02 at loweST FiO2 keep SpO2/PaO2 Never Withhold O2 to hypOXIC - . · asypnca/back to breath pattern normal ABG respiratory Therapy: good 02/ventilation , correct hypoxemia/acid-base - - . Capillaries destroy membrane or affect blood flow thro pulm alveolar Capillary - comorbid = tobacco , nutrition , HF CKD Prevention: - Diffusion Impairment : Capillary membrane is compromised - decrease chest wall compliance, muscle strength , delay compensation , End tidal CO2 monitor , Y/a scan · fallure: reduce ventilatory capacity Cough/clear secretions , lung sound within baseline - - common: Chest X-ray , ABG , Pulse OX , 12 lead ECG , Blood/ sputum culture Four . Maintain patent airway , no auscultate : Fine crackle = PE , coarse-fluids , absent = Pneumonia/hypovent. at elect - protein/energy can't eat maintai , management - - Pleural friction rub = Pneumonia in Pleura therapy , Paradoxical breath-abdomen/chest move outward w/exhale , Inward /Inhale - worsen respiratory start enteral nutrition within 24-48 hrs risk factors resp - . - can't breath = = Gerontologic Considerations - . for PEEP and dec Shunt - change rapid-Slow RR indicate severe muscle fatigue Resp arrest - heart shunt : pass thro anatomic channel ,bypass the lungs ↳ need mechanical vent. . S tudies Diagnostic Extreme V/Q mismatch-due concentration/pressure - headache , confuse , disorient , dec Loc , lethargy - Breath Pattern = Rapid/Shallow (hypoxemia) , Slow RR (CO2) treat underlying cause Acute : BIPAP , , ↳ due to Pneumonia Pulm Edema , COPD , - Co2 nutritional . O2 = restless confuse agitation Change Mental Status - dec , Observe: Position = le down , upright, tripod WOB = huff/cuff , common= COPD , Pneumonia , Asthma Shunt : blood leaves heart who - . UTI , Pneumonia , . , - Inc = - Benzodiazepine/oploid : reduce anxiety , pain restless - Priority: quick assess ability to breathe/provide assist= intubate/mech Vent. - ↳ others : result pain atelect , Pulm Emboli I antibiotics : treat Infections - Early Signs : heart/longs trying to compensate - Tachycard/pnea pallor Hypoxemic normal: V = 4-G L/min , blood flow (Q) = 4-6L/min = . Late signs: Cyanosis (unreliable) , Paoz less/equal 45 mm he - · - IV diuretic , morphine , nitroglycerin : relieve pulm Congestion (vasodilation , BP/LOC Physiologic Mechanisms First signs : - develop Slowly = stable compensatory changes V/Q ratio - dec - relieve bronchospasm Bronchodilators : - . Ventilation-perfusion (Y/Q) mismatch · - , corticosterolds : reduce airway inflammation - - ↳ fallure compensatory mechanism lead resp fallure unable to compensate insufficient CO2 remove compensation , prevent PH change , treat primary cause - = = allow o onset : Sudden > dec . Pao2 or rapid Inc . In PacO2 exchange 02 btwn alveol/capillary . Drug Therapy , Clinical manifestations Inspired 02 concentration Ph less 7 35 = respiratory acidosis , . hypercapnic Pacoz-D > 50mmhg = Ventilatory fallure - - . . CO2 level BETTER than dec. 02 Level consequences : Body tolerate Inc Slow Change In CO2 / level of pressure (Innale/exhale , = - must be awake , alert , Stable VS BIPAP : more support > both Inhale/exhale = Increase PEEP , If not= intubate mech Vent. - , - = . CPAP : constant pressure = - ARF not disease but symptom reflect long function HypoXeMIC - Chest Wall abnormal: Prevent movement chest wall-limit long expand , provides 02 and dec WoB -non-invasive PPV : - ↳ severe Obesity , flail Chest Kyphoscoliosis ↳ caused by COPD Pneumonia Cardiac , cas neuromus · , . Assessed by ABGS and pulse Ox , ↳Contraindicate WI trauma brain Injury suction (as need) humid ,hydrate CnS problems: Supress drive to breathe = DrugOD , Brain Infarct Spinal cord neuromuscular : Resp Muscle weak/paralysis can't eliminate Co2 - , - Chest Physiotherapy= Postural drain (side/side), Percussion/vibration (must ORDER) - , ↳ mechanical ventilation PEEP - . Co2 level or dec alveolar vent. CO2 level can't be maintain due-inc . insufficient O2 = Hypoxemia - dec . Pao2/Sa02 - management Hypercaphic Respiratory fallure when 02 , Ventilation or both are Inadequate - energy-Waste product : Lactic acid lactic harder to remove than CO2-metabolic acd=tissue death - Cough: Staged = -good long down = - push pillow against diaphragm while coughing use the good lung down , BAD Up Augment push upward from base long as patient cough = Acute respiratory Distress Syndrome Clinical Progression of ARDS ARDS Sudden progressive form of ARF Severe = P/F rato less 100 - M embrane become damage , permeable Intravascular (edemal alveolar - most common : SEPSIS multiple organ asyfunction syndrome (MODS) , edema , fluid enter alveolar space hypoxemia/ juxt a receptors = Capillary blood CAN IT Pulm - - - Mild : = = refractory hypoxemia , hypercapnia - - telectasis - Severe: less than - mecha Vent - management goals for ArDS : Paoz within limit (baseline) , Sa02190 % PPY , chest X-ray = whiteout/pleural effusions - calculate : 80% room air , F102 =. 6 -80/0 6 = 133 ARDS moderate - - resolve precipitate factors, clear lung sounds ARDS is complex and unpredictable Reparative or Proliferative Phase :I -2 wKs after long Injury · invasions WBC continues - - - . PVR and pulm. HTR = long compliance decline > Inc - . = 02 mech. Vent , low VT , Permissive hypercapnia want - , higher CO2 -D Support 02 , PEEP (cause heart wi less space . airway resist Inc Prolif phase complete = diseased long replaced by densel fibrous tissue - Prone position extracorporeal membrane oxygenation (Ecmo) , reparative persist - Widespread flbrosis results - Respiratory Therapy reparative stopped > lesions will resolve - · Implementation - hypoxemia worsen due alveolar membrane thickened 02 demand Monitor-10 , Bun , creatinine , dialysis , crrt 100 . . and PEEP to reduce risk AKI : dec renal perfusion and delivery 02 to Kidney - . to ET tube and . . continued Progression : profound asypnea , hypoxemia , Inc . WoB resp distress , lead , Ventilate wh smaller tidal Vol and less/equal to 200 equal to or . emphysema Pneumothorax ,tension (emergency to meet greater than 200 and less/equal to 300 during mech Vent. r t diversion blood from G1-resp. Gl Ulcers : High risk - calculate PaOz(ABG) /FiO2 ratio (P/Fratio) : moderate : greater than 100 - gas exchange Severe V/Q mismatch/Shunt = hypoxemia - Severity of hypoxemia - . 20/02 Edema/ shunt Increase = compensation falls dec . ABGS : . (compensatory necrotic cells , fibrin that line alveoli-dec Barotrauma : rupture of over distend alveoli ↳ cause : . alveolar cells damaged : surfactant dysfunction - - - , hypoventilation cause severe gas exchange alterations Resp Failure - . ↑symptoms worsen Inc. WoB tachy Diaphoresis , daily assess daily oral care , strict infection control - , , of ready for extubation , Gl ulcer prophylaxis , VTE prophylaxis , . ARDS progression - ↳ lead to : Inc RR/dec. VT-Inc. CO2 removal result resp Alkalosis . Ventilation bundle protocol : Handwash , HoB 30-45 - , Stiff long parenchyma (fluid fill) then CO2 build U p = Metabolic acidosis , mental changes , Cyanosis pallor , crackles and worsen X-ray Oxygenated result V/Q Mismatch and shunt = Engorgement - host defense invasive monitor device, aspirate GI content mild hypoxemia and resp Alkalosis from hyperventilation = as ARDS evolves - = = - , Pneumonia/ infection begins (sooner treat the better outcome - . Ventilator associated Pneumonia (VAP) risk factors : IMP - , Chest X-ray = normal or diffusely scattered minimal infiltrate - Injury or exudative Phase : begins 24-72 his after lung Injury - ABGS - Changes Phases Pathophysiologic contributes : mech. Vent , duration/time ventilated , life support - restless , lung sounds scattered crackles - - abnormal long can persist years-scarring/change with in lungs initial present : 24-72hrs = mild a sypca , tachypnca , cough - to body-DMODS(heart/lung) D progress ARDS · . require long term mech. Vent ARDS Abnormal long function: recover within 6 months - , = Indirect lung Injury : SEPSIS occur UTI - Kidney - progress - - recovery/progress depends on Injury comorbid genetic - Direct lung Injury : Pathogens in lungs - Poor Survival-fibrotic phase - ↳ multiple risk factors 3-4 = likely develop ARDS Injury: Pulm edema resolves complete recovery within week, - - - some Survive acute phase long - Complications of - Fibrotic or Fibroproliferative phase : Chronic/late phase -not all enter this - Mechanical Yent : Pressure-control = POOR Prognosis - analgesia/sedation: given IVP/continous Infusion compensate w/ gradual Inc., requires reduce pressure - Kidney must work = so can rid - drugs , dec discomfort inflate enough 02 , reduce mortality ph = 7 35- 7 45 . neuromuscular blocking agent : Vecuronium , Pancuronium - give W) analgesia/sedation intubation , normal values - = - 7 45 . helps open up collapsed alveoli high level- dec Venous return , BP , Co . - Prone : Improve V/Q Mismatch , Injury . Asynchronous ventilation (fighting ventilation) ↳ . = dec perfusion . 16 hrs/day symptoms ETT , reduce WOB - ABG = Ph 7 30 . Intrathoracic pressure, dec Venous return trauma complication: Inc , ↳ Opioid-fentanyl , Benzo-Midozolam - > - brain/systemic circulation , . Low VT : Avoid Volutrauma/barotrauma - PEEP : Maintain 5cm H20 - further long Injury permanent lung compliance Supportive therapy = going into stiff , help prevent noncompliant long from stage-depend on treatment/progress Lung is remodeled by fibrous tissue - - Hypercapnia: Iow VT Permissive - monitor level airway support must be in placed PaCO2 = . 35 45 - Bicarb = 22 26 - PaO2 = 80-100 PaO2 WI ArDS = 55-80 = mild resp. ↑ - Asypnea , tachypnea , cough , restless reparative symptoms worsens , chest xray(diffuse bilat infiltrate = fibroprolif = dec long compliance , scar lungs .
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