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356 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

COLLABORATIVE PRACTICE of medications will vary depending on the underlying
A patient with ARF requires extensive multidisciplinary cause of respiratory failure, these are discussed in each
collaboration between nurses, physiotherapists, specialist section respectively.
medical staff, speech and occupational therapists, dieti-
tians, social workers, radiologists and radiographers. SPECIAL CONSIDERATIONS
Patients may require additional oxygen delivery through Respiratory failure in patients who are pregnant, elderly
an adequate haemoglobin level for oxygen transportation or have comorbidities require specific attention to avoid
and a cardiac output sufficient to supply oxygenated clinical deterioration. Respiratory physiology and the
6
blood to the tissues. At times this may require blood respiratory tract itself are altered during pregnancy; this
transfusion and/or the use of vasoactive medications (see may result in exacerbation of preexisting respiratory
Chapters 11 and 20). disease or increased susceptibility to disease (see Chapter
26). Upper airway mucosal oedema may increase the
Chest physiotherapy is a routine activity for managing likelihood of upper respiratory tract infection. Lung func-
patients with ARF. This involves positioning, manual tion and lung volume are also altered, compensated by
hyperinflation, percussion and vibration and suctioning. an increase in respiratory drive and minute ventilation.
The evidence base for these techniques is limited, however, The impact of these alterations on chronic conditions
with a systematic review not demonstrating an improve- such as asthma/COPD and acute illness are explored
12
ment in mortality. Guidelines for physiotherapy assess- in the subsequent sections. The impact on the fetus of
ment have enabled identification of patient characteristics infection, hypoxia and drug therapy is an important
for treatments to be prescribed and modified on an indi- consideration. 6
13
vidual basis. Table 14.3 6,13,15 outlines a number of col-
laborative practice issues for patients with respiratory The elderly have ageing organs and systems and other
failure, particularly those who may require prolonged comorbidities that may exacerbate their respiratory dys-
mechanical ventilation. function. Drug metabolism and excretion is slowed, com-
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plicating drug dosing and response. Metabolism of
Medications anaesthetic agents is slower due to the diminished physio-
logy of ageing organs. Common comorbidities may also
Medications commonly prescribed in respiratory failure be present, including obesity, heart disease, diabetes, and
include inhalation steroids and bronchodilators, intrave- renal impairment or muscle wasting. Pneumonia is a
nous steroids and bronchodilators, antibiotic therapy, common presentation in the elderly and is often exacer-
analgesia and sedation to maintain patient–ventilator bated by chronic lung conditions. 6
synchrony, but may also involve nitric oxide, glucocorti-
coid or surfactant administration. A patient’s condition, Comorbidities add to the complexity of managing a
comorbidities and the above-mentioned pharmacologi- patient’s primary condition and increase the risk of addi-
cal therapy may also be supported with inotropic and tional organ dysfunction or failure. Chronic respiratory
other resuscitation therapies (see Chapter 11). As the use conditions can have a significant impact on the severity

TABLE 14.3 Collaborative practices for patients with respiratory failure

Long-term patient management Best practice
Timing of tracheostomy insertion Where mechanical ventilation is expected to be 10 days or more, tracheostomy should be
performed as soon as identified. Early tracheostomy is associated with less nosocomial
pneumonia, reduced ventilation time and shorter ICU stay.
Weaning protocols Specific plan is patient dependent; better outcomes are achieved when there is an agreed and
well communicated weaning plan (see Chapter 15)
Nutrition Consider adequate nutrition for physiological needs – important to not overfeed as this increases
CO 2 production and need to have balance of vitamins and minerals
Swallow assessment Assess for dysphagia
Mobilisation Sitting out of bed, mobilising (see Chapter 4)
Communication Communication aids, speaking valves
Activities Activity plan/routine, entertainment (TV/Films), visitors, outings
Sleep Clustering cares, reducing stimuli to promote sleep (see Chapter 7)
Family support Importance of providing physical, emotional and/or spiritual support to family members (see
Chapter 8)
Tracheostomy follow-up Outreach team: follow-up care by nurses experienced in tracheostomy care can prevent
complications and improve outcomes
End-of-life decisions in ARF see Chapter 5