Respiratory Failure
•
•
•
•
•
Tempo:
Goal:
Immediate Assessment & Treatment
Indications For Intubation
Non-Invasive Ventilatory Options
Therapeutic Thoracentesis
Initial Ventilator Settings
seconds…
Reflex Reaction
1 – 5 minutes..…
Emergency Assessment
20 minutes….
Additional Therapy
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” Assessment
Focused 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 Sounds
Bronchospasm
Pneumonia
Pneumothorax
Atelectasis
Pulmonary
Edema
Effusion
Fremitus
Pectoriloquy
Percussion
Extra Sounds
Focused Exam
Breath
Sounds
Bronchospasm
Pneumonia
Pneumothorax
Atelectasis
Pulmonary
Edema
Effusion
Fremitus
Pectoriloquy
Percussion
Extra Sounds
Wheezing
Focused Exam
Breath Sounds
Bronchospasm
Pneumonia
Pneumothorax
Atelectasis
Pulmonary
Edema
Effusion
Fremitus
Pectoriloquy
Percussion
Extra Sounds
Wheezing
Focused Exam
Breath Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Pneumonia
Pneumothorax
Atelectasis
Pulmonary
Edema
Effusion
Extra Sounds
Wheezing

(Bronchial)

Dull
(Crackles)
Focused Exam
Breath
Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Pneumonia
Pneumothorax
Atelectasis
Pulmonary
Edema
Effusion
Extra Sounds
Wheezing

(Bronchial)

Dull
(Crackles)
Focused Exam
Breath
Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Wheezing
Pneumonia

(Bronchial)

Dull
Pneumothorax


Hyperresonant
Atelectasis
Pulmonary
Edema
Effusion
Extra Sounds
(Crackles)
Focused Exam
Breath Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Wheezing
Pneumonia

(Bronchial)

Dull
Pneumothorax


Hyperresonant
Atelectasis
Pulmonary
Edema
Effusion
Extra Sounds
(Crackles)
Focused Exam
Breath Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Wheezing
Pneumonia

(Bronchial)

Dull
Pneumothorax


Hyperresonant
Atelectasis


Dull
Pulmonary
Edema
Effusion
Extra Sounds
(Crackles)
Focused Exam
Breath Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Wheezing
Pneumonia

(Bronchial)

Dull
Pneumothorax


Hyperresonant
Atelectasis


Dull
Pulmonary
Edema
Effusion
Extra Sounds
(Crackles)
Crackles
Focused Exam
Breath Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Wheezing
Pneumonia

(Bronchial)

Dull
Pneumothorax


Hyperresonant
Atelectasis


Dull
Pulmonary
Edema
Effusion
Extra Sounds
(Crackles)
Crackles
Focused Exam
Breath Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Wheezing
Pneumonia

(Bronchial)

Dull
Pneumothorax


Hyperresonant
Atelectasis


Dull
Pulmonary
Edema
Effusion
Extra Sounds
Crackles,
Egophony
Crackles


Dull
Egophony
Focused Exam
Breath Sounds
Fremitus
Pectoriloquy
Percussion
Bronchospasm
Wheezing
Pneumonia

(Bronchial)

Dull
Pneumothorax


Hyperresonant
Atelectasis


Dull
Pulmonary
Edema
Effusion
Extra Sounds
Crackles,
Egophony
Crackles


Dull
Egophony
Common CXR Dilemmas
• White Out
Three Major Causes:
1.
2.
3.
How to Distinguish:
• Pneumo vs Skin Fold
How 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 oneway 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 oneway 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 autoPEEP
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 autoPEEP (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