Acute respiratory distress syndrome (ARDS) is a life-threatening condition where the lungs cannot provide the body's vital organs with enough oxygen. It's usually a complication of a serious existing health condition. This means most people are already in hospital by the time they develop ARDS. Symptoms of ARDS can include: Although most people get ARDS when they're already in hospital, this is not always the case. It can start quickly as a result of an infection, such as pneumonia, or if someone accidentally inhales their vomit. Call 999 immediately to ask for an ambulance if a child or adult is having breathing problems. ARDS happens when the lungs become severely inflamed from an infection or injury. The inflammation causes fluid from nearby blood vessels to leak into the tiny air sacs in your lungs, making breathing increasingly difficult. The lungs can become inflamed after: There's no specific test to diagnose ARDS. A full assessment is needed to identify the underlying cause and rule out other conditions. The assessment is likely to include: If you develop ARDS, you'll probably be admitted to an intensive care unit (ICU) and use a breathing machine (ventilator) to help your breathing. You breathe through a mask attached to the machine. If your breathing is severely affected, a breathing tube may be inserted down your throat and into your lungs. Fluids and nutrients will be supplied through a feeding tube (nasogastric tube) that's passed through your nose and into your stomach. The underlying cause of ARDS should also be treated. For example, if it's caused by a bacterial infection, you may need antibiotics. How long you'll need to stay in hospital depends on your individual circumstances and the cause of ARDS. Most people respond well to treatment, but it may be several weeks or months before you're well enough to leave hospital. Because ARDS is often caused by a serious health condition, about 1 in 3 people who get it will die. But most deaths are the result of the underlying illness, rather than ARDS itself. For those who survive, the main complications are linked with nerve and muscle damage, which causes pain and weakness. Some people also develop psychological problems, such as post-traumatic stress disorder (PTSD) and depression. The lungs usually recover and long-term lung failure after ARDS is rare.
Page last reviewed: 12 March 2020 Respiratory failure happens when the respiratory system fails to maintain gas exchange and is classified into type 1 and type 2 according to blood gases abnormalities. In type 1 (hypoxemic) respiratory failure, the partial pressure of arterial oxygen (PaO2) is less than 60 millimeters of mercury (mmHg), and the partial pressure of arterial carbon dioxide (PaCO2) may be either normal or low. In type 2 (hypercapnic) respiratory failure, the PaCO2 is greater than 50 mmHg, and PaO2 may be normal or, in the event of respiratory pump failure, low. This activity describes the evaluation, diagnosis, and management of respiratory failure and stresses the role of team-based interprofessional care for affected patients. Objectives:
Respiratory failure is a clinical condition that happens when the respiratory system fails to maintain its main function, which is gas exchange, in which PaO2 is lower than 60 mmHg and/or PaCO2 is higher than 50 mmHg. Respiratory failure is classified according to blood gases abnormalities into type 1 and type 2. Type 1 (hypoxemic) respiratory failure has a PaO2 < 60 mmHg with normal or subnormal PaCO2. In this type, the gas exchange is impaired at the level of the aveolar-capillary membrane. Examples of type I respiratory failures are carcinogenic or non-cardiogenic pulmonary edema and severe pneumonia. Type 2 (hypercapnic) respiratory failure has a PaCO2 > 50 mmHg. Hypoxemia is common, and it is due to respiratory pump failure. Also, respiratory failure is classified according to its onset, course, and duration into acute, chronic, and acute on top of chronic respiratory failure. Respiratory failure may be due to pulmonary or extra-pulmonary causes which include: CNS causes due to depression of the neural drive to breath as in cases of overdose of a narcotic and sedative. Disorders of the peripheral nervous system: Respiratory muscle and chest wall weakness as in cases of Guillian-Barre syndrome and myasthenia gravis. Upper and lower airways obstruction: due to various causes as in cases of exacerbation of chronic obstructive pulmonary diseases and acute severe bronchial asthma Abnormities of the alveoli that result in type 1 (hypoxemic) respiratory failure as in cases of pulmonary edema and severe pneumonia.[1] The overall frequency of respiratory failure is not well known as respiratory failure is a syndrome rather than a single disease process. The main path physiologic mechanisms of respiratory failure are: Hypoventilation: Depression of CNS from drugs is an example of this condition. V/P mismatch: this is the most common cause of hypoxemia. Administration of 100% O2 eliminates hypoxemia. Shunt: in which there is persistent hypoxemia despite 100% O2 inhalation. In cases of a shunt, the deoxygenated blood (mixed venous blood) bypasses the alveoli without being oxygenated and mixes with oxygenated blood that has flowed through the ventilated alveoli, and this leads to hypoxemia as in cases of pulmonary edema (cardiogenic or noncardiogenic), pneumonia and atelectasis Symptoms and signs of hypoxemia
Symptoms and signs of hypercapnia
Symptoms and signs of the underlying disease Examples: Fever, cough, sputum production, chest pain in cases of pneumonia. History of sepsis, polytrauma, burn, or blood transfusions before the onset of acute respiratory failure may point to acute respiratory distress syndrome[2]. The following investigations are needed:
This includes supportive measures and treatment of the underlying cause. Supportive measures depend on airways management to maintain adequate ventilation and correction of the blood gases abnormalities Correction of Hypoxemia The goal is to maintain adequate tissue oxygenation, generally achieved with an arterial oxygen tension (PaO2) of 60 mm Hg or arterial oxygen saturation (SaO2), about 90%. Un-controlled oxygen supplementation can result in oxygen toxicity and CO2 (carbon dioxide) narcosis. So the inspired oxygen concentration should be adjusted at the lowest level, which is sufficient for tissue oxygenation. Oxygen can be delivered by several routes depending on the clinical situations in which we may use a nasal cannula, simple face mask nonrebreathing mask, or high flow nasal cannula. Extracorporeal membrane oxygenation may be needed in refractory cases[3]. Correction of hypercapnia and respiratory acidosis This may be achieved by treating the underlying cause or providing ventilatory support.[4] Ventilatory support for the patient with respiratory failure The goals of ventilatory support in respiratory failure are:
Common indications for mechanical ventilation include the following:
The choice of invasive or noninvasive ventilatory support depends on the clinical situation, whether the condition is acute or chronic, and how severe it is. It also depends on the underlying cause. If there are no absolute indications for invasive mechanical ventilation or intubations and if there are no contraindications for noninvasive ventilation non-invasive ventilation is preferred particularly in cases of chronic obstructive pulmonary disease (COPD) exacerbation[6][7], Cardiogenic pulmonary edema[6][8] and obesity hypoventilation syndrome[9]. Differential DiagnosisComplications from respiratory failure may be a result of blood gases disturbances or from the therapeutic approach itself Examples of these complications: Lung complications: for example, pulmonary embolism irreversible scarring of the lungs, pneumothorax, and dependence on a ventilator. Cardiac complications: for example, heart failure arrhythmias, cardiac arrest, and acute myocardial infarction[10]. Neurological complications: a prolonged period of brain hypoxia can lead to irreversible brain damage and brain death. Renal: acute renal failure may occur due to hypoperfusion and/or nephrotoxic drugs. Gastro-intestinal: stress ulcer, ileus, and hemorrhage[11] Nutritional: malnutrition, diarrhea hypoglycemia, electrolyte disturbances[12] Infectious: sepsis is the most common cause of death in patients with acute respiratory failure Mortality is often due to multiorgan failure. During the management of respiratory failure consultation for other specialties may be indicated like cardiac and neurological consultation. Pearls and Other Issues
The diagnosis of the underlying cause of respiratory failure and its treatment is challenging as respiratory failure may result from numerous pulmonary and extrapulmonary causes, so consultation for other specialties, for example, neurological and cardiac consultation, may be mandatory. As complications from respiratory failure may be due to improper patient positioning and poor adherence to infection control policies, the nurses are vital members of the interprofessional group, assuring that an appropriate position is rendered. Also, complications can be the result of drug toxicities or drug interactions, so a pharmacist should be incorporated in the management team for respiratory failure cases. The job of the nurse carries a far more important role if the patient is on a mechanical ventilator. The nurse has to monitor the patient 24/7 and assess each organ system several times a day. The nurse also is responsible for suctioning, positioning, and feeding the patient. Because the patient with respiratory failure is usually on multiple medications, the pharmacist is responsible for ensuring the most appropriate drug is administered without causing drug interactions or severe adverse reactions. Finally, a patient with respiratory failure is also looked after by respiratory therapists for chest therapy or administration of oxygen. [14][15][16] [Level 5] Outcomes The prognosis of respiratory failure varies according to underlying causes and other factors like the age of the patients and the associated comorbidities [17]. Review Questions1. Patel S, Sharma S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 24, 2021. Respiratory Acidosis. [PubMed: 29494037] 2.Rawal G, Yadav S, Kumar R. Acute Respiratory Distress Syndrome: An Update and Review. J Transl Int Med. 2018 Jun;6(2):74-77. [PMC free article: PMC6032183] [PubMed: 29984201] 3.Moerer O, Vasques F, Duscio E, Cipulli F, Romitti F, Gattinoni L, Quintel M. Extracorporeal Gas Exchange. Crit Care Clin. 2018 Jul;34(3):413-422. [PubMed: 29907273] 4.Faverio P, De Giacomi F, Sardella L, Fiorentino G, Carone M, Salerno F, Ora J, Rogliani P, Pellegrino G, Sferrazza Papa GF, Bini F, Bodini BD, Messinesi G, Pesci A, Esquinas A. Management of acute respiratory failure in interstitial lung diseases: overview and clinical insights. BMC Pulm Med. 2018 May 15;18(1):70. [PMC free article: PMC5952859] [PubMed: 29764401] 5.Cavalleri M, Barbagelata E, Diaz de Teran T, Ferraioli G, Esquinas A, Nicolini A. Noninvasive and invasive ventilation in severe pneumonia: Insights for the noninvasive ventilatory approach. J Crit Care. 2018 Dec;48:479. [PubMed: 30126747] 6.Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug;50(2) [PubMed: 28860265] 7.Fazekas AS, Aboulghaith M, Kriz RC, Urban M, Breyer MK, Breyer-Kohansal R, Burghuber OC, Hartl S, Funk GC. Long-term outcomes after acute hypercapnic COPD exacerbation : First-ever episode of non-invasive ventilation. Wien Klin Wochenschr. 2018 Oct;130(19-20):561-568. [PMC free article: PMC6209011] [PubMed: 30066095] 8.Miró Ò, Martínez G, Masip J, Gil V, Martín-Sánchez FJ, Llorens P, Herrero-Puente P, Sánchez C, Richard F, Lucas-Invernón J, Garrido JM, Mebazaa A, Ríos J, Peacock WF, Hollander JE, Jacob J., ICA-SEMES Research Group Researchers. Effects on short term outcome of non-invasive ventilation use in the emergency department to treat patients with acute heart failure: A propensity score-based analysis of the EAHFE Registry. Eur J Intern Med. 2018 Jul;53:45-51. [PubMed: 29572091] 9.Fernández Álvarez R, Rubinos Cuadrado G, Ruiz Alvarez I, Hermida Valverde T, Iscar Urrutia M, Vázquez Lopez MJ, Casan Clara P. Hypercapnia Response in Patients with Obesity-Hypoventilation Syndrome Treated with Non-Invasive Ventilation at Home. Arch Bronconeumol (Engl Ed). 2018 Sep;54(9):455-459. [PubMed: 29871766] 10.Radovanović NN, Pavlović SU, Milašinović G, Kirćanski B, Platiša MM. Bidirectional Cardio-Respiratory Interactions in Heart Failure. Front Physiol. 2018;9:165. [PMC free article: PMC5845639] [PubMed: 29559923] 11.Avendaño-Reyes JM, Jaramillo-Ramírez H. [Prophylaxis for stress ulcer bleeding in the intensive care unit]. Rev Gastroenterol Mex. 2014 Jan-Mar;79(1):50-5. [PubMed: 24629722] 12.Vora CS, Karnik ND, Gupta V, Nadkar MY, Shetye JV. Clinical Profile of Patients Requiring Prolonged Mechanical Ventilation and their Outcome in a Tertiary Care Medical ICU. J Assoc Physicians India. 2015 Oct;63(10):14-9. [PubMed: 27608686] 13.Grensemann J, Fuhrmann V, Kluge S. Oxygen Treatment in Intensive Care and Emergency Medicine. Dtsch Arztebl Int. 2018 Jul 09;115(27-28):455-462. [PMC free article: PMC6111205] [PubMed: 30064624] 14.Villar J, Ferrando C, Kacmarek RM. Managing Persistent Hypoxemia: what is new? F1000Res. 2017;6:1993. [PMC free article: PMC5686475] [PubMed: 29188024] 15.Boer C, Touw HR, Loer SA. Postanesthesia care by remote monitoring of vital signs in surgical wards. Curr Opin Anaesthesiol. 2018 Dec;31(6):716-722. [PubMed: 30095483] 16.Yazdannik A, Atashi V, Ghafari S. Performance of ICU Nurses in Providing Respiratory Care. Iran J Nurs Midwifery Res. 2018 May-Jun;23(3):178-182. [PMC free article: PMC5954637] [PubMed: 29861754] 17.Hensel M, Strunden MS, Tank S, Gagelmann N, Wirtz S, Kerner T. Prehospital non-invasive ventilation in acute respiratory failure is justified even if the distance to hospital is short. Am J Emerg Med. 2019 Apr;37(4):651-656. [PubMed: 30068489] |
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary
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