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

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

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Respiratory Talk Respiratory Talk Presentation Transcript

  • 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
  • Contents
    • 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
  • 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 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.
      • 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
    • 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
      • Respiratory Airways
        • Respiratory Bronchioles
        • Terminal Respiratory Bronchioles
        • Alveolar Ducts/Sacs
        • Alveoli
      • Primary Function
        • Gas exchange
    Upper vs. Lower Respiratory Tract
    • 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
    • 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
    • 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
  • Alveolar Capillary Membrane
    • 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
  • 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
  • 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
  • Barriers to Diffusion/Perfusion
    • 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
  • 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
  • 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
  • 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
  • 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)
  • Signs & Symptoms of Respiratory Acidosis
    • 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
  • Signs & Symptoms of Respiratory Alkalosis
    • 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
  • 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)
  • 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 -
  • 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
  • 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
  • PaO 2
    • 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
  • 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
    • 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
  • 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
    • 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
  • 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.
  • 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.
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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 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
  •  
  • Mechanical Ventilation
  • Iron Lung
  • Reasons for Mechanical Ventilation
    • 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
  • Signs & Symptoms of Respiratory Insufficiency/Failure
  • Respiratory Insufficiency/Failure
    • 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
  • 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
  • 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
  • Surgical/Procedural
    • 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
  • 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
  • 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 - 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)
  • 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)
  • 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 )
  • 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
  • Monitoring – How Are We Doing?
    • 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
  • PEEP
  • PEEP
    • PEEP 0 5 12 20
  • Modes of Ventilation
    • 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
    • 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
  • 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)
  • Breath Delivery types
    • 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
  • Breath Delivery Types (cont)
    • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Patient Consideration
    • 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
    • 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
  • 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
  • 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
  • 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
  • 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
  • Most common Neuroleptic Drug in ICU:
    • 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
  • Anesthetics
    • 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
  • Paralytics
    • 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)
  • Respiratory Diseases
    • 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
  • 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
  • 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
  • Chest Trauma
    • 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
  • Questions?
  • Thank you