What does nursing management of respiratory failure involve?

Nursing Management of Respiratory Failure

Nursing management of respiratory failure centers on continuous monitoring, optimizing oxygenation through positioning and ventilatory support, maintaining airway patency, and early recognition of deterioration requiring escalation of care.

Initial Assessment and Monitoring

Nurses must perform rapid initial assessment to triage patients to the appropriate level of care and establish baseline parameters. 1

• Continuously monitor oxygen saturation via pulse oximetry, targeting SpO₂ 88-92% in Type 2 respiratory failure (COPD, neuromuscular disease) and 94-98% in Type 1 respiratory failure 1, 2
• Assess respiratory rate every 15-30 minutes initially; rates >25 breaths/min indicate significant respiratory distress requiring escalation 1, 2
• Monitor work of breathing by observing use of accessory muscles, ability to speak in full sentences, and presence of orthopnea 1, 2
• Evaluate mental status closely, as drowsiness or confusion indicates impending respiratory failure requiring immediate physician notification 2
• Document arterial blood gas results at 1-2 hours after initiating treatment, then every 4-6 hours once stable 1, 3

Oxygen Therapy Administration

Nurses are responsible for initiating and titrating oxygen therapy according to established protocols while monitoring for complications.

• Administer supplemental oxygen immediately via nasal cannula (1-6 L/min) or simple face mask (5-10 L/min) depending on severity 2
• For Type 2 respiratory failure, use controlled oxygen therapy targeting SpO₂ 88-92% to avoid worsening hypercapnia 1, 4
• Escalate to high-flow nasal oxygen (HFNO) at 40-60 L/min if SpO₂ remains <90% despite conventional oxygen therapy 2
• Add supplemental oxygen to non-invasive ventilation if SpO₂ <85% 1, 3

Non-Invasive Ventilation (NIV) Management

Nurses play a critical role in setting up, maintaining, and monitoring patients on NIV, which requires specialized training and frequent assessment. 1

NIV Setup and Initiation

• Select a full-face mask as the preferred interface since mouth breathing predominates in acute hypercapnic respiratory failure 3
• Hold the mask in place initially to familiarize the patient before securing with straps 1, 3
• Set initial bi-level pressure support with IPAP 10-15 cmH₂O and EPAP 4-8 cmH₂O 3
• Attach pulse oximeter before commencing NIV 1, 3
• Explain the procedure to the patient and instruct them how to remove the mask and summon help 1

Ongoing NIV Monitoring

• Reassess patient after a few minutes and adjust settings as needed 1, 3
• Check arterial blood gases at 1-2 hours after initiating NIV 1, 3
• If PaCO₂ and pH have deteriorated after 1-2 hours on optimal settings, notify physician immediately for alternative management plan 1, 3
• If no improvement in PaCO₂ and pH by 4-6 hours, prepare for intubation and invasive mechanical ventilation 1, 3

Staffing Requirements for NIV

NIV requires enhanced nursing staffing ratios, particularly during the first 24 hours of treatment. 1

• Maintain one nurse for every 2 NIV cases, especially during the first 24 hours 1
• Ensure NIV is delivered in areas with level 2 equivalence capability 1
• Outside ICU/HDU, nurses or physiotherapists must be available to set up NIV as on-call medical staff typically lack time 1

Mechanical Ventilation Nursing Care

For patients requiring invasive mechanical ventilation, nurses must maintain airway patency, prevent complications, and monitor ventilator parameters. 5, 6, 7

Ventilator Monitoring

• Perform nursing detection of ventilator performance, tightness, pipeline safety, and airway patency before use 5
• Monitor tidal volume delivery (should be 6-8 mL/kg predicted body weight) 3
• Ensure plateau pressure remains ≤30 cmH₂O to prevent barotrauma 3
• Verify adequate expiratory time with I:E ratio of approximately 1:2 or 1:3 to prevent air trapping 3

Airway Management

• Maintain artificial airway patency through regular suctioning as needed 5
• Monitor for signs of airway obstruction or displacement 5
• Ensure humidification is functioning properly to prevent secretion inspissation 5

Patient Positioning

Positioning is a key nursing intervention to optimize ventilation-perfusion matching and reduce work of breathing. 2, 6

• Position patients semi-recumbent (30-45° head elevation) if hemodynamically stable to optimize ventilation-perfusion matching 2
• Implement prone positioning in severe ARDS when ordered, as this requires specialized nursing expertise 6
• Reposition patients regularly to prevent pressure ulcers and optimize lung recruitment 6

Hemodynamic Management

Nurses must monitor and manage hemodynamic parameters that directly affect oxygenation. 6

• Monitor blood pressure, heart rate, and cardiac output as these affect oxygen delivery 6
• Administer vasoactive medications as ordered to maintain adequate perfusion pressure 6
• Monitor fluid balance closely, as both hypovolemia and fluid overload worsen respiratory failure 6

Psychological Nursing Care

Respiratory failure causes significant anxiety and fear, requiring dedicated psychological support. 5

• Provide reassurance and clear explanations of all procedures to reduce patient anxiety 5
• Ensure patients can summon help and understand how to communicate their needs 1
• Involve family members in care planning and provide consistent information on the management plan 1

Documentation and Communication

Accurate documentation and timely communication with physicians are essential nursing responsibilities. 1

• Document all changes in respiratory status, work of breathing, and mental status 1
• Communicate unsatisfactory responses to treatment (persistent low saturation, worsening blood gases) immediately to the physician with an accompanying management plan 1
• Record side effects of treatment including electrolyte imbalances 1
• Ensure clear documentation of management plan if NIV fails, including whether patient will be intubated 1, 3

Common Nursing Pitfalls to Avoid

• Never delay escalation of care when pH <7.35 and PaCO₂ >6.0 kPa, as this misses the therapeutic window for NIV 4
• Avoid administering high-flow oxygen without monitoring CO₂ in Type 2 respiratory failure, as this can precipitate CO₂ narcosis and respiratory arrest 4
• Do not continue ineffective NIV beyond 4-6 hours without improvement in blood gases, as delayed intubation worsens mortality 1, 4
• Never assume stable patients will remain stable—perform regular reassessments as respiratory failure can deteriorate rapidly 1

Discharge Planning and Follow-up

Once stabilized, nurses should coordinate comprehensive discharge planning. 1

• Perform structured clinical, psychological, and social assessment using validated tools 1
• Arrange referral to multidisciplinary disease management programs 1
• For neuromuscular disease patients, coordinate referral to home NIV services 1
• Provide warning cards and inform ambulance services about future need for controlled oxygen therapy in COPD patients 1