美國呼吸衰竭治療方案英文第1頁/共64頁RESPIRATORYFAILURE

MANAGEMENT第2頁/共64頁RESPIRATORYCAREAmbientPressureTherapyPositivePressureTherapy第3頁/共64頁AMBIENTPRESSURETHERAPYOxygenTherapyHumidityTherapyBronchialHygeineTherapyPharmacotherapy第4頁/共64頁OXYGENTHERAPYOxygenDelivery=O2ContentxCardiacOutputO2Content=HbxSaO2x1.34+PaO2x0.003第5頁/共64頁OXYGENTHERAPYAimstoimprovePaO2byincreasingFiO2EffectiveFiO2-0.24-0.50FiO2>0.50notindicated第6頁/共64頁OXYGENTHERAPYDeliveredbyVariablePerformance/LowFlowSystemFixedPerformance/HighFlowSystem第7頁/共64頁LOWFLOWSYSTEM第8頁/共64頁LOWFLOWSYSTEMFiO2dependsonSizeofO2ReservoirO2FlowRateBreathingPattern第9頁/共64頁LOWFLOWSYSTEMSimplicityPatientComfortEconomicalInaccurate/Notdependable第10頁/共64頁PERFORMANCEO2FlowRate(L/M)FiO2Nasalcannula20.2840.3660.44OxygenMask5-60.406-70.507-80.60Maskwithbag60.6080.8010>0.80第11頁/共64頁HIGHFLOWSYSTEM3-4timesMinuteVolumeAccurateoverarangeofMinuteVolumeFiO20.24-0.40HigherFiO2bylarge-volumenebulisers第12頁/共64頁HIGHFLOWSYSTEM第13頁/共64頁HUMIDITYTHERAPYAIR50%HUMIDIFIED20oC<10mg/LALVEOLI100%HUMIDIFIED37oC44mg/LNose第14頁/共64頁HUMIDITYTHERAPYDeliveredbyHumidifiersNebulisersHMEseg.Thermovent第15頁/共64頁HUMIDIFIERSWaterbathsSupplyheated,humidifiedair100%saturatedPreventwaterlossfromlungsCannotsupplyadditionalwater第16頁/共64頁NEBULISERSAerosolmistsParticlesize2-5mSupply150-1500mg/LwaterUsefulforliquefyingdriedsecretionsDelivermedications第17頁/共64頁NEBULISERSTypes:VenturiUltrasound第18頁/共64頁第19頁/共64頁ULTRASONICNEBULISERWaterbrokenupbyresonatorUpto6mlin1min.Particlesize~2mCancausewateroverloadMainlyusedformedication第20頁/共64頁HMEHeatandMoistureexchangerAlsocalled‘Artificialnose’Efficiency70%↑ResistanceBacteriostatic?第21頁/共64頁BRONCHIALHYGEINETHERAPYRetainedsecretionscancauseAtelectasisPneumoniaV/QmismatchHypoxaemia第22頁/共64頁BRONCHIALHYGEINETHERAPYProphylactic:ChestPhysiotherapy-Posturaldrainage,Chestpercussion,CoughassistIncentiveSpirometryAerosol第23頁/共64頁BRONCHIALHYGEINETHERAPYTherapeutic:EndotrachealsuctioningFiberopticBronchoscopyChestphysiotherapy第24頁/共64頁ENDOTRACHEALSUCTIONHarmfuleffects:TraumaAlveolarcollapse↑VagalactivityPrecautions:PreoxygenateCathetersizeTimeObligatoryhighinflation第25頁/共64頁FIBEROPTICBRONCHOSCOPYAfterallothermeanshavefailedIrrigationSuctionForreexpandingcollapsedsegments第26頁/共64頁CHESTPHYSIOTHERAPYMostimportantPosturaldrainageChestPercussionandVibrationIncentiveSpirometry第27頁/共64頁PHARMACOTHERAPYClassification:DrugscausingbronchodilatationDrugsreducingmucosaloedemaDrugsthatliquifymucus第28頁/共64頁BROCHODILATORS2StimulantsTheophyllineAnticholinergics第29頁/共64頁BETASTIMULANTSUsefulasAerosolorMDIBronchialsmoothmusclerelaxantSalbutamol,Metaproterenol,RacemicEpinephrineSideeffects:Tachcardia,Tremors,Hypokalaemia,Hyperglycaemia第30頁/共64頁BETASTIMULANTS

Dosage:DrugNebulisedMDIFrequencySalbutamol2.5-5.0mg90g/puff(2puffs)4-6HrlyMetaproterenol5%0.3ml0.65mg/puff4-6HrlyRacemicEpinephrine2.25%0.5ml-Hrly第31頁/共64頁THEOPHYLLINENotusuallyrecommendedLesseffectiveMoresideeffectsNosignificantreliefinAcutestates第32頁/共64頁THEOPHYLLINEPhosphodiesteraseinhibitorAminophylline-Theophylline+EthylenediamineDesiredTherapeuticlevel:10mg/LToxicity:>20mg/L第33頁/共64頁THEOPHYLLINELoadingdose:NopriorRx6mg/kgOngoingRxTD-TP/0.6Rateofinfusion<0.2mg/kg/hr第34頁/共64頁THEOPHYLLINEContinuousRate:Standard0.5mg/kg/hrLowcardiacoutput0.2mg/kg/hrSmokers0.8mg/kg/hr第35頁/共64頁ANTICHOLINERGICIpratropiumInhibitsvagallymediatedreflexesAdjuvanttosympathomimetics第36頁/共64頁IPRATROPIUMBROMIDENebulised-0.5mg/DoseMDI-18g/puff(2puffs)4thhrlyCanbemixedwithstimulantsTakes20min.toactEfficacydoubtful第37頁/共64頁CORTICOSTEROIDS↓Inflammation&OedemaofsmallairwaysNoteffectiveinAc.StatesUsefulinlaterstagesTake6-8hrs.toactAerosol/IV第38頁/共64頁CORTICOSTEROIDSAerosolDrugNebulisedMDIBeclomethasone6hrly-42g/puff(2puffs)Dexamethasone6hrly1mg-Triamcinalonetid-100g/puff(2puffs)第39頁/共64頁CORTICOSTEROIDSIntravenousHydrocortisone:2mg/kgStatand2mg/kg4hrlyMethylprednisolone:80-125mgStatand80mg6hrly第40頁/共64頁MUCOKINETICTHERAPYBlandaerosolsN-acetylcysteine(NAC)第41頁/共64頁BLANDAEROSOLSLiquifythicktenaceoussecretionsSaline-Hyper-,Hypo-orIsotonicDistilledwaterHypertonicinducescough第42頁/共64頁

N-ACETYLCYSTEINE10%and20%solutionsAerosolDirectinstillationintracheaDisagreeabletaste-nausea&vomitingIrritant-Cough&BronchospasmHypertonic-Bronchorrhoea第43頁/共64頁POSITIVEPRESSURETHERAPYPositivepressureappliedtoairwayduringanyphaseofresp.cycleforsupportingorimprovingresp.functionAchievedbymechanicalventilatorsNeedariseswhenCardiopulmonaryreservesofthepatientareoverwhelmedorcompromisedbyapathologicalstate第44頁/共64頁POSITIVEPRESSURETHERAPYWhentogoforPositivepressuretherapy?Apnoea/Vent.PatterninconsistentwithlifeAcuteventilatoryfailureImpendingventilatoryfailureWhenindoubt-GOAHEAD第45頁/共64頁MODESOFVENTILATIONFullSupportControlmodeventilationAssistmodeventilationPartialSupportIMV/SIMV/MMVPressureSupportVentilationAirwayPressureReleaseVentilation第46頁/共64頁PHYSIOLOGICALEFFECTS↑Physiologicaldeadspace↑ZoneI-V/Q>0.8↓CardiacOutput↑MeanIntrathoracicPressure-↓VenousReturn↓Sympathetictone

第47頁/共64頁SUPPORTIVEMODESPositiveEndExpiratoryPressure(PEEP)ContinuousPositiveAirwayPressure(CPAP)ExpiratoryPositiveAirwayPressure(EPAP)第48頁/共64頁WEANINGFROMVENTILATORWhendoesoneweanapatientfromventilator?Underlyingindication-improved?Cardiopulmonaryreserves-Adequate?Factors↑ventilatorydemand-Present?第49頁/共64頁CRITERIAFORWEANINGVitalCapacity-10-15ml/kgTidalVolume-immediatespont.>2ml/kgRespiratoryRate-preferably<25/minTachycardia-DiscouragingBloodPressureArrhythmia-tobeevaluatedHaemoglobin-OptimisedAbsenceofconditionswhich↑VentilatoryDemand-HighMetabolicRates,acidosisetc.第50頁/共64頁COMPLICATIONSDeviceDysfunctionAirwayComplicationsPulmonaryinfectionPulmonaryBarotrauma第51頁/共64頁AerosoltreatmentRepeat.Repeat.20min.20min.20min.PEFR>70%40-70%25-40%<25%IVSTEROIDSIVSTEROIDSINTUBATEIVSTEROIDSADMITTOHOSPITALADMITTOICU60min.PEFRDISCHARGEREPEATAEROSOL>70%<70%第52頁/共64頁CHRONICOBSTRUCTIVEAIRWAYDISEASEProblems:↑AirwayResistance-↑WorkofBreathingThoracicHyperinflation-↓InspiratorymuscleeffeciencyImpairedgasexchange第53頁/共64頁CHRONICOBSTRUCTIVEAIRWAYDISEASE↓AirwayResistanceBronchodilators-2agonists,Ipratropium,?Theophylline,?CorticosteroidsBronchialHygeineTherapy-important第54頁/共64頁CHRONICOBSTRUCTIVEAIRWAYDISEASEImproveGasExchangeOxygenTherapy-HighFlowSystemsPositivePressureTherapy-ifneededMaintainPaO250-60mmHg第55頁/共64頁ACUTELUNGINJURYSpectrumofDisorderMild→Moderate→SevereDiagnosisNoncardiogenicOedemaARDSHypoxaemiaModerateSevere↑FiO2ResponsiveRefractoryCompliance↓↓↓WorkofBreathing↑↑↑第56頁/共64頁ACUTERESPIRATORYDISTRESSSYNDROMEMaintainVascularVolume-CVP,PACEnsureadequateHblevelMaintainPaO2(atleast50-60mmHg)-Ventilate↓FiO2<0.5-UsePEEPAvoidalveolaroverdistension-lowVT-PIP<35cmH2O-PermissiveHypercapnia第57頁/共64頁