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Respiratory Failure

Immediate Assessment & Treatment Indications For Intubation Non-Invasive Ventilatory Options Therapeutic Thoracentesis Initial Ventilator Settings. Respiratory Failure. Tempo: seconds… Reflex Reaction 1 – 5 minutes.. … Emergency Assessment 20 minutes…. Additional Therapy

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Respiratory Failure

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  1. Immediate Assessment & Treatment Indications For Intubation Non-Invasive Ventilatory Options Therapeutic Thoracentesis Initial Ventilator Settings Respiratory Failure Tempo: seconds… Reflex Reaction 1 – 5 minutes.. … Emergency Assessment 20 minutes…. Additional Therapy Goal: Stabilize the Patient within 20 minutes!

  2. “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)

  3. “Emergency” AssessmentFocused Exam / Important Labs / Differential DOES THIS PATIENT NEED TO BE INTUBATED!!! “The Look” vs “VOPS”

  4. Speech Pattern Vital Signs Breathing Pattern Accessory Muscles Retractions Thoraco-Abdominal Paradox Hoover’s Sign Pulsus Paradox Air Movement Cyanosis Patient’s Own Assessment “The Look”

  5. 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” Assessment and Treatment - Continued

  6. Focused Exam

  7. Focused Exam

  8. Focused Exam

  9. Focused Exam

  10. Focused Exam

  11. Focused Exam

  12. Focused Exam

  13. Focused Exam

  14. Focused Exam

  15. Focused Exam

  16. Focused Exam

  17. Focused Exam

  18. White Out Three Major Causes: 1. 2. 3. How to Distinguish: Pneumo vs Skin Fold How to Distinguish: Common CXR Dilemmas

  19. 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.

  20. 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

  21. Oxygen • How Much? • Once Saturated is More Better? • ? Blunting Drive to Breath ? • Type of Delivery Device

  22. Nasal Cannula 24-44% FIO2 ? FIO2 per liter Oxygen Delivery Devices

  23. Nasal Cannula 24-44% FiO2 Simple Face Mask 40 –60% FiO2 Oxygen Delivery DevicesC

  24. 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

  25. Venturi Mask Includes a valve allowing precise FiO2 delivery (? Advantage for COPD patients) 24-40% FiO2 Oxygen Delivery Devices

  26. 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 Oxygen Delivery Devices

  27. 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)

  28. 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 CPAP / BiPAP

  29. 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

  30. 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

  31. 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

  32. ?’s

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