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 Goal: Stabilize the Patient within 20 minutes!

“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)

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

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”

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

Focused Exam

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

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.

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

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

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

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

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

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

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

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)

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

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

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

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

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Respiratory Failure