呼吸衰竭和急性呼吸窘迫综合征.ppt

UTHSCSAPediatricResidentCurriculumforthePICU,RESPIRATORYFAILURE&ARDS,RESPIRATORYFAILURE,Inabilityofthepulmonarysystemtomeetthemetabolicdemandsofthebodythroughadequategasexchange.Twotypesofrespiratoryfailure:HypoxemicHypercarbicEachcanbefurtherdividedintoacuteandchronic.Bothtypesofrespiratoryfailurecanbepresentinthesamepatient.,CENTRALETIOLOGIES,Trauma:headinjury,asphyxiation,hemorrhageInfection:meningitis,encephalitisTumorsDrugs:narcotics,sedativesNeonatalapneaSeverehypoxemiaorhypercarbiaIncreasedICPfromanyoftheabovecauses,OBSTRUCTIVEETIOLOGIES,UpperAirwayAnatomic:choanalatresia,tracheomalacia,tonsillarhypertrophy,laryngealweb,vascularrings,vocalcordparalysis,macroglossiaAspiration:mucus,foreignbody,vomitusInfection:epiglottitis,abscesses,laryngotracheitisTumors:hemangioma,cystichygroma,papilloma,Laryngpospasm,LowerAirwayAnatomic:bronchomalacia,lobaremphysemaAspiration:FB,mucus,meconium,vomitusInfection:pneumonia,pertussis,bronchiolitis,CFTumors:teratoma,bronchogeniccystBronchospasm,RESTRICTIVEETIOLOGIES,LungParenchymaAnatomic:agenesis,cyst,pulmonarysequestrationAtelectasisHyalinemembranediseaseARDSInfection:pneumonia,bronchiectasis,pleuraleffusion,PneumocystiscariniiAirleak:pneumothoraxMisc:hemorrhage,edema,pneumonitis,fibrosis,ChestWallMuscular:diaphragmatichernia,myastheniagravis,musculardystrophy,botulismSkeletal:hemivertebrae,absentribs,fusedribs,scoliosisMisc:distendedabdomen,flailchest,obesity,HYPOXEMIA,V/QmismatchMostcommonreason.Bloodperfusesnon-ventilatedlung.Seeninatelectasis,pneumonia,bronchiectasisGlobalhypoventilation:apneaRight-to-leftshuntIntracardiaclesions,e.g.,tetralogyofFallotIncompletediffusionOxygenmustdiffuseacrossincreaseddistancesecondarytointerstitialedema,fibrosis,orhyalinemembrane.LowinspiredFiO2:highaltitude,HYPERCARBIA,PumpFailureReducedcentraldrive:apnea,metabolicalkalosis,drugs,brainsteminjury,hypoxiaMusclefatigue:musculardystrophyIncreasedpulmonaryworkload:decreasedcompliance,increasedobstructionIncreasedCO2production:fever,seizure,malignanthyperthermiaIncreaseddeadspace:V/Qmismatch(ventilationofnon-perfusedlung),PHYSICALEXAM,TachypneaDyspneaRetractionsNasalflaringGruntingDiaphoresisTachycardiaHypertension,AlteredmentalstatusConfusionAgitationRestlessnessSomnolenceCyanosis(need5mg/dlofunoxygenatedblood),CXRFINDINGS,CXRmaybenormalifproblemiswithupperairwayCanseehyperinflation,atelectasis,infiltrate,cardiomegalyAdditionalstudiesmaybeneeded,e.g.,chestCT,bariumswallow,echocardiogram,BLOODGAS,Foranyagepatient,breathingroomair,respiratoryfailureisdefinedasarterialpCO250mmHgorarterialpO2600mlO2/min/m2.KeepHct30%,higherifsignsofheartfailure.Useinotropestoaugmentcardiacoutput.Ensureadequatepreload.,LIMITSECONDARYINFECTIONS,Washyourhands.Usethegutassoonaspossiblefornutritionandmeds.Discontinueindwellingcathetersassoonaspossible.Havehighindexofsuspicion.Treatinfectionsearly,buttailorantibioticstocultureresults.,DRUGS,Diuretics:adrylungisagoodlung.InotropesSteroids:2mg/kg/daybegunafteraweekintothecoursemaybeofbenefit,otherwisedontuse.Pulmonaryvasodilators(nitricoxide,prostaglandins,nitroprusside):oflittlebenefit.NOmaybeofbenefitinsomepatients.Surfactantreplacement:probablynobenefitNSAIDs:noclinicalbenefit,NUTRITION,Ensureadequatecaloriesassoonaspossible:50-60kcal/kg/dayininfants35-45kcal/kg/dayinolderchildren.Afterday4,increasecaloriesby25-50%abovebaseline.Beginenteralfeedsassoonasissafe.“Pulmonary”formulasprobablyoflittleben