RESPIRATORY

INFECTIONS
JAM VALLES CORROS, SN
 INTRODUCTION
● We take our breathing and our respiratory health for granted, but the lung is a vital organ that is
vulnerable to airborne infection and injury. Respiratory diseases are leading causes of death and
disability in the world.
● An estimated 65 million people have moderate to severe chronic obstructive pulmonary disease
(COPD), from which about 3 million die each year, making it the third leading cause of death
worldwide – and the numbers are increasing.
● About 334 million people suffer from asthma, which is the most common chronic disease of
childhood, affecting 14% of children globally. The prevalence of asthma in children is rising.
● For decades, acute lower respiratory tract infections have been among the top three causes of death
and disability among both children and adults. Although the burden is difficult to quantify, it is
estimated that lower respiratory tract infection causes nearly 4 million deaths annually and is a
leading cause of death among children under 5 years old.
● Moreover, acute lower respiratory tract infections in children predispose for chronic respiratory
diseases later in life. Respiratory tract infections caused by influenza kill between 250,000 and
500,000 people and cost between US$71 and 167 billion annually.
● In 2015, 10.4 million people developed tuberculosis (TB) and 1.4 million people died from it.
● The most common lethal neoplasm in the world is lung cancer, which kills 1.6 million people
each year ; and the numbers are growing.
Table of Contents

PLEURAL CONDITIONS
01 PLEURISY, PLEURAL
EFFUSION, EMPHYEMA

02 PULMONARY EDEMA

03 ACUTE RESPIRATORY
FAILURE
 PLEURAL
CONDITIO
01
N
A. PLEURISY
 OVERVIEW
● Pleurisy is a medical condition affecting the two layer of tissue called “pleura”, which
act as a separator between the lungs and the chest wall.
● One of the layers lines the exterior of the lung, while the other wraps around the inner
chest wall. There is a space between those two membranes, which has a thin sheet
liquid that acts as a lubricant.
● The smooth gliding action between these two layers enables the two-way breathing
process of lung expansion and contraction. Pleurisy, also known as “pleuritis”, occurs
when there is swelling and inflammation of the pleura. In addition to this, the fluid in
the pleural space may thicken, causing the pleura to rub together. These conditions
manifest as a sharp chest pain called “pleuritic pain”, and can be worse during
respirations.
 PATHOPHYSIOLOGY
● Pleurisy (pleuritis) refers to inflammation of both layers of the pleurae
(parietal and visceral). Pleurisy may develop in conjunction with pneumonia
or an upper respiratory tract infection, TB, or collagen disease; after trauma
to the chest, pulmonary infarction, or Pulmonary Embolism; in patients with
primary or metastatic cancer; and after thoracotomy. The parietal pleura has
nerve endings, and the visceral pleura does not. When the inflamed pleural
membranes rub together during respiration (intensified on inspiration), the
result is severe, sharp, knifelike pain.
 Causes
1. Infection: The most common cause of pleurisy is infection. Several viruses that cause pleurisy
include influenza or flu virus, cytomegalovirus (CMV), parainfluenza virus, and Epstein-Barr virus.
Bacterial infections resulting to pleurisy are less common and can be caused by streptococcus (related
to pneumonia and throat infections), staphylococcus (related to skin infections and sepsis) or
Mycobacterium tuberculosis. Fungal infection can also cause pleurisy.

2. Trauma: Mechanical injury can result to pleurisy. The pleura can have swelling and inflammation
when there is bruising or fracture of the ribs.

3. Pulmonary embolism: A blood clot that blocks the lungs can cause reduced blood flow and oxygen
levels in some parts of the lungs and eventually cause tissue death. This can also result to pleurisy.

4. Pneumothorax: The buildup of air in the lungs following chest trauma or mechanical ventilation.
5. Cancer: When a tumor grows in the pleural cavity, fluid buildup occurs,
causing pleurisy and pleural effusion.

6. Autoimmune disorders: Illnesses such as lupus or rheumatoid arthritis

involve the immune system abnormally attacking healthy tissues.

7. Certain medications with a side effect that manifests as a lupus-like

condition, such as hydralazine, isoniazid, and procainamide.
 Signs and Symptoms
● Pleuritic pain – a sharp, stabbing chest pain that gets worse with breathing,
coughing, or sneezing. This might also be worsened by moving the upper
body and may radiate to the shoulders or back.
● Shortness of breath or difficulty of breathing – the patient tends to have
less respirations or perform shallow breathing as a response to the pain
● Fever, in some cases, especially when infection is the cause of pleurisy
● Cough, in some cases
 Complications
1. Pleural Effusion: In cases when pleurisy is caused by a bacterial infection (such as
tuberculosis) or a pulmonary embolism, an excessive buildup of fluid in the pleural cavity
is evident. This is called pleural effusion, which is characterized by chest pain, shortness
of breath, and cough. Treating the underlying cause of pleurisy usually resolves pleural
effusion. If unresolved, surgical intervention such as putting a chest drain may be needed.

2. Atelectasis: Pleurisy may eventually lead to the partial or total collapse of the lung due
to fluid buildup in the alveoli.

3. Empyema: Bacterial infections resulting to pleurisy may eventually develop pockets of

pus in the pleural space known as empyema or purulent pleuritis.
 Diagnostic Tests
● Imaging – chest X-ray, CT scan, or ultrasound Blood tests – to determine
any bacterial, viral, or fungal pathogens, or any autoimmune disease
● Electrocardiogram (ECG) – to check if the chest pain is heart-related or
pleurisy
● Thoracentesis – needle insertion to remove small amounts of pleural fluid
from the lungs, and study a sample fluid to see the cause of pleurisy
● Thoracoscopy – the use of thoracoscope to view the thoracic cavity
 Treatments
● Antibiotics that are specific for bacteria-caused pleurisy
● Antifungals –for fungal-caused pleurisy
● If pleurisy is caused by a virus – antiviral may not be required as it can resolve on its
own.
● The doctor may ask the patient to rest for a few days, with close monitoring.
● Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen are effective to
relieve pleuritic pain
● In cases when NSAIDS are not helpful, paracetamol or codeine can be administered.
Codeine can also help suppress cough.
● Chest drain –If pleurisy is associated with pleural effusion, a tube is inserted into the
pleural space to drain excess fluid
 Nursing Management
● Because the patient has pain on inspiration, the nurse offers suggestions to
enhance comfort, such as turning frequently onto the affected side to splint
the chest wall and reduce the stretching of the pleurae.
● The nurse also educates the patient to use the hands or a pillow to splint the
rib cage while coughing.

Possible nursing diagnosis:

- Ineffective Airway Clearance
- Anxiety related to pleuritic pain
B. PLEURAL
EFUSSION
 OVERVIEW
● Pleura effusion, a collection of fluid in the pleural space, is rarely a
primary disease process; it is usually secondary to other diseases.
Normally, the pleura space contains a small amount of fluid (5 to
15ml), which acts as a lubricant that allows the pleural surfaces to
move without friction.
● Pleural effusion may be a complication of heart failure, TB,
Pneumonia, Pulmonary Infection (particularly viral infection),
nephrotic syndrome, connective tissue disease, and neoplastic
tumors. The most common malignancy associated with pulmonary
effusion is bronchogenic carcinoma.
 Pathophysiology
In certain disorders, fluid may accumulate in the pleural space to point at which It
becomes clinically evident. This almost always has pathologic significance.

● The Effusion can be relatively clear fluid, or it can be bloody or purulent.

- An effusion with clear fluid may be a transudate or an Exudate.
- A Transudate (filtrate of plasma that moves across intact capillary walls) occurs when
factors influencing the formation and reabsorption of pleural fluid are altered, usually
by imbalances in hydrostatic or oncotic pressures. This implies that generally the
pleural membrane is not diseased, and is commonly resulted from heart failure.
- An Exudate (extravasation of fluid into tissue or a cavity) usually results from
inflammation by bacterial products or tumors involving the pleura surfaces. (Heffner,
2015)
 Signs and Symptoms of Pleural Effusion
● Dyspnea – shortness of breath or labored breathing
● Pleuritic pain or pleurisy – chest pain, especially when deep
breathing
● Fever
● Dry, non-productive cough
● Orthopnea – inability to breathe properly unless sitting up straight or
standing
 Complications of Pleural Effusion
● 1. Lung dysfunction. Since the pleural space normally has a small amount of
fluid, having these excesses can impede with the normal functioning of the
lungs. This will make breathing difficult, restricting the natural expansion of
the lungs, and thus causing dyspnea. Moreover, the accumulated air in the
pleura may exert increased thoracic pressure, resulting to chest pain.

● 2. Empyema. A localized infection called empyema may arise due to the

pooling of excess fluid and will produce further complications.
ASSESSMENT AND DIAGNOSTIC FINDINGS
● Assessment of the area of the pleural effusion reveals decreased or absent
breath sounds, decrease fremitus (Fremitus refers to vibratory tremors
that can be felt through the chest by palpation), and a dull, flat sound on
percussion.
● On Extreme Large Pleural Effusion, the assessment reveals a patient in
acute respiratory distress. Tracheal Deviation away from the affected side
may also be apparent.
● Physical Examination, Chest X-ray, Chest CT, and Thoracentesis
confirm the presence of fluid.
● In some instances, Lateral Decubitus X-ray is obtained. For this xray, the
pt lies on the affected side in a side-lying position. A pleural effusion can be
diagnosed because this position allows for the “layering out” of the fluid,
and an air-fluid line is visible.
TRACHEAL DEVIATION
Lateral Decubitus x ray (Chest and Abdomen)
● Pleural Fluid is analyzed by bacterial culture, Gram
Stain, AFB Stain (for TB), red and white blood cell
count, chemistry study. Cytologic analysis for
malignant cells, and pH.
● A pleural biopsy also may be performed as diagnostic
tool.
 Treatment of Pleural Effusion
1. Treating the underlying causes- To prevent re-accumulation of fluid; and to relieve
discomfort, dyspnea, and respiratory compromise.
2. Thoracentesis- This involves puncturing and draining the excess fluid from the
pleural space.
3. Tube thoracostomy. This procedure includes thoracentesis and the placement of a
draining tube to the pleural space to drain the excess fluid. It may take several days
before the tube is removed.
4. Pleural drain. This procedure involves long term drain for chronic pleural effusion.
5. Pleurodesis. This procedure involves the application of an irritating substance into the
pleural space, causing inflammation, thus binding the pleura and chest wall as they
heal together.
Tube Thoracostomy
 NURSING MANAGEMENT
● Supporting the medical regimen.
● The nurse prepares and position the pt. for thoracentesis and offers support throughout
the procedure.
● The nurse is responsible for making sure the thoracentesis fluid is recorded and sent
for appropriate lab testing.
● If a chest tube drainage and water-seal system is used, the nurses is responsible for
monitoring the system’s function and recording the amount of drainage at prescribed
intervals.
● If the tube is inserted for Talc instillation (Talc is used to prevent malignant pleural
effusion) in people who have already had this condition., pain management is priority
and the nurse helps the pt. assume position that are the least painful. However frequent
turning and movement are important to facilitate adequate spreading of the talc over
the pleural surface.
● Evaluated pt’s pain level and administers analgesic agents as prescribed and as
needed.
Possible Nursing Diagnosis:

1. Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as

evidenced by tachypnea, presence of crackles on both lung fields and
dyspnea
2. Impaired Gas Exchange R/T Alveolar –Capillary Membrane Changes  and
respiratory fatigue Secondary to Pleural Effusion
3. Activity Intolerance
4. Acute Pain
C.
EMPHYEMA
 OVERVIEW
● An abnormal accumulation of thick, purulent fluid within the pleural space, often with
fibrin development and loculated (walled-off) area where infection is located.
(Strange, 2016)
● They can form if a bacterial infection is left untreated, or if it fails to fully respond to
treatment.
● The term empyema is most commonly used to refer to pus-filled pockets that develop
in the pleural space. This is the slim space between the outside of the lungs and the
inside of the chest cavity.
● Empyema is a serious condition that requires treatment. It can cause fever, chest pains,
breathlessness and coughing up mucus.
● Although it can occasionally be life threatening, it's not a common condition, as most
bacterial infections are effectively treated with antibiotics before they get to this stage.
 PATHOPHYSIOLOGY
● Most empyemas occurs as complication of bacterial pneumonia or lung
abscess. They also result from penetrating chest trauma, hematogenous
infection of the pleural space, nonbacterial infection, and iatrogenic causes
(after thoracic surgery or thoracentesis.
● At first the pleural fluid is thin, with low leukocyte count, but it frequently
progesses to a fibropurulent stage and, finally, to a stage where it encloses
the lung within a thick exudative membrane (loculated emphyema)
 CLINICAL MANIFESTATION
● The patient is accurately ill and has signs and symptoms similar to
those of an acute respiratory infection or pneumonia; fever, night
sweats, pleural pain, cough, dyspnea, anorexia, weight loss.)
● If the patient is Immunocompromised, the symptoms may be vague.
If the pt has received antimicrobial therapy, the clinical
manifestation may be less obvious.
 Assessment and Diagnostic Findings
● Chest auscultation demonstrates decreased or absent breath
sounds over the affected area, and there is dullness on chest
percussion as well as decreased fremitus. The diagnosis is
established by chest CT. Usually, a diagnostic thoracentesis is
performed, often under ultrasound guidance.
 Medical Management
● The objectives of treatment are to drain the pleural cavity and to achieve complete
expansion of the lung. The fluid is drained, and appropriate antibiotics (usually
begun by the IV route) in large doses are prescribed based on the causative organism.
Sterilization of the empyema cavity requires 4 to 6 weeks of antibiotics (Strange,
2016). Drainage of the pleural fluid depends on the stage of the disease and is
accomplished by one of the following methods:
● Needle aspiration (thoracentesis) with a thin percutaneous catheter, if the volume is
small and the fluid is not too purulent or too thick
● Tube thoracostomy (chest drainage using a large-diameter intercostal tube attached to
water-seal drainage with fibrinolytic agents instilled through the chest tube in patients
with loculated or complicated pleural effusions
● Open chest drainage via thoracotomy, including potential ribresection, to remove
the thickened pleura, pus, and debris and to remove the underlying diseased
pulmonary tissue
Thoracentesis
Tube thoracostomy
Open Chest Drainage Via Thoracotomy
● With long-standing inflammation, an exudate can form over the lung,
trapping it and interfering with its normal expansion. This exudate must be
removed surgically (decortication).
● The drainage tube is left in place until the pus-filled space is obliterated
completely. The complete obliteration of the pleural space is monitored by
serial chest x-rays, and the patient should be informed that treatment may be
long term (weeks to months). Patients are frequently discharged from the
hospital with a chest tube in place, with instructions to monitor fluid
drainage at home.
Pleurectomy and Decortication
 Nursing Management
● The nurse helps the patient cope with the condition and instructs the
patient in lung-expanding breathing exercises to restore normal
respiratory function.
● The nurse also provides care specific to the method of drainage of
the pleural fluid (e.g., needle aspiration, closed chest drainage, rib
resection, and drainage).
● When the patient is discharged home with a drainage tube or system
in place, the nurse instructs the patient and family on care of the
drainage system and drain site, measurement and observation of
drainage, signs and symptoms of infection, and how and when to
contact the primary provider.
Possible Nursing Diagnosis:
1. Ineffective airway clearance related to bronchus spams, increased
production of secretions, weakness
2. Impaired Gas Exchange related to airway obstruction secondary to the
buildup of secretions, Bronchospasm.
3. Imbalanced Nutrition, Less Than Body Requirements related to Shortness of
breath, anorexia, nausea, vomiting, drug effects, weakness
 PULMONARY
02 EDEMA
 OVERVIEW
● Pulmonary edema is defined as abnormal accumulation of fluid in the lung
tissue, the alveolar space, or both. It is a severe, life-threatening condition.
● Pulmonary edema can be classified as cardiogenic or noncardiogenic:
● Noncardiogenic pulmonary edema- occurs due to damage of the
pulmonary capillary lining.
● Cardiogenic Pulmonay Edema- reflects the accumulation of fluid with a
low-protein content in the lung interstitium and alveoli as a result of cardiac
dysfunction.
 PATHOPHYSIOLOGY
● Noncardiogenic Pulmonary Edema- occurs due to damage of the pulmonary capillary lining. It may
be due to direct injury to the lung (e.g., chest trauma, aspiration, and smoke inhalation),
hematogenous injury to the lung (e.g., sepsis, pancreatitis, multiple transfusions, and cardiopulmonary
bypass), or injury plus elevated hydrostatic pressures.
● Cardiogenic Pulmonary Edema occurs following acute MI or as an exacerbation of chronic Heart
Failure.
● When the left ventricle begins to fail, blood backs up into the pulmonary circulation, causing
pulmonary interstitial edema. This may occur quickly in some patients, a condition
sometimes called flash pulmonary edema. Pulmonary edema can also develop slowly,
especially when it is caused by noncardiac disorders such as kidney injury and other
conditions that cause fluid overload.
● The pathophysiology is an extreme form of that seen in left-sided HF. The left ventricle cannot handle
the volume overload, and blood volume and pressure build up in the left atrium. The rapid increase in
atrial pressure results in an acute increase in pulmonary venous pressure, which produces an increase
in hydrostatic pressure that forces fluid out of the pulmonary capillaries and into the interstitial spaces
and alveoli (Grossman & Porth, 2014)
● The fluid within the alveoli mixes with air, producing the classic sign of pulmonary
edema— frothy pink (blood-tinged) sputum. The large amounts of alveolar fluid
create a diffusion block that severely impairs gas exchange. The result is hypoxemia,
which is often severe.
 CLINICAL MANIFESTATION
● As a result of decreased cerebral oxygenation, the patient becomes increasingly
restless and anxious.
● Along with a sudden onset of breathlessness and a sense of suffocation, the patient is
tachypnec with noisy breathing and low oxygen saturation rates.
● The skin and mucous membranes may be pale to cyanotic, and the hands may be
cool and moist.
● Tachycardia and JVD are common signs.
● Incessant coughing may occur, producing increasing quantities of foamy sputum.
● As pulmonary edema progresses, the patient’s anxiety and restlessness increase.
● The patient may become confused and then stuporous.
● The patient, nearly suffocated by the blood-tinged, frothy fluid filling the alveoli, is
literally drowning in secretions. The situation demands emergent action.
ASSESSMENT AND DIAGNOSTIC FINDINGS
● The patient’s airway and breathing are assessed to determine the severity of
respiratory distress, along with vital signs.
● The patient is placed on a cardiac monitor, and IV access is confirmed or
established for administration of drugs.
● Laboratory tests are obtained, including arterial blood gases, electrolytes,
BUN, and creatinine (Pinto & Kociol, 2015).
● A chest x-ray is obtained to confirm the extent of pulmonary edema in the
lung fields.
 PREVENTION
● Like many emergent conditions, pulmonary edema is easier to prevent than to treat.
● To recognize it early, the nurse assesses the degree of dyspnea, auscultates the lung
fields and heart sounds, and assesses the degree of peripheral edema.
● A hacking cough, fatigue, weight gain, increased edema, and decreased activity
tolerance may be early indicators of developing pulmonary edema.
● In its early stage, pulmonary edema may be alleviated by increasing dosages of
diuretics and by implementing other interventions to decrease preload. For instance,
placing the patient in an upright position with the feet and legs dependent reduces left
ventricular workload.
● The treatment regimen and the patient’s understanding of and adherence to it are
assessed.
● The long-range approach for preventing pulmonary edema must be directed at
identifying and managing its precipitating factors.
 MEDICAL MANAGEMENT
● Clinical management of a patient with acute pulmonary edema due to left ventricular failure is directed
toward reducing volume overload, improving ventricular function, and increasing oxygenation.
● These goals are accomplished through a combination of oxygen and ventilatory support, IV medication, and
nursing assessment and interventions.
● Management of noncardiogenic pulmonary edema mirrors that of cardiogenic pulmonary edema however,
hypoxemia may persist despite high concentrations of supplemental oxygen, due to the intrapulmonary
shunting of blood.

OXYGEN THERAPY
- Oxygen is given in concentrations adequate to relieve hypoxemia and dyspnea. A nonrebreathing mask is
used initially. If respiratory failure is severe or persists, noninvasive positive pressure ventilation is the
preferred mode of assisted ventilation (Pinto & Kociol, 2015)
- For some patients, endotracheal (ET) intubation and mechanical ventilation are required. The ventilator can
provide positive end-expiratory pressure, which is effective in reducing venous return, decreasing fluid
movement from the pulmonary capillaries to the alveoli, and improving oxygenation. Oxygenation is
monitored by pulse oximetry and by measurement of arterial blood gases.
DIURETICS
- Diuretics promote the excretion of sodium and water by the kidneys.
- Furosemide or another loop diuretic is given by IV push or as a continuous infusion to produce a
rapid diuretic effect.
- The blood pressure is closely monitored as the urine output increases, because it is possible for
the patient to become hypotensive as intravascular volume decreases.
- The intake and output, daily weights, serum electrolytes, and creatinine are carefully monitored.
- As the clinical manifestations stabilize, the patient is transitioned to oral diuretics.

VASODILATORS
- Vasodilators such as IV nitroglycerin or nitroprusside may enhance symptom relief in pulmonary
edema (Pinto & Kociol, 2015). Their use is contraindicated in patients who are hypotensive.
- Blood pressure is continually assessed in patients receiving IV vasodilator infusions.
 NURSING MANAGEMENT
● Positioning the Patient to Promote Circulation Proper positioning can help reduce venous return to the heart. The
patient is positioned upright, preferably with the legs dangling over the side of the bed. This has the immediate
effect of decreasing venous return, decreasing right ventricular SV, and decreasing lung congestion.
● Providing Psychological Support As the ability to breathe decreases, the patient’s fear and anxiety rise
proportionately, making the condition more severe. Reassuring the patient and providing skillful anticipatory
nursing care are integral parts of the therapy. Because the patient is in an unstable condition, the nurse must
remain with the patient. The nurse gives the patient simple, concise in a reassuring voice about what is being done
to treat the and the expected results.
● Monitoring Medications The patient receiving diuretic therapy may excrete a large volume of urine within
minutes after a potent diuretic is given. A bedside commode may be used to decrease the energy required by the
patient and to reduce the resultant increase in cardiac workload induced by getting on and off a bedpan. If
necessary, in order to carefully monitor urine output, an indwelling urinary catheter may be inserted. The patient
receiving continuous IV infusions of diuretics and vasoactive medications requires continuous ECG monitoring
and frequent measurement of vital signs. Patients who receive continuing therapy require management in an ICU.
POSSIBLE NURSING DIAGNOSIS:
1. Impaired Gas Exchange related to pulmonary edema
2. Ineffective Breathing Pattern related to pulmonary edema
3. Activity Intolerance
4. Anxiety related to Acute Pulmonary Edema
 ACUTE
RESPIRATORY
03 FAILURE
 OVERVIEW
● Respiratory failure is a sudden and life-threatening deterioration of the gas exchange function of
the lung and indicates failure of the lungs to provide adequate oxygenation or ventilation for the
blood. Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to
less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to
greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35 (Fournier, 2014).
● It is important to distinguish between acute and chronic respiratory failure. Chronic respirator
failure is defined as deterioration in the gas exchange function of the lung that has developed
insidiously or has persisted for a long period after an episode of acute respiratory failure. The
absence of acute symptoms and the presence of a chronic respiratory acidosis suggest the
chronicity of the respiratory failure.
● Two causes of chronic respiratory failure are COPD and neuromuscular diseases.
● Patients with these disorders develop a tolerance to the gradually worsening hypoxemia and
hypercapnia. However, patients with chronic respiratory failure can develop acute failure. For
example, a patient with COPD may develop an exacerbation or infection that causes additional
deterioration of gas exchange.
● The principles of management of acute versus chronic respiratory failure are different; the
following discussion is limited to acute respiratory failure.
 PATHOPHYSIOLOGY
● In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired.
● Ventilatory failure mechanisms leading to acute respiratory failure include impaired function of the central
nervous system (i.e., drug overdose, head trauma, infection, hemorrhage, and sleep apnea), neuromuscular
dysfunction (i.e., myasthenia gravis, Guillain–Barré syndrome, amyotrophic lateral sclerosis, and spinal
cord trauma), musculoskeletal dysfunction (i.e., chest trauma, kyphoscoliosis, and malnutrition), and
pulmonary dysfunction (i.e., COPD, asthma, and cystic fibrosis).
● Oxygenation failure mechanisms leading to acute respiratory failure. include pneumonia, acute respiratory
distress syndrome (ARDS), heart failure, COPD, PE, and restrictive lung diseases (diseases that cause
decrease in lung volumes).
● In the postoperative period, especially after major thoracic or abdominal surgery, inadequate ventilation and
respiratory failure may occur because of several factors. During this period, for example, acute respiratory
failure may be caused by the effects of anesthetic, analgesic, and sedative agents, which may depress
respiration (as described earlier) or enhance the effects of opioids and lead to hypoventilation.
● Pain may interfere with deep breathing and coughing. A V./Q. mismatch is the usual cause of respiratory
failure after major abdominal, cardiac, or thoracic surgery.
 Clinical Manifestation
● Early signs are those associated with impaired oxygenation and may include restlessness,
fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the
hypoxemia progresses, more obvious signs may be present, including confusion, lethargy,
tachycardia, tachypnea, central cyanosis, diaphoresis, and finally respiratory arrest.
● Physical findings are those of acute respiratory distress, including the use of accessory muscles,
decreased breath sounds if the patient cannot adequately ventilate, and other findings
related specifically to the underlying disease process and cause of acute respiratory failure.
● In the early phase of acute respiratory failure, vague signs and symptoms such as restlessness,
anxiety, fatigue, and headache make it difficult to determine what the patient is experiencing.
However, as oxygenation becomes more impaired, hypoxemia increases and leads to more
obvious signs such as tachycardia, tachypnea, circumoral cyanosis, diaphoresis, accessory
muscle use, inability to speak in full sentences, and altered mental status. Pain usually is not
present. Some patients may progress through these phases over several hours, whereas others may
progress within seconds.
 MEDICAL MANAGEMENT
● The objectives of treatment are to correct the underlying cause and to restore
adequate gas exchange in the lung.
● Endotracheal intubation and mechanical ventilation may be required to
maintain adequate ventilation and oxygenation while the underlying cause is
corrected.
 NURSING MANAGEMENT
● Nursing management of patients with acute respiratory failure includes assisting with
intubation and maintaining mechanical ventilation
● Patients are usually managed in the intensive care unit (ICU). The nurse assesses the
patient’s respiratory status by monitoring the level of responsiveness, arterial blood
gases, pulse oximetry, and vital signs.
● In addition, the nurse assesses the entire respiratory system and implements strategies
(e.g., turning schedule, mouth care, skin care, and range of motion of extremities) to
prevent complications.
● The nurse also assesses the patient’s understanding of the management strategies that
are used and initiates some form of communication to enable the patient to express
concerns and needs to the health care team.
● Finally, the nurse addresses the problems that led to the acute respiratory failure. As
the patient’s status improves, the nurse assesses the patient’s knowledge of the
underlying disorder and provides education as appropriate to address the disorder.
Possible Nursing Diagnosis:
● Ineffective Airway Clearance
● Ineffective Breathing Pattern
● Impaired Gas Exchange
● Anxiety
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