Respiratory Talk

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Information about Respiratory Talk

Published on January 13, 2009

Author: guestf41297

Source: slideshare.net

Description

Slideshow from Debbie O's Supplemental Learning Session on January 10th.

Essentials of Respiratory Care Paul Barraza RRT, RCP Education Coordinator, Santa Clara Valley Medical Center Adjunct Faculty, Department of Biological Sciences, Foothill College

Contents Anatomy and Physiology of the Respiratory System Function of Respiratory System Upper vs. Lower Airway Cellular Properties of the Alveolus Ventilation / Respiration Diffusion / Perfusion Basics of Acid-Base Imbalances Arterial Blood Gas Interpretation

Anatomy and Physiology of the Respiratory System

Function of Respiratory System

Upper vs. Lower Airway

Cellular Properties of the Alveolus

Ventilation / Respiration

Diffusion / Perfusion

Basics of Acid-Base Imbalances

Arterial Blood Gas Interpretation

Contents Mechanical Ventilation Indications Goals Monitoring Basics of ventilation Sedatives, Analgesics, and Paralytics Disease Specific Management Pneumonia Pulmonary Embolus Chest Trauma ARDS

Mechanical Ventilation

Indications

Goals

Monitoring

Basics of ventilation

Sedatives, Analgesics, and Paralytics

Disease Specific Management

Pneumonia

Pulmonary Embolus

Chest Trauma

ARDS

Anatomy and Physiology

Function Primary function of the respiratory system is the continuous absorption of O 2 and the excretion of CO 2 External Respiration The exchange of gas from the atmosphere and the blood Internal Respiration The exchange of gases between blood and the tissues

Primary function of the respiratory system is the continuous absorption of O 2 and the excretion of CO 2

External Respiration

The exchange of gas from the atmosphere and the blood

Internal Respiration

The exchange of gases between blood and the tissues

Upper vs. Lower Respiratory Tract Upper Respiratory Tract All structures starting at the mouth or nose and extending down to the trachea Nose Vestibule (hairs act as gross filter) Concha (turbinates increase surface area of nose to aid in filtration and humidification) Oral Cavity Soft palate and uvula (control flow of air, fluid and food during eating, drinking, sneezing and coughing)

Upper Respiratory Tract

All structures starting at the mouth or nose and extending down to the trachea

Nose

Vestibule (hairs act as gross filter)

Concha (turbinates increase surface area of nose to aid in filtration and humidification)

Oral Cavity

Soft palate and uvula (control flow of air, fluid and food during eating, drinking, sneezing and coughing)

Upper Respiratory Tract Cont. Pharynx Subdivided into: Nasopharynx Oropharynx Hypopharynx Larynopharynx Primary function is to aid in filtration and in speech Upper vs. Lower Respiratory Tract

Upper Respiratory Tract Cont.

Pharynx

Subdivided into:

Nasopharynx

Oropharynx

Hypopharynx

Larynopharynx

Primary function is to aid in filtration and in speech

Upper Respiratory Tract Cont. Larynx Formed by cartilage and muscle Thyroid Cricoid Epiglottis Vocal Cords Primary function Protect the respiratory tract during eating and drinking Phonation Upper vs. Lower Respiratory Tract

Upper Respiratory Tract Cont.

Larynx

Formed by cartilage and muscle

Thyroid

Cricoid

Epiglottis

Vocal Cords

Primary function

Protect the respiratory tract during eating and drinking

Phonation

Lower Respiratory Tract Conducting Airways Trachea Right & Left Main Bronchi Lobar Segmental Subsegmental Bronchi Terminal bronchi Bronchioles (No cartilage) Terminal Bronchioles (No cartilage) Primary Function Airway conduction Upper vs. Lower Respiratory Tract

Lower Respiratory Tract

Conducting Airways

Trachea

Right & Left Main Bronchi

Lobar

Segmental

Subsegmental

Bronchi

Terminal bronchi

Bronchioles (No cartilage)

Terminal Bronchioles (No cartilage)

Primary Function

Airway conduction

Lower Respiratory Tract Respiratory Airways Respiratory Bronchioles Terminal Respiratory Bronchioles Alveolar Ducts/Sacs Alveoli Primary Function Gas exchange Upper vs. Lower Respiratory Tract

Lower Respiratory Tract

Respiratory Airways

Respiratory Bronchioles

Terminal Respiratory Bronchioles

Alveolar Ducts/Sacs

Alveoli

Primary Function

Gas exchange

Estimates range from 270 to 790 million Average 480 million Number increase with height of subject Average 0.2mm in diameter when at FRC Larger in apecies than in bases due to organ weight Alveoli

Estimates range from 270 to 790 million

Average 480 million

Number increase with height of subject

Average 0.2mm in diameter when at FRC

Larger in apecies than in bases due to organ weight

Type I pneumocytes (extremely flat squamous epithelia) Covers 93% of alveolar surface Create patchwork like surface over the alveolar capillaries forming the gas exchange surface of the alveolus Type II pneumocytes (cuboidal epithelia) Cover 7% of the alveolar surface Manufacture surfactant and secretes it onto the alveolar surface Alveoli

Type I pneumocytes (extremely flat squamous epithelia)

Covers 93% of alveolar surface

Create patchwork like surface over the alveolar capillaries forming the gas exchange surface of the alveolus

Type II pneumocytes (cuboidal epithelia)

Cover 7% of the alveolar surface

Manufacture surfactant and secretes it onto the alveolar surface

Macrophages Defensive cell that patrol alveolar region and phagocytize foreign particles and cells (bacteria) Canals of Lambert Small openings that connect the alveoli to the respiratory bronchioles Pores of Kohn Small openings in the alveolar septa that allow gas to flow from one alveolus to another Alveoli

Macrophages

Defensive cell that patrol alveolar region and phagocytize foreign particles and cells (bacteria)

Canals of Lambert

Small openings that connect the alveoli to the respiratory bronchioles

Pores of Kohn

Small openings in the alveolar septa that allow gas to flow from one alveolus to another

Alveolar Capillary Membrane Surfactant Layer (outermost layer) Type I cell Interstitial Space Basement membranes Matrix material connective tissue fibers Alveolar capillary Plasma Erythrocytes

Surfactant Layer (outermost layer)

Type I cell

Interstitial Space

Basement membranes

Matrix material connective tissue fibers

Alveolar capillary

Plasma

Erythrocytes

Alveolar Capillary Membrane

Ventilation vs. Respiration Ventilation The process of moving gas into and out of the lungs Respiration The process of getting oxygen into the body for tissue utilization and removal of carbon dioxide into the atmosphere

Ventilation

The process of moving gas into and out of the lungs

Respiration

The process of getting oxygen into the body for tissue utilization and removal of carbon dioxide into the atmosphere

Diffusion/Perfusion The process whereby molecules move from areas of high concentration to areas of low concentration Driven by kinetic energy Gases have high kinetic energy Lighter gases diffuse more rapidly than heavy gases Increasing kinetic energy will increase diffusion Heat Mechanical agitation

The process whereby molecules move from areas of high concentration to areas of low concentration

Driven by kinetic energy

Gases have high kinetic energy

Lighter gases diffuse more rapidly than heavy gases

Increasing kinetic energy will increase diffusion

Heat

Mechanical agitation

Diffusion/Perfusion O 2 & CO 2 move between the lungs and the tissue via diffusion Oxygen PO 2 ~ 159mmHg in atmosphere PO 2 ~ 40mmHg in capillaries Carbon Dioxide PCO 2 ~ 60mmHg in the cells PCO 2 ~ 1mmHg in room air

O 2 & CO 2 move between the lungs and the tissue via diffusion

Oxygen

PO 2 ~ 159mmHg in atmosphere

PO 2 ~ 40mmHg in capillaries

Carbon Dioxide

PCO 2 ~ 60mmHg in the cells

PCO 2 ~ 1mmHg in room air

Barriers to Diffusion/Perfusion Alveolar Capillary Membrane Alveolar epithelium Interstitial space Capillary endothelium Erythrocyte Membrane

Alveolar Capillary Membrane

Alveolar epithelium

Interstitial space

Capillary endothelium

Erythrocyte Membrane

Diffusion/Perfusion Impairment Interstitial lung Disease (thickening of interstitium Pulmonary Fibrosis Asbestosis Sarcoidosis Emphysema (destruction of alveoli) Pulmonary Vascular Abnormalities Pulmonary hypertension Pulmonary embolus

Interstitial lung Disease (thickening of interstitium

Pulmonary Fibrosis

Asbestosis

Sarcoidosis

Emphysema (destruction of alveoli)

Pulmonary Vascular Abnormalities

Pulmonary hypertension

Pulmonary embolus

Ventilation/Perfusion Mismatch Dead space (physiologic) Areas ventilated but not perfused Anatomic dead space The volume of the conducting airways ~ 1ml/lb Alveolar dead space The volume of gas ventilating unperfused alveoli Shunt Areas perfused but not ventilated

Dead space (physiologic)

Areas ventilated but not perfused

Anatomic dead space

The volume of the conducting airways ~ 1ml/lb

Alveolar dead space

The volume of gas ventilating unperfused alveoli

Shunt

Areas perfused but not ventilated

Ventilation/Perfusion Mismatch

 

Basics of Acid-Base Imbalances

Terminology Acid : A substance that donates hydrogen ions Base : A substance that accepts hydrogen ions Acidemia : a condition of blood pH of less than 7.35 Alkalemia : a condition of blood pH of greater than 7.45 Acidosis : is the process of causing acidemia Alkalosis : is the process of casing alkalemia Correction : is the process in which the system that was not properly functioning is repaired and hereby returns the pH toward the normal range

Acid : A substance that donates hydrogen ions

Base : A substance that accepts hydrogen ions

Acidemia : a condition of blood pH of less than 7.35

Alkalemia : a condition of blood pH of greater than 7.45

Acidosis : is the process of causing acidemia

Alkalosis : is the process of casing alkalemia

Correction : is the process in which the system that was not properly functioning is repaired and hereby returns the pH toward the normal range

Terminology Compensation : is the process in which the system that is still functioning properly is responsible for returning the pH toward the normal range. pH : power of hydrogen measures blood acidity and concentration of hydrogen ions PaO 2 : tension of O 2 gas in the arterial blood PaCO 2 tension of CO 2 in the arterial blood HCO 3 - : Blood bicarbonate. The principal buffer against drastic changes in pH that would occur with changes in PaCO 2 . It is an indicator of metabolic/ kidney function. Buffer : is a substance that resists change in H+ concentration upon addition of a strong acid or base

Compensation : is the process in which the system that is still functioning properly is responsible for returning the pH toward the normal range.

pH : power of hydrogen measures blood acidity and concentration of hydrogen ions

PaO 2 : tension of O 2 gas in the arterial blood

PaCO 2 tension of CO 2 in the arterial blood

HCO 3 - : Blood bicarbonate. The principal buffer against drastic changes in pH that would occur with changes in PaCO 2 . It is an indicator of metabolic/ kidney function.

Buffer : is a substance that resists change in H+ concentration upon addition of a strong acid or base

Normal Adult Blood Gas Values at Sea Level 0 + 2 0 + 2 B.E. 24 mEq/L + 2 24 mEq/L + 2 HCO 3 - 70-75% 95% or better SaO 2 41-51 mmHg 40 mmHg (35-45) PaCO 2 35-40 mmHg 80-100 mmHg PaO 2 7.36 (7.31-7.41) 7.40 (7.35-7.45) pH Venous Arterial

Causes of Respiratory Acidosis With normal lungs CNS depression--sedatives, CNS disease, obesity, hypoventilation Neuromuscular disease Trauma Severe restrictive disorders With abnormal lungs COPD Pneumonia Pleural disease (pneumothorax) Acute airway obstruction (asthma exacerbation)

With normal lungs

CNS depression--sedatives, CNS disease, obesity, hypoventilation

Neuromuscular disease

Trauma

Severe restrictive disorders

With abnormal lungs

COPD

Pneumonia

Pleural disease (pneumothorax)

Acute airway obstruction (asthma exacerbation)

Signs & Symptoms of Respiratory Acidosis Tachypnea Headache Confusion Drowsiness Coma Dysrhythmias

Tachypnea

Headache

Confusion

Drowsiness

Coma

Dysrhythmias

Causes of Respiratory Alkalosis With normal lungs With abnormal lungs Anxiety Usually a respiratory Fever response to hypoxia Stimulant drugs Acute asthma exacerbation CNS lesion/trauma Pneumonia Pain Pulmonary edema Sepsis High altitude

With normal lungs With abnormal lungs

Anxiety Usually a respiratory

Fever response to hypoxia

Stimulant drugs Acute asthma exacerbation

CNS lesion/trauma Pneumonia

Pain Pulmonary edema

Sepsis

High altitude

Signs & Symptoms of Respiratory Alkalosis Dizziness Numbness & Tingling Muscular weakness Twitching Irregular heart rhythm

Dizziness

Numbness & Tingling

Muscular weakness

Twitching

Irregular heart rhythm

Causes of Metabolic Acidosis Lactic acidosis (hypoxia) Keto acidosis (diabetes) Ingestion of base depleting drugs Aspirin Alcohol Renal failure Diarrhea

Lactic acidosis (hypoxia)

Keto acidosis (diabetes)

Ingestion of base depleting drugs

Aspirin

Alcohol

Renal failure

Diarrhea

Causes of Metabolic Alkalosis Excessive administration of steroids (K+depletion---incr. HCO3- reabsorption) Gastric suctioning/vomiting Hypochloremia (usually from vomiting) Hypokalemia Several days of IV therapy w/o adequate replacement of K+, diuretic therapy, diarrhea) Excessive administration /ingestion of HCO 3 - (licorice)

Excessive administration of steroids

(K+depletion---incr. HCO3- reabsorption)

Gastric suctioning/vomiting

Hypochloremia (usually from vomiting)

Hypokalemia

Several days of IV therapy w/o adequate replacement of K+, diuretic therapy, diarrhea)

Excessive administration /ingestion of HCO 3 - (licorice)

Acid-Base Disorders and Parameter Changes     N chronic N N N   acute Respiratory Alkalemia (alveolar hyperventilation)  N    N chronic N N N   acute Respiratory Acidemia (ventilatory failure) Cl - K + HCO 3 - PCO 2 pH

Acid-Base Disorders and Parameter Changes    N  acute      partially compensated N N   N compensated Metabolic Acidemia N N   N compensated      partially compensated    N  acute Metabolic Alkalemia Cl - K + HCO 3 - PCO 2 pH

Acid-Base Disorders and Parameter Changes Cl - K + HCO 3 - PCO 2 pH      Combined Respiratory and Metabolic Alkalemia      Combined Respiratory and Metabolic Acidemia

Compensatory Mechanisms for Acid - Base Imbalances Respiratory Acidosis Kidneys restore pH by reabsorbing HCO 3 - into the blood Respiratory Alkalosis Kidneys restore pH by urinary elimination of HCO 3 -

Respiratory Acidosis

Kidneys restore pH by reabsorbing HCO 3 - into the blood

Respiratory Alkalosis

Kidneys restore pH by urinary elimination of HCO 3 -

Compensatory Mechanisms for Acid - Base Imbalances Metabolic Acidosis The lungs restore the pH by eliminating CO2 Metabolic Alkalosis The lungs restore the pH by retaining CO2

Metabolic Acidosis

The lungs restore the pH by eliminating CO2

Metabolic Alkalosis

The lungs restore the pH by retaining CO2

Compensatory Mechanisms for Acid - Base Imbalances Lungs compensate quickly for metabolic acid-base abnormalities because ventilation can change the CO 2 within seconds Kidneys require more time to retain or excrete HCO 3 - therefore compensation is much slower

Lungs compensate quickly for metabolic acid-base abnormalities because ventilation can change the CO 2 within seconds

Kidneys require more time to retain or excrete HCO 3 - therefore compensation is much slower

PaO 2 Varies with age Normal PaO 2 = 104 - (0.3 x age)

Varies with age

Normal PaO 2 = 104 - (0.3 x age)

Hypoxemia Normal PaO 2 80 - 100 mmHg Mild hypoxemia PaO 2 60-79 mmHg Moderate hypoxemia PaO 2 40-59 mmHg Severe hypoxemia PaO 2 <40 mmHg

Normal PaO 2 80 - 100 mmHg

Mild hypoxemia PaO 2 60-79 mmHg

Moderate hypoxemia PaO 2 40-59 mmHg

Severe hypoxemia PaO 2 <40 mmHg

Arterial Blood Gas Interpretation

Steps for Interpretation Step 1: Acidemic or Alkalemic Step 2: Is the primary disturbance respiratory or metabolic Step 3: Assess for compensation

Step 1: Acidemic or Alkalemic

Step 2: Is the primary disturbance respiratory or metabolic

Step 3: Assess for compensation

Step 1: Acidemic or Alkalemic pH indicates the status of the body pH > 7.45 is alkaline pH < 7.35 is acid The pH of the arterial blood gas measurement identifies the disorder as alkalemic or acidemic.

pH indicates the status of the body

pH > 7.45 is alkaline

pH < 7.35 is acid

The pH of the arterial blood gas measurement identifies the disorder as alkalemic or acidemic.

Step 1: Acidemic or Alkalemic Categorize pH Determine whether it is: Acid Base Normal 7.25 Acid_____ Base_____ Normal___ X

Categorize pH

Determine whether it is:

Acid Base Normal

7.25

Acid_____ Base_____ Normal___

Step 2: Primarily Respiratory or Metabolic A respiratory disturbance alters the arterial PaCO 2 (normal value 40, range 35-45) If PaCO 2 < 35 respiratory acidosis is present If PaCO 2 > 45, respiratory alkalosis is present A metabolic disturbance alters the serum HCO 3 - (normal value 24, range 22-26) If HCO 3 - < 22, metabolic acidosis is present. If HCO 3 - > 26, metabolic alkalosis is present

A respiratory disturbance alters the arterial PaCO 2 (normal value 40, range 35-45)

If PaCO 2 < 35 respiratory acidosis is present

If PaCO 2 > 45, respiratory alkalosis is present

A metabolic disturbance alters the serum HCO 3 - (normal value 24, range 22-26)

If HCO 3 - < 22, metabolic acidosis is present.

If HCO 3 - > 26, metabolic alkalosis is present

PH 7.25 Acid__ Base__ Normal__ PaCO 2 37 mmHg Acid__ Base__ Normal__ HCO 3 - 17 mEq/l Acid__ Base__ Normal__ When either (or both) the lung or kidneys agree with the body it is the cause of the body’s condition Step 2: Primarily Respiratory or Metabolic X X X

PH 7.25 Acid__ Base__ Normal__

PaCO 2 37 mmHg Acid__ Base__ Normal__

HCO 3 - 17 mEq/l Acid__ Base__ Normal__

When either (or both) the lung or kidneys agree with the body it is the cause of the body’s condition

What if both PaCO2 & HCO3 are abnormal? Example: pH = 7.27 (low) PaCO 2 = 27 mm Hg (low) HCO 3 - = 10 mEq/L (low)  One represents the primary disorder; the other represents compensation. Which is which? The value that is moving in the right abnormal relationship is the primary problem.

Example: pH = 7.27 (low) PaCO 2 = 27 mm Hg (low) HCO 3 - = 10 mEq/L (low)  One represents the primary disorder; the other represents compensation. Which is which? The value that is moving in the right abnormal relationship is the primary problem.

Step 3: Assess for Compensation Whenever resp & metabolic conditions are in opposite directions compensation is presumed. When either the lungs or kidneys disagree with the body it is a compensatory mechanism. Compensation is complete when the pH is within normal limits. Compensation is partial when the pH remains out of range (but closer to normal than if there was no compensation. The body will never fully compensate.

Whenever resp & metabolic conditions are in opposite directions compensation is presumed.

When either the lungs or kidneys disagree with the body it is a compensatory mechanism.

Compensation is complete when the pH is within normal limits.

Compensation is partial when the pH remains out of range (but closer to normal than if there was no compensation.

The body will never fully compensate.

Step 3: Assess for Compensation Example 1 pH = 7.29 (low) PaCO 2 = 31 mm Hg (low) HCO 3 - = 12 mEq/L (low)  Partially Compensated Metabolic Acidosis

Example 1

pH = 7.29 (low) PaCO 2 = 31 mm Hg (low) HCO 3 - = 12 mEq/L (low) 

Partially Compensated Metabolic Acidosis

Step 3: Assess for Compensation Example 2 pH = 7.36 (Normal) PaCO 2 = 25 mm Hg (low) HCO 3 - = 12 mEq/L (low)  Compensated Metabolic Acidosis

Example 2

pH = 7.36 (Normal) PaCO 2 = 25 mm Hg (low) HCO 3 - = 12 mEq/L (low) 

Compensated Metabolic Acidosis

Step 3: Assess for Compensation Example 3 pH = 7.37 (Normal) PaCO 2 = 60 mm Hg (high) HCO 3 - = 30 mEq/L (high)  Compensated Respiratory Acidosis

Example 3

pH = 7.37 (Normal) PaCO 2 = 60 mm Hg (high) HCO 3 - = 30 mEq/L (high) 

Compensated Respiratory Acidosis

Blood Gas Interpretation Practice Practice 1 pH = 7.25 PaCO 2 = 65 mmHg PaO 2 = 55 mmHg HCO 3 - = 28 mEq/L Respiratory Acidosis with moderate hypoxemia

Practice 1

pH = 7.25

PaCO 2 = 65 mmHg

PaO 2 = 55 mmHg

HCO 3 - = 28 mEq/L

Respiratory Acidosis with moderate hypoxemia

Blood Gas Interpretation Practice Practice 2 pH = 7.10 PaCO 2 = 99 mmHg PaO 2 = 22 mmHg HCO 3 - = 30 mEq/L Partially compensated respiratory acidosis with severe hypoxemia

Practice 2

pH = 7.10 PaCO 2 = 99 mmHg

PaO 2 = 22 mmHg

HCO 3 - = 30 mEq/L

Partially compensated respiratory acidosis

with severe hypoxemia

Blood Gas Interpretation Practice Practice 3 pH = 7.55 PaCO 2 = 38 mmHg PaO 2 = 155 mmHg HCO 3 - = 32 mEq/L Uncompensated metabolic alkalosis with hyperoxia

Practice 3

pH = 7.55 PaCO 2 = 38 mmHg

PaO 2 = 155 mmHg

HCO 3 - = 32 mEq/L

Uncompensated metabolic alkalosis

with hyperoxia

The Base Excess The amount of acid (in mmol) required to restore 1 litre of blood to its normal pH, at a PCO 2 of 40mmHg. During the calculation any change in pH due to the PCO 2 of the sample is eliminated, therefore, the base excess reflects only the metabolic component of any disturbance of acid base balance.

The amount of acid (in mmol) required to restore 1 litre of blood to its normal pH, at a PCO 2 of 40mmHg.

During the calculation any change in pH due to the PCO 2 of the sample is eliminated, therefore, the base excess reflects only the metabolic component of any disturbance of acid base balance.

The Base Excess If there is a metabolic alkalosis the base excess will be positive due to a gain of base or a loss of acid from non-respiratory causes However, if there is a metabolic acidosis, the base excess is negative due to a loss of base or a gain of acid from non-respiratory causes

If there is a metabolic alkalosis the base excess will be positive due to a gain of base or a loss of acid from non-respiratory causes

However, if there is a metabolic acidosis, the base excess is negative due to a loss of base or a gain of acid from non-respiratory causes

 

Mechanical Ventilation

Iron Lung

Reasons for Mechanical Ventilation Respiratory Insufficiency/Failure Airway Protection Inadequate Respiratory Drive Surgical/Procedural

Respiratory Insufficiency/Failure

Airway Protection

Inadequate Respiratory Drive

Surgical/Procedural

Respiratory Insufficiency/Failure Textbook Definition: Respiratory activity is absent or is insufficient to maintain adequate oxygen uptake and carbon dioxide clearance Insufficiency – during exertion Failure – at rest Clinical Definition: Inability to maintain arterial PO 2 , PCO 2 and pH at acceptable levels PO 2 < predicted normal for age on R/A PCO 2 > 50mmHg and rising pH 7.25 and below

Textbook Definition:

Respiratory activity is absent or is insufficient to maintain adequate oxygen uptake and carbon dioxide clearance

Insufficiency – during exertion

Failure – at rest

Clinical Definition:

Inability to maintain arterial PO 2 , PCO 2 and pH at acceptable levels

PO 2 < predicted normal for age on R/A

PCO 2 > 50mmHg and rising

pH 7.25 and below

Signs & Symptoms of Respiratory Insufficiency/Failure

Respiratory Insufficiency/Failure Indications for mechanical ventilation Apnea Acute ventilatory failure Impending acute ventilatory failure Severe oxygenation deficit

Indications for mechanical ventilation

Apnea

Acute ventilatory failure

Impending acute ventilatory failure

Severe oxygenation deficit

Respiratory Insufficiency/Failure Clinical indications for mechanical ventilation Primarily pulmonary ARDS Pneumonia Pulmonary Emboli Mechanical ability Ventilatory muscle fatigue Thoracic injury / abnormalities Pleural diseases Neurological diseases Nutritional deficiencies

Clinical indications for mechanical ventilation

Primarily pulmonary

ARDS

Pneumonia

Pulmonary Emboli

Mechanical ability

Ventilatory muscle fatigue

Thoracic injury / abnormalities

Pleural diseases

Neurological diseases

Nutritional deficiencies

Airway Protection Obstruction of the airway Secretion Mucosal edema Bronchoconstriction Airway inflammation Foreign body obstruction Inability to avoid aspiration HIE (Hypoxic Ischemic Encephalopathy) Severe CNS defects

Obstruction of the airway

Secretion

Mucosal edema

Bronchoconstriction

Airway inflammation

Foreign body obstruction

Inability to avoid aspiration

HIE (Hypoxic Ischemic Encephalopathy)

Severe CNS defects

Inadequate Respiratory Drive CNS disorders/injury HIE Stroke Structural Neuromuscular disorders Amyotrophic lateral sclerosis (ALS) Multiple sclerosis (MS) Muscular dystrophy (MD) Myasthenia gravis Spinal muscular atrophy (SMA) Central Hypoventilation Syndrome AKA Ondyne’s Curse

CNS disorders/injury

HIE

Stroke

Structural

Neuromuscular disorders

Amyotrophic lateral sclerosis (ALS)

Multiple sclerosis (MS)

Muscular dystrophy (MD)

Myasthenia gravis

Spinal muscular atrophy (SMA)

Central Hypoventilation Syndrome AKA Ondyne’s Curse

Surgical/Procedural Paralysis Reduced drive due to pharmacologic agents Opiates Cardiac or thoracic procedure involving lung manipulation

Paralysis

Reduced drive due to pharmacologic agents

Opiates

Cardiac or thoracic procedure involving lung manipulation

Goal of Mechanical Ventilation To provide the most appropriate amount of support via the least harmful and most comfortable manner

To provide the most appropriate amount of support via the least harmful and most comfortable manner

Goals of Mechanical Ventilation Gently……. Exchange of CO 2 (ventilation) and O 2 (oxygenation) Achieve goal pH range Avoid baro/volutrauma Avoid hypo/hypercarbia, hypo/hyperoxia

Gently…….

Exchange of CO 2 (ventilation) and O 2 (oxygenation)

Achieve goal pH range

Avoid baro/volutrauma

Avoid hypo/hypercarbia, hypo/hyperoxia

Ventilation – Getting CO 2 Out Ventilation controls PaCO 2 Determined by Minute (Alveolar) Ventilation (MV) in liters/minute MV – amount of gas in and out of the alveoli MV = tidal volume (V t ) x rate (RR); the more gas exchange, the lower the CO 2 ; the less gas exchanged, the higher the CO 2

Ventilation controls PaCO 2

Determined by Minute (Alveolar) Ventilation (MV) in liters/minute

MV – amount of gas in and out of the alveoli

MV = tidal volume (V t ) x rate (RR); the more gas exchange, the lower the CO 2 ; the less gas exchanged, the higher the CO 2

Ventilation - Getting CO 2 Out Respiratory rate (RR) - directly set Tidal volume (V t ): Goal 8-10 ml/kg Can be directly set (volume ventilation) Or can be determined by the pressures used to ventilate (pressure ventilation)

Respiratory rate (RR) - directly set

Tidal volume (V t ): Goal 8-10 ml/kg

Can be directly set (volume ventilation)

Or can be determined by the pressures used to ventilate (pressure ventilation)

Oxygenation - Getting O 2 In PaO 2 determined by : FiO 2 – directly set Mean airway pressure Mean airway pressure (MAP) An average pressure across airway Good estimate of alveolar pressure Determined by PEEP and PIP Also influenced by inspiratory time (It)

PaO 2 determined by :

FiO 2 – directly set

Mean airway pressure

Mean airway pressure (MAP)

An average pressure across airway

Good estimate of alveolar pressure

Determined by PEEP and PIP

Also influenced by inspiratory time (It)

Oxygenation – Getting O 2 In Mean Airway Pressure (MAP) In CMV majority of MAP is determined by PEEP As rate increases, larger contribution from PIP Too little, not enough open alveoli (and thus lung); too much, inhibit pulmonary blood flow Inspiratory Time (I t )

Mean Airway Pressure (MAP)

In CMV majority of MAP is determined by PEEP

As rate increases, larger contribution from PIP

Too little, not enough open alveoli (and thus lung); too much, inhibit pulmonary blood flow

Inspiratory Time (I t )

Monitoring – How Are We Doing? Physical exam Chest rise Color Examination of the chest: Breath sounds Air exchange Extra sounds, i.e., crackles, wheezes, rhonchi… Radiographic studies

Physical exam

Chest rise

Color

Examination of the chest:

Breath sounds

Air exchange

Extra sounds, i.e., crackles, wheezes, rhonchi…

Radiographic studies

Monitoring – How Are We Doing? Gasses pH, PO 2 , PCO 2 , serum bicarbonate (calculated) TcCO 2 monitoring In vivo monitoring

Gasses

pH, PO 2 , PCO 2 , serum bicarbonate (calculated)

TcCO 2 monitoring

In vivo monitoring

Now Let’s Talk About Ventilation

Some Terms Peak End Expiratory Pressure (PEEP) Maintains open alveoli Distending pressure across airways Peak Inspiratory Pressure (PIP) Highest pressure reached during breath Provides pressure to move gas into lungs in positive pressure ventilation ∆P = PIP - PEEP In general, determines tidal volume

Peak End Expiratory Pressure (PEEP)

Maintains open alveoli

Distending pressure across airways

Peak Inspiratory Pressure (PIP)

Highest pressure reached during breath

Provides pressure to move gas into lungs in positive pressure ventilation

∆P = PIP - PEEP

In general, determines tidal volume

PEEP

PEEP PEEP 0 5 12 20

PEEP 0 5 12 20

Modes of Ventilation Assist Control (A/C, CMV) Synchronized Intermittent Mandatory Ventilation (SIMV)

Assist Control (A/C, CMV)

Synchronized Intermittent Mandatory Ventilation (SIMV)

Modes of Ventilation Assist Control (A/C, CMV) The ventilator has a number of preset machine breaths, at a set tidal volume or inspiratory pressure level (Vt or I P ) each minute. The patient is capable of initiating their own spontaneous breaths in between machine breaths Spontaneous breaths will be equal to preset ventilator breaths

Assist Control (A/C, CMV)

The ventilator has a number of preset machine breaths, at a set tidal volume or inspiratory pressure level (Vt or I P ) each minute.

The patient is capable of initiating their own spontaneous breaths in between machine breaths

Spontaneous breaths will be equal to preset ventilator breaths

Synchronized Intermittent Mandatory Ventilation (SIMV) The ventilator has a number of preset machine breaths, at a set tidal volume or inspiratory pressure level (Vt or I P ) each minute. The patient is capable of initiating their own spontaneous breaths in between machine breaths Spontaneous breath will be whatever size the patient wants to take Used most often in conjunction with Pressure Support (PS) Modes of Ventilation

Synchronized Intermittent Mandatory Ventilation (SIMV)

The ventilator has a number of preset machine breaths, at a set tidal volume or inspiratory pressure level (Vt or I P ) each minute.

The patient is capable of initiating their own spontaneous breaths in between machine breaths

Spontaneous breath will be whatever size the patient wants to take

Used most often in conjunction with Pressure Support (PS)

Breath Delivery Types Volume Control Pressure Control Pressure Regulated Volume Control Spontaneous Breath Types CPAP (Continuous Positive Airway Pressure) Pressure Support Volume Support BiPAP (Biphasic Positive Airway Pressure)

Volume Control

Pressure Control

Pressure Regulated Volume Control

Spontaneous Breath Types

CPAP (Continuous Positive Airway Pressure)

Pressure Support

Volume Support

BiPAP (Biphasic Positive Airway Pressure)

Breath Delivery types Volume Control Preset Vt, Respiratory Rate and sometimes flow Peak Pressure (PIP) is variable while the volume remains constant.

Volume Control

Preset Vt, Respiratory Rate and sometimes flow

Peak Pressure (PIP) is variable while the volume remains constant.

Breath Delivery Types (cont) Pressure Control Ventilation (PCV) Preset RR, Inspiratory Time and Inspiratory Pressure Vt is variable while pressure remains constant

Pressure Control Ventilation (PCV)

Preset RR, Inspiratory Time and Inspiratory Pressure

Vt is variable while pressure remains constant

Breath Delivery Types (cont) Pressure Regulated Volume Control (PRVC) Preset RR, Inspiratory Time and Vt Pressure is variable yet limited while Vt remains constant

Pressure Regulated Volume Control (PRVC)

Preset RR, Inspiratory Time and Vt

Pressure is variable yet limited while Vt remains constant

Continuous Positive Airway Pressure (CPAP) Preset level of pressure added to the circuit as the patient exhales. The patient does all the work No set RR or tidal volume Used most often with Pressure Support Spontaneous Breath Delivery Types

Continuous Positive Airway Pressure (CPAP)

Preset level of pressure added to the circuit as the patient exhales.

The patient does all the work

No set RR or tidal volume

Used most often with Pressure Support

Spontaneous Breath Delivery Types Pressure Support (PS) Preset level of pressure added to the spontaneous breath during inspiration only This helps augment the patients tidal volume Pressure is constant but tidal volume varies

Pressure Support (PS)

Preset level of pressure added to the spontaneous breath during inspiration only

This helps augment the patients tidal volume

Pressure is constant but tidal volume varies

Spontaneous Breath Delivery Types Volume Support (VS) Variable pressure support added to the ventilator during inspiration only, to deliver a preset Vt Tidal volume is constant but pressure varies

Volume Support (VS)

Variable pressure support added to the ventilator during inspiration only, to deliver a preset Vt

Tidal volume is constant but pressure varies

Spontaneous Breath Delivery Types Biphasic Positive Airway Pressure (BiPAP) Preset level of pressure added to the circuit during both inspiratory and expiratory phases. Differing levels of inspiratory and expiratory support The patient does all the work No set RR or tidal volume

Biphasic Positive Airway Pressure (BiPAP)

Preset level of pressure added to the circuit during both inspiratory and expiratory phases.

Differing levels of inspiratory and expiratory support

The patient does all the work

No set RR or tidal volume

The Alphabet Game Combined Modes of Ventilation PRVC (pressure regulated volume control) APRV (airway pressure release ventilation) BiVent BiLevel VAPS (volume assured pressure support) VS (volume support) Automode

Combined Modes of Ventilation

PRVC (pressure regulated volume control)

APRV (airway pressure release ventilation)

BiVent

BiLevel

VAPS (volume assured pressure support)

VS (volume support)

Automode

Determination of Ventilator Settings Mode Depends on patient Breath Delivery Type Depends on patient Vt 6-10cc’s/kg RR 12 – 40 bpm’s (depending on age & desired Minute Ventilation) FiO2 Usually start at 100% Less if patient has been on a vent for a while PEEP Depends on patient PS Depends on patient

Mode

Depends on patient

Breath Delivery Type

Depends on patient

Vt

6-10cc’s/kg

RR

12 – 40 bpm’s (depending on age & desired Minute Ventilation)

FiO2

Usually start at 100%

Less if patient has been on a vent for a while

PEEP

Depends on patient

PS

Depends on patient

Patient Consideration Humidification HME Heated (37 ◦ C & 44mg/L Water Vapor) Suctioning Saline Nutrition Enteral (Gavage) Parenteral (TPN)

Humidification

HME

Heated (37 ◦ C & 44mg/L Water Vapor)

Suctioning

Saline

Nutrition

Enteral (Gavage)

Parenteral (TPN)

Sedatives, Analgesics, and Paralytics

 

Sedatives Benzodiazepines Opioids Neuroleptics

Benzodiazepines

Opioids

Neuroleptics

Benzodiazepines Drugs of choice for treatment of anxiety Relatively low cost Muscle-relaxing Anticonvulsant Amnesiac effects May cause respiratory depression if administered to COPD patients on opioids Minimal cardiovascular effects, BP depression possible in hemodynamically unstable patients

Drugs of choice for treatment of anxiety

Relatively low cost

Muscle-relaxing

Anticonvulsant

Amnesiac effects

May cause respiratory depression if administered to COPD patients on opioids

Minimal cardiovascular effects, BP depression possible in hemodynamically unstable patients

Most common benzos in ICU Generic Name (Trade Name) ½ life Diazepam (Valium) 20- 120 hrs Rapid onset Midazolam (Versed) 3 – 11 hrs Onset 2-3 minutes Lorazepam (Ativan) 8 – 15 hrs Onset 5 – 20 minutes

Generic Name (Trade Name) ½ life

Diazepam (Valium) 20- 120 hrs

Rapid onset

Midazolam (Versed) 3 – 11 hrs

Onset 2-3 minutes

Lorazepam (Ativan) 8 – 15 hrs

Onset 5 – 20 minutes

Opioids Primarily used for pain relief Secondarily used for as anxiolytic and sedation Many serious side effects Respiratory Depression Nausea Constipation Vomiting Cardiovascular depression Reduced GI motility Convulsions High physical dependence

Primarily used for pain relief

Secondarily used for as anxiolytic and sedation

Many serious side effects

Respiratory Depression

Nausea

Constipation

Vomiting

Cardiovascular depression

Reduced GI motility

Convulsions

High physical dependence

Opioids Recovery period lengthened in renal/hepatic insufficiency May cause histamine release and bronchoconstriction Reversal medication Naloxone Hydrochloride (Narcan) 30 minutes half life May require IV infusion for opioid withdrawal

Recovery period lengthened in renal/hepatic insufficiency

May cause histamine release and bronchoconstriction

Reversal medication

Naloxone Hydrochloride (Narcan)

30 minutes half life

May require IV infusion for opioid withdrawal

Most common Opioids in ICU Generic name (Trade name) Fentanyl Hydrochloride (Sublimaze) Synthetic 1 - 4 hours duration with fast onset 100 – 150 times more potent than MS Less cardiac side effects than MS Morphine Sulfate (Duramorph) 1- 6 hours duration with slower onset Preferred for lower cost

Generic name (Trade name)

Fentanyl Hydrochloride (Sublimaze)

Synthetic

1 - 4 hours duration with fast onset

100 – 150 times more potent than MS

Less cardiac side effects than MS

Morphine Sulfate (Duramorph)

1- 6 hours duration with slower onset

Preferred for lower cost

Neuroleptics Used to treat extreme agitation and delirium (increased in elderly and burn patients) Side effects Decreased seizure threshold Cardiac dysrhythmias Parkinson’s-type symptoms Muscle rigidity Lethargy Drowsiness

Used to treat extreme agitation and delirium (increased in elderly and burn patients)

Side effects

Decreased seizure threshold

Cardiac dysrhythmias

Parkinson’s-type symptoms

Muscle rigidity

Lethargy

Drowsiness

Most common Neuroleptic Drug in ICU: Generic name (Trade name) Haloperidol (Haldol) 3 - 5 minute onset 5 - 24 hours half-life

Generic name (Trade name)

Haloperidol (Haldol)

3 - 5 minute onset

5 - 24 hours half-life

Anesthetics Used for sedative, hypnotic & amnesiac properties NO analgesic effects Many hemodynamic effects Decreased SVR Decreased BP Bradycardia Good for IC bleeds Neurosurgical patients = decreases ICP Rapid “wake-up”… no hangover Painful on injection Used in OR, ICU Lipid based solution prone to contamination

Used for sedative, hypnotic & amnesiac properties

NO analgesic effects

Many hemodynamic effects

Decreased SVR

Decreased BP

Bradycardia

Good for IC bleeds

Neurosurgical patients = decreases ICP

Rapid “wake-up”… no hangover

Painful on injection

Used in OR, ICU

Lipid based solution prone to contamination

Anesthetics Generic name (Trade name) Diprivan (Propofol) Onset 1 minute, Half-life <30 minute Expensive

Generic name (Trade name)

Diprivan (Propofol)

Onset 1 minute,

Half-life <30 minute

Expensive

Paralytics Used to: Facilitate mechanical ventilation Treat extreme agitation Facilitate intubation and other procedures Manage tetanus Extreme hyperventilation Reduction of O 2 consumption & CO 2 production Can cause Decreased BP Cardiac dysrhythmias Prolonged paralysis in patients with renal/hepatic insufficiency

Used to:

Facilitate mechanical ventilation

Treat extreme agitation

Facilitate intubation and other procedures

Manage tetanus

Extreme hyperventilation

Reduction of O 2 consumption & CO 2 production

Can cause

Decreased BP

Cardiac dysrhythmias

Prolonged paralysis in patients with renal/hepatic insufficiency

Paralytics NO SEDATIVE EFFECTS NO ANALGESIC EFFECTS Essentially it paralyzes your patient - MUST be given WITH analgesic and sedative!!

NO SEDATIVE EFFECTS

NO ANALGESIC EFFECTS

Essentially it paralyzes your patient - MUST be given WITH analgesic and sedative!!

Paralytics Generic name (Trade name) Panacuronium (Pavulon) “ Vec” Vecuronium (Norcuron) “ Rock” Rocuronium (Zemuron) “ Sux” Succinylcholine (Anectine)

Generic name (Trade name)

Panacuronium (Pavulon)

“ Vec” Vecuronium (Norcuron)

“ Rock” Rocuronium (Zemuron)

“ Sux” Succinylcholine (Anectine)

Respiratory Diseases Pneumonia PE ARDS Chest Trauma

Pneumonia

PE

ARDS

Chest Trauma

Pneumonia Definition: Inflammation process that primarily effects the gas exchange area’s of the lung Etiology: Bacteria, viruses, fungi, TB, etc. Clinical Manifestation: Initially dry cough, turning productive with blood streaked sputum, crackles, rhonchi, dyspnea, cyanosis Treatment: O 2 therapy, bronchial hygiene, bronchodilators, antibiotics

Definition:

Inflammation process that primarily effects the gas exchange area’s of the lung

Etiology:

Bacteria, viruses, fungi, TB, etc.

Clinical Manifestation:

Initially dry cough, turning productive with blood streaked sputum, crackles, rhonchi, dyspnea, cyanosis

Treatment:

O 2 therapy, bronchial hygiene, bronchodilators, antibiotics

Pulmonary Embolism Definition: Complete or partial obstruction of the pulmonary artery blood flow to a distal portion of the lung by a plug brought by the blood Etiology: Blood clots (blood stasis, vessel wall abnormalities, abnormal blood coagulation), Fat, Tumors, Air Clinical Manifestation: Asymptomatic to death, dyspnea and sharp chest pain most common, Treatment: O 2 therapy, anticoagulation therapy, steroids, embolectomy

Definition:

Complete or partial obstruction of the pulmonary artery blood flow to a distal portion of the lung by a plug brought by the blood

Etiology:

Blood clots (blood stasis, vessel wall abnormalities, abnormal blood coagulation), Fat, Tumors, Air

Clinical Manifestation:

Asymptomatic to death, dyspnea and sharp chest pain most common,

Treatment:

O 2 therapy, anticoagulation therapy, steroids, embolectomy

ARDS Definition: An acute restrictive disease of ↓ing FRC and severe hypoxia due to injury to the alveolar capillary membrane resulting in ↓ed surfactant, atelectasis and ↓ing compliance Etiology: Shock (severe hemorrhage, trauma, MI, CVA, CABG) Inhalation (O 2 , aspiration, near drowning, burns) Infection (viral pneumonia, sepsis) Over-hydration, chemical injury, blood infusion, etc. Clinical Manifestation: Rapid onset, dyspnea, hypoxia, tachypnea, tachycardia, ↓ed compliance, Treatment: Treat underline cause, O 2 , PEEP, CPT, Sx, diuretics, ventilator

Definition:

An acute restrictive disease of ↓ing FRC and severe hypoxia due to injury to the alveolar capillary membrane resulting in ↓ed surfactant, atelectasis and ↓ing compliance

Etiology:

Shock (severe hemorrhage, trauma, MI, CVA, CABG)

Inhalation (O 2 , aspiration, near drowning, burns)

Infection (viral pneumonia, sepsis)

Over-hydration, chemical injury, blood infusion, etc.

Clinical Manifestation:

Rapid onset, dyspnea, hypoxia, tachypnea, tachycardia, ↓ed compliance,

Treatment:

Treat underline cause, O 2 , PEEP, CPT, Sx, diuretics, ventilator

Chest Trauma Account for ¼ of all trauma deaths Blunt Trauma Steering wheels Falls Penetrating Trauma Knife wounds Gunshots Primary concern ABC C-Spine

Account for ¼ of all trauma deaths

Blunt Trauma

Steering wheels

Falls

Penetrating Trauma

Knife wounds

Gunshots

Primary concern

ABC

C-Spine

Chest Trauma Fractures/Flail chest High or low fx, watch for concurrent injuries Pneumothorax Spontaneous or trauma, < or >20%, 2 nd ICS MCL or 5 th ICS MAL Hemothorax Mild <300cc, Moderate b/w 300-1400cc, Severe >1400cc Drain, surgery for >200cc/hr, transfusions Sucking chest wound Open flap in chest wall, sucking sound, tension pneumo ?, sterile dressing over 3 sides

Fractures/Flail chest

High or low fx, watch for concurrent injuries

Pneumothorax

Spontaneous or trauma, < or >20%, 2 nd ICS MCL or 5 th ICS MAL

Hemothorax

Mild <300cc, Moderate b/w 300-1400cc, Severe >1400cc

Drain, surgery for >200cc/hr, transfusions

Sucking chest wound

Open flap in chest wall, sucking sound, tension pneumo ?, sterile dressing over 3 sides

Questions?

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