NURSING MANAGEMENT OF RESPIRATORY FAILURE Assessment Patients with acute respiratory failure should be closely observed for potential

deterioration. Respiratory assessment should occur on a frequent/continual basis. Monitoring may involve intermittent/continual pulse oximetry and regular peak expiratory flow rate measurement but should always include basic respiratory rate monitoring and general assessment. Patients at risk of developing oxygen insufficiency are an ideal group for these systems and their use should be encouraged. Any changes in physiological signs should be reported promptly to the senior practitioner. Nursing diagnoses and interventions Oxygen insufficiency is a life threatening situation. It can be result from respiratory failure, ARDS, Severe pneumonia, Interstitial lung disease, Pulmonary thromboembolism,

Spontaneous pneumothorax pneumomediastinum and respiratory depression. The important nursing diagnoses include : Impaired gas exchange Related factors: alveolar hypo ventilation, V/Q mismatch and diffusion impairment as evidenced by hypoxemia and/ or hypercapnia. Defining characteristics: cyanosis, retractions, tachypnoea, Out comes: oxygen saturation, PaO2, PaCO2, arterial pH, ventilation perfusion balance . Interventions Assess breath sounds. Monitor ABGs Maintain airway. Place patient in position to allow maximum lung expansion. Maintain O2 delivery system as needed.

Anticipate the need for intubation and mechanical ventilation.

Altered cerebral perfusion Related factors: impaired gas exchange, decreased oxygen in blood, Defining characteristics: altered level of consciousness, inappropriate behaviour, altered papillary response, Out comes: maximal cerebral perfusion as evidenced by alert responsive mentation or no further reduction in mental status.

Interventions: Assess level of consciousness. Assess for cranial nerve response especially vagus (breathing, gag, cough) absence indicates need for artificial airway maintenance. Monitor for increased ICP Assess for seizure activity. Elevate head end of bed. Administer hyperventilation- blow of CO2 to control cerebral blood flow and in turn control increased ICP. Maintain oxygenation levels to prevent further hypoxemic damage Administer anticonvulsants as prescribed.

Inability to sustain spontaneous ventilation Related factors: CNS factors, respiratory muscle factors, metabolic factors Defining characteristics: shortness of breath, increased PaCO2 level, decreased PaO2 level, decreased O2 saturation, increased restlessness and irritability, dyspnea, tachypnea, cyanosis. Outcomes: patients ventilator demand is decreased as evidenced by eupnea, and ABG normal for the patient.

Interventions : Anxiety Patients will most likely be frightened and anxious as a result of dyspnoea. While undertaking assessments and during subsequent care it is very important to try to alleviate these anxieties and provide reassurance. Simple techniques, such as patient positioning, may reduce symptoms by maximising lung expansion. Patients may advise which position they feel offers some relief. Communication skills, such as asking closed questions during assessment, may be used if patients are breathless to a point where they cannot answer in sentences. Pulmonary Secretions Many processes leading to acute respiratory failure are associated with an increase in pulmonary secretions. Tissues or receptacles for sputum should be provided to assist patients to void secretions independently. If their ability to void is limited, assistance may be required in the form of oropharyngeal/nasopharyngeal suction. These procedures should not be undertaken without appropriate training. Sputum and other samples may be required for microbiological screening this should be performed according to local guidelines PainManagement If patients are experiencing pain, relief should be provided and future control optimised. Expert advice may be necessary because of the respiratory depressant effects of some analgesics. Liaison with multidisciplinary specialists such as acute or chronic pain specialists may be required. Oxygen therapy The majority of patients in acute respiratory failure will need oxygen supplementation. Before starting oxygen therapy, it is important to explain the reasons for this to them, their relatives and carers, and check their understanding (Jevon and Ewens, 2001). Unless Review respiratory health history and perform thorough assessment. Maintain airway Administer O2 as needed. Pace activities to prevent fatigue. Maintain planned rest periods. When necessary prepare for intubation.

in a medical emergency situation, the oxygen flow rate or percentage and duration of therapy should be prescribed. Nurses are best placed to select the most appropriate delivery system for a particular patient. The system chosen should aim to deliver therapy with maximum effectiveness and optimise patient independence. The detrimental effects of oxygen therapy, such as the dehydration of mucosa, should be observed for and appropriate therapies such as gas humidification introduced where necessary. Tissue damage from a delivery device may occur in particular, oxygen masks cause soreness behind the ears after longer-term use and nasal cannulas cause irritation to the nostrils. Small adaptations to the device, such as adding gauze padding, may prevent or alleviate this.

Breathing exercises Reduced ventilatory demand may be obtained by reducing the metabolic load. Patients with COPD can achieve physiological benefits from well designed programmes of exercise training. Substantial improvements in dyspnoea, exercise tolerance and healthrelated quality of life can be obtained as a result of exercise training programmes in mild to severe COPD. The improvements in exercise tolerance have been found to be associated with physiological changes such as: Improved muscle function (including more rapid oxygen uptake kinetics following exercise onset); Altered breathing pattern, consisting of higher tidal volume and lower breathing frequency leading to a reduced dead space/tidal volume ratio and, thus, a lower ventilatory requirement for exercise; Reduction in lactic acidosis, minute ventilation (VE) and heart rate for a given work rate; enhanced activity of mitochondrial enzymes; and capillary density in the trained muscles. Intensity of exercise training is of key importance. Breathing retraining is a term for a range of techniques aimed at reducing dynamic hyperinflation, increasing strength and

endurance of the respiratory muscles and optimising the pattern of thoraco-abdominal motion.10 This term covers different techniques, such as: Inspiratory muscle training. Inspiratory muscle weakness and/or dysfunction has been suggested to be among the contributors to dyspnoea in COPD patients. Different modalities of inspiratory muscle training have been shown to decrease dyspnoea through improvement in inspiratory muscle function. However, the clinical long-term effectiveness of this modality in COPD patients must be confirmed. Pursed-lips breathing. This technique involves exhalation through a resistance created by constriction of the lips. Although this manoeuvre is often spontaneously adopted by COPD patients, it is also routinely taught as a breathing retraining exercise in pulmonary rehabilitation programmes, because it is thought to alleviate dyspnoea. However, some patients with COPD obtain relief of dyspnoea with this technique whereas others do not. Pursed lips breathing can have a variable effect on dyspnoea when performed volitionally during exercise by patients with COPD. The effect is related to the combined change in the tidal volume and end expiratory lung volume and their impact on the available capacity of the respiratory muscles to meet the demands placed on them in terms of pressure generation. Diaphragmatic breathing. Using this technique, the patient is told to move the abdominal wall predominantly during inspiration and to reduce upper rib cage motion. For a long time suggested to be effective in reducing dyspnoea in COPD patients, this modality has recently been found to be accompanied by increased asynchronous and paradoxical breathing movements and increased work of breathing with related worsening in dyspnoea.

Positioning

Relief of dyspnea is often experienced by patients in the forward leaning position a body position commonly adopted by patients with lung disease. The benefit of this position seems unrelated to the severity of airway obstruction, changes in minute ventilation, or improved oxygenation .However, the presence of hyperinflation and paradoxical abdominal movement were indeed related to relief of dyspnea in the forward leaning position. Forward leaning is associated with a significant reduction in EMG activity of the scalenes and sternomastoid muscles, an increase in transdiaphragmatic pressure, and a significant improvement in

thoracoabdominal movements. From these open studies, it was concluded that the subjective improvement of dyspnea in patients with COPD was the result of the more favorable position of the diaphragm on its length-tension curve. In addition, forward leaning with arm support allows accessory muscles (Pectoralis minor and major) to significantly contribute to rib cage elevation. In summary, the forward leaning position has been shown to improve diaphragmatic function and, hence, improve chest wall movement and decrease accessory muscle recruitment and dyspnea. In addition, accessory muscles contribute to inspiration by allowing arm or head support in this position.

Incentive spirometry

Definition: Incentive spirometry, also known as Sustained Maximal Inspiration (SMI), is a technique used to encourage a patient to take a maximal inspiration using a device to measure flow or volume. A maximal inspiration sustained over three seconds may increase the transpulmonary pressure thereby improving inspiratory volumes and inspiratory muscle performance. With repetition, and as part of an overall bronchial hygiene program, SMI manoeuvres may reverse lung atelectasis and restore and maintain airway patency. The device used to facilitate SMI, the incentive spirometer, incorporates visual indicators of performance in order to aid the therapist in coaching the patient to optimal performance. Likewise, patients may use this visual feedback to monitor their own efforts o Chest physiotherapy Conventional chest physiotherapy consists of a combination of forced exhalation (directed cuff or huff) postural drainage, percussion, and or shaking. Conventional CPT has become the standard to which all other bronchial hygiene techniques are compared. Patient satisfaction with conventional CPT has become the standard to which all other hronchial hygiene techniques are compared. Patient satisfaction with conventional CPT is less than with other bronchial hygiene techniques given the potential for hazard the time required for therapy, and the paucity of evidence to support its use, prudence is necessary regarding the use of CPT.