The Critically Ill PatientStuart ConquerAdvanced Physiotherapist Paediatric ICU, Surgery & MedicineSheffield Childrens Hospital

Aims of sessionRecap of essentials of assessment:Respiratory FailureAuscultationCXRFBCReview of treatment options:PositioningBreathing TechniquesSecretion clearanceAdjunctsOn call:Case StudiesAppropriate/inappropriateQuestions to ask

Assessment

DefinitionsVentilation:

Respiratory Failure:

Ventilation is the drive to get CO2 out not to get O2 in

An inability to sufficiently eliminate carbon dioxide from, or provide oxygen to the organ systems during spontaneous respiration.

Cant get oxygen in

+/-

Cant get carbon dioxide out

Respiratory FailureInability to get oxygen inHypoxaemiaCardiac:

Resp:

Inability to get carbon dioxide outHypercapnoeaCauses:

Type I Type IIPulmonary OedemaEmbolismPneumoniaAsthmaARDSFibrosisAirway obstructionChest injuryNeurological lesionsMuscle/neuromuscular junction problemsChronic lung disease

AuscultationThyroid cartilageCricoid cartilageTracheal cartilageLeft upper lobeLeft main bronchusOblique fissureBronchiolesLeft lowerlobeRight lowerlobeOblique fissureRight middlelobeHorizontal fissureRight mainbronchusRight upper lobe

AuscultationBronchialVesicularBreath sounds:NormalEqualComplete

Crackles:Inspiratory/ExpiratoryCoarse/FineAll or partWhere is it?Wheeze:Inspiratory/ExpiratoryAll or partMonophonic/PolyphonicWhere is it?

Chest X-raysBe methodicalDemographicsType of filmExposurePositionHeartLungsRibsAnything AddedAbnormal:Too whiteToo DarkToo Big/smallIn the wrong place

Left upper lobe

Left lower lobe Right upper lobe

Right middle lobe

Right lower lobe

Blood CountHbWCC:Royal Marines:

Royal Marine Commandos:

SAS:

SBS:

CRP

PlateletsUreaCreatinineAlbuminLactateSodiumPotassiumOthers at a later date if required

NeutrophilsLymphocytesMacrophagesEosinophils

Treatment

OptionsPositioningBreathing TechniquesSecretion Clearance TechniquesAdjuncts

BE METHODICAL

On callTREAT?RUN?MANUAL TECHNIQUES?COMPUTER SAYS NO!SLEEP

Case Study 1Capt. C CavemanRetired Colonel BAFICU admission with AAA repair (emergency)CV Instability post-opReduced air entry L LZsType I respiratory failureSecretion retention

Case Study 2Ms P PittstopRacing DriverCrash sustaining # Ribs and pneumothorax L Blood Stained secretionsPain++Oxygen requirement

Case Study 3Mr H K PhooeyJanitor (mild Mannered of course!)Keeps exotic birdsAtypical pneumoniaIncreased WOBSecretion Retention

Case Study 4Dame Crystal Tipps85 year old millionaire Smokes 60 park-drive/day COPDIncreased WOBThick green secretionsType II respiratory failure