Respiratory Failure Immediate Assessment & Treatment Indications For Intubation Non-Invasive...
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Transcript of Respiratory Failure Immediate Assessment & Treatment Indications For Intubation Non-Invasive...
Respiratory Failure
• Immediate Assessment & Treatment• Indications For Intubation• Non-Invasive Ventilatory Options• Therapeutic Thoracentesis• Initial Ventilator Settings
Tempo: seconds… Reflex Reaction
1 – 5 minutes..… Emergency Assessment
20 minutes…. Additional Therapy
Goal: Stabilize the Patient within 20 minutes!
“Doctor…Your patient is in Respiratory Distress….?”
“Reflex” Reaction…..
• Vitals– Including pulse ox
• Oxygen…. – 50% face mask
• “Albuterol Neb”– 0.5 cc solution mixed with 2.5 cc NS (= 2.5mg)
“Emergency” AssessmentFocused Exam / Important Labs / Differential
DOES THIS PATIENT NEED TO BE INTUBATED!!!
“The Look” vs “VOPS”
“The Look”
• Speech Pattern• Vital Signs• Breathing Pattern
– Accessory Muscles
– Retractions
– Thoraco-Abdominal Paradox
– Hoover’s Sign
– Pulsus Paradox
• Air Movement• Cyanosis• Patient’s Own
Assessment
Assessment and Treatment - Continued
• Focused Physical– Wheezing vs Crackles vs
No Breath Sounds
• Pulse Oximeter/ABG• CXR
– CHF– Pneumonia– Effusions– Atelectasis– Pneumothorax– Clear
• what should you think of?
• Therapeutic Thoracentesis
• Oxygen• Bronchodilators• Adequate Nursing /
Monitoring• ? Non-Invasive
Ventilation– “CPAP” or “BiPAP”
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath Sounds
Fremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath Sounds
Fremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath Sounds
Fremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Crackles
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Crackles
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull
Crackles, Egophony
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Crackles
Effusion Dull Egophony
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull
Crackles, Egophony
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Crackles
Effusion Dull Egophony
Common CXR Dilemmas
• White OutThree Major Causes:
1.
2.
3.
How to Distinguish:
• Pneumo vs Skin FoldHow to Distinguish:
Emergency Needle Decompression
• Prepare area (i.e., Betadine). • Technique:
– 14 or 16-gauge IV catheter – Second intercostal space– Superior to the third rib– Midclavicular line– 1-2 cm from the sternal edge– hold perpendicular to the chest wall– listen for the hissing sound of air escaping– remove the needle while leaving the catheter in place.
• Prepare the patient for tube thoracostomy.
Therapeutic Thoracentesis• If effusion is large and symptoms are significant.
– Otherwise, if non-urgent, call the Pulmonary Procedure Fellow in the morning (63893)
• Technique– http://content.nejm.org/misc/videos.shtml?ssource+recentVideos
• Common Mistakes– Preparation
• Location (specific rib)• Comfort
– Angle– Volume
Oxygen
• How Much?– Once Saturated is More Better?– ? Blunting Drive to Breath ?
• Type of Delivery Device
Oxygen Delivery Devices
• Nasal Cannula– 24-44% FIO2
– ? FIO2 per liter
Oxygen Delivery DevicesC
• Nasal Cannula– 24-44% FiO2
• Simple Face Mask– 40 –60% FiO2
Oxygen Delivery Devices
• Nasal Cannula– 24-44% FiO2
• Simple Face Mask– 40 –60% FiO2
• Non-Rebreather Mask– “resevoir” with one-
way valve
– 60-100% FiO2
Oxygen Delivery Devices
• Venturi Mask– Includes a valve
allowing precise FiO2 delivery (? Advantage for COPD patients)
– 24-40% FiO2
Oxygen Delivery Devices
• Nasal Cannula– 24-44% FiO2
• Simple Face Mask– 40 –60% FiO2
• Non-Rebreather Mask– “resevoir” with one-
way valve
– 60-100% FiO2
• Venturi Mask– Includes a valve
allowing precise FiO2 delivery (? Advantage for COPD patients)
– 24-40% FiO2
Bronchodilators
• Indication– Any Wheezing– Any “Silent” Chest– ? Other
• Which One(s)?– Albuterol – 2.5 to 5 mg (0.5 to 1 cc of 0.5% sltn)– Ipratropium – 500 mcg (one vial)
CPAP / BiPAP
CPAP
• Continuous Positive Airway Pressure
• CPAP PEEP– Redistributes Edema Fluid
– Reduces Atelectasis
– Reduces WOB in COPD by Counterbalancing auto-PEEP
BiPAP
• Bilevel Positive Airway Pressure
• EPAP CPAP PEEP
• IPAP PS
– Augments TV
– Reduces Atelectasis
– Reduces WOB
BiPAP Indications
• Acute Pulmonary Edema– PEEP/CPAP redistributes the alveolar edema
• COPD Exacerbation– reduces WOB caused by auto-PEEP
• Pulmonary Infiltrates in the BMTU
• Post-Extubation Failures– reduces atelectasis…...buys time…maybe
BiPAP
• Initial Settings:– EPAP = 5 cm H2O
– IPAP = 3 cm H2O
• Titrate to Effect:– Get rid of “The Look”
EPAP to improve oxygenation and counter-balance auto-PEEP (hard to assess!)
IPAP to TV & RR
• Requires Close Nursing Supervision
Initial Vent Settings
• Initial Goal…– Get rid of “The Look”– aka “Rest” the patient
• A good place to start:– a/c, TV = 500 cc, RR = 12
– FiO2 = 100%, PEEP = 5 cm H2O
?’s