Dan Higgins, RGN, ENB100, ENB998; John Guest, RN, ENB100; both are senior charge nurses, critical care, University Hospital Birmingham NHS Foundation Trust.
Abstract Higgins, D., Guest, J. (2008) Acute respiratory failure 2: nursing management. Nursing Times; 104: 37, 22–23.
This is the second in a two-part unit on acute respiratory failure. Part 1 defined this condition, explored the causes of different types of failure and outlined basic respiratory assessment. This part outlines medical and nursing management of patients in acute respiratory failure.
The medical management of patients with acute respiratory failure will vary depending on the cause and type of failure. Treatment should be targeted at the cause. Therapeutic goals should focus on preventing cellular damage from hypoxia, preventing acidosis from hypercapnoea and relieving patients’ symptoms and distress.
Airway obstruction is a clinical emergency. If this is the cause of respiratory failure it should be treated and a safe airway maintained as a priority. This may require simple clearance such as the removal of a foreign body, or secretions using suction. Patient positioning and manipulation of the airway will be required to open it if obstructed. Artificial airway adjuncts such as oropharyngeal airways may be required. Airway obstruction may occur for many reasons and the cause should be identified as soon as possible. Acute soft tissue swelling of the upper airway, as seen in anaphylactic shock, will require treatment in line with European Resuscitation Council guidelines (Resuscitation Council UK, 2008).
Regardless of the aetiology of respiratory failure, virtually all patients with acute hypoxia will require oxygen supplementation. Oxygen therapy aims to supplement the inspired oxygen concentration to prevent tissue hypoxia and resultant cellular dysfunction. However, cellular oxygen delivery not only depends on inspired oxygen but also relies on haemoglobin concentration, its ability to saturate with oxygen, and cardiac output as a mechanism to deliver oxygen to the cells (Higgins, 2005).
Various devices are available to deliver oxygen including fixed and variable rate performance devices. The method of delivery depends on the concentration of oxygen required, patients’ compliance with therapy and the underlying pathophysiology (Jevon and Ewens, 2001).
In certain patients, such as those with chronic hypercapnoea, titration of oxygen therapy will require specialist advice and serial arterial blood gas analysis as high concentrations may be contraindicated. Oxygen therapy may require humidification, particularly at high flow rates. Humidification moistens the oxygen during administration, preventing dehydration of the mucous membranes and pulmonary secretions (Bennett, 2003).
Bronchodilatory drugs cause relaxation of the smooth muscles in the airways, improving airway calibre. They may be administered using a variety of routes, in particular inhaled in the form of aerosol sprays or nebulisers.
Inhaled bronchodilators are an essential component in the treatment of asthma and obstructive airways disease. Peak expiratory flow rate measurements taken pre and post dose are usually recorded to assess effectiveness. Other medications – particularly anti-inflammatory drugs such as steroids – may be required.
Antimicrobial, antiviral or antifungal therapy is usually initiated if the cause of respiratory failure is considered to be of infective origin. Again, these drugs may be administered using a variety of routes and time periods.
Ventilatory support may be required in type 1 or type 2 respiratory failure. This may take the form of continuous positive airway pressure, non-invasive ventilation or invasive ventilation. Non-invasive ventilation has been shown to be a particularly effective treatment for COPD-related respiratory failure (British Thoracic Society Standards of Care Committee, 2002).
All patients with acute respiratory failure should be assessed regularly by a physiotherapist to provide treatment and advice on sputum clearance and optimising gaseous exchange. Other medical management of acute respiratory failure includes serial blood gas analysis, electrocardiography and chest X-ray, in conjunction with management of potentially related disease processes or conditions. Further pulmonary function testing and investigative procedures may be required.
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. Physiological track and trigger warning systems are widely used to identify patients on general wards at risk of clinical deterioration (NICE, 2007). These systems provide a framework to access higher levels of care. Patients at risk of developing acute respiratory failure 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.
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.
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.
Pain, particularly associated with abdominal or thoracic surgery or injury, can limit chest expansion. 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.
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 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.
If aerosol-inhaled medications are prescribed, effective delivery will only occur through patient compliance. Therapeutic effectiveness can be improved by providing education on inhaler technique. It is imperative that appropriate devices are chosen and patients’ technique is adequate (Bennett, 2003). When administering nebulisers, patients should be sat upright (as tolerated), be encouraged to take normal breaths and avoid talking in order to maximise drug delivery (Bennett, 2003). Nebulised medication may be administered using air flow or oxygen and nurses should ensure the type of gas used to deliver the drug is prescribed. Certain concentrations of oxygen may be contraindicated in certain patients. Practitioners should also bear in mind that patients may be dependent on a certain oxygen flow before nebulisation and interrupting this may be contraindicated.
Attempts should be made to minimise oxygen consumption (Smyth, 2005). This can be achieved by minimising patient exertion. They should be assisted with activities of daily living such as meeting hygiene needs, and all essential items, such as sputum pots, drinks and nurse call bells, should be within easy reach. Patients will also require time to ‘catch their breath’ following exertion, so activities should be planned with this in mind.
Acute respiratory failure is a process that, if not recognised and treated early, can be fatal. Many patients are at risk for a variety of reasons so the key element is early recognition, assessment and management.
Treating acute respiratory failure and any respiratory disease needs a multidisciplinary, collaborative approach. Nurses are in an ideal position to assess patients’ risk of developing respiratory failure, to monitor them, and evaluate their care and coordinate a multidisciplinary approach.
Bennett, C. (2003) Nursing the breathless patient. Nursing Standard; 17: 17, 45–51.
British Thoracic Society Standards of Care Committee (2002) Non-invasive ventilation in acute respiratory failure. Thorax; 57: 13, 192–211.
Higgins, D. (2005) Oxygen therapy. Nursing Times; 101: 4, 30–31.
NICE (2007) Acutely Ill Patients in Hospital. Recognition of and Response to Acute Illness in Adults in Hospital. www.nice.org.uk
Resuscitation Council (UK) (2008) Emergency Treatment of Anaphylactic Reactions. Guidelines for Healthcare Providers. www.resus.org.uk
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