呼吸衰竭处理.ppt
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RESPIRATORY FAILURE
MANAGEMENT
Dr.Sivasubramanian.T.A.
DEPARTMENT OF ANAESTHESIOLOGY
IBRI REGIONAL REFERRAL HOSPITAL
RESPIRATORY CARE
? Ambient Pressure Therapy
? Positive Pressure Therapy
AMBIENT PRESSURE THERAPY
? Oxygen Therapy
? Humidity Therapy
? Bronchial Hygeine Therapy
? Pharmacotherapy
OXYGEN THERAPY
Oxygen Delivery = O2 Content x Cardiac Output
O2 Content = Hb x SaO2 x 1.34 + PaO2 x 0.003
OXYGEN THERAPY
? Aims to improve PaO2 by increasing FiO2
? Effective FiO2 - 0.24 - 0.50
? FiO2 > 0.50 not indicated
OXYGEN THERAPY
Delivered by
? Variable Performance / Low Flow System
? Fixed Performance / High Flow System
LOW FLOW SYSTEM
LOW FLOW SYSTEM
FiO2 depends on
? Size of O2 Reservoir
? O2 Flow Rate
? Breathing Pattern
LOW FLOW SYSTEM
? Simplicity
? Patient Comfort
? Economical
? Inaccurate / Not dependable
PERFORMANCE
HIGH FLOW SYSTEM
? 3 - 4 times Minute Volume
? Accurate over a range of Minute Volume
? FiO20.24 - 0.40
? Higher FiO2 by large-volume nebulisers
HIGH FLOW SYSTEM
HUMIDITY THERAPY
HUMIDITY THERAPY
Delivered by
? Humidifiers
? Nebulisers
? HMEs eg. Thermovent
HUMIDIFIERS
? Water baths
? Supply heated, humidified air
? 100 % saturated
? Prevent water loss from lungs
? Cannot supply additional water
NEBULISERS
? Aerosol mists
? Particle size 2 - 5 (m
? Supply 150 - 1500 mg/L water
? Useful for liquefying dried secretions
? Deliver medications
NEBULISERS
Types:
? Venturi
? Ultrasound
ULTRASONIC NEBULISER
? Water broken up by resonator
? Up to 6 ml in 1 min.
? Particle size ~ 2 (m
? Can cause water overload
? Mainly used for medication
HME
? Heat and Moisture exchanger
? Also called 'Artificial nose'
? Efficiency 70 %
? ↑ Resistance
? Bacteriostatic ?
BRONCHIAL HYGEINE THERAPY
Retained secretions can cause
? Atelectasis
? Pneumonia
? V/Q mismatch
? Hypoxaemia
BRONCHIAL HYGEINE THERAPY
Prophylactic:
? Chest Physiotherapy - Postural drainage, Chest percussion, Cough assist
? Incentive Spirometry
? Aerosol
BRONCHIAL HYGEINE THERAPY
Therapeutic:
? Endotracheal suctioning
? Fiberoptic Bronchoscopy
? Chest physiotherapy
ENDOTRACHEAL SUCTION
Harmful effects:
? Trauma
? Alveolar collapse
? ↑Vagal activity
Precautions:
? Preoxygenate
? Catheter size
? Time
? Obligatory high inflation
FIBEROPTIC BRONCHOSCOPY
? After all other means have failed
? Irrigation
? Suction
? For reexpanding collapsed segments
CHEST PHYSIOTHERAPY
? Most important
? Postural drainage
? Chest Percussion and Vibration
? Incentive Spirometry
PHARMACOTHERAPY
Classification:
? Drugs causing bronchodilatation
? Drugs reducing mucosal oedema
? Drugs that liquify mucus
BROCHODILATORS
? (2 Stimulants
? Theophylline
? Anticholinergics
BETA STIMULANTS
? Useful as Aerosol or MDI
? Bronchial smooth muscle relaxant
? Salbutamol, Metaproterenol, Racemic Epinephrine
? Side effects: Tachcardia, Tremors, Hypokalaemia, Hyperglycaemia
BETA STIMULANTS
Dosage:
THEOPHYLLINE
? Not usually recommended
? Less effective
? More side effects
? No significant relief in Acute states
THEOPHYLLINE
? Phosphodiesterase inhibitor
? Aminophylline - Theophylline + Ethylenediamine
? Desired Therapeutic level : 10mg/L
? Toxicity :> 20 mg/L
THEOPHYLLINE
Loading dose:
THEOPHYLLINE
Continuous Rate:
ANTICHOLINERGIC
? Ipratropium
? Inhibits vagally mediated reflexes
? Adjuvant to sympathomimetics
IPRATROPIUM BROMIDE
? Nebulised- 0.5 mg / Dose
? MDI - 18 (g / puff ( 2 puffs) 4th hrly
? Can be mixed with ( stimulants
? Takes 20 min. to act
? Efficacy doubtful
CORTICOSTEROIDS
? ↓Inflammation & Oedema of small airways
? Not effective in Ac. States
? Useful in later stages
? Take 6 - 8 hrs. to act
? Aerosol / IV
CORTICOSTEROIDS
Aerosol
CORTICOSTEROIDS
Intravenous
? Hydrocortisone:
2mg /kg Stat and 2mg / kg 4 hrly
? Methylprednisolone:
80 - 125 mg Stat and 80 mg 6 hrly
MUCOKINETIC THERAPY
? Bland aerosols
? N- acetyl cysteine (NAC)
BLAND AEROSOLS
? Liquify thick tenaceous secretions
? Saline -
Hyper-, Hypo - or Iso tonic
? Distilled water
? Hypertonic induces cough
N - ACETYL CYSTEINE
? 10 % and 20 % solutions
? Aerosol
? Direct instillation in trachea
? Disagreeable taste - nausea & vomiting
? Irritant - Cough & Bronchospasm
? Hypertonic - Bronchorrhoea
POSITIVE PRESSURE THERAPY
? Positive pressure applied to airway during any phase of resp. cycle for supporting or improving resp. function
? Achieved by mechanical ventilators
? Need arises when Cardiopulmonary reserves of the patient are overwhelmed or compromised by a pathological state
POSITIVE PRESSURE THERAPY
When to go for Positive pressure therapy ?
? Apnoea / Vent. Pattern inconsistent with life
? Acute ventilatory failure
? Impending ventilatory failure
When in doubt - GO AHEAD
MODES OF VENTILATION
Full Support
? Control mode ventilation
? Assist mode ventilation
Partial Support
? IMV / SIMV / MMV
? Pressure Support Ventilation
? Airway Pressure Release Ventilation
PHYSIOLOGICAL EFFECTS
? ↑ Physiological dead space↑ Zone I - V/Q > 0.8
? ↓ Cardiac Output
? ↑ Mean Intrathoracic Pressure -↓ Venous Return......（后略) ......
RESPIRATORY FAILURE
MANAGEMENT
Dr.Sivasubramanian.T.A.
DEPARTMENT OF ANAESTHESIOLOGY
IBRI REGIONAL REFERRAL HOSPITAL
RESPIRATORY CARE
? Ambient Pressure Therapy
? Positive Pressure Therapy
AMBIENT PRESSURE THERAPY
? Oxygen Therapy
? Humidity Therapy
? Bronchial Hygeine Therapy
? Pharmacotherapy
OXYGEN THERAPY
Oxygen Delivery = O2 Content x Cardiac Output
O2 Content = Hb x SaO2 x 1.34 + PaO2 x 0.003
OXYGEN THERAPY
? Aims to improve PaO2 by increasing FiO2
? Effective FiO2 - 0.24 - 0.50
? FiO2 > 0.50 not indicated
OXYGEN THERAPY
Delivered by
? Variable Performance / Low Flow System
? Fixed Performance / High Flow System
LOW FLOW SYSTEM
LOW FLOW SYSTEM
FiO2 depends on
? Size of O2 Reservoir
? O2 Flow Rate
? Breathing Pattern
LOW FLOW SYSTEM
? Simplicity
? Patient Comfort
? Economical
? Inaccurate / Not dependable
PERFORMANCE
HIGH FLOW SYSTEM
? 3 - 4 times Minute Volume
? Accurate over a range of Minute Volume
? FiO20.24 - 0.40
? Higher FiO2 by large-volume nebulisers
HIGH FLOW SYSTEM
HUMIDITY THERAPY
HUMIDITY THERAPY
Delivered by
? Humidifiers
? Nebulisers
? HMEs eg. Thermovent
HUMIDIFIERS
? Water baths
? Supply heated, humidified air
? 100 % saturated
? Prevent water loss from lungs
? Cannot supply additional water
NEBULISERS
? Aerosol mists
? Particle size 2 - 5 (m
? Supply 150 - 1500 mg/L water
? Useful for liquefying dried secretions
? Deliver medications
NEBULISERS
Types:
? Venturi
? Ultrasound
ULTRASONIC NEBULISER
? Water broken up by resonator
? Up to 6 ml in 1 min.
? Particle size ~ 2 (m
? Can cause water overload
? Mainly used for medication
HME
? Heat and Moisture exchanger
? Also called 'Artificial nose'
? Efficiency 70 %
? ↑ Resistance
? Bacteriostatic ?
BRONCHIAL HYGEINE THERAPY
Retained secretions can cause
? Atelectasis
? Pneumonia
? V/Q mismatch
? Hypoxaemia
BRONCHIAL HYGEINE THERAPY
Prophylactic:
? Chest Physiotherapy - Postural drainage, Chest percussion, Cough assist
? Incentive Spirometry
? Aerosol
BRONCHIAL HYGEINE THERAPY
Therapeutic:
? Endotracheal suctioning
? Fiberoptic Bronchoscopy
? Chest physiotherapy
ENDOTRACHEAL SUCTION
Harmful effects:
? Trauma
? Alveolar collapse
? ↑Vagal activity
Precautions:
? Preoxygenate
? Catheter size
? Time
? Obligatory high inflation
FIBEROPTIC BRONCHOSCOPY
? After all other means have failed
? Irrigation
? Suction
? For reexpanding collapsed segments
CHEST PHYSIOTHERAPY
? Most important
? Postural drainage
? Chest Percussion and Vibration
? Incentive Spirometry
PHARMACOTHERAPY
Classification:
? Drugs causing bronchodilatation
? Drugs reducing mucosal oedema
? Drugs that liquify mucus
BROCHODILATORS
? (2 Stimulants
? Theophylline
? Anticholinergics
BETA STIMULANTS
? Useful as Aerosol or MDI
? Bronchial smooth muscle relaxant
? Salbutamol, Metaproterenol, Racemic Epinephrine
? Side effects: Tachcardia, Tremors, Hypokalaemia, Hyperglycaemia
BETA STIMULANTS
Dosage:
THEOPHYLLINE
? Not usually recommended
? Less effective
? More side effects
? No significant relief in Acute states
THEOPHYLLINE
? Phosphodiesterase inhibitor
? Aminophylline - Theophylline + Ethylenediamine
? Desired Therapeutic level : 10mg/L
? Toxicity :> 20 mg/L
THEOPHYLLINE
Loading dose:
THEOPHYLLINE
Continuous Rate:
ANTICHOLINERGIC
? Ipratropium
? Inhibits vagally mediated reflexes
? Adjuvant to sympathomimetics
IPRATROPIUM BROMIDE
? Nebulised- 0.5 mg / Dose
? MDI - 18 (g / puff ( 2 puffs) 4th hrly
? Can be mixed with ( stimulants
? Takes 20 min. to act
? Efficacy doubtful
CORTICOSTEROIDS
? ↓Inflammation & Oedema of small airways
? Not effective in Ac. States
? Useful in later stages
? Take 6 - 8 hrs. to act
? Aerosol / IV
CORTICOSTEROIDS
Aerosol
CORTICOSTEROIDS
Intravenous
? Hydrocortisone:
2mg /kg Stat and 2mg / kg 4 hrly
? Methylprednisolone:
80 - 125 mg Stat and 80 mg 6 hrly
MUCOKINETIC THERAPY
? Bland aerosols
? N- acetyl cysteine (NAC)
BLAND AEROSOLS
? Liquify thick tenaceous secretions
? Saline -
Hyper-, Hypo - or Iso tonic
? Distilled water
? Hypertonic induces cough
N - ACETYL CYSTEINE
? 10 % and 20 % solutions
? Aerosol
? Direct instillation in trachea
? Disagreeable taste - nausea & vomiting
? Irritant - Cough & Bronchospasm
? Hypertonic - Bronchorrhoea
POSITIVE PRESSURE THERAPY
? Positive pressure applied to airway during any phase of resp. cycle for supporting or improving resp. function
? Achieved by mechanical ventilators
? Need arises when Cardiopulmonary reserves of the patient are overwhelmed or compromised by a pathological state
POSITIVE PRESSURE THERAPY
When to go for Positive pressure therapy ?
? Apnoea / Vent. Pattern inconsistent with life
? Acute ventilatory failure
? Impending ventilatory failure
When in doubt - GO AHEAD
MODES OF VENTILATION
Full Support
? Control mode ventilation
? Assist mode ventilation
Partial Support
? IMV / SIMV / MMV
? Pressure Support Ventilation
? Airway Pressure Release Ventilation
PHYSIOLOGICAL EFFECTS
? ↑ Physiological dead space↑ Zone I - V/Q > 0.8
? ↓ Cardiac Output
? ↑ Mean Intrathoracic Pressure -↓ Venous Return......（后略) ......
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