Respiratory Failure

• Immediate Assessment & Treatment• Indications For Intubation• Non-Invasive Ventilatory Options• Therapeutic Thoracentesis• Initial Ventilator Settings

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”

“The Look”

• Speech Pattern• Vital Signs• Breathing Pattern

– Accessory Muscles

– Retractions

– Thoraco-Abdominal Paradox

– Hoover’s Sign

– Pulsus Paradox

• Air Movement• Cyanosis• Patient’s Own

Assessment

Assessment and Treatment - Continued

• 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”

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm

Pneumonia

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath Sounds

Fremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull (Crackles)

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath Sounds

Fremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull (Crackles)

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath Sounds

Fremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull (Crackles)

Pneumothorax Hyper-resonant

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull (Crackles)

Pneumothorax Hyper-resonant

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull (Crackles)

Pneumothorax Hyper-resonant

Atelectasis Dull

Pulmonary Edema

Effusion

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull (Crackles)

Pneumothorax Hyper-resonant

Atelectasis Dull

Pulmonary Edema

Crackles

Effusion

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull (Crackles)

Pneumothorax Hyper-resonant

Atelectasis Dull

Pulmonary Edema

Crackles

Effusion

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull

Crackles, Egophony

Pneumothorax Hyper-resonant

Atelectasis Dull

Pulmonary Edema

Crackles

Effusion Dull Egophony

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm Wheezing

Pneumonia

(Bronchial) Dull

Crackles, Egophony

Pneumothorax Hyper-resonant

Atelectasis Dull

Pulmonary Edema

Crackles

Effusion Dull Egophony

Common CXR Dilemmas

• White OutThree Major Causes:

1.

2.

3.

How to Distinguish:

• Pneumo vs Skin FoldHow to Distinguish:

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

Oxygen Delivery Devices

• Nasal Cannula– 24-44% FIO2

– ? FIO2 per liter

Oxygen Delivery DevicesC

• Nasal Cannula– 24-44% FiO2

• Simple Face Mask– 40 –60% 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

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

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 / BiPAP

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

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

?’s