Grand Rounds:
Acute Respiratory Failure
Ashley Hazelwood
Demographics
78 year old African
American Female
One Daughter
Height: 64 inches
Widowed
Weight: 84.9 Kg
Baptist
Allergy: Tetanus
Never employed
Full Code
Events Leading to Hospitalization
Total hysterectomy late February
Sent to rehab facility after surgery
Found her unresponsive
Experiencing agonal respirations
Taken to hospital and intubated on 3/21
Risk Factors
Age
Ovarian Cancer stage III
Total hysterectomy (abdominal incision)
Hypertension
Diabetes
Anemia
Past Medical History
Right sided
hydronephrosis
secondary to ovarian
cancer
Pyelonephritis
Gout
Hyperlipidemia
Diabetes
Hypertension
Anemia
Osteoarthritis
Medical Diagnosis
Acute Respiratory Failure
MRSA
Acute Respiratory Failure
Classified as blood gas abnormalities
Occurs rapidly
Gives little time for body to compensate
Three types: Failure of oxygenation, failure of ventilation,
and failure of both
Failure of Oxygenation
Thoracic pressures are normal
Pulmonary blood not adequately oxygenated
4 Mechanisms
– Hypoventilation
– Intrapulmonary shunting
– Ventilation/perfusion mismatch
– Diffusion defects
Failure of Oxygenation
Hypoventilation:
– Buildup of CO2
displaces O2
(abdominal surgery)
Intrapulmonary shunting:
– Blood is shunted past
lungs
– Unoxygenated blood
sent back to left side
of heart (atelectasis)
Ventilation/Perfusion
mismatch:
– Degree of a shunt
– Degree of dead space
– Most common cause
of hypoxemia
Diffusion:
– Distance between
alveoli and capillaries
is increased
Failure of Ventilation
Perfusion is normal
Ventilation inadequate
Little oxygen reaches alveoli
Carbon dioxide is retained
Hypoxemia develops
2 mechanisms
– Hypoventilation
– Ventilation/Perfusion mismatch
Failure of Ventilation
Hypoventilation:
– CO2 accumulates in
alveoli
– CO2 is not blown off
Ventilation/Perfusion
mismatch:
– Increase in volume of
dead space
– Area no longer
participates in gas
exchange
Symptoms
Hallmark: Dyspnea
Hypoxemia
Decreased level of
consciousness
Tachycardia
Hypercapnia
Increased blood pressure
Release of lactic acid
Peripheral
vasoconstriction
Complications
Immobility
Medication side effects
Fluid and electrolyte
imbalance
Hazards of mechanical
ventilation
Hazards of mechanical
ventilation:
– Aspiration
– Volutrauma
– Oxygen toxicity
– Ventilator associated
pneumonia
MRSA-Methicillin Resistant
Staphylococcus Aureus
Bacteria resistant to certain antibiotics.
Frequently found in:
– Immunocompromised patients
– Hospitalized patients
Collaboration of Care
Nurses
Nursing Students
Nursing Instructor
Physicians
Respiratory Therapists
Family
Respiratory Alkalosis
ABGs 3/22/08
pH
Result
7.54
High/Low
High
Normal:7.357.45
Rationale
Mechanical
ventilation
PCO2
34.0 mmHg
Low
Normal: 35-45
Increased
respiratory rate
PO2
109 mmHg
Hyperventilation
High
Normal 80-100
HCO3
20 mmol/L
Low
Normal 22-26
Compensating
for alkalosis
Laboratory Results
Lab
Result
High/Low
Rationale
Serum Protein: <5.0 mg/dL
Prealbumin
3/25/2008
Low
Normal: 18-25
Inflammation r/t
acute
respiratory
failure
Coagulation:
PTT
3/25/2008
70.9 Sec.
High
Normal: 22-35
Prolonged
clotting time r/t
Lovenox
therapy
MRSA swab
3/27/2008
Positive for
MRSA
Abnormal
Normal:
negative swab
MRSA infection
Laboratory Results
Hematology
3/27/2008
Results
High/Low
WBC
28.7x10^3/mm3 High
Normal:4.310.0
Infection,
stress,
inflammation
RBC
3.37x10^6/mm3 Low
Normal:4.05.40
History of
Anemia
Hemoglobin
9.3g/dl
History of
Anemia
Hematocrit
29.6%
Low
Normal:12.016.0
Low
Normal:3547%
Rationale
History of
Anemia
Laboratory Results
Hematology
3/27/2008
Results
High/Low
Platelets
15.3
High
History of
Normal:11.5 Anemia
-14.5
Glucose
175
High mg/dL
Normal:70110
Rationale
Diabetes
Diagnostics: X-Rays
Diagnostic
X-Ray: Placement of
ET tube
Date
3/21
Findings
Above Canna(1-2cm)
No infiltrates or
infusions
X-Ray: Abdomen Flexi
flow placement
3/22
Tip in transport
position in duodenal
flap
X-Ray: Chest, post
procedure of
thoracentesis
3/25
No pneumothorax,
mild volume loss right
lung, no pulmonary
edema
X-Ray: portable chest
PICC placement
3/26
Right Upper Extremity,
tip in mid-SVC
X-Ray: Chest
3/27
Atelectasis in lower left
base
Diagnostics: CT and US
Diagnostics
CT: Head
Date
3/21
Findings
Negative for injury
Lower Extremity
Doppler Exam
3/22
No deep vein
thrombosis present
CT: Chest with IV
3/24
Contrast, Pulmonary
embolism protocol
US: Right
thoracentesis for
right pleural effusion
3/25
Right Pleural
effusion, no
evidence of
pulmonary
embolism.
200cc straw colored
fluid aspirated from
right pleural space
Medications
Medication
Class
Dose
Route
Frequency
Rationale
Insulin
Regular
Short acting
insulin
BG100/20=# U
SubQ
QID,AC,
Bedtime
Diabetes
Insulin
Lantus
Long acting 15 Units
insulin
SubQ
Qday
Diabetes
Pulmocare
Tube
Feeding
Nutrition
supplement
40mL/h
Per Tube
Continuous
Feeding
Q24 hours
Respiratory
failure
Benazepril
(Lotensin)
ACE
inhibitor
10mg
Per Tube
BID
HTN Hold if
SBP<100
Diltiazem
(Cardizem)
Ca channel
blocker
60mg
Per Tube
Q6h
tachycardia,
HTN
Amlodipine
(Norvasc)
Ca channel
blocker
10mg
Per Tube
Qday
HTN,
Tachycardia
Medications
Medication
Class
Dose
Route
Frequency
Rationale
Esomaprazole
Proton
pump
inhibitor
40mg
Per Tube
add 15 mL
of water
Qday
Prevent
stress
ulcers
Albuterol
Bronchodilator
4 puffs
Inhalation
By RT
Q4h
Respiratory
Failure
Potassium
Chloride
Electrolyte
40 mEq
Per Tube
TID
Prevent
(nexium)
hypokalemia
Enoxaparin Anticoagulant, 40mg
low
(Lovenox)
molecular
weight
heparin
SubQ
abdomen
Q24h
Prevent
Deep vein
thrombosis
Medications
Medication
Class
Dose
Route
Frequency
Rationale
PiperacillinTazobactum
(Zosyn)
Extended
Spectrum
penicillin
3.375 gm
IV solution
100mL/h
Q6H
MRSA,
Respiratory
Failure
Linezolid
(Zyvox)
Oxazolidinone
600mg
IV solution
300mL/h
BID
MRSA
Furosemide
(Lasix)
Loop
Diuretic
40mg
Per Tube
BID
Peripheral
Edema
Loperamide
(Immodium)
Piperidine
Derivative
2-4mg
Per Tube
PRN for
diarrhea
Diarrhea
Several soft
stools a day
Assessment
Vital Signs:
– BP:158/62
– HR: 101
– RR: 29
– O2 sat: 99
– Temp: 98.4
– Pain: 0
Intake:
– D5W with 40
Potassium at 30mL/h
Output:
– 3 to 4 stools a day
– Zossi Placed
– Urine average of 4060 mL/h
Assessment: Neurological
LOC:
– easily aroused
– alert responds to
verbal stimuli
– calm, nods to
questions
Pupils are PERRLA
Coma Score:
– Eyes Open: Spont. 4
– Best Verbal
Response: T (Trach)
– Best Motor Response:
Obeys Commands 6
– Total: 10T
Assessment: HEENT
Head:
– No lumps, lesions or
tenderness
– Symmetrical
Face:
– Symmetrical
– No weakness
– No involuntary
movements
Eyes:
– Brows and lashes
present
– No ptosis
– Conjunctiva clear
– Sclera white
– No lesions
Ears:
– No masses, or lesions
– No tenderness or
discharge
Assessment: HEENT
Nose:
– Symmetrical
– No drainage
– Flexi Flow in left
nostril
– No skin breakdown
Throat:
– Endotracheal tube in
place
– Trachea midline
– No pain
– Teeth missing
– Mucosa pink and dry
Assessment: Musculoskeletal
Nonambulatory
Minimal equal weakness:
upper extremities
Limited range of motion
Assist with all activities of
daily living
General weakness: left
lower extremity
Greater weakness: right
lower extremity
Assessment: Cardiovascular
Normal heart sounds, S1
and S2 noted
Right and left dorsalis
pedis weak
Telemetry: Normal sinus
rhythm with premature
atrial beats
Right and left radial 2+
No jugular vein distention
Capillary Refill <3
seconds
2+ edema in lower
extremities
1+ edema in hands
Assessment: Respiratory
Clear lung sounds
Diminished lung sounds
in bases bilaterally
Sputum thick and white
Mechanical
Ventilation Settings:
–
–
–
–
–
CPAP
PEEP: 5
FiO2: 30%
Pressure Support: 20
Vt: 600
Assessment: Gastrointestinal
Bowel sounds in all four
quadrants
Impaired swallowing:
mechanical ventilation
Abdomen Soft and
distended
NPO
Flexi Flow NGT
Healed abdominal
incision from
hysterectomy (midline)
– Continuous feeding:
Pulmacore at 40mL/h
Several loose, yellow
stools a day
Zossi Placed
Assessment: Genitourinary
Urine clear
Color: pale yellow
Urine output > 30mL/h
Foley catheter in place and patent
Assessment: Integumentary
Excoriated skin on
buttocks and perineum
Stage 2 breakdown
Braden Score:
– Sensory Perception:
no impairment 4
– Moisture: very moist
2
– Activity: bedfast 1
– Mobility: very limited
2
– Nutrition: adequate
3
– Friction & Shear:
problem 1
– Total: 13
interventions in
place
Assessment: Integumentary
Other areas of skin dry,
warm, and intact
No clubbing
PICC on right upper
forearm:
– No infiltration or
inflammation
– Dressing dry and
intact
– Patent
Assessment: Psychosocial
Patient cried a few times
from impaired
communication and
several accidents
Most of the time was
calm and resting
Had family support at
bedside
Daughter visited
everyday
Was there by 0800 every
morning
Impaired Gas Exchange
Related to altered oxygen
supply secondary to
acute respiratory failure.
As Evidenced By:
– abnormal ABGs
(pH:7.54,
CO2:34.0mmHg,
O2:109mmHg,
HCO3:29.2mmol/L)
– tachypnea (varying
from 29-33)
– tachycardia (101)
– anxiety
– dyspnea
– mechanical ventilation
– decreased RBCs
(3.37x10^6/mm3), Hgb
(9.3g/dl), Hct (29.6%)
Goals and Interventions
Goal: Patient will not
experience discomfort in
maintaining air exchange
Interventions:
– Monitor VS and I&O
every hour
– Position every 2
hours
– Suction as needed
– Elevate HOB
– Assess lung sounds
every assessment
– Assess for
restlessness and
change in LOC
– Provide ADLs, rest
Evaluation
Vital signs and I&O
recorded every hour
Positioned every two
hours to promote gas
exchange
No further ABGs were
drawn
Suctioned twice a day
Lung sounds remained
clear
Remained alert and
oriented
Mouth care and bathing
was performed
Head of bed elevated
O2 oximetry stayed
above 90
No signs of respiratory
distress
Impaired Skin Integrity
Related to immobility
secondary to mechanical
ventilation
As Evidenced By:
– Excoriated buttocks
and perineum, stage 2
– Braden score of 13
– Inflammation
– Diarrhea
– Increased WBC
(28.7x10^3/mm3)
– Low pre albumin
(<5.0mg/dL)
– Decreased RBCs
(3.37x10^6/mm3), Hgb
(9.3g/dl), Hct (29.6%)
Goals and Interventions
Goal: Patient will not
exhibit any further
breakdown.
Interventions:
– Assess skin every
shift assessment
– Keep skin dry and
clean
– Turn and position
every two hours
– Clean accidents
promptly, make sure
zossi is draining
with no leaks.
– Apply skin cream
– Consult with wound
care nurse
Evaluation
Skin assessed and
documented every eight
hours.
Patient cleaned promptly
when had accident
Patient was bathed and
skin dried
Turned and positioned
every two hours
No further breakdown
occurred
Impaired Verbal Communication
Related to artificial airway
and mechanical
ventilation secondary to
respiratory failure
As Evidenced By:
– ET tube
– Anxiety
– Few episodes of
crying
– Frustration
Goals and Interventions
Goal: Patient will be able
to communicate her
needs to the best of her
ability
Interventions
– Establish method that
is appropriate for her
– Attempt reading
gestures
– Speak slowly and
clearly
– Explain procedures
– Expect frustration
– Involve family
Evaluation
I used yes/no questions
to communicate with N.M.
Able to nod to answer my
questions
Every procedure was
explained in a clear slow
manner
Frustration and anxiety
were decreased when
she used the yes/no
responses
Family was involved in
trying to communicate
with N.M.
Research Article
A Prospective, Randomized Study of
Ventilator-Associated Pneumonia in
Patients Using a Closed vs. Open
Suction System
Purpose
Verify incidence of nosocomial pneumonia in
mechanically ventilated patients having suctioning by
open vs. closed suction method
Methods and Sample Size
Methods:
– Randomized assay
– Parallel groups
– Approval was given
Sample:
– Forty seven patients
– Twenty-four received
open suction
– Twenty-three received
closed suction
– All older than thirteen
– Mechanical ventilation
greater than forty eight
hours
Results
Of 24 receiving open
suctioning
– 11 developed
ventilator-associated
pneumonia
Of 23 receiving closed
suctioning
– 7 developed ventilatorassociated pneumonia
Use of a closed suction
system did not decrease
the incidence compared
with the open system
Relation to patient
On mechanical ventilation
At risk for developing ventilator-associated pneumonia
Receiving closed system suctioning
Did not acquire pneumonia during my care
References
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Zeitoun, S., Barros, A., Diccini, S. (2003). A prospective, randomized study of
ventilator-associated pneumonia in patients using a closed vs. open suction
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