美国呼吸衰竭治疗方案英文版.ppt

1、RESPIRATORY FAILUREMANAGEMENT,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,Ox

2、ygen 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

3、,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 FiO2 0.24 - 0.40 Higher

4、 FiO2 by large-volume nebulisers,HIGH FLOW SYSTEM,HUMIDITY THERAPY,AIR 50 % HUMIDIFIED 20 C 10 mg / L,ALVEOLI 100 % HUMIDIFIED 37 C 44 mg / L,Nose,HUMIDITY THERAPY,Delivered by Humidifiers Nebulisers HMEs eg. Thermovent,HUMIDIFIERS,Water baths Supply heated, humidified air 100 % saturated Prevent wa

5、ter 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. Partic

6、le 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,Prop

7、hylactic: 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 Prec

8、autions: 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,

9、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: Tac

10、hcardia, Tremors, Hypokalaemia, Hyperglycaemia,BETA STIMULANTSDosage:,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

11、 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 a

12、ct 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

13、 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 Disagreeabl

14、e 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

15、 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

16、 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 Sympathetic tone,SUPPORTIVE

17、MODES,Positive End Expiratory Pressure ( PEEP ) Continuous Positive Airway Pressure ( CPAP ) Expiratory Positive Airway Pressure ( EPAP ),WEANING FROM VENTILATOR,When does one wean a patient from ventilator? Underlying indication - improved ? Cardiopulmonary reserves - Adequate? Factors ventilatory

18、demand - Present?,CRITERIA FOR WEANING,Vital Capacity - 10 - 15 ml / kg Tidal Volume - immediate spont. 2 ml / kg Respiratory Rate - preferably 25/ min Tachycardia - Discouraging Blood Pressure Arrhythmia - to be evaluated Haemoglobin - Optimised Absence of conditions which Ventilatory Demand - High

19、 Metabolic Rates, acidosis etc.,COMPLICATIONS,Device Dysfunction AirwayComplications Pulmonary infection Pulmonary Barotrauma,Aerosol treatment,Repeat.,Repeat.,20 min.,20 min.,20 min.,PEFR,70%,40 - 70 %,25 - 40 %,25 %,IV STEROIDS,IV STEROIDS,INTUBATE IV STEROIDS,ADMIT TO HOSPITAL,ADMIT TO ICU,60 min

20、.,PEFR,DISCHARGE,REPEAT AEROSOL,70%, 70 %,CHRONIC OBSTRUCTIVE AIRWAY DISEASE,Problems: Airway Resistance - Work of Breathing Thoracic Hyperinflation - Inspiratory muscle effeciency Impaired gas exchange,CHRONIC OBSTRUCTIVE AIRWAY DISEASE,Airway Resistance Bronchodilators - 2 agonists, Ipratropium, ?

21、 Theophylline , ? Corticosteroids Bronchial Hygeine Therapy - important,CHRONIC OBSTRUCTIVE AIRWAY DISEASE,Improve Gas Exchange Oxygen Therapy - High Flow Systems Positive Pressure Therapy - if needed Maintain PaO2 50 -60 mmHg,ACUTE LUNG INJURY,ACUTE RESPIRATORY DISTRESS SYNDROME,Maintain Vascular Volume - CVP, PAC Ensure adequate Hb level Maintain PaO2 ( at least 50 - 60 mm Hg) - Ventilate FiO2 0.5 - Use PEEP Avoid alveolar over distension - low VT - PIP 35 cm H2O -Permissive Hypercapnia,PERMISSIVE HYPERCAPNIA,PaCO2 50 mmHg - if pH 7.25,