美国呼吸衰竭治疗方案英文版课件

RESPIRATORYFAILUREMANAGEMENT专注医疗 Dr Sivasubramanian T A DEPARTMENTOFANAESTHESIOLOGYIBRIREGIONALREFERRALHOSPITAL RESPIRATORYCARE AmbientPressureTherapyPositivePressureTherapy AMBIENTPRESSURETHERAPY OxygenTherapyHumidityTherapyBronchialHygeineTherapyPharmacotherapy OXYGENTHERAPY OxygenDelivery O2ContentxCardiacOutputO2Content HbxSaO2x1 34 PaO2x0 003 OXYGENTHERAPY AimstoimprovePaO2byincreasingFiO2EffectiveFiO2 0 24 0 50FiO2 0 50notindicated OXYGENTHERAPY DeliveredbyVariablePerformance LowFlowSystemFixedPerformance HighFlowSystem LOWFLOWSYSTEM LOWFLOWSYSTEM FiO2dependsonSizeofO2ReservoirO2FlowRateBreathingPattern LOWFLOWSYSTEM SimplicityPatientComfortEconomicalInaccurate Notdependable PERFORMANCE HIGHFLOWSYSTEM 3 4timesMinuteVolumeAccurateoverarangeofMinuteVolumeFiO20 24 0 40HigherFiO2bylarge volumenebulisers HIGHFLOWSYSTEM HUMIDITYTHERAPY AIR50 HUMIDIFIED20 C 10mg L ALVEOLI100 HUMIDIFIED37 C44mg L Nose HUMIDITYTHERAPY DeliveredbyHumidifiersNebulisersHMEseg Thermovent HUMIDIFIERS WaterbathsSupplyheated humidifiedair100 saturatedPreventwaterlossfromlungsCannotsupplyadditionalwater NEBULISERS AerosolmistsParticlesize2 5 mSupply150 1500mg LwaterUsefulforliquefyingdriedsecretionsDelivermedications NEBULISERS Types VenturiUltrasound ULTRASONICNEBULISER WaterbrokenupbyresonatorUpto6mlin1min Particlesize 2 mCancausewateroverloadMainlyusedformedication HME HeatandMoistureexchangerAlsocalled Artificialnose Efficiency70 ResistanceBacteriostatic BRONCHIALHYGEINETHERAPY RetainedsecretionscancauseAtelectasisPneumoniaV QmismatchHypoxaemia BRONCHIALHYGEINETHERAPY Prophylactic ChestPhysiotherapy Posturaldrainage Chestpercussion CoughassistIncentiveSpirometryAerosol BRONCHIALHYGEINETHERAPY Therapeutic EndotrachealsuctioningFiberopticBronchoscopyChestphysiotherapy ENDOTRACHEALSUCTION Harmfuleffects TraumaAlveolarcollapse VagalactivityPrecautions PreoxygenateCathetersizeTimeObligatoryhighinflation FIBEROPTICBRONCHOSCOPY AfterallothermeanshavefailedIrrigationSuctionForreexpandingcollapsedsegments CHESTPHYSIOTHERAPY MostimportantPosturaldrainageChestPercussionandVibrationIncentiveSpirometry PHARMACOTHERAPY Classification DrugscausingbronchodilatationDrugsreducingmucosaloedemaDrugsthatliquifymucus BROCHODILATORS 2StimulantsTheophyllineAnticholinergics BETASTIMULANTS UsefulasAerosolorMDIBronchialsmoothmusclerelaxantSalbutamol Metaproterenol RacemicEpinephrineSideeffects Tachcardia Tremors Hypokalaemia Hyperglycaemia BETASTIMULANTSDosage THEOPHYLLINE NotusuallyrecommendedLesseffectiveMoresideeffectsNosignificantreliefinAcutestates THEOPHYLLINE PhosphodiesteraseinhibitorAminophylline Theophylline EthylenediamineDesiredTherapeuticlevel 10mg LToxicity 20mg L THEOPHYLLINE Loadingdose THEOPHYLLINE ContinuousRate ANTICHOLINERGIC IpratropiumInhibitsvagallymediatedreflexesAdjuvanttosympathomimetics IPRATROPIUMBROMIDE Nebulised 0 5mg DoseMDI 18 g puff 2puffs 4thhrlyCanbemixedwith stimulantsTakes20min toactEfficacydoubtful CORTICOSTEROIDS Inflammation OedemaofsmallairwaysNoteffectiveinAc StatesUsefulinlaterstagesTake6 8hrs toactAerosol IV CORTICOSTEROIDS Aerosol CORTICOSTEROIDS IntravenousHydrocortisone 2mg kgStatand2mg kg4hrlyMethylprednisolone 80 125mgStatand80mg6hrly MUCOKINETICTHERAPY BlandaerosolsN acetylcysteine NAC BLANDAEROSOLS LiquifythicktenaceoussecretionsSaline Hyper Hypo orIsotonicDistilledwaterHypertonicinducescough N ACETYLCYSTEINE 10 and20 solutionsAerosolDirectinstillationintracheaDisagreeabletaste nausea vomitingIrritant Cough BronchospasmHypertonic Bronchorrhoea POSITIVEPRESSURETHERAPY Positivepressureappliedtoairwayduringanyphaseofresp cycleforsupportingorimprovingresp functionAchievedbymechanicalventilatorsNeedariseswhenCardiopulmonaryreservesofthepatientareoverwhelmedorcompromisedbyapathologicalstate POSITIVEPRESSURETHERAPY WhentogoforPositivepressuretherapy Apnoea Vent PatterninconsistentwithlifeAcuteventilatoryfailureImpendingventilatoryfailureWhenindoubt GOAHEAD MODESOFVENTILATION FullSupportControlmodeventilationAssistmodeventilationPartialSupportIMV SIMV MMVPressureSupportVentilationAirwayPressureReleaseVentilation PHYSIOLOGICALEFFECTS Physiologicaldeadspace ZoneI V Q 0 8 CardiacOutput MeanIntrathoracicPressure VenousReturn Sympathetictone SUPPORTIVEMODES PositiveEndExpiratoryPressure PEEP ContinuousPositiveAirwayPressure CPAP ExpiratoryPositiveAirwayPressure EPAP WEANINGFROMVENTILATOR Whendoesoneweanapatientfromventilator Underlyingindication improved Cardiopulmonaryreserves Adequate Factors ventilatorydemand Present CRITERIAFORWEANING VitalCapacity 10 15ml kgTidalVolume immediatespont 2ml kgRespiratoryRate preferably 25 minTachycardia DiscouragingBloodPressureArrhythmia tobeevaluatedHaemoglobin OptimisedAbsenceofconditionswhich VentilatoryDemand HighMetabolicRates acidosisetc COMPLICATIONS DeviceDysfunctionAirwayComplicationsPulmonaryinfectionPulmonaryBarotrauma Aerosoltreatment Repeat Repeat 20min 20min 20min PEFR 70 40 70 25 40 25 IVSTEROIDS IVSTEROIDS INTUBATEIVSTEROIDS ADMITTOHOSPITAL ADMITTOICU 60min PEFR DISCHARGE REPEATAEROSOL 70 70 CHRONICOBSTRUCTIVEAIRWAYDISEASE Problems AirwayResistance WorkofBreathingThoracicHyperinflation InspiratorymuscleeffeciencyImpairedgasexchange CHRONICOBSTRUCTIVEAIRWAYDISEASE AirwayResistanceBronchodilators 2agonists Ipratropium Theophylline CorticosteroidsBronchialHygeineTherapy important CHRONICOBSTRUCTIVEAIRWAYDISEASE ImproveGasExchangeOxygenTherapy HighFlowSystemsPositivePressureTherapy ifneededMaintainPaO250 60mmHg ACUTELUNGINJURY ACUTERESPIRATORYDISTRESSSYNDROME MaintainVascularVolume CVP PACEnsureadequateHblevelMaintainPaO2 atleast50 60mmHg Ventilate FiO2 0 5 UsePEEPAvoidalveolaroverdistension lowVT PIP 35cmH2O PermissiveHypercapnia PERMISSIVEHYPERCAPNIA PaCO250mmHg ifpH 7 25