Acute respiratory failure is an inadequate ventilation resulting from the inability of the lungs to adequately maintain arterial oxygenation or eliminate carbon dioxide

Two classifications:
- Hypoxemic (type I), the most common type, with partial pressure of arterial oxygen (PaO2) less than 55 mm Hg, arterial oxygen saturation less than 88%, and normal or low partial pressure of arterial carbon dioxide (PaCO2)
- Hypercapnic (type II), with PaCO2 greater than 50 mm Hg accompanied by acidemia or a pH less than 7.3

Pathophysiology

Primarily hypercapnic respiratory failure results from inadequate alveolar ventilation due to a ventilation-perfusion mismatch and shunting.
Primarily hypoxemic respiratory failure results from inadequate oxygen exchange between the alveoli and capillaries.
Combined hypercapnic and hypoxemic respiratory failure commonly occurs.

Causes

Airway obstruction
Any condition that increases the work of breathing and decreases the respiratory drive of patients with chronic obstructive pulmonary disease
Central nervous system depression
Disorders of the peripheral nervous system, respiratory muscles, and chest wall
Endocrine or metabolic disorders
Gas exchange failure
Heart failure
Myocardial infarction (MI)
Pulmonary emboli
Pulmonary edema
Respiratory tract infection
Thoracic, alveolar, or airway abnormalities
Ventilatory failure
Sleep apnea
Stroke

Risk Factors

History of any disease or condition that affects the muscles, nerves, bones, or tissues that support breathing
Accumulated secretions secondary to cough suppression
History of lung disease
Smoking
History of heart disease
Narcotic use
Severe or continuous bronchospasm
Obesity-hypoventilation syndrome
Hypothyroidism
Kyphoscoliosis
Toxin exposure

Incidence

Acute respiratory failure occurs in patients with hypercapnia or hypoxemia. However, the overall frequency of the condition isn't clear.
The disorder occurs in patients who have an acute deterioration in arterial blood gas (ABG) values.

Complications

Tissue hypoxia
Pulmonary embolism
Barotrauma
Pneumonia
Hypotension
Arrhythmia
Acute MI
Endocarditis
Pericarditis
Stress ulcers, gastric distention, pneumoperitoneum
Chronic respiratory acidosis
Metabolic alkalosis
Respiratory and cardiac arrest
Acute kidney injury

Assessment

History

Presence of risk factor or underlying disease process
Restlessness
Change in mental status or level of consciousness
Cyanosis
Dyspnea
Morning headache

Physical Findings

Changes in mental status, confusion, somnolence
Cyanosis of the oral mucosa, lips, and nail beds
Yawning and use of accessory muscles
Pursed-lip breathing
Nasal flaring
Ashen skin
Tachypnea
Cold, clammy skin
Asymmetrical chest movement
Accessory muscle use
Decreased tactile fremitus over obstructed bronchi or a pleural effusion
Increased tactile fremitus over consolidated lung tissue
Hyperresonance
Diminished or absent breath sounds
Wheezes (with asthma)
Rhonchi (with bronchitis)
Crackles (with pulmonary edema)
Myoclonus, seizures (with severe hypoxemia)
Asterixis (with severe hypercapnia)
Tachycardia

Diagnostic Test Results

Laboratory

Arterial blood gas analysis reveals hypercapnia and/or hypoxemia. (Commonly accepted values include PaO2 of less than 55 mm Hg and PaCO2 of more than 50 mm Hg on room air.)
White blood cell count and differential is increased in bacterial infections.
Serum hemoglobin level test and hematocrit test may show anemia, which decreases oxygen-carrying capacity.
Potassium level (serum) results may reveal hypokalemia, and chloride level (serum) results may show hypochloremia.
Blood culture or sputum culture shows the pathogen.
Cardiac enzymes may identify MI as a causative factor.
Decreased thyroid-stimulating hormone level (serum) may indicate hypothyroidism as a causative factor.

Imaging

Chest radiography may show underlying pulmonary diseases or conditions, such as emphysema, atelectasis, lesions, pneumothorax, infiltrates, and effusions.
Echocardiography may reveal a cardiac cause of respiratory failure.
Computed tomography scanning (thorax) may reveal abnormalities, such as pulmonary embolus.

Diagnostic Procedures

Electrocardiography may show arrhythmias, cor pulmonale, or myocardial ischemia.
Pulse oximetry may show decreased arterial oxygen saturation.
Pulmonary function tests are abnormal.

Identifying respiratory failure

Use these measurements to identify respiratory failure:

Vital capacity less than 15 mL/kg
Tidal volume less than 3 mL/kg
Negative inspiratory force less than -25 cm H2O
Respiratory rate more than twice the normal rate
Diminished PaO2 despite increased fraction of inspired oxygen
Elevated PaCO2, with pH lower than 7.3

Treatment

General

Treatment of underlying cause
Venous thromboembolism (VTE) prophylaxis while hospitalized

Diet

Fluid restriction (if the underlying cause is heart failure)
Small frequent meals when on noninvasive positive pressure ventilation or when extubated
Enteral tube feedings or parenteral nutrition if the patient is mechanically ventilated

Activity

Bed rest initially, early mobilization as tolerated
Passive or active range-of-motion exercises

Medications

Cautious oxygen therapy to increase PaO2
Possible high-flow nasal cannula oxygen therapy for patients with acute hypoxemic respiratory failure
Histamine-receptor antagonists, such as famotidine, as ordered
Antibiotics to treat underlying infection
Antipyretics, such as acetaminophen or ibuprofen, for fever if infection is the underlying cause
Bronchodilators, such as terbutaline sulfate, albuterol sulfate, theophylline, or ipratropium bromide, to alleviate obstruction and bronchospasm
Corticosteroids such as methylPREDNISolone to reduce inflammation
Positive inotropic agents, such as DOPamine hydrochloride or DOBUTamine hydrochloride, to increase cardiac contractility and vasodilation to improve perfusion
Loop diuretics such as furosemide for pulmonary vascular congestion or pulmonary edema or to alleviate heart failure
Nitrates, such as nitroglycerin or nitroprusside sodium, to reduce preload and afterload resulting in a decreased myocardial oxygen demand
Morphine sulfate as an adjunct treatment for acute pulmonary edema to decrease preload and systemic vascular resistance and to reduce anxiety
Enoxaparin sodium for VTE drug prophylaxis

Procedures

Extracorporeal membrane oxygenation for severe but potentially reversible respiratory failure
Noninvasive positive pressure ventilation for mild to moderate respiratory failure
Mechanical ventilation with an endotracheal (ET) tube or a tracheostomy tube

Surgery

Possible tracheostomy

Nursing Considerations

Nursing Interventions

Give prescribed drugs as indicated (via inhalation, oral route, nebulization, or IV). If giving IV, ensure patent IV access and perform IV site care according to facility guidelines.
Orient the patient frequently. Provide reminders to help the patient remain oriented.
Administer humidified supplemental oxygen as ordered based on oxygen saturation levels via pulse oximetry readings or ABG values.
Maintain a patent airway.
Help clear the patient's secretions with postural drainage and chest physiotherapy; also suction as necessary.
Obtain blood samples for ABG analysis, as ordered.
Routinely check all noninvasive positive pressure device and ventilator settings according to facility guidelines.
Secure the ET or tracheostomy tube and perform care according to facility guidelines.
Administer enteral tube feedings as ordered and monitor tolerance.
Provide alternative communication means, such as a pen and paper or communication board.
Provide sedation as necessary.
Encourage pursed-lip breathing, coughing, and diaphragmatic breathing exercises.
Note the color and characteristics of any sputum produced.
Encourage the use of incentive spirometry to promote lung expansion.
Turn and reposition the patient regularly and frequently, unless contraindicated. Base the frequency of repositioning on the patient's tissue tolerance, skin condition, mobility, medical condition, and treatment goals. Assist with or perform oral hygiene.
Auscultate heart and lung sounds for changes.
Position the patient for comfort, with the head of the bed elevated 30 to 45 degrees, if appropriate, to promote optimal gas exchange and prevent ventilator-associated pneumonia (if a ventilator is being used).
Maintain normothermia with antipyretics.
Cluster care activities to provide for frequent, uninterrupted rest periods. Institute energy conservation measures.
Obtain daily weight. Check skin turgor and inspect mucous membranes for changes in color or moisture.
Ensure adequate hydration and nutrition. Test stool and other drainage for occult blood.
Obtain specimens for such laboratory tests as complete blood counts, serum electrolyte levels, and ABG values, as ordered.
Apply antiembolism stockings or sequential compression stockings to prevent VTE.

Monitoring

Vital signs and pulse oximetry
Oxygen saturation levels
Respiratory status, including respiratory rate and depth and breath sounds
Intake and output
Laboratory studies, including ABG and electrolyte levels
Daily weight
Level of consciousness
Cardiac rate and rhythm
Hemodynamic values
Chest radiography results
Complications
Sputum quality, consistency, and color
Signs and symptoms of infection
Skin integrity
Noninvasive positive-pressure ventilation device and ventilator settings, including positive end-expiratory pressure and fraction of inspired oxygen
ET tube position and patency; tracheostomy tube function, patency, and insertion site
Signs and symptoms of stress ulcer
Enteral tube feeding tolerance

Associated Nursing Procedures

Aerosol treatment
Alignment and pressure-reducing device application
Arterial puncture for blood gas analysis
Bedside spirometry
Cardiac monitoring
Chest physiotherapy
Continuous positive airway pressure (CPAP) use
Endotracheal tube removal
Endotracheal tube repositioning
Enteral feeding tube insertion, gastric and duodenal
Enteral feeding tube removal, gastric and duodenal
Extracorporeal membrane oxygenation (ECMO) monitoring and care
Humidifier therapy, active, bubble
Incentive spirometry
Intubation with direct visualization
Mechanical ventilation, positive pressure
Nasotracheal suctioning
Oral care for an intubated patient
Oronasopharyngeal suctioning
Oropharyngeal airway insertion and care
Oxygen administration
Pulse oximetry
Sputum collection by expectoration
Sputum collection by tracheal suctioning
Tracheal cuff pressure measurement
Tracheal suctioning, intubated patient
Tracheostomy cuff inflation and deflation
Tracheostomy ties change
Tracheostomy tube cannula and stoma care
Weaning a patient from a ventilator

Patient Teaching

General

Include the patient's family or caregiver in your teaching, when appropriate. Provide information according to their individual communication and learning needs. Be sure to cover:

disorder, diagnostic testing, underlying causes, monitoring, and treatment, including the possible need for intubation, equipment, and monitoring devices being used
medications and their potential adverse effects, such as increased heart rate with bronchodilators and electrolyte imbalances with diuretics
signs and symptoms of therapy effectiveness
need for and use of mechanical ventilation
rationale for tracheostomy, if indicated; tracheostomy tube and site care
potential complications of treatment, such as gastrointestinal bleeding and infection
signs and symptoms to report to the practitioner, such as increasing respiratory difficulty
smoking cessation, if appropriate
communication techniques if the patient is intubated
signs and symptoms of respiratory infection
measures to prevent VTE
need for continued monitoring and follow-up to evaluate the effectiveness of therapy
recommendations for immunizations, such as pneumococcal and influenza vaccines, to reduce the risk of infection.

Discharge Planning

Participate as part of a multidisciplinary team to coordinate discharge planning efforts. The team may include the bedside nurse, social worker, care manager, respiratory therapist, physical therapist, nutritionist, and pulmonologist.
Determine the appropriate posthospital setting to which the patient should be discharged.
Assess the patient's and family's understanding of the diagnosis, treatment, prognosis, follow-ups, and warning signs for which to seek medical attention.
Assess the patient's level of independence before admission.
Evaluate how the current illness will impact the patient's independence.
Identify the patient's formal and informal supports.
Identify the patient's and family's goals, preferences, comprehension, and concerns about discharge.
Confirm arrangements for transportation to initial follow-ups.
Provide a list of prescribed drugs, including the dosage, prescribed time schedule, and adverse reactions to report to the practitioner. Provide the patient (and family or caregiver, as needed) with written information on the medications that the patient should take after discharge.
Assess the patient's and family's understanding of prescribed medication, including dosage, administration, expected results, duration, and possible adverse effects.
Assess the patient's ability to obtain medications; identify the party responsible for obtaining medications.
Instruct the patient to provide a list of medications to the practitioner who will be caring for the patient after discharge; to update the information when the practitioner discontinues medications, changes doses, or adds new medications (including over-the-counter products); and to carry a medication list that contains all of this information at all times in the event of an emergency.
Ensure that the patient and caregivers receive medical contact information.
Ensure that the patient or caregiver receives a copy of the discharge instructions and that a copy is placed in the patient's medical record.
Provide information on smoking cessation, if appropriate.
Provide contact information regarding local support groups or services.
Document the discharge planning evaluation in the patient's clinical record, including who was involved in discharge planning and teaching, their understanding of the teaching provided, and any need for follow-up teaching.