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1、Respiratory Failure 呼吸衰竭呼吸衰竭Respiratory FailureRespiratory Failure is a syndrome in which the respiratory system fails in one or both of its gas exchange function: oxygenation氧氧 & carbon dioxide 二氧化碳二氧化碳 elimination. PaO2 60 mmHg or PaCO2 50 mmHgnAcute respiratory failure is present when alveolar ve
2、ntilation is inadequately to meet the bodys need; the lung can no longer adequately oxygenate the blood.Respiratory FailureRisk factor:1.The critically ill patient2.The patient who has undergone recent abdominal 腹部腹部or thoracic胸部胸部surgery, as a result of splinting夹板夹板of the incision切口切口, abdominal d
3、istention, restrictive bandages绷带绷带, tubes引流引流管管, and reduced ventilation通气减少通气减少because of pain.3.The extremely obese肥胖肥胖patient because of restriction of ventilation.4.The patient who has sustained a thoracic or spinal cord脊髓脊髓injury5.The comatose昏迷昏迷patient or patient with decreased level of cons
4、ciousness and depression of the respiratory center.6.The patient who has lung disease or who smokes, especially when an infection develops or surgery is needed.7.The immunosuppressed免疫抑制免疫抑制patients8.The older adultsChronic respiratory failure - days or longer - pH is slightly decreased; allowing ti
5、me for renal compensation and an increase in bicarbonate concentration ClassificationAcute respiratory failure - minutes or hours - pH 7.3 Type I: Hypoxemia Respiratory Failure低氧血症呼吸衰竭低氧血症呼吸衰竭 PaO2 60 mmHg with a normal or low PaCO2 Most common: Associated to all acute diseases of the lung Involve f
6、luid filling or collapse塌陷塌陷of alveoli (cardiogenic or noncardiogenic pulmonary edema, pneumonia, hemorrhage出血出血)Classification Type II: Hypercapnia Respiratory Failure高碳酸血症呼吸衰竭高碳酸血症呼吸衰竭 PaCO2 50 mmHg with hypoxemia (severe airway disorders e.g. asthma, COPD, drug overdose吸毒过量吸毒过量, neuromuscular dis
7、ease神经肌肉疾病神经肌肉疾病, chest wall abnormalities胸壁畸形胸壁畸形 )ClassificationMechanisms of type I respiratory failurenMechanisms that may cause hypoxemia and subsequent hypoxemic respiratory failure are: 1.Ventilation-Perfusion (V/Q) mismatch通气血流比例失调通气血流比例失调2.Shunts分流分流3.Diffusion abnormalities弥散障碍弥散障碍4.Alveol
8、ar ventilation肺泡通气不足肺泡通气不足Mechanisms of type I respiratory failure1.Ventilation-Perfusion (V/Q) mismatch通气血流（通气血流（V / Q )比例失调比例失调:nalter (V/Q) relationship in the lungs or V/Q mismatch, is the most common cause of hypoxemia低氧血症低氧血症.nThe V/Q relationship means that where there is ventilation in the l
9、ungs, there must be matching blood perfusion to that area for efficient gas exchange occur. nIn the normal lung the overall V/Q ratio is 0.8.Mechanisms of type I respiratory failure1.Ventilation-Perfusion (V/Q) mismatchnAn alteration or mismatch occurs if there is blood flow to areas of decrease or
10、absent ventilation or if there is ventilation to areas of decrease or absent blood flow. nExamples of process that cause V/Q mismatch are: pneumoniam肺炎肺炎, atelectasis肺不张肺不张, chronic acute bronchitis, severe emphysema肺气肿肺气肿, asthma哮喘哮喘and pulmonary embolism肺栓塞肺栓塞.Mechanisms of type I respiratory fail
11、ure2.Shunts分流分流nA shunt occurs when blood enters the arterial system动脉系统动脉系统from venous system静脉系统静脉系统without being exposed to ventilated areas通气通气区域区域of the lung. nEssentially, the blood is shunted from the right to the left side of the heart without participating in gas exchange. nBlood that has a
12、 PO2 similar to venous blood is mixed with arterial blood as it enters the left atrium左心房左心房of the heart.Mechanisms of type I respiratory failure2.Shunts nA shunt can be viewed as extremely V/Q imbalance.nThe most common shunts are extrapulmonary肺外分流肺外分流and include those that occur in congenital hea
13、rt disease先天性心脏病先天性心脏病through atrial or septal defects房或室间隔缺损房或室间隔缺损or a patent ductus arteriosus动脉导管未闭动脉导管未闭. nIntrapulmonary anatomic shunts肺内解剖相关的肺内解剖相关的分流分流are associated with arteriovenous fistulas动静脉瘘动静脉瘘in congenital defects. Mechanisms of type I respiratory failure3. Diffusion abnormalities扩
14、散异常扩散异常Diffusion abnormalities indicates an impairment in the equilibration between the O2 pressure in the alveoli and in the pulmonary capillarie.Disease in which a a diffusion abnormalities may contribute to hypoxemia include:Diffuse interstitial fibrosis弥漫性间质纤维化Collagen vascular disease胶原血管疾病of t
15、he lung (e.g., scleroderma硬皮病, systemic lupus erythematosus系统性红斑狼疮)Asbestosis石棉病Sarcoidosis结节病Interstitial pneumonia间质性肺炎Cardiogenic pneumonic edma心源性肺水肿Mechanisms of type I respiratory failure4.Alveolar hypoventilation (PaCO250mmHg): is generalized decrease in ventilation of the lungs with buildup
16、of CO2 in the blood.nAlthough alveolar hypoventilation肺泡通气不肺泡通气不足足is primarily a mechanism of type II respiratory failure, it is mentioned here because in can cause hypoxemia低氧血症低氧血症.nHypoventilation通气过低通气过低is commonly the result of diseases outside the lungs.Pathophysiologic effects of hypoxemianHy
17、hoxemia低氧血症低氧血症 occurs when the amount of oxygen in the blood is not adequate to support aerobic metabolism. nCO2 is the waste product of aerobic metabolism有氧代氧代谢谢. When O2 insufficiency persists, the cell must shift from aerobic to anaerobic metabolism无氧代谢无氧代谢.nThe waste product of anaerobic metabo
18、lism, lactic acid乳酸乳酸, is more difficult than CO2 to remove from the body because it has to be buffered with sodium bicarbonate碳酸氢钠碳酸氢钠. nWhen the body does not have adequate amounts of sodium bicarbonate to buffer lactic acid, metabolic acidosis代谢性酸中毒代谢性酸中毒and cell death occur.Pathophysiologic effe
19、cts of hypoxemianHyhoxemia低氧血症低氧血症and metabolic acidosis代谢性酸中代谢性酸中毒毒have adverse effect on vital organs, especially the heart and central nervous system (CNS). Permanent brain damage may occur because of depressant effect on the brain.nThe heart try to compensate for the decrease O2 level by increas
20、ing heart rate and cardio output. As oxygenation decreases and acidosis increases, however, the heart muscle is unable to function and a slowing and eventual cessation of cardiac activity occur, resulting in systemic shock全身性休克全身性休克.nRenal function is also impaired, and sodium retention, proteinuria
21、, edema formation, tubular necrosis and uremia may occur.nGastrointestinal system alteration include abnormal liver function, abdominal pain and bowel infarction.Mechanisms of type II respiratory failurenMechanisms that may cause type II respiratory failure (hypercapnia) are: 1.Alveolar hypoventilat
22、ion通气不足通气不足 2.Ventilation-Perfusion (V/Q) mismatchMechanisms of type II respiratory failure1.Alveolar hypoventilation肺泡过低通气肺泡过低通气nAlveolar ventilation肺泡通气肺泡通气: is the volume of gas气体容量气体容量per breath that is available for gas exchange in functioning alveoli功能性肺泡功能性肺泡.nThe PaCO2 is inversely related t
23、o the effective alveolar ventilation. Therefore increase PaCO2 indicates decreased alveolar ventilation.nAlveolar hypoventilation is commonly caused by diseases outside the lungs, and often the lungs are normal.Mechanisms of type II respiratory failure2.Ventilation-Perfusion (V/Q) mismatchnThis may
24、occur in a patient who has an increased work of breathing, most likely secondary to a large increase in airway resistance. nBecause the patient does not have the energy or ability to overcome this increased resistance, ventilation decreases and PaCO2 increases.Pathophysiologic effects of hypercapnia
25、nThe main physiologic feature of hypoventilation通气通气过低过低is hypercapnia高碳酸血症高碳酸血症. This occurs because ventilation is inadequate to remove the CO2 produced by cell metabolism.nSubsequent physiologic effect of hypercapnia are: 1.Decrease in PaO2The level of CO2 in the blood (PaCO2 ) the level of CO2 i
26、n the alveolar lest space left in alveolar for O2 PaO2 2.Decrease PHRespiratory acidosis results as CO2 accumulates in the plasma: CO2 + H2O H2CO3 H+ + HCO3 Pathophysiologic effects of hypercapnianSubsequent physiologic effect of hypercapnia are: 2.Potassium shift (hypokalemia低钾血症低钾血症)nAs the CO2 ac
27、cumulates, and with it hydrogen ions (H+), the serum become more acidic H+ enters the cells and K+ move out of the cells to the plasma血浆in an attempt to achieve electorneutrality中和电解质.nInitially, serum K+ may be increase, but as acidemia酸血症becomes prolonged or more pronounced, total body K+ is deple
28、ted as excess extracellular K+ is excreted by the kidneys.Pathophysiologic effects of hypercapnia3. Chloride shift (hypochloremia低氯血症低氯血症)nA low serum chloride lever occurs in acute respiratory failure: as HCO3 move from the cell to the plasma to buffer H2CO3 , the chloride ions move into the cell t
29、o maintain electroneutrality电解质平衡电解质平衡. Clinical manifestation临床表现临床表现 Hypoxemia低氧血症低氧血症:nDyspnea呼吸困难nRestlessness 烦躁不安nAgitation躁动nDisorientation定向障碍nConfusion精神混乱nDelirium谵妄nLoss of consciousness意识丧失Finding:nCardiac dysrhythmia心律失常nTrachycardia心动过速nHypertensionnTrachypnea呼吸过速nCyanosis (may not be
30、present until hypoxemia is severe)nPale, cool, clammy skin脸色苍白，皮肤湿冷脸色苍白，皮肤湿冷Clinical manifestation临床表现临床表现 Hypercapia高碳酸血症高碳酸血症:nHeadachenSomnolence嗜睡nDizziness头晕ncoma昏迷Finding:nHypertensionnTrachycardianDiaphoresis发汗nWarm, flushed skin皮肤温暖潮红皮肤温暖潮红nBounding pulse脉冲脉脉冲脉nAsterixis扑翼样震颤扑翼样震颤 nPapillede
31、ma视神经乳头水肿视神经乳头水肿nDecreased deep tendon reflexes深腱反射降低深腱反射降低Diagnostic studies辅助检查辅助检查Evaluation of oxygenationnArterial blood gas analysis (PaO2, O2 saturation)nPulse oximetry (SpO2)nMixed venous oxygen (PvO2)nShunt equation (Qs/Qt)nAlveolar-arterial oxygen difference D(A-a) O2nAlterial-alveolar rat
32、io (a/A gradient or PaO2/PAO2 ratio)nHypoxemia score (PaO2/FIO2 ratio)Evaluation of ventilation nArterial blood gas analysis (PaCO2)nCapnography (PetCO2)nTidal volume (Vt)nForced vital capacity (FVC)nMinute ventilation or volume (VE)nNegative inspiratory force (NIF) or maximum inspiratory pressure (
33、MIP)nPhysiologic dead space (VD/VT ratio) Nursing implementation护理措施护理措施 Maintenance of adequate oxygenation维持足维持足够的氧合够的氧合1.Oxygen administration to keep PaO2 60mmHg : if hypoxemia is secondary to hypoventilation, provision and maintenance of adequate ventilation usually will overcome the problem of
34、 gas exchange.Hypoxemia secondary to V/Q mismatch V/Q比例失调比例失调usually responds favorably to the lowest concentration of O2 (administered by mask or cannula) necessary to maintain a PaO2 of at least 55-60 mmHg.Hypoxemia secondary to shunting 分流分流is usually refractory to the administration of high conc
35、entration of O2 by mask and ultimately requires mechanical ventilation Nursing implementation Maintenance of adequate oxygenation2. Maintenance of adequate Hb concentration血红血红蛋白浓度蛋白浓度and cardiac output心输出量心输出量To ensure adequate O2 delivery to the tissues, keep the patients PaO2 equal to 60mm Hg or
36、greater will provide adequate O2 saturation. When the PaO2 is 60mm Hg or greater, the Hb is 90% saturated.BP should be maintained at the most beneficial level each patient. Usually , a systolic BP of at least 90 mmHg is adequate to maintain perfusion to vital organs.A urine output of 0.5 ml/kg per h
37、our or more is an indication of adequate renal perfusion. Nursing implementation Maintenance of adequate oxygenation3. Prevention and assessment of tissue hypoxia 缺氧Close observation for clinical manifestations of vital organ hypoxia is needed, including:Mental and neurologic status: clouding of sen
38、sorium感觉迟钝感觉迟钝, poor concentration, restlessness, stupor昏睡昏睡, lethargy嗜睡嗜睡, somnolence tremors, slurred speech, depressed tendon reflexes跟键反射减弱跟键反射减弱, and asterixis扑翼样震颤扑翼样震颤.Cardiovascular status: direct or indirect BP monitoring, cardiac rate and rhythm心律和心率心律和心率, symptoms of right-sided and left-
39、sided heart failure.Fluid and electrolyte levels: continuous or serial monitoring of oxygenation status is essential; serial evaluations of serum electrolytes are made to determine excesses or deficiencies.Nursing implementation Maintenance of adequate oxygenation4. Measures to decrease stress and p
40、romote comfortnThe patient should be maintained in an atmosphere as quite and relaxed as possible.nPositioning the patient for comfort and for the most efficient ventilation is important.nFrequent rest periods needed to be provided and efficient scheduling (pacing) of care, treatments, assessments a
41、nd diagnostic studies are important to help with conserving the patients energy.nIt is helpful to explain to the patient the possible sensation that may be encountered with each new experience (e.g., suctioning, drawing ABGs) so that coping strategies can be purposefully selected.nMeasures to increa
42、se physical comfort are also important: mouth care, removing perspiration-soaked gown, sponging the upper torso躯干上部躯干上部酒精擦浴酒精擦浴. Nursing implementation Improvement of alveolar ventilation nMaintenance of patent airway维持气道的开放维持气道的开放1.Effective coughingAugmented coughing增加咳嗽增加咳嗽may be useful in the pa
43、tient with neuromuscular weakness or in an exhausted patient.If the patients cough is ineffective in removing secretions, nasopharyneal or nasotracheal suctioning is indicated.Coughing at the end of expiration呼气末呼气末is helpful in the patient with sever airway obstruction because it can cause compress
44、ion of the more distal or peripheral airways and may help “milk” or move secretions into the proximal airway.Nursing implementation Maintenance of patent airway2.Positioning体位体位nPositioning the patient either by elevating the head of the bed to at least 45 degree (if tolerated) or by using a reclini
45、ng chair bed may maximize thoracic expansion.nA patient with only one functioning lung should be positioned with the unaffected lung健侧健侧in the dependent position. This position is important in preventing hypoxemia because the “down” lung gets more perfusion. If the diseased lung was “down”, more V/Q
46、 mismatch would occur.nThe patient should be lying on the side if there is any possibility that the tongue will obstruct the airway or that aspiration may occur.Nursing implementation Maintenance of patent airway3. Suctioning吸引吸引 nAdequate oxygenation and monitoring of the patient are essential duri
47、ng suctioning procedures.nAlthough rarely indicated, bronchoscopy may be used to remove secretions, especially if they are extremely thick and tenacious.Nursing implementation Improvement of alveolar ventilation4.Measures to liquefy and mobilize secretionsHumidification加湿加湿Adequate hydration Chest p
48、hysiotherapy (if indicated)Aerosol and untrasonic nebulization雾化雾化nIf suctioning or other measures to mobilize secretions are ineffective, it may become necessary to insert endotracheal or tracheostomy tube to facilitate suctioning of secretions.Improvement of alveolar ventilation5. Relief of bronch
49、ospasm减轻支气管痉挛减轻支气管痉挛Bronchodilators支气管扩张剂支气管扩张剂nRelief of bronchospasm (if present) will aid in maximal bronchodilatation and increase effective alveolar ventilation.nAdministration of an O2-riched gas mixture simultaneously with the bronchodilator may help to alleviate the subsequently hypoxemia.Co
50、rticosteroids (when indicated)nCorticosteroids are used in conjunction with bronchodilating agents when bronchospasm and inflammation are present.Nursing implementation Improvement of alveolar ventilationnVentilation assistanceIf intensive measures fail to improve alveolar ventilation and the patien
51、t continues to deteriorate clinically, mechanical ventilation may be instituted to assist or control ventilation;nContinuous positive pressure breathing (CPPB)连续正压呼吸nNoninvasive positive pressure breathing (NIPPV)无创正压呼吸Nursing implementation Treatment of underlying cause of failurenIn a patient with
52、 absolute hypoventilation, the primary problem usually can be diagnosed rapidly, and appropriate therapy initiated.Continuous monitoring of the effects of treatmentnAccurate, clear documentation of subjective and objective assessments on the patients flowchart is an important aspect of care.nA flowc
53、hart that shows the patients ABG measurement, vital signs, pulmonary artery pressure, weights, intake and output, medications and dosages, electrolytes, respiratory parameters is extremely helpful.Nursing intervention and rationalesnIneffective airway clearance related to accumulation of secretion,
54、exudate, sputum in airways, decreased level of consciousness, thoracic and/or abdominal neuromuscular dysfunction, pain and expiratory airflow obstruction 1.Evaluate patients ability to cough to determine the need for assistance in removing secretion.2.Perform chest physiotherapy to enhance removal
55、of secretions.3.Perform tracheobronchial suctioning if coughing is effective.4.Humidify inspired air if upper airway is bypassed or O2 is being used at 3L/min to prevent drying of mucosa.5.Splint chest abdominal incision with pillow or hand to reduce pain and allow deeper, more effective breathing a
56、nd coughing.6.Turn q2hr to prevent stasis of secretions and promote optimal ventilation7.Stabilizer artificial airway to prevent accidental extubation.8.Ensure adequate fluid intake of 2-3L/24hr to liquefy secretions and prevent dehydration9.Administer prescribed bronchodilator and mucolytic medicat
57、ion.Nursing intervention and rationalesnIneffective breathing pattern related to neuromuscular impairment, pain, muscularskeletal impairment, anxiety, CNS depression, respiratory muscle fatigue or failure, increased work of breathing, expiratory obstruction to airflow .1.Provide comfort measures (e.
58、g., positioning, analgesics) to reduce anxiety and allow maximum cooperation with respiratory procedures.2.Provide mechanical support if indicated to prevent or treat acute respiratory failure and maintain adequate oxygenation and ventilation.Nursing intervention and rationalesnAltered nutrition: le
59、ss than body requirement related to poor appetite, lowered energy level, shortness of breath, and increased caloric requirements.1.Provide high-protein, high-caloric, enteral or parenteral nutrition as prescribed.2.Monitor serum albumin血清白蛋白血清白蛋白or transferrin转铁转铁蛋白蛋白levels to determine adequacy of
60、protein and iron and potential for anemia贫血贫血and muscle wasting肌肉消瘦肌肉消瘦.3.Monitor fluid status (intake and output, weight)4.With parenteral nutrition, monitor for sings of CO2 increase during weaning as a result of carbohydrate loads as carbohydrates may increases CO2 levels in patients with hyperca
61、pnia. Nursing intervention and rationalesnAnxiety related to dyspnea, intubation, severity of illness, loss of personal control and uncertain outcome1.Perform intervention in clam, assured manner to decrease patients anxiety and foster hope about the outcome.2.Answer question simply and honestly to
62、provided patient needed information.3.Teach and demonstrate to patient slow pursed-lip breathing.4.Explain sensations patient may experience during procedures.5.Explain equipment, procedures, and treatments in familiar term so patient can purposefully select coping strategies to reduce anxiety and fear.
