Respiratory Failure Nursing Guide 2026: Types, ARDS, and Oxygen Therapy

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Contents: Type 1 vs Type 2 Respiratory Failure Respiratory Assessment Oxygen Delivery Systems Non-Invasive Ventilation ARDS COPD Exacerbation NCLEX High-Yield

Type 1 vs Type 2 Respiratory Failure

Feature	Type 1 (Hypoxemic)	Type 2 (Hypercapnic)
Definition	Low PaO2 (<60 mmHg) with normal or low PaCO2; problem is OXYGENATION	Elevated PaCO2 (>50 mmHg) with respiratory acidosis; problem is VENTILATION (can't eliminate CO2)
Mechanism	V/Q mismatch, shunt, diffusion impairment, low FiO2	Reduced respiratory drive, neuromuscular weakness, airway obstruction, chest wall restriction — insufficient alveolar ventilation
Common Causes	ARDS, pneumonia, pulmonary edema, PE, pneumothorax, atelectasis	COPD exacerbation, opioid overdose, neuromuscular disease (Guillain-Barré, myasthenia gravis), severe asthma, obesity hypoventilation
ABG Findings	pH normal or high; PaO2 low (<60); PaCO2 normal or low; SaO2 low	pH low (<7.35 if acute); PaCO2 high (>50); HCO3 normal (acute) or high (compensated chronic); PaO2 may be low
Oxygen Response	RESPONDS well to supplemental O2 (V/Q mismatch improves); shunt does NOT respond well to O2	O2 helps hypoxemia but does NOT correct the hypercapnia; ventilation is the key treatment

Respiratory Assessment Priorities

Parameter	Normal	Concern Thresholds
Respiratory Rate	12–20 breaths/min	<10 or >30 = significant; RR >30 is a sensitive early warning sign of respiratory compromise
SpO2 (pulse oximetry)	≥95%	<95% investigate; <90% = significant hypoxemia; NOT reliable with poor perfusion, CO poisoning, or dark nail polish
ABG PaO2	80–100 mmHg	<80 = hypoxemia; <60 = significant hypoxemia (SpO2 ≈ 90%); <40 = severe (SpO2 ≈ 75%)
Work of breathing	No accessory muscle use; no retractions	Accessory muscles (SCM, scalene, intercostal retractions, nasal flaring, abdominal paradox) = significant respiratory distress; immediate intervention
Auscultation	Vesicular breath sounds; equal bilateral	Crackles = fluid (pneumonia, CHF); wheezing = bronchospasm (asthma, COPD); absent sounds one side = pneumothorax or effusion; stridor = upper airway obstruction

Signs of impending respiratory failure requiring immediate escalation: RR >35, SpO2 <90% on high-flow O2, altered mental status (CO2 narcosis or hypoxemia), inability to speak full sentences, paradoxical breathing (abdomen moves in while chest moves out).

Oxygen Delivery Systems

Device	FiO2 Delivered	Flow Rate	Key Points
Nasal Cannula (NC)	24–44%	1–6 L/min (each L adds ~4% FiO2 above room air 21%)	Most comfortable; patient can eat and talk; dries mucosa >4 L/min (use humidification); unreliable FiO2 with mouth breathing or high RR
Simple Face Mask	35–50%	6–10 L/min (min 6 to prevent CO2 rebreathing)	Minimum 6 L/min to flush CO2 from mask; uncomfortable; impairs eating/talking
Non-Rebreather Mask (NRB)	60–95%	10–15 L/min	Reservoir bag must stay inflated; one-way valves prevent rebreathing; highest non-invasive O2 delivery; used for CO poisoning, significant hypoxemia, trauma
Venturi Mask	Precise: 24%, 28%, 31%, 35%, 40%, 60%	Varies by color-coded adaptor	MOST PRECISE O2 delivery; preferred for COPD (controlled O2 to avoid hypoxic drive suppression); color-coded jet adaptors
High-Flow Nasal Cannula (HFNC)	21–100% (adjustable)	10–60 L/min	Delivers heated/humidified O2 at high flows; reduces work of breathing; generates small amount of PEEP; used for severe hypoxemia; allows eating and talking; alternative to intubation

COPD and oxygen: The "hypoxic drive" concern is real but often overstated. Hypoxic COPD patients should STILL receive O2 for SpO2 <88–92%; target SpO2 88–92% (not 95–100%). Use Venturi mask for precise delivery. Do NOT withhold O2 from a COPD patient in distress.

Non-Invasive Ventilation (NIV)

Mode	Settings	Indications	Contraindications
CPAP (Continuous Positive Airway Pressure)	Single constant pressure (5–20 cmH2O); patient breathes spontaneously; maintains PEEP only	Obstructive sleep apnea; cardiogenic pulmonary edema; Type 1 respiratory failure; post-extubation support	Respiratory arrest; inability to protect airway; hemodynamic instability; unable to tolerate mask
BiPAP (Bilevel Positive Airway Pressure)	IPAP (inspiratory pressure 10–20 cmH2O) + EPAP (expiratory pressure 4–8 cmH2O); helps both ventilation AND oxygenation	COPD exacerbation (first-line, reduces intubation 50%+); CHF; neuromuscular disease; OHS; Type 2 respiratory failure	Same as CPAP contraindications; vomiting or high aspiration risk; recent facial surgery; inability to fit mask

NIV Nursing Care

Fit mask carefully (tight enough to seal, loose enough to prevent pressure injury)
Apply barrier dressing to nose bridge to prevent pressure ulcer
Patient must have adequate mental status to remove mask if needed
Continuous SpO2 and RR monitoring; assess every hour for tolerance and response
Offer breaks every 2–4 hours for skin assessment, oral care, medications
Have intubation equipment at bedside — NIV can fail rapidly
Document patient's response to NIV after 1–2 hours; persistent distress = escalate to intubation

ARDS (Acute Respiratory Distress Syndrome)

Berlin Definition (2012)

Acute onset within 1 week of a known clinical insult or new/worsening respiratory symptoms
Bilateral opacities on chest imaging (not explained by effusions, atelectasis, or nodules)
NOT fully explained by cardiac failure or fluid overload (TRALI distinction)
P/F ratio (PaO2/FiO2): Mild = 200–300; Moderate = 100–200; Severe = <100

Common ARDS triggers: sepsis (most common, 40%), pneumonia, aspiration, trauma, massive transfusion, pancreatitis, drowning, inhalation injury.

Nursing Priorities in ARDS

Lung-protective ventilation: 6 mL/kg IBW tidal volume; Pplat ≤30 cmH2O
PEEP titration per ARDSnet table to maintain oxygenation
Prone positioning: 16+ hr/day for P/F <150 reduces mortality significantly; requires dedicated team; monitor skin, eye, tube security
Fluid management: conservative strategy once hemodynamically stable (negative fluid balance improves lung function)
Avoid oxygen toxicity: wean FiO2 below 0.60 as quickly as tolerated
Sedation and analgesia per ABCDEF bundle
Daily spontaneous awakening + breathing trials

COPD Exacerbation

Acute worsening of respiratory symptoms beyond normal day-to-day variation. Most common trigger: respiratory infection (viral URI 50%).

COPD Exacerbation Management

Oxygen: Target SpO2 88–92% (not higher); Venturi mask preferred for precise delivery
Bronchodilators: SABA (albuterol) + SAMA (ipratropium) nebulizers/MDI; scheduled and PRN
Systemic corticosteroids: Methylprednisolone or prednisone 40 mg x 5 days (reduces treatment failure and length of stay)
Antibiotics: If purulent sputum, increased sputum volume, or increased dyspnea; amoxicillin-clavulanate, azithromycin, doxycycline
Non-invasive ventilation (BiPAP): First-line for moderate-severe exacerbation with respiratory acidosis (pH <7.35); reduces intubation rate by 50%
Intubation: If BiPAP fails or patient cannot protect airway

NCLEX High-Yield Points

Type 1 = oxygenation failure (low PaO2, normal/low CO2); Type 2 = ventilation failure (high CO2)
CO poisoning: SpO2 may be falsely NORMAL (oximetry can't distinguish COHb from OxyHgb); use co-oximetry; treat with 100% O2
COPD target SpO2: 88–92% (not 95–100%); Venturi mask for controlled delivery
Non-rebreather mask: highest non-invasive FiO2 delivery; reservoir bag must stay inflated
BiPAP for COPD exacerbation: reduces intubation need; IPAP helps inspiration, EPAP = PEEP
ARDS: bilateral infiltrates + P/F ratio <300; Berlin criteria; lung-protective ventilation + prone positioning
Prone positioning: for ARDS P/F <150; 16+ hours/day; significant mortality reduction
Signs of impending respiratory arrest: RR >35, SpO2 <90% on high-flow, altered consciousness, paradoxical breathing

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