呼吸衰竭诊断指标及救治措施高建苑.pptx

第四军医大学第一附属医院第四军医大学第一附属医院惠宾病房惠宾病房 高建苑高建苑 高高高高 建建建建 苑苑苑苑 现任第四军医大学西京医院主任医师、教现任第四军医大学西京医院主任医师、教现任第四军医大学西京医院主任医师、教现任第四军医大学西京医院主任医师、教授，为中华实用医药杂志编委、中华现代影像学杂志常务授，为中华实用医药杂志编委、中华现代影像学杂志常务授，为中华实用医药杂志编委、中华现代影像学杂志常务授，为中华实用医药杂志编委、中华现代影像学杂志常务编辑、中华综合临床杂志编委会副主任委员和美国现代中编辑、中华综合临床杂志编委会副主任委员和美国现代中编辑、中华综合临床杂志编委会副主任委员和美国现代中编辑、中华综合临床杂志编委会副主任委员和美国现代中医学编委，美国医学编委，美国医学编委，美国医学编委，美国the ADA Professional Section the ADA Professional Section the ADA Professional Section the ADA Professional Section 会员，会员，会员，会员，中华内分泌学会陕西分会委员中华内分泌学会陕西分会委员中华内分泌学会陕西分会委员中华内分泌学会陕西分会委员,中华医学会陕西疗养保健中华医学会陕西疗养保健中华医学会陕西疗养保健中华医学会陕西疗养保健分会副主任委员，陕西省老年医学专业委员副会长。分会副主任委员，陕西省老年医学专业委员副会长。分会副主任委员，陕西省老年医学专业委员副会长。分会副主任委员，陕西省老年医学专业委员副会长。临床特点临床特点临床特点临床特点 ：老年顽固性心衰、严重肺部感染、高血老年顽固性心衰、严重肺部感染、高血老年顽固性心衰、严重肺部感染、高血老年顽固性心衰、严重肺部感染、高血压危象、糖尿病高渗性昏迷等有比较丰富的经验压危象、糖尿病高渗性昏迷等有比较丰富的经验压危象、糖尿病高渗性昏迷等有比较丰富的经验压危象、糖尿病高渗性昏迷等有比较丰富的经验。糖尿病。糖尿病。糖尿病。糖尿病患者快速强化治疗，高血压、糖尿病、冠心病、高脂血症、患者快速强化治疗，高血压、糖尿病、冠心病、高脂血症、患者快速强化治疗，高血压、糖尿病、冠心病、高脂血症、患者快速强化治疗，高血压、糖尿病、冠心病、高脂血症、痛风等生活方式干预治疗，协助心脏内科（痛风等生活方式干预治疗，协助心脏内科（痛风等生活方式干预治疗，协助心脏内科（痛风等生活方式干预治疗，协助心脏内科（PTCAPTCAPTCAPTCA、RFCARFCARFCARFCA）。）。）。）。临床研究方向：老年和特殊人群糖尿病防治。曾参加过新临床研究方向：老年和特殊人群糖尿病防治。曾参加过新临床研究方向：老年和特殊人群糖尿病防治。曾参加过新临床研究方向：老年和特殊人群糖尿病防治。曾参加过新加坡和墨西哥总统的保健工作。加坡和墨西哥总统的保健工作。加坡和墨西哥总统的保健工作。加坡和墨西哥总统的保健工作。接待外国患者就诊和住接待外国患者就诊和住接待外国患者就诊和住接待外国患者就诊和住院治疗。能进行院治疗。能进行院治疗。能进行院治疗。能进行英语单语教学和担任国际会议专业英语的英语单语教学和担任国际会议专业英语的英语单语教学和担任国际会议专业英语的英语单语教学和担任国际会议专业英语的现场翻译现场翻译现场翻译现场翻译，善于演讲专业知识。，善于演讲专业知识。，善于演讲专业知识。，善于演讲专业知识。第一作发表第一作发表第一作发表第一作发表SCISCISCISCI文章二篇文章二篇文章二篇文章二篇 ，最高影响因子，最高影响因子，最高影响因子，最高影响因子5.3875.3875.3875.387；核心和；核心和；核心和；核心和源期刊上者论文源期刊上者论文源期刊上者论文源期刊上者论文60606060多篇。多篇。多篇。多篇。主编临床专著：主编临床专著：主编临床专著：主编临床专著：临床常见内科疾病的点评临床常见内科疾病的点评临床常见内科疾病的点评临床常见内科疾病的点评 Clinical Practice in DiabetesClinical Practice in DiabetesClinical Practice in DiabetesClinical Practice in Diabetes 现代临床糖尿病学现代临床糖尿病学现代临床糖尿病学现代临床糖尿病学 副主编副主编副主编副主编实用临床急危重症诊断与处理实用临床急危重症诊断与处理实用临床急危重症诊断与处理实用临床急危重症诊断与处理，临床呼吸内临床呼吸内临床呼吸内临床呼吸内科学科学科学科学，现代内分泌疾病诊疗学现代内分泌疾病诊疗学现代内分泌疾病诊疗学现代内分泌疾病诊疗学，实用临床急危重实用临床急危重实用临床急危重实用临床急危重症诊断与处理症诊断与处理症诊断与处理症诊断与处理，现代临床内科学现代临床内科学现代临床内科学现代临床内科学。主持糖尿病的治疗研究省部级基金主持糖尿病的治疗研究省部级基金主持糖尿病的治疗研究省部级基金主持糖尿病的治疗研究省部级基金5 5 5 5项，主编的项，主编的项，主编的项，主编的Clinical Practice in DiabetesClinical Practice in DiabetesClinical Practice in DiabetesClinical Practice in Diabetes获获获获2009200920092009年度中国西年度中国西年度中国西年度中国西部科技图书一等奖。部科技图书一等奖。部科技图书一等奖。部科技图书一等奖。Respiratory Failure 2 TypesHypoxemic Respiratory FailureHypercapnic Respiratory FailureHypoxemic Respiratory FailurePaO2 50 mmHg in an otherwise healthy individualAKA“Ventilatory Failure”Caused by increased WOB,ventilatory drive,or muscle fatigueorofacial masks Nasal masks full face masks Nasal PillowsTotal face mask Helmet mask.Company LogoPrinciples of Mechanical VentilationDavid M.Lieberman,MDAllen S.Ho,MDSurgery ICU ServiceStanford University Medical CenterSeptember 25,2006The BasicsCompany LogoOrigins of mechanical ventilationNegative-pressure ventilators(“iron lungs”)Non-invasive ventilation first used in Boston Childrens Hospital in 1928Used extensively during polio outbreaks in 1940s 1950sPositive-pressure ventilatorsInvasive ventilation first used at Massachusetts General Hospital in 1955Now the modern standard of mechanical ventilationThe era of intensive care medicine began with positive-pressure ventilationThe iron lung created negative pressure in abdomen as well as the chest,decreasing cardiac output.Iron lung polio ward at Rancho Los Amigos Hospital in 1953.Company LogoOutlineTheoryVentilation vs.OxygenationPressure Cycling vs.Volume CyclingModesVentilator SettingsIndications to intubateIndications to extubateManagement algorithimFAQsCompany LogoPrinciples(1):VentilationThe goal of ventilation is to facilitate CO2 release and maintain normal PaCO2Minute ventilation(VE)Total amount of gas exhaled/min.VE=(RR)x(TV)VE comprised of 2 factorsVA=alveolar ventilationVD=dead space ventilationVD/VT=0.33VE regulated by brain stem,responding to pH and PaCO2Ventilation in context of ICUIncreased CO2 productionfever,sepsis,injury,overfeedingIncreased VDatelectasis,lung injury,ARDS,pulmonary embolismAdjustments:RR and TVV/Q Matching.Zone 1 demonstrates dead-space ventilation(ventilation without perfusion).Zone 2 demonstrates normal perfusion.Zone 3 demonstrates shunting(perfusion without ventilation).Company LogoPrinciples(2):OxygenationThe primary goal of oxygenation is to maximize O2 delivery to blood(PaO2)Alveolar-arterial O2 gradient(PAO2 PaO2)Equilibrium between oxygen in blood and oxygen in alveoliA-a gradient measures efficiency of oxygenationPaO2 partially depends on ventilation but more on V/Q matchingOxygenation in context of ICUV/Q mismatchingPatient position(supine)Airway pressure,pulmonary parenchymal disease,small-airway diseaseAdjustments:FiO2 and PEEPV/Q Matching.Zone 1 demonstrates dead-space ventilation(ventilation without perfusion).Zone 2 demonstrates normal perfusion.Zone 3 demonstrates shunting(perfusion without ventilation).Company LogoPressure ventilation vs.volume ventilationPressure-cycled modes deliver a fixed pressure at variable volume(neonates)Volume-cycled modes deliver a fixed volume at variable pressure(adults)Pressure-cycled modesPressure Support Ventilation(PSV)Pressure Control Ventilation(PCV)CPAPBiPAPVolume-cycled modesControlAssistAssist/ControlIntermittent Mandatory Ventilation(IMV)Synchronous Intermittent Mandatory Ventilation(SIMV)Volume-cycled modes have the inherent risk of volutrauma.Company LogoPressure Support Ventilation(PSV)Patient determines RR,VE,inspiratory time a purely spontaneous modeParametersTriggered by pts own breathLimited by pressureAffects inspiration onlyUsesComplement volume-cycled modes(i.e.,SIMV)Does not augment TV but overcomes resistance created by ventilator tubingPSV aloneUsed alone for recovering intubated pts who are not quite ready for extubationAugments inflation volumes during spontaneous breaths BiPAP(CPAP plus PS)PSV is most often used together with other volume-cycled modes.PSV provides sufficient pressure to overcome the resistance of the ventilator tubing,and acts during inspiration only.Company LogoPressure Control Ventilation(PCV)Ventilator determines inspiratory time no patient participationParametersTriggered by timeLimited by pressureAffects inspiration onlyDisadvantagesRequires frequent adjustments to maintain adequate VEPt with noncompliant lungs may require alterations in inspiratory times to achieve adequate TVCompany LogoCPAP and BiPAPCPAP is essentially constant PEEP;BiPAP is CPAP plus PSParametersCPAP PEEP set at 5-10 cm H2OBiPAP CPAP with Pressure Support(5-20 cm H2O)Shown to reduce need for intubation and mortality in COPD ptsIndicationsWhen medical therapy fails(tachypnea,hypoxemia,respiratory acidosis)Use in conjunction with bronchodilators,steroids,oral/parenteral steroids,antibiotics to prevent/delay intubationWeaning protocolsObstructive Sleep ApneaCompany LogoAssist/Control ModeControl ModePt receives a set number of breaths and cannot breathe between ventilator breathsSimilar to Pressure ControlAssist ModePt initiates all breaths,but ventilator cycles in at initiation to give a preset tidal volumePt controls rate but always receives a full machine breathAssist/Control ModeAssist mode unless pts respiratory rate falls below preset valueVentilator then switches to control modeRapidly breathing pts can overventilate and induce severe respiratory alkalosis and hyperinflation(auto-PEEP)Ventilator delivers a fixed volumeCompany LogoIMV and SIMVIMV and SIMV Volume-cycled modes typically augmented with Pressure SupportIMVPt receives a set number of ventilator breathsDifferent from Control:pt can initiate own(spontaneous)breathsDifferent from Assist:spontaneous breaths are not supported by machine with fixed TVVentilator always delivers breath,even if pt exhalingSIMVMost commonly used modeSpontaneous breaths and mandatory breathsIf pt has respiratory drive,the mandatory breaths are synchronized with the pts inspiratory effortCompany LogoVent settings to improve FIO2Simplest maneuver to quickly increase PaO2Long-term toxicity at 60%Free radical damageInadequate oxygenation despite 100%FiO2 usually due to pulmonary shuntingCollapse AtelectasisPus-filled alveoli PneumoniaWater/Protein ARDSWater CHFBlood-HemorrhagePEEP and FiO2 are adjusted in tandemCompany LogoVent settings to improve PEEP Increases FRCPrevents progressive atelectasis and intrapulmonary shuntingPrevents repetitive opening/closing(injury)Recruits collapsed alveoli and improves V/Q matchingResolves intrapulmonary shuntingImproves complianceEnables maintenance of adequate PaO2 at a safe FiO2 levelDisadvantagesIncreases intrathoracic pressure(may require pulmonary a.catheter)May lead to ARDSRupture:PTX,pulmonary edemaPEEP and FiO2 are adjusted in tandemOxygen delivery(DO2),not PaO2,should be used to assess optimal PEEP.Company LogoVent settings to improve Respiratory rateMax RR at 35 breaths/min Efficiency of ventilation decreases with increasing RRDecreased time for alveolar emptyingTVGoal of 10 ml/kgRisk of volutraumaOther means to decrease PaCO2Reduce muscular activity/seizuresMinimizing exogenous carb loadControlling hypermetabolic statesPermissive hypercapneaPreferable to dangerously high RR and TV,as long as pH 7.15RR and TV are adjusted to maintain VE and PaCO2I:E ratio(IRV)Increasing inspiration time will increase TV,but may lead to auto-PEEPPIPElevated PIP suggests need for switch from volume-cycled to pressure-cycled modeMaintained at 45cm H2O to minimize barotraumaPlateau pressuresPressure measured at the end of inspiratory phaseMaintained at 35Hypoxia:pO2 55mm HgMinute ventilation10 L/minTidal volume 5-10 ml/kgNegative inspiratory force 25cm H2O(how strong the pt can suck in)Initial vent settingsFiO2=50%PEEP=5cm H2ORR=12 15 breaths/minVT=10 12 ml/kgCOPD=10 ml/kg(prevent overinflation)ARDS=8 ml/kg(prevent volutrauma)Permissive hypercapneaPressure Support=10cm H2OHow the values trend should significantly impact clinical decisionsCompany LogoIndications for extubationClinical parametersResolution/Stabilization of disease processHemodynamically stableIntact cough/gag reflexSpontaneous respirationsAcceptable vent settingsFiO2 50%,PEEP 75,pH 7.25General approachesSIMV WeaningPressure Support Ventilation(PSV)WeaningSpontaneous breathing trialsDemonstrated to be superiorNo weaning parameter completely accurate when used aloneNumerical ParametersNormal RangeWeaning ThresholdP/F 400 200Tidal volume5-7 ml/kg5 ml/kgRespiratory rate14-18 breaths/min 40 breaths/minVital capacity65-75 ml/kg10 ml/kgMinute volume5-7 L/min-90 cm H2O-25 cm H2ORSBI(Rapid Shallow Breathing Index)(RR/TV)50 100 Marino P,The ICU Book(2/e).1998.Company LogoSpontaneous Breathing TrialsSettingsPEEP=5,PS=0 5,FiO2 35 for 5 minSaO2 30 secHR 140Systolic BP 180 or 90mm HgSustained increased work of breathingCardiac dysrhythmiapH 7.32SBTs do not guarantee that airway is stable or pt can self-clear secretionsCauses of Failed SBTsTreatmentsAnxiety/AgitationBenzodiazepines or haldolInfectionDiagnosis and txElectrolyte abnormalities (K+,PO4-)CorrectionPulmonary edema,cardiac ischemiaDiuretics and nitratesDeconditioning,malnutritionAggressive nutritionNeuromuscular diseaseBronchopulmonary hygiene,early consideration of trachIncreased intra-abdominal pressureSemirecumbent positioning,NGTHypothyroidismThyroid replacementExcessive auto-PEEP(COPD,asthma)Bronchodilator therapySena et al,ACS Surgery:Principles and Practice(2005).Company LogoContinued ventilation after successful SBTCommonly cited factorsAltered mental status and inability to protect airwayPotentially difficult reintubationUnstable injury to cervical spineLikelihood of return trips to ORNeed for frequent suctioningInherent risks of intubation balanced against continued need for intubationCompany LogoNeed for tracheostomyAdvantagesIssue of airway stability can be separated from issue of readiness for extubationMay quicken decision to extubateDecreased work of breathingAvoid continued vocal cord injuryImproved bronchopulmonary hygieneImproved pt communicationDisadvantagesLong term risk of tracheal stenosisProcedure-related complication rate(4%-36%)Prolonged intubation may injure airway and cause airway edema1-Vocal cords.2-Thyroid cartilage.3-Cricoid cartilage.4-Tracheal cartilage.5-Balloon cuff.Company LogoVentilator management algorithimInitial intubation FiO2=50%PEEP=5 RR=12 15 VT=8 10 ml/kgSaO2 90%SaO2 90%Adjust RR to maintain PaCO2=40Reduce FiO2 50%as toleratedReduce PEEP 8 as toleratedAssess criteria for SBT dailySaO2 90%)Increase PEEP to max 20Identify possible acute lung injuryIdentify respiratory failure causesAcute lung injuryNo injuryFail SBTAcute lung injuryLow TV(lung-protective)settingsReduce TV to 6 ml/kgIncrease RR up to 35 to keep pH 7.2,PaCO2 50Adjust PEEP to keep FiO2 60%SaO2 90%SaO2 90%Continue lung-protective ventilation until:PaO2/FiO2 300Criteria met for SBTPersistently fail SBTConsider tracheostomyResume daily SBTs with CPAP or tracheostomy collarPass SBTAirway stableExtubateIntubated 2 wksConsider PSV wean(gradual reduction of pressure support)Consider gradual increases in SBT duration until endurance improvesProlonged ventilator dependencePass SBTPass SBTAirway stableModified from Sena et al,ACS Surgery:Principles and Practice(2005).Mechanical Ventilation for NursingMelissa Dearing,BS,RRT-NPS,RCPAssociate Professor of Respiratory CareCurtis Shelley,BS,RRT-NPS,RCPRespiratory Educator Hermann Childrens Hospital Indications for Mechanical Ventilation Airway Compromise airway patency is in doubt or patient may be at risk of losing patencyIndications for Mechanical VentilationNeed to Protect the AirwayFor some reason the patients ability to sneeze,gag or cough has been dulled and aspiration is possible.Contraindications for an Artificial AirwayWhen a pts desire to not be resuscitated has been expressed and is documented in the pts chartEstablishing an Artificial Airway Adult female 8.0 Adult male 9.0Miller vs.MacIntosh Blades Intubation ProcedureCheck and Assemble Equipment:Oxygen flowmeter and O2 tubingSuction apparatus and tubingSuction catheter or yankauerAmbu bag and maskLaryngoscope with assorted blades3 sizes of ET tubesStyletStethoscopeTapeSyringeMagill forcepsTowels for positioning Intubation ProcedurePosition your patient into the sniffing position Intubation ProcedurePreoxygenate with 100%oxygen to provide apneic or distressed patient with reserve while attempting to intubate.Do not allow more than 30 seconds to any intubation attempt.If intubation is unsuccessful,ventilate with 100%oxygen for 3-5 minutes before a reattempt.Intubation Procedure Insert Laryngoscope Intubation Procedure Intubation Procedure After displacing the epiglottis insert the ETT.The depth of the tube for a male patient on average is 21-23 cm at teethThe depth of the tube on average for a female patient is 19-21 at teeth.Intubation Procedure Confirm tube position:By auscultation of the chestBilateral chest riseTube location at teethCO2 detector (esophageal detection device)Intub