呼吸衰竭和急性呼吸窘迫综合征-英文幻灯片课件

呼吸衰竭和急性呼吸窘迫综合征-英文幻灯片PPT本PPT课件仅供学习交流使用请学习完毕自行删除本PPT课件仅供学习交流使用请学习完毕自行删除本PPT课件仅供学习交流使用请学习完毕自行删除RESPIRATORYFAILUREInabilityofthepulmonarysystemtomeetthemetabolicdemandsofthebodythroughadequategasexchange.Twotypesofrespiratoryfailure:HypoxemicHypercarbicEachcanbefurtherdividedintoacuteandchronic.Bothtypesofrespiratoryfailurecanbepresentinthesamepatient.CENTRALETIOLOGIESTrauma:headinjury,asphyxiation,hemorrhageInfection:meningitis,encephalitisTumorsDrugs:narcotics,sedativesNeonatalapneaSeverehypoxemiaorhypercarbiaIncreasedICPfromanyoftheabovecausesOBSTRUCTIVEETIOLOGIESUpperAirwayAnatomic:choanalatresia,tracheomalacia,tonsillarhypertrophy,laryngealweb,vascularrings,vocalcordparalysis,macroglossiaAspiration:mucus,foreignbody,vomitusInfection:epiglottitis,abscesses,laryngotracheitisTumors:hemangioma,cystichygroma,papilloma,LaryngpospasmLowerAirwayAnatomic:bronchomalacia,lobaremphysemaAspiration:FB,mucus,meconium,vomitusInfection:pneumonia,pertussis,bronchiolitis,CFTumors:teratoma,bronchogeniccystBronchospasmRESTRICTIVEETIOLOGIESLungParenchymaAnatomic:agenesis,cyst,pulmonarysequestrationAtelectasisHyalinemembranediseaseARDSInfection:pneumonia,bronchiectasis,pleuraleffusion,PneumocystiscariniiAirleak:pneumothoraxMisc:hemorrhage,edema,pneumonitis,fibrosisChestWallMuscular:diaphragmatichernia,myastheniagravis,musculardystrophy,botulismSkeletal:hemivertebrae,absentribs,fusedribs,scoliosisMisc:distendedabdomen,flailchest,obesityHYPOXEMIAV/QmismatchMostcommonreason.Bloodperfusesnon-ventilatedlung.Seeninatelectasis,pneumonia,bronchiectasisGlobalhypoventilation:apneaRight-to-leftshuntIntracardiaclesions,e.g.,tetralogyofFallotIncompletediffusionOxygenmustdiffuseacrossincreaseddistancesecondarytointerstitialedema,fibrosis,orhyalinemembrane.LowinspiredFiO2:highaltitudeHYPERCARBIAPumpFailureReducedcentraldrive:apnea,metabolicalkalosis,drugs,brainsteminjury,hypoxiaMusclefatigue:musculardystrophyIncreasedpulmonaryworkload:decreasedcompliance,increasedobstructionIncreasedCO2production:fever,seizure,malignant hyperthermiaIncreaseddeadspace:V/Qmismatch(ventilationof non-perfusedlung)PHYSICALEXAMTachypneaDyspneaRetractionsNasalflaringGruntingDiaphoresisTachycardiaHypertensionAlteredmentalstatusConfusionAgitationRestlessnessSomnolenceCyanosis(need5mg/dlofunoxygenatedblood) CXRFINDINGSCXRmaybenormalifproblemiswithupperairwayCanseehyperinflation,atelectasis,infiltrate,cardiomegalyAdditionalstudiesmaybeneeded,e.g.,chestCT,bariumswallow,echocardiogramBLOODGASForanyagepatient,breathingroomair,respiratoryfailureisdefinedasarterialpCO2>50mmHgorarterialpO2<60mmHg.Ifthepatientishyperventilating,anormalpCO2isdisturbing.Theabovedefinitionassumestheabsenceofananatomicshunt.ChronichypercarbicrespiratoryfailurewilloftenhaveanormalpHbecauseofcompensatorymetabolicalkalosis.MANAGEMENTREMEMBERPALSAirwayBreathingCirculationAIRWAYRepositioningPositionofcomfortJawthrust/chinliftOralairwayUnconsciouspatientsonlyNasaltrumpetNasalormaskCPAPBag-maskventilationUseduringpreparationforintubationTrachealintubationBREATHINGDecreaserespiratoryworkloadß-agonistsDecadronorsteroidsAntibioticsCPAPSupplementalO2NasalcannulaClosedfacemaskNon-rebreatherCounteractdrugeffectsBag-maskventilationMechanicalventilationCIRCULATIONSuppressanaerobicmetabolismandacidosisCorrectanemiatoimproveoxygendeliveryEnsureadequatecardiacoutputInotropes:oxygen,vasopressorsFluidbolusesARDSApatientmustmeetallofthefollowing:AcuteonsetofrespiratorysymptomsCXRwithbilateralinfiltratesNoevidenceofleftheartfailurePaO2/FiO2<200mmHg(regardlessofPEEP)American-EuropeanConsensusConferenceonARDS(AmJRespCritCareMed149:818,1994)Thefollowingareimplied:PreviouslynormallungsDecreasedlungcomplianceIncreasedshuntingHypoxemicrespiratoryfailureETIOLOGYARDSrepresentsabout3%ofPICUadmissions.Numerousprecipitatingevents:TraumaPneumoniaBurnsSepsisDrowningShockPATHOPHYSIOLOGYAcuteInjuryLatentPeriodEarlyExudativePhaseCellularProliferativePhaseFibroticProliferativePhaseRoyallandLevinJPeds112:169-180;335-347,1988PATHOLOGYOFARDSGreenarrowspointtohyalinemembraneBluearrowspointtotypeIIpneumocytesandalveolarmacrophagesMANAGEMENTMeticuloussupportivecareisthemainstayoftherapyPreventsecondarylunginjuryEnsureadequatecardiacoutputLimitsecondaryinfectionsDrugsGoodnutritionVENTILATORSTRATEGIES

ThehallmarkofARDSisheterogeneouslung.LimitBarotraumaKeepPIP<35cmH2OUsepressure-controlventilationUseTVof6-10cc/kgKeeprate<30bpmPermissivehypercapniaUsebicarborTHAMtokeeppH>7.20LimitO2ToxicityGiveenoughPEEPtolowerFiO2to<60%whilemaintainingO2>90%.PEEP<15cmH2Oshouldn’tdecreasecardiacoutput.Increasemeanairwaypressurewithinverseratio(I>E)ventilation.CARDIACOUTPUTKeepcardiacoutput>4.5L/min/m2.KeepO2delivery>600mlO2/min/m2.KeepHct>30%,higherifsignsofheartfailure.Useinotropestoaugmentcardiacoutput.Ensureadequatepreload.LIMITSECONDARYINFECTIONSWashyourhands.Usethegutassoonaspossiblefornutritionandmeds.Discontinueindwellingcathetersassoonaspossible.Havehighindexofsuspicion.Treatinfectionsearly,buttailorantibioticstocultureresults.DRUGSDiuretics:adrylungisagoodlung.InotropesSteroids:2mg/kg/daybegunafteraweekintothecoursemaybeofbenefit,otherwisedon’tuse.Pulmonar