RESPIRATORYFAILURE

MANAGEMENT1ppt課件RESPIRATORYCAREAmbientPressureTherapyPositivePressureTherapy2ppt課件AMBIENTPRESSURETHERAPYOxygenTherapyHumidityTherapyBronchialHygeineTherapyPharmacotherapy3ppt課件OXYGENTHERAPYOxygenDelivery=O2ContentxCardiacOutputO2Content=HbxSaO2x1.34+PaO2x0.0034ppt課件OXYGENTHERAPYAimstoimprovePaO2byincreasingFiO2EffectiveFiO2-0.24-0.50FiO2>0.50notindicated5ppt課件OXYGENTHERAPYDeliveredbyVariablePerformance/LowFlowSystemFixedPerformance/HighFlowSystem6ppt課件LOWFLOWSYSTEM7ppt課件LOWFLOWSYSTEMFiO2dependsonSizeofO2ReservoirO2FlowRateBreathingPattern8ppt課件LOWFLOWSYSTEMSimplicityPatientComfortEconomicalInaccurate/Notdependable9ppt課件PERFORMANCEO2FlowRate(L/M)FiO2Nasalcannula20.2840.3660.44OxygenMask5-60.406-70.507-80.60Maskwithbag60.6080.8010>0.8010ppt課件HIGHFLOWSYSTEM3-4timesMinuteVolumeAccurateoverarangeofMinuteVolumeFiO20.24-0.40HigherFiO2bylarge-volumenebulisers11ppt課件HIGHFLOWSYSTEM12ppt課件HUMIDITYTHERAPYAIR50%HUMIDIFIED20oC<10mg/LALVEOLI100%HUMIDIFIED37oC44mg/LNose13ppt課件HUMIDITYTHERAPYDeliveredbyHumidifiersNebulisersHMEseg.Thermovent14ppt課件HUMIDIFIERSWaterbathsSupplyheated,humidifiedair100%saturatedPreventwaterlossfromlungsCannotsupplyadditionalwater15ppt課件NEBULISERSAerosolmistsParticlesize2-5mSupply150-1500mg/LwaterUsefulforliquefyingdriedsecretionsDelivermedications16ppt課件NEBULISERSTypes:VenturiUltrasound17ppt課件18ppt課件ULTRASONICNEBULISERWaterbrokenupbyresonatorUpto6mlin1min.Particlesize~2mCancausewateroverloadMainlyusedformedication19ppt課件HMEHeatandMoistureexchangerAlsocalled‘Artificialnose’Efficiency70%↑ResistanceBacteriostatic?20ppt課件BRONCHIALHYGEINETHERAPYRetainedsecretionscancauseAtelectasisPneumoniaV/QmismatchHypoxaemia21ppt課件BRONCHIALHYGEINETHERAPYProphylactic:ChestPhysiotherapy-Posturaldrainage,Chestpercussion,CoughassistIncentiveSpirometryAerosol22ppt課件BRONCHIALHYGEINETHERAPYTherapeutic:EndotrachealsuctioningFiberopticBronchoscopyChestphysiotherapy23ppt課件ENDOTRACHEALSUCTIONHarmfuleffects:TraumaAlveolarcollapse↑VagalactivityPrecautions:PreoxygenateCathetersizeTimeObligatoryhighinflation24ppt課件FIBEROPTICBRONCHOSCOPYAfterallothermeanshavefailedIrrigationSuctionForreexpandingcollapsedsegments25ppt課件CHESTPHYSIOTHERAPYMostimportantPosturaldrainageChestPercussionandVibrationIncentiveSpirometry26ppt課件PHARMACOTHERAPYClassification:DrugscausingbronchodilatationDrugsreducingmucosaloedemaDrugsthatliquifymucus27ppt課件BROCHODILATORS2StimulantsTheophyllineAnticholinergics28ppt課件BETASTIMULANTSUsefulasAerosolorMDIBronchialsmoothmusclerelaxantSalbutamol,Metaproterenol,RacemicEpinephrineSideeffects:Tachcardia,Tremors,Hypokalaemia,Hyperglycaemia29ppt課件BETASTIMULANTS

Dosage:DrugNebulisedMDIFrequencySalbutamol2.5-5.0mg90g/puff(2puffs)4-6HrlyMetaproterenol5%0.3ml0.65mg/puff4-6HrlyRacemicEpinephrine2.25%0.5ml-Hrly30ppt課件THEOPHYLLINENotusuallyrecommendedLesseffectiveMoresideeffectsNosignificantreliefinAcutestates31ppt課件THEOPHYLLINEPhosphodiesteraseinhibitorAminophylline-Theophylline+EthylenediamineDesiredTherapeuticlevel:10mg/LToxicity:>20mg/L32ppt課件THEOPHYLLINELoadingdose:NopriorRx6mg/kgOngoingRxTD-TP/0.6Rateofinfusion<0.2mg/kg/hr33ppt課件THEOPHYLLINEContinuousRate:Standard0.5mg/kg/hrLowcardiacoutput0.2mg/kg/hrSmokers0.8mg/kg/hr34ppt課件ANTICHOLINERGICIpratropiumInhibitsvagallymediatedreflexesAdjuvanttosympathomimetics35ppt課件IPRATROPIUMBROMIDENebulised-0.5mg/DoseMDI-18g/puff(2puffs)4thhrlyCanbemixedwithstimulantsTakes20min.toactEfficacydoubtful36ppt課件CORTICOSTEROIDS↓Inflammation&OedemaofsmallairwaysNoteffectiveinAc.StatesUsefulinlaterstagesTake6-8hrs.toactAerosol/IV37ppt課件CORTICOSTEROIDSAerosolDrugNebulisedMDIBeclomethasone6hrly-42g/puff(2puffs)Dexamethasone6hrly1mg-Triamcinalonetid-100g/puff(2puffs)38ppt課件CORTICOSTEROIDSIntravenousHydrocortisone:2mg/kgStatand2mg/kg4hrlyMethylprednisolone:80-125mgStatand80mg6hrly39ppt課件MUCOKINETICTHERAPYBlandaerosolsN-acetylcysteine(NAC)40ppt課件BLANDAEROSOLSLiquifythicktenaceoussecretionsSaline-Hyper-,Hypo-orIsotonicDistilledwaterHypertonicinducescough41ppt課件N-ACETYLCYSTEINE10%and20%solutionsAerosolDirectinstillationintracheaDisagreeabletaste-nausea&vomitingIrritant-Cough&BronchospasmHypertonic-Bronchorrhoea42ppt課件POSITIVEPRESSURETHERAPYPositivepressureappliedtoairwayduringanyphaseofresp.cycleforsupportingorimprovingresp.functionAchievedbymechanicalventilatorsNeedariseswhenCardiopulmonaryreservesofthepatientareoverwhelmedorcompromisedbyapathologicalstate43ppt課件POSITIVEPRESSURETHERAPYWhentogoforPositivepressuretherapy?Apnoea/Vent.PatterninconsistentwithlifeAcuteventilatoryfailureImpendingventilatoryfailureWhenindoubt-GOAHEAD44ppt課件MODESOFVENTILATIONFullSupportControlmodeventilationAssistmodeventilationPartialSupportIMV/SIMV/MMVPressureSupportVentilationAirwayPressureReleaseVentilation45ppt課件PHYSIOLOGICALEFFECTS↑Physiologicaldeadspace↑ZoneI-V/Q>0.8↓CardiacOutput↑MeanIntrathoracicPressure-↓VenousReturn↓Sympathetictone

46ppt課件SUPPORTIVEMODESPositiveEndExpiratoryPressure(PEEP)ContinuousPositiveAirwayPressure(CPAP)ExpiratoryPositiveAirwayPressure(EPAP)47ppt課件WEANINGFROMVENTILATORWhendoesoneweanapatientfromventilator?Underlyingindication-improved?Cardiopulmonaryreserves-Adequate?Factors↑ventilatorydemand-Present?48ppt課件CRITERIAFORWEANINGVitalCapacity-10-15ml/kgTidalVolume-immediatespont.>2ml/kgRespiratoryRate-preferably<25/minTachycardia-DiscouragingBloodPressureArrhythmia-tobeevaluatedHaemoglobin-OptimisedAbsenceofconditionswhich↑VentilatoryDemand-HighMetabolicRates,acidosisetc.49ppt課件COMPLICATIONSDeviceDysfunctionAirwayComplicationsPulmonaryinfectionPulmonaryBarotrauma50ppt課件AerosoltreatmentRepeat.Repeat.20min.20min.20min.PEFR>70%40-70%25-40%<25%IVSTEROIDSIVSTEROIDSINTUBATEIVSTEROIDSADMITTOHOSPITALADMITTOICU60min.PEFRDISCHARGEREPEATAEROSOL>70%<70%51ppt課件CHRONICOBSTRUCTIVEAIRWAYDISEASEProblems:↑AirwayResistance-↑WorkofBreathingThoracicHyperinflation-↓InspiratorymuscleeffeciencyImpairedgasexchange52ppt課件CHRONICOBSTRUCTIVEAIRWAYDISEASE↓AirwayResistanceBronchodilators-2agonists,Ipratropium,?Theophylline,?CorticosteroidsBronchialHygeineTherapy-important53ppt課件CHRONICOBSTRUCTIVEAIRWAYDISEASEImproveGasExchangeOxygenTherapy-HighFlowSystemsPositivePressureTherapy-ifneededMaintainPaO250-60mmHg54ppt課件ACUTELUNGINJURYSpectrumofDisorderMild→Moderate→SevereDiagnosisNoncardiogenicOedemaARDSHypoxaemiaModerateSevere↑FiO2ResponsiveRefractoryCompliance↓↓↓WorkofBreathing↑↑↑55ppt課件ACUTERESPIRATORYDISTRESSSYNDROMEMaintainVascularVolume-CVP,PACEnsureadequateHblevelMaintainPaO2(atleast50-60mmHg)-Ventilate↓FiO2<0.5-UsePEEPAvoidalveolaroverdistension-lowVT-PIP<35cmH2O-PermissiveHypercapnia56ppt課件PER