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ACUTE RESPIRATORY FAILURE

Definition: Acute respiratory failure is defined as a fall in arterial oxygen tension (PaO2) to less than 50 mm Hg (Hypoxemia) and a rise in arterial carbon dioxide
(PaCO2) to greater than 50 mm Hg (Hypercapnia), with an arterial pH of less than 7.35. In Acute Respiratory Failure, the ventilation or perfusion mechanisms in the
lungs are impaired.

Four types of Acute Respiratory Failure

Type I Respiratory Failure Type II Respiratory Failure Type III Respiratory Failure Type IV Respiratory Failure
(Hypoxemic) (Hypercapnic) (Peri-operative) (Shock)

Definition:

It is associated with damage to lung Occurs when alveolar ventilation is Type III refers as peri-operative Type IV Respiratory Failure is a Shock
tissue which prevents adequate insufficient to excrete the carbon respiratory failure. It occurs when a State. It means that the body cannot
oxygenation of the blood. However, dioxide being produced. Inadequate person has had surgery and the small adequately provide oxygen and
the remaining normal lung is still ventilation is due to reduced airways in the lungs have closed in maintain blood pressure on its own.
sufficient to excrete carbon dioxide. ventilatory effort or inability to greater numbers. Factors such as pain This is secondary to cardiovascular
This results in low oxygen, and normal overcome increased resistance to or stomach surgery, which place higher instability. Hypoperfusion can lead to
or low carbon dioxide level. Arterial ventilation. It affects the lung as a pressure on the lungs, can also respiratory failure. Ventilator therapy
oxygen pressure (PaO2) is <8 kPa (60 whole, and therefore carbon dioxide contribute to this type of respiratory is often instituted in order to minimize
mm Hg) with normal or low arterial accumulates, presenting with PaO2 of failure. the steal of the limited cardiac output
carbon dioxide pressure (PaO2). <8 kPa (60 mm Hg) or normal, with by overworking respiratory muscles
Considered as the most common form hypercapnia PaCO2 >6.0 kPa (>50 mm until the etiology of the hypoperfusion
of respiratory failure. Hg). state is identified and corrected.

Signs & Symptoms:

▪ Dyspnea ▪ Change of behavior ▪ Decreased FRC ▪ Abnormal arterial blood gas

▪ Irritability ▪ Headache ▪ Upper Abdominal Incision results
▪ Confusion ▪ Coma ▪ Difficulty Breathing ▪ Agitation

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▪ Somnolence ▪ Warm Extremities ▪ Aspiration ▪ Somnolence

▪ Fits ▪ Asterixis ▪ Atelectasis ▪ Peripheral or central cyanosis
▪ Tachycardia ▪ Papilledema ▪ Decreased oxygen saturation
▪ Arrhythmia ▪ Tachycardia
▪ Tachypnea ▪ Hypertension
▪ Cyanosis ▪ Diaphoresis
▪ Accessory muscle use
▪ Intercostal indrawing
▪ Suprasternal retractions
▪ Tachypnea
▪ Abdominal Paradox

Pathophysiology:

There are four pathophysiological At a constant rate of CO2 production, Alveolar hypoventilation, ventilation- Type IV respiratory failure ensues
mechanism that account for the PaCO2 is determined by the level of perfusion mismatch, shunt and when the circulation fails and resolves
hypoxemia seen in a wide variety of alveolar ventilation. The relationship diffusion limit are the when shock is corrected, as long as one
diseases: alveolar hypoventilation, between alveolar ventilation, rate of pathophysiological processes that of the other types of respiratory failure
ventilation-perfusion mismatch, shunt, CO2 production and PaCO2. When account for hypoxemia in a wide range has not supervened.
and diffusion limit. V.CO2 is constant, PaCO2 is of illnesses. In neuromuscular diseases
determined by V.a which in turn is that impact the respiratory system,
▪ Alveolar hypoventilation occurs in dictated by two factors: Minute alveolar hypoventilation develops. In
neuromuscular disorders that ventilation and the relationship the absence of underlying pulmonary
affect the respiratory system. In between v.e and v.a. illness in sickle cell disease,
the absence of underlying hypoxemia associated with alveolar
pulmonary in sickle cell disease, The latter is determined by the hypoventilation is defined by a normal
the hypoxemia accompanying proportion of V.e that constitutes dead alveolar-arterial oxygen gradient.
alveolar hypoventilation is space ventilation that is, the dead space
characterized by a normal to tidal volume ratio. Diseases characterized by a widening
alveolar-arterial oxygen gradient. of the alveolar-arterial oxygen
▪ Hypoxemia is contributed to by gradient, which is typically less than 20
ventilation relative to perfusion. millimeters of mercury, in contrast to
disorders characterized by any of the

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▪ Similarly with a shunt, either other three operating processes. When

intrapulmonary or intracardiac there is a ventilation perfusion
deoxygenated mixed venous blood mismatch, regions of low hypoxemia
bypasses ventilated alveoli, are caused by ventilation compared to
resulting in venous admixture. perfusion. Similarly, deoxygenated
▪ Diseases that increase the mixed venous blood bypasses
diffusion pathway for oxygen ventilated alveoli through a shunt,
from the alveolar space to either intrapulmonary or intracardiac,
pulmonary capillary oxygen resulting in venous admixture.
transport is impaired across the
alveolar capillary membrane. The oxygen diffusion pathway from
alveolar space to the pulmonary
capillary oxygen transport is hampered
over the alveolar capillary membrane.
Even though variations in minute and
alveolar ventilation might occur.

Assessment / Diagnostic Procedures:

▪ Arterial Blood Gases (ABG) – measures oxygen and carbon dioxide levels in the blood.
▪ Renal and Liver Function Tests – may indicate the etiology of respiratory failure or identify complications associated with it.
▪ Pulmonary Function Test – identifies obstruction, restriction, and gas diffusion abnormalities. Normal values for force expiratory volume in 1 second
(FEV1) and forced vital capacity (FVC) suggest a disturbance in respiratory control. Decrease in FEV1 to FVC ratio indicates airflow obstruction. A decrease
in FEV1 and FVC and maintenance of FEV1 to FVC ratio suggest restrictive lung disease.
▪ Electrocardiography (ECG)
▪ Chest Radiography – it is needed as it can detect chest wall, pleural and lung parenchymal lesions.
▪ Complete Blood Count (CBC) - may indicate anemia which can contribute to tissue hypoxia, whereas polycythemia may indicate chronic hypoxemic
respiratory failure.
▪ Sputum, Blood and Urine Culture
▪ Blood Electrolytes and Thyroid Function Tests
▪ Echocardiography – it is useful when a cardiac cause of acute respiratory failure is suspected. It also provides an estimate of right ventricular function and
pulmonary artery pressure in patients with chronic hypercapnic respiratory failure.
▪ Bronchoscopy

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Medical Management:

▪ Inhaled medications. Helps ▪ Continuous supplemental ▪ Administer Epidural Opioids Supportive measure which depends on
open up airways. oxygen. ▪ Early ambulation and airways management to maintain
▪ Supplemental oxygen is ▪ Continuous Positive Airway techniques that encourage deep adequate ventilation and correction of
administered via nasal prongs Pressure (CPAP). breathing. the blood gases abnormalities.
or face mask. ▪ Biphasic Positive Airway ▪ Chest Physiotherapy.
▪ Proper positioning of the Pressure. ▪ Incentive Spirometry. ▪ Correction of Hypoxemia – the
patient. ▪ IV Fluids. Having the correct ▪ CPAP can be used as a last goal is to maintain adequate
▪ Bed rest during early phase of amount of fluid in the body means in attempting to prevent tissue oxygenation, generally
respiratory failure supports proper blood flow and intubation. achieved with an arterial
management. transportation of nutrition ▪ Preoperative Fasting. oxygen tension of 60 mm Hg or
▪ IV Fluids. Having the correct throughout the body, without ▪ IV Fluids. Having the correct arterial oxygen saturation of
amount of fluid in the body causing fluid to build up in the amount of fluid in the body about 90%.
supports proper blood flow and lungs. supports proper blood flow and ▪ Correction of hypercapnia and
transportation of nutrition transportation of nutrition respiratory acidosis
throughout the body, without throughout the body, without ▪ Ventilatory Support for patient
causing fluid to build up in the causing fluid to build up in the with respiratory failure.
lungs. lungs. ▪ IV Fluids. Having the correct
amount of fluid in the body
supports proper blood flow and
transportation of nutrition
throughout the body, without
causing fluid to build up in the
lungs.

Surgical Management:

Surgery may be necessary depending on the severity of the respiratory failure and it’s underlying cause. Possible surgical interventions include:

▪ Lung Transplantation

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▪ Tracheostomy – it is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help ease breathing. A
tracheostomy may be carried out to deliver oxygen to the lungs if the patient is unable to breathe normally. It is also performed to provide a long-
term route for mechanical ventilation in cases of respiratory failure or to provide pulmonary toilet. Inadequate cough brought on by chronic pain or
weakness, aspiration and an inability to deal with secretions. The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing
contents. Thus, this intervention can prevent aspiration and provide for the removal of any aspirated substances.

Nursing Management:

Nursing Assessment: Nursing Assessment: Nursing Assessment: Nursing Assessment:

▪ Assess for airway patency. ▪ Note for changes in behavior or ▪ Assess for airway patency. ▪ Note for changes in behavior or
Maintaining patent airways is mental status. Maintaining patent airways is mental status.
always the first priority. ▪ Note for changes in HR, BP, always the first priority. ▪ Note for changes in HR, BP,
▪ Auscultate lungs for presence and temperature. ▪ Auscultate lungs for presence and temperature.
of normal or adventitious ▪ Use pulse oximetry to monitor of normal or adventitious ▪ Use pulse oximetry to monitor
breath sounds. oxygen saturation; assess breath sounds. oxygen saturation; assess
▪ Assess respiration. Note the arterial blood gases (ABG). ▪ Assess respiration. Note the arterial blood gases (ABG).
quality, rate, pattern, depth, ▪ Monitor for symptoms of quality, rate, pattern, depth, ▪ Monitor for symptoms of
flaring of nostrils, dyspnea on respiratory failure. flaring of nostrils, dyspnea on respiratory failure.
exertion, use of accessory exertion, use of accessory ▪ Assess for airway patency.
muscle and position for Nursing Diagnoses may include: muscle and position for Maintaining patent airways is
breathing. ▪ Ineffective Airway Clearance breathing. always the first priority.
▪ Assess for hydration status: ▪ Ineffective Breathing Pattern ▪ Assess for hydration status: ▪ Auscultate lungs for presence
skin turgor, mucous ▪ Impaired Gas Exchange skin turgor, mucous of normal or adventitious
membranes, tongue. ▪ Anxiety membranes, tongue. breath sounds.
▪ Monitor respiratory and ▪ Monitor respiratory and ▪ Assess respiration. Note the
oxygenation status to detect Nursing Intervention: oxygenation status to detect quality, rate, pattern, depth,
systemic and clinical ▪ Encourage slow, deep systemic and clinical flaring of nostrils, dyspnea on
manifestations of decreased breathing; turning and manifestations of decreased exertion, use of accessory
oxygen and increased carbon coughing to promote secretion oxygen and increased carbon muscle and position for
dioxide levels. removal. dioxide levels. breathing.

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Nursing Diagnoses may include: ▪ Perform endotracheal or Nursing Diagnoses may include: ▪ Assess for hydration status:
nasotracheal suctioning to skin turgor, mucous
▪ Ineffective Airway Clearance remove secretions and improve ▪ Ineffective Airway Clearance membranes, tongue.
▪ Ineffective Breathing Pattern oxygenation. ▪ Ineffective Breathing Pattern ▪ Monitor respiratory and
▪ Impaired Gas Exchange ▪ Position patient to maximize ▪ Impaired Gas Exchange oxygenation status to detect
▪ Anxiety ventilation. ▪ Anxiety systemic and clinical
▪ Administer humidified air or manifestations of decreased
Nursing Interventions: oxygen to prevent drying of the Nursing Interventions: oxygen and increased carbon
mucosa. dioxide levels.
▪ Initiate and maintain ▪ Perform chest physical therapy ▪ Position the patient to minimize
supplemental oxygen and to enhance removal of respiratory efforts (e.g. elevate Nursing Diagnoses may include:
prescribed and titrate to secretions. the head of the bed and provide
increase PaO2 and SaO2 levels ▪ Regulate fluid intake to overbed table for patient to lean ▪ Ineffective Airway Clearance
and improve clinical optimize fluid balance to on) to preserve energy for ▪ Ineffective Breathing Pattern
assessment findings. liquify secretions. breathing. ▪ Impaired Gas Exchange
▪ Provide mechanical ventilatory ▪ Teach pursed-lip breathing ▪ Anxiety
support, if necessary, to techniques to reverse I : E ratio.
maintain adequate gas ▪ Initiate resuscitation efforts Nursing Intervention:
exchange. because airway support may be
▪ Apply ECG electrode and needed in the event of severely ▪ Provide electrolyte replacement
connect to cardiac monitor to impaired ventilation or apnea. as prescribed.
identify dysrhythmias. ▪ Assist with insertion of an ▪ Administer fluid and blood
▪ Provide health teaching about endotracheal tube by gathering replacement therapy as
proper ways of coughing and necessary intubation and prescribed.
breathing exercises. emergency equipment, ▪ Initiate and maintain
▪ Give medications as prescribed ensuring adequate intravenous supplemental oxygen and
by the primary physician. access, administering prescribed and titrate to
▪ Pace activities especially for medications as ordered and increase PaO2 and SaO2 levels
patient with reduced energy. monitoring the patient for and improve clinical
Maintain planned rest periods. complications during insertion assessment findings.
Promote energy-conservation achieve adequate oxygenation ▪ Provide mechanical ventilatory
method. and effective ventilation. support, if necessary, to

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maintain adequate gas

exchange.
▪ Apply ECG electrode and
connect to cardiac monitor to
identify dysrhythmias.
▪ Provide health teaching about
proper ways of coughing and
breathing exercises.
▪ Give medications as prescribed
by the primary physician.
▪ Pace activities especially for
patient with reduced energy.
Maintain planned rest periods.
Promote energy-conservation
method.

References:

▪ Brunner, L. S., Suddarth, D. S., Smeltzer, S. C. O., & Bare, B. G. (2004). Brunner & Suddarth's textbook of medical-surgical nursing (10th ed.).
Philadelphia: Lippincott Williams & Wilkins.
▪ Malalur, C.(2018, March). Respiratory Failure. https://www.slideshare.net/ChaithanyaMalalur/respiratory-failure-90124183
▪ Physiopedia. (2018). Respiratory Failure. https://www.physio-pedia.com/Respiratory_Failure
▪ McGill. (2021). Acute Respiratory Failure. https://www.mcgill.ca/criticalcare/teaching/files/acute
▪ Kaynar, A.M., Pinsky, M. (2020, April). Respiratory Failure Treatment and Management. https://emedicine.medscape.com/article/167981-
treatment#showall

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