Respiratory Failure
Respiratory Failure
Respiratory Failure
1. Definition:
Respiratory failure is an alteration in the function of the respiratory gas exchange system that
causes the arterial oxygen (PaO2) level to fall below 60 mm Hg (hypoxemia) and/or the arterial
carbon dioxide (PaCO2) level to rise above 50 mm Hg (hypercapnia), as determined by arterial
blood gas (ABG) analysis. Respiratory failure is classified as acute, chronic, or combined acute
and chronic.
Respiratory failure
2. Classification:
a. Acute Respiratory Failure
Occurs over a period of days to months to years, allowing for activation of compensatory
mechanisms, including bicarbonate retention with normalization of pH.
Extent of deterioration is best assessed by comparing the patient's present ABG levels
with previous ABG levels (patient baseline).
3. Etiology;
A. Hypoxemic Respiratory Failure
Characterized by a decrease in PaO2 and normal or decreased PaCO2.
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4. Pathophysiology:
A. Hypoxemic Respiratory Failure
Characterized by a decrease in PaO2 and normal or decreased PaCO2.
Hypocapnia may result from hypoxemia and decreased pulmonary compliance. Fluid
within the lungs makes the lung less compliant or stiffer.
o Change in compliance reflexively stimulates the increased ventilation.
o Ventilation is also increased as a response to hypoxemia.
o Ultimately, if treatment is unsuccessful, PaCO 2 will increase, and the patient will
experience both an increase in PaCO2 and a decrease in PaO2.
The carbon dioxide (CO2) not excreted by the lungs combines with water (H2O) to form
carbonic acid (H2CO3). This predisposes to acidosis and a fall in pH.
Hypercapnia occurs because damage to the lung parenchyma and/or airway obstruction
limits the amount of CO2 removed by the lungs.
o Primary problem is preexisting lung diseaseusually chronic bronchitis,
emphysema, or severe asthma. This limits CO2 removal from the lungs.
The CO2 not excreted by the lungs combines with H 2O to form H2CO3. This predisposes
to acidosis and a fall in pH.
5. Clinical Manifestations:
Asynchronous respirations
6. Diagnostic Evaluation:
ABG analysisshows changes in PaO2, PaCO2, and pH from patient's normal; or PaO 2 less than
50 mm Hg, PaCO2 greater than 50 mm Hg, pH less than 7.35.
7. Management:
Turn patient regularly and mobilize when clinically stable to improve ventilation and
oxygenation.
8. Complications:
9. Nursing management:
Nursing Assessment
Assess level of consciousness (LOC) and ability to tolerate increased work of breathing.
o Confusion, lethargy, rapid shallow breathing, abdominal paradox (inward
movement of abdominal wall during inspiration), and intercostal retractions
suggest inability to maintain adequate minute ventilation.
Determine vital capacity (VC) and respiratory rate and compare with values indicating
need for mechanical ventilation:
o VC < 15 mL/kg.
o Respiratory rate > 30 breaths/minute.
o Negative inspiratory force < -15 to -25 cm H2O.
o Refractory hypoxia
Determine hemodynamic status (blood pressure [BP], heart rate, pulmonary wedge
pressure, cardiac output, SvO2) and compare with previous values. If patient is on
mechanical ventilation with positive end-expiratory pressure (PEEP), venous return may
be limited, resulting in decreased cardiac output.
Nursing Diagnoses
Impaired Gas Exchange related to inadequate respiratory center activity or chest wall
movement, airway obstruction, and/or fluid in lungs
Nursing Interventions
Improving Gas Exchange
Monitor fluid balance by intake and output measurement, daily weight, and direct
measurement of pulmonary capillary wedge pressure to detect presence of hypovolemia
or hypervolemia.
Provide measures to prevent atelectasis and promote chest expansion and secretion
clearance, as ordered (incentive spirometer, nebulization, head of bed elevated 30
degrees, turn frequently, out of bed when clinically stable).
Compare monitored values with criteria indicating need for mechanical ventilation (see
section titled Nursing Assessment). Report and prepare to assist with noninvasive
ventilation or intubation and initiation of mechanical ventilation, if indicated.