Respiratory Talk


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

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  • Respiratory Talk

    1. 1. Essentials of Respiratory Care Paul Barraza RRT, RCP Education Coordinator, Santa Clara Valley Medical Center Adjunct Faculty, Department of Biological Sciences, Foothill College
    2. 2. Contents <ul><li>Anatomy and Physiology of the Respiratory System </li></ul><ul><ul><li>Function of Respiratory System </li></ul></ul><ul><ul><li>Upper vs. Lower Airway </li></ul></ul><ul><ul><li>Cellular Properties of the Alveolus </li></ul></ul><ul><ul><li>Ventilation / Respiration </li></ul></ul><ul><ul><li>Diffusion / Perfusion </li></ul></ul><ul><li>Basics of Acid-Base Imbalances </li></ul><ul><li>Arterial Blood Gas Interpretation </li></ul>
    3. 3. Contents <ul><li>Mechanical Ventilation </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><li>Goals </li></ul></ul><ul><ul><li>Monitoring </li></ul></ul><ul><ul><li>Basics of ventilation </li></ul></ul><ul><li>Sedatives, Analgesics, and Paralytics </li></ul><ul><li>Disease Specific Management </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Pulmonary Embolus </li></ul></ul><ul><ul><li>Chest Trauma </li></ul></ul><ul><ul><li>ARDS </li></ul></ul>
    4. 4. Anatomy and Physiology
    5. 5. Function <ul><li>Primary function of the respiratory system is the continuous absorption of O 2 and the excretion of CO 2 </li></ul><ul><ul><li>External Respiration </li></ul></ul><ul><ul><ul><li>The exchange of gas from the atmosphere and the blood </li></ul></ul></ul><ul><ul><li>Internal Respiration </li></ul></ul><ul><ul><ul><li>The exchange of gases between blood and the tissues </li></ul></ul></ul>
    6. 6. Upper vs. Lower Respiratory Tract <ul><li>Upper Respiratory Tract </li></ul><ul><ul><li>All structures starting at the mouth or nose and extending down to the trachea </li></ul></ul><ul><ul><ul><li>Nose </li></ul></ul></ul><ul><ul><ul><ul><li>Vestibule (hairs act as gross filter) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Concha (turbinates increase surface area of nose to aid in filtration and humidification) </li></ul></ul></ul></ul><ul><ul><ul><li>Oral Cavity </li></ul></ul></ul><ul><ul><ul><ul><li>Soft palate and uvula (control flow of air, fluid and food during eating, drinking, sneezing and coughing) </li></ul></ul></ul></ul>
    7. 7. <ul><li>Upper Respiratory Tract Cont. </li></ul><ul><ul><li>Pharynx </li></ul></ul><ul><ul><ul><li>Subdivided into: </li></ul></ul></ul><ul><ul><ul><ul><li>Nasopharynx </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Oropharynx </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypopharynx </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Larynopharynx </li></ul></ul></ul></ul><ul><ul><ul><li>Primary function is to aid in filtration and in speech </li></ul></ul></ul>Upper vs. Lower Respiratory Tract
    8. 8. <ul><li>Upper Respiratory Tract Cont. </li></ul><ul><ul><li>Larynx </li></ul></ul><ul><ul><ul><li>Formed by cartilage and muscle </li></ul></ul></ul><ul><ul><ul><ul><li>Thyroid </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cricoid </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Epiglottis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vocal Cords </li></ul></ul></ul></ul><ul><ul><ul><li>Primary function </li></ul></ul></ul><ul><ul><ul><ul><li>Protect the respiratory tract during eating and drinking </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Phonation </li></ul></ul></ul></ul>Upper vs. Lower Respiratory Tract
    9. 9. <ul><li>Lower Respiratory Tract </li></ul><ul><ul><li>Conducting Airways </li></ul></ul><ul><ul><ul><li>Trachea </li></ul></ul></ul><ul><ul><ul><li>Right & Left Main Bronchi </li></ul></ul></ul><ul><ul><ul><li>Lobar </li></ul></ul></ul><ul><ul><ul><li>Segmental </li></ul></ul></ul><ul><ul><ul><li>Subsegmental </li></ul></ul></ul><ul><ul><ul><li>Bronchi </li></ul></ul></ul><ul><ul><ul><li>Terminal bronchi </li></ul></ul></ul><ul><ul><ul><li>Bronchioles (No cartilage) </li></ul></ul></ul><ul><ul><ul><li>Terminal Bronchioles (No cartilage) </li></ul></ul></ul><ul><ul><li>Primary Function </li></ul></ul><ul><ul><ul><li>Airway conduction </li></ul></ul></ul>Upper vs. Lower Respiratory Tract
    10. 10. <ul><li>Lower Respiratory Tract </li></ul><ul><ul><li>Respiratory Airways </li></ul></ul><ul><ul><ul><li>Respiratory Bronchioles </li></ul></ul></ul><ul><ul><ul><li>Terminal Respiratory Bronchioles </li></ul></ul></ul><ul><ul><ul><li>Alveolar Ducts/Sacs </li></ul></ul></ul><ul><ul><ul><li>Alveoli </li></ul></ul></ul><ul><ul><li>Primary Function </li></ul></ul><ul><ul><ul><li>Gas exchange </li></ul></ul></ul>Upper vs. Lower Respiratory Tract
    11. 11. <ul><li>Estimates range from 270 to 790 million </li></ul><ul><li>Average 480 million </li></ul><ul><li>Number increase with height of subject </li></ul><ul><li>Average 0.2mm in diameter when at FRC </li></ul><ul><li>Larger in apecies than in bases due to organ weight </li></ul>Alveoli
    12. 12. <ul><li>Type I pneumocytes (extremely flat squamous epithelia) </li></ul><ul><ul><li>Covers 93% of alveolar surface </li></ul></ul><ul><ul><li>Create patchwork like surface over the alveolar capillaries forming the gas exchange surface of the alveolus </li></ul></ul><ul><li>Type II pneumocytes (cuboidal epithelia) </li></ul><ul><ul><li>Cover 7% of the alveolar surface </li></ul></ul><ul><ul><li>Manufacture surfactant and secretes it onto the alveolar surface </li></ul></ul>Alveoli
    13. 13. <ul><li>Macrophages </li></ul><ul><ul><li>Defensive cell that patrol alveolar region and phagocytize foreign particles and cells (bacteria) </li></ul></ul><ul><li>Canals of Lambert </li></ul><ul><ul><li>Small openings that connect the alveoli to the respiratory bronchioles </li></ul></ul><ul><li>Pores of Kohn </li></ul><ul><ul><li>Small openings in the alveolar septa that allow gas to flow from one alveolus to another </li></ul></ul>Alveoli
    14. 14. Alveolar Capillary Membrane <ul><li>Surfactant Layer (outermost layer) </li></ul><ul><li>Type I cell </li></ul><ul><li>Interstitial Space </li></ul><ul><ul><li>Basement membranes </li></ul></ul><ul><ul><li>Matrix material connective tissue fibers </li></ul></ul><ul><li>Alveolar capillary </li></ul><ul><ul><li>Plasma </li></ul></ul><ul><ul><li>Erythrocytes </li></ul></ul>
    15. 15. Alveolar Capillary Membrane
    16. 16. Ventilation vs. Respiration <ul><li>Ventilation </li></ul><ul><ul><li>The process of moving gas into and out of the lungs </li></ul></ul><ul><li>Respiration </li></ul><ul><ul><li>The process of getting oxygen into the body for tissue utilization and removal of carbon dioxide into the atmosphere </li></ul></ul>
    17. 17. Diffusion/Perfusion <ul><li>The process whereby molecules move from areas of high concentration to areas of low concentration </li></ul><ul><ul><li>Driven by kinetic energy </li></ul></ul><ul><ul><ul><li>Gases have high kinetic energy </li></ul></ul></ul><ul><ul><li>Lighter gases diffuse more rapidly than heavy gases </li></ul></ul><ul><ul><li>Increasing kinetic energy will increase diffusion </li></ul></ul><ul><ul><ul><li>Heat </li></ul></ul></ul><ul><ul><ul><li>Mechanical agitation </li></ul></ul></ul>
    18. 18. Diffusion/Perfusion <ul><li>O 2 & CO 2 move between the lungs and the tissue via diffusion </li></ul><ul><li>Oxygen </li></ul><ul><ul><li>PO 2 ~ 159mmHg in atmosphere </li></ul></ul><ul><ul><li>PO 2 ~ 40mmHg in capillaries </li></ul></ul><ul><li>Carbon Dioxide </li></ul><ul><ul><li>PCO 2 ~ 60mmHg in the cells </li></ul></ul><ul><ul><li>PCO 2 ~ 1mmHg in room air </li></ul></ul>
    19. 19. Barriers to Diffusion/Perfusion <ul><li>Alveolar Capillary Membrane </li></ul><ul><ul><li>Alveolar epithelium </li></ul></ul><ul><ul><li>Interstitial space </li></ul></ul><ul><ul><li>Capillary endothelium </li></ul></ul><ul><li>Erythrocyte Membrane </li></ul>
    20. 20. Diffusion/Perfusion Impairment <ul><li>Interstitial lung Disease (thickening of interstitium </li></ul><ul><ul><li>Pulmonary Fibrosis </li></ul></ul><ul><ul><li>Asbestosis </li></ul></ul><ul><ul><li>Sarcoidosis </li></ul></ul><ul><li>Emphysema (destruction of alveoli) </li></ul><ul><li>Pulmonary Vascular Abnormalities </li></ul><ul><ul><li>Pulmonary hypertension </li></ul></ul><ul><ul><li>Pulmonary embolus </li></ul></ul>
    21. 21. Ventilation/Perfusion Mismatch <ul><li>Dead space (physiologic) </li></ul><ul><ul><li>Areas ventilated but not perfused </li></ul></ul><ul><ul><li>Anatomic dead space </li></ul></ul><ul><ul><ul><li>The volume of the conducting airways ~ 1ml/lb </li></ul></ul></ul><ul><ul><li>Alveolar dead space </li></ul></ul><ul><ul><ul><li>The volume of gas ventilating unperfused alveoli </li></ul></ul></ul><ul><li>Shunt </li></ul><ul><ul><li>Areas perfused but not ventilated </li></ul></ul>
    22. 22. Ventilation/Perfusion Mismatch
    23. 24. Basics of Acid-Base Imbalances
    24. 25. Terminology <ul><li>Acid : A substance that donates hydrogen ions </li></ul><ul><li>Base : A substance that accepts hydrogen ions </li></ul><ul><li>Acidemia : a condition of blood pH of less than 7.35 </li></ul><ul><li>Alkalemia : a condition of blood pH of greater than 7.45 </li></ul><ul><li>Acidosis : is the process of causing acidemia </li></ul><ul><li>Alkalosis : is the process of casing alkalemia </li></ul><ul><li>Correction : is the process in which the system that was not properly functioning is repaired and hereby returns the pH toward the normal range </li></ul>
    25. 26. Terminology <ul><li>Compensation : is the process in which the system that is still functioning properly is responsible for returning the pH toward the normal range. </li></ul><ul><li>pH : power of hydrogen measures blood acidity and concentration of hydrogen ions </li></ul><ul><li>PaO 2 : tension of O 2 gas in the arterial blood </li></ul><ul><li>PaCO 2 tension of CO 2 in the arterial blood </li></ul><ul><li>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. </li></ul><ul><li>Buffer : is a substance that resists change in H+ concentration upon addition of a strong acid or base </li></ul>
    26. 27. 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
    27. 28. Causes of Respiratory Acidosis <ul><li>With normal lungs </li></ul><ul><ul><li>CNS depression--sedatives, CNS disease, obesity, hypoventilation </li></ul></ul><ul><ul><li>Neuromuscular disease </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Severe restrictive disorders </li></ul></ul><ul><li>With abnormal lungs </li></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Pleural disease (pneumothorax) </li></ul></ul><ul><ul><li>Acute airway obstruction (asthma exacerbation) </li></ul></ul>
    28. 29. Signs & Symptoms of Respiratory Acidosis <ul><li>Tachypnea </li></ul><ul><li>Headache </li></ul><ul><li>Confusion </li></ul><ul><li>Drowsiness </li></ul><ul><li>Coma </li></ul><ul><li>Dysrhythmias </li></ul>
    29. 30. Causes of Respiratory Alkalosis <ul><li>With normal lungs With abnormal lungs </li></ul><ul><ul><li>Anxiety Usually a respiratory </li></ul></ul><ul><ul><li>Fever response to hypoxia </li></ul></ul><ul><ul><li>Stimulant drugs Acute asthma exacerbation </li></ul></ul><ul><ul><li>CNS lesion/trauma Pneumonia </li></ul></ul><ul><ul><li>Pain Pulmonary edema </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>High altitude </li></ul></ul>
    30. 31. Signs & Symptoms of Respiratory Alkalosis <ul><li>Dizziness </li></ul><ul><li>Numbness & Tingling </li></ul><ul><li>Muscular weakness </li></ul><ul><li>Twitching </li></ul><ul><li>Irregular heart rhythm </li></ul>
    31. 32. Causes of Metabolic Acidosis <ul><li>Lactic acidosis (hypoxia) </li></ul><ul><li>Keto acidosis (diabetes) </li></ul><ul><li>Ingestion of base depleting drugs </li></ul><ul><ul><li>Aspirin </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul><ul><li>Renal failure </li></ul><ul><li>Diarrhea </li></ul>
    32. 33. Causes of Metabolic Alkalosis <ul><li>Excessive administration of steroids </li></ul><ul><ul><li>(K+depletion---incr. HCO3- reabsorption) </li></ul></ul><ul><li>Gastric suctioning/vomiting </li></ul><ul><li>Hypochloremia (usually from vomiting) </li></ul><ul><li>Hypokalemia </li></ul><ul><ul><li>Several days of IV therapy w/o adequate replacement of K+, diuretic therapy, diarrhea) </li></ul></ul><ul><li>Excessive administration /ingestion of HCO 3 - (licorice) </li></ul>
    33. 34. 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
    34. 35. 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
    35. 36. Acid-Base Disorders and Parameter Changes Cl - K + HCO 3 - PCO 2 pH      Combined Respiratory and Metabolic Alkalemia      Combined Respiratory and Metabolic Acidemia
    36. 37. Compensatory Mechanisms for Acid - Base Imbalances <ul><li>Respiratory Acidosis </li></ul><ul><ul><li>Kidneys restore pH by reabsorbing HCO 3 - into the blood </li></ul></ul><ul><li>Respiratory Alkalosis </li></ul><ul><ul><li>Kidneys restore pH by urinary elimination of HCO 3 - </li></ul></ul>
    37. 38. Compensatory Mechanisms for Acid - Base Imbalances <ul><li>Metabolic Acidosis </li></ul><ul><ul><li>The lungs restore the pH by eliminating CO2 </li></ul></ul><ul><li>Metabolic Alkalosis </li></ul><ul><ul><li>The lungs restore the pH by retaining CO2 </li></ul></ul>
    38. 39. Compensatory Mechanisms for Acid - Base Imbalances <ul><li>Lungs compensate quickly for metabolic acid-base abnormalities because ventilation can change the CO 2 within seconds </li></ul><ul><li>Kidneys require more time to retain or excrete HCO 3 - therefore compensation is much slower </li></ul>
    39. 40. PaO 2 <ul><li>Varies with age </li></ul><ul><li>Normal PaO 2 = 104 - (0.3 x age) </li></ul>
    40. 41. Hypoxemia <ul><li>Normal PaO 2 80 - 100 mmHg </li></ul><ul><li>Mild hypoxemia PaO 2 60-79 mmHg </li></ul><ul><li>Moderate hypoxemia PaO 2 40-59 mmHg </li></ul><ul><li>Severe hypoxemia PaO 2 <40 mmHg </li></ul>
    41. 42. Arterial Blood Gas Interpretation
    42. 43. Steps for Interpretation <ul><li>Step 1: Acidemic or Alkalemic </li></ul><ul><li>Step 2: Is the primary disturbance respiratory or metabolic </li></ul><ul><li>Step 3: Assess for compensation </li></ul>
    43. 44. Step 1: Acidemic or Alkalemic <ul><li>pH indicates the status of the body </li></ul><ul><li>pH > 7.45 is alkaline </li></ul><ul><li>pH < 7.35 is acid </li></ul><ul><li>The pH of the arterial blood gas measurement identifies the disorder as alkalemic or acidemic. </li></ul>
    44. 45. Step 1: Acidemic or Alkalemic <ul><li>Categorize pH </li></ul><ul><li>Determine whether it is: </li></ul><ul><li>Acid Base Normal </li></ul><ul><li>7.25 </li></ul><ul><ul><li>Acid_____ Base_____ Normal___ </li></ul></ul>X
    45. 46. Step 2: Primarily Respiratory or Metabolic <ul><li>A respiratory disturbance alters the arterial PaCO 2 (normal value 40, range 35-45) </li></ul><ul><ul><li>If PaCO 2 < 35 respiratory acidosis is present </li></ul></ul><ul><ul><li>If PaCO 2 > 45, respiratory alkalosis is present </li></ul></ul><ul><li>A metabolic disturbance alters the serum HCO 3 - (normal value 24, range 22-26) </li></ul><ul><ul><li>If HCO 3 - < 22, metabolic acidosis is present. </li></ul></ul><ul><ul><li>If HCO 3 - > 26, metabolic alkalosis is present </li></ul></ul>
    46. 47. <ul><li>PH 7.25 Acid__ Base__ Normal__ </li></ul><ul><li>PaCO 2 37 mmHg Acid__ Base__ Normal__ </li></ul><ul><li>HCO 3 - 17 mEq/l Acid__ Base__ Normal__ </li></ul><ul><li>When either (or both) the lung or kidneys agree with the body it is the cause of the body’s condition </li></ul>Step 2: Primarily Respiratory or Metabolic X X X
    47. 48. What if both PaCO2 & HCO3 are abnormal? <ul><li>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. </li></ul>
    48. 49. Step 3: Assess for Compensation <ul><li>Whenever resp & metabolic conditions are in opposite directions compensation is presumed. </li></ul><ul><li>When either the lungs or kidneys disagree with the body it is a compensatory mechanism. </li></ul><ul><li>Compensation is complete when the pH is within normal limits. </li></ul><ul><li>Compensation is partial when the pH remains out of range (but closer to normal than if there was no compensation. </li></ul><ul><li>The body will never fully compensate. </li></ul>
    49. 50. Step 3: Assess for Compensation <ul><li>Example 1 </li></ul><ul><li>pH = 7.29 (low) PaCO 2 = 31 mm Hg (low) HCO 3 - = 12 mEq/L (low)  </li></ul><ul><li>Partially Compensated Metabolic Acidosis </li></ul>
    50. 51. Step 3: Assess for Compensation <ul><li>Example 2 </li></ul><ul><li>pH = 7.36 (Normal) PaCO 2 = 25 mm Hg (low) HCO 3 - = 12 mEq/L (low)  </li></ul><ul><li>Compensated Metabolic Acidosis </li></ul>
    51. 52. Step 3: Assess for Compensation <ul><li>Example 3 </li></ul><ul><li>pH = 7.37 (Normal) PaCO 2 = 60 mm Hg (high) HCO 3 - = 30 mEq/L (high)  </li></ul><ul><li>Compensated Respiratory Acidosis </li></ul>
    52. 53. Blood Gas Interpretation Practice <ul><li>Practice 1 </li></ul><ul><li>pH = 7.25 </li></ul><ul><li>PaCO 2 = 65 mmHg </li></ul><ul><li>PaO 2 = 55 mmHg </li></ul><ul><li>HCO 3 - = 28 mEq/L </li></ul><ul><li>Respiratory Acidosis with moderate hypoxemia </li></ul>
    53. 54. Blood Gas Interpretation Practice <ul><li>Practice 2 </li></ul><ul><li>pH = 7.10 PaCO 2 = 99 mmHg </li></ul><ul><li>PaO 2 = 22 mmHg </li></ul><ul><li>HCO 3 - = 30 mEq/L </li></ul><ul><li>Partially compensated respiratory acidosis </li></ul><ul><li>with severe hypoxemia </li></ul>
    54. 55. Blood Gas Interpretation Practice <ul><li>Practice 3 </li></ul><ul><li>pH = 7.55 PaCO 2 = 38 mmHg </li></ul><ul><li>PaO 2 = 155 mmHg </li></ul><ul><li>HCO 3 - = 32 mEq/L </li></ul><ul><li>Uncompensated metabolic alkalosis </li></ul><ul><li>with hyperoxia </li></ul>
    55. 56. The Base Excess <ul><li>The amount of acid (in mmol) required to restore 1 litre of blood to its normal pH, at a PCO 2 of 40mmHg. </li></ul><ul><li>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. </li></ul>
    56. 57. The Base Excess <ul><li>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 </li></ul><ul><li>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 </li></ul>
    57. 59. Mechanical Ventilation
    58. 60. Iron Lung
    59. 61. Reasons for Mechanical Ventilation <ul><li>Respiratory Insufficiency/Failure </li></ul><ul><li>Airway Protection </li></ul><ul><li>Inadequate Respiratory Drive </li></ul><ul><li>Surgical/Procedural </li></ul>
    60. 62. Respiratory Insufficiency/Failure <ul><li>Textbook Definition: </li></ul><ul><ul><li>Respiratory activity is absent or is insufficient to maintain adequate oxygen uptake and carbon dioxide clearance </li></ul></ul><ul><ul><ul><li>Insufficiency – during exertion </li></ul></ul></ul><ul><ul><ul><li>Failure – at rest </li></ul></ul></ul><ul><li>Clinical Definition: </li></ul><ul><ul><li>Inability to maintain arterial PO 2 , PCO 2 and pH at acceptable levels </li></ul></ul><ul><ul><ul><li>PO 2 < predicted normal for age on R/A </li></ul></ul></ul><ul><ul><ul><li>PCO 2 > 50mmHg and rising </li></ul></ul></ul><ul><ul><ul><li>pH 7.25 and below </li></ul></ul></ul>
    61. 63. Signs & Symptoms of Respiratory Insufficiency/Failure
    62. 64. Respiratory Insufficiency/Failure <ul><li>Indications for mechanical ventilation </li></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Acute ventilatory failure </li></ul></ul><ul><ul><li>Impending acute ventilatory failure </li></ul></ul><ul><ul><li>Severe oxygenation deficit </li></ul></ul>
    63. 65. Respiratory Insufficiency/Failure <ul><li>Clinical indications for mechanical ventilation </li></ul><ul><ul><li>Primarily pulmonary </li></ul></ul><ul><ul><ul><li>ARDS </li></ul></ul></ul><ul><ul><ul><li>Pneumonia </li></ul></ul></ul><ul><ul><ul><li>Pulmonary Emboli </li></ul></ul></ul><ul><ul><li>Mechanical ability </li></ul></ul><ul><ul><ul><li>Ventilatory muscle fatigue </li></ul></ul></ul><ul><ul><ul><li>Thoracic injury / abnormalities </li></ul></ul></ul><ul><ul><ul><li>Pleural diseases </li></ul></ul></ul><ul><ul><ul><li>Neurological diseases </li></ul></ul></ul><ul><ul><ul><li>Nutritional deficiencies </li></ul></ul></ul>
    64. 66. Airway Protection <ul><li>Obstruction of the airway </li></ul><ul><ul><li>Secretion </li></ul></ul><ul><ul><li>Mucosal edema </li></ul></ul><ul><ul><li>Bronchoconstriction </li></ul></ul><ul><ul><li>Airway inflammation </li></ul></ul><ul><ul><li>Foreign body obstruction </li></ul></ul><ul><li>Inability to avoid aspiration </li></ul><ul><ul><li>HIE (Hypoxic Ischemic Encephalopathy) </li></ul></ul><ul><ul><li>Severe CNS defects </li></ul></ul>
    65. 67. Inadequate Respiratory Drive <ul><li>CNS disorders/injury </li></ul><ul><ul><li>HIE </li></ul></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Structural </li></ul></ul><ul><li>Neuromuscular disorders </li></ul><ul><ul><li>Amyotrophic lateral sclerosis (ALS) </li></ul></ul><ul><ul><li>Multiple sclerosis (MS) </li></ul></ul><ul><ul><li>Muscular dystrophy (MD) </li></ul></ul><ul><ul><li>Myasthenia gravis </li></ul></ul><ul><ul><li>Spinal muscular atrophy (SMA) </li></ul></ul><ul><ul><li>Central Hypoventilation Syndrome AKA Ondyne’s Curse </li></ul></ul>
    66. 68. Surgical/Procedural <ul><li>Paralysis </li></ul><ul><li>Reduced drive due to pharmacologic agents </li></ul><ul><ul><li>Opiates </li></ul></ul><ul><li>Cardiac or thoracic procedure involving lung manipulation </li></ul>
    67. 69. Goal of Mechanical Ventilation <ul><li>To provide the most appropriate amount of support via the least harmful and most comfortable manner </li></ul>
    68. 70. Goals of Mechanical Ventilation <ul><li>Gently……. </li></ul><ul><li>Exchange of CO 2 (ventilation) and O 2 (oxygenation) </li></ul><ul><li>Achieve goal pH range </li></ul><ul><li>Avoid baro/volutrauma </li></ul><ul><li>Avoid hypo/hypercarbia, hypo/hyperoxia </li></ul>
    69. 71. Ventilation – Getting CO 2 Out <ul><li>Ventilation controls PaCO 2 </li></ul><ul><li>Determined by Minute (Alveolar) Ventilation (MV) in liters/minute </li></ul><ul><li>MV – amount of gas in and out of the alveoli </li></ul><ul><li>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 </li></ul>
    70. 72. Ventilation - Getting CO 2 Out <ul><li>Respiratory rate (RR) - directly set </li></ul><ul><li>Tidal volume (V t ): Goal 8-10 ml/kg </li></ul><ul><li>Can be directly set (volume ventilation) </li></ul><ul><li>Or can be determined by the pressures used to ventilate (pressure ventilation) </li></ul>
    71. 73. Oxygenation - Getting O 2 In <ul><li>PaO 2 determined by : </li></ul><ul><ul><li>FiO 2 – directly set </li></ul></ul><ul><ul><li>Mean airway pressure </li></ul></ul><ul><li>Mean airway pressure (MAP) </li></ul><ul><ul><li>An average pressure across airway </li></ul></ul><ul><ul><li>Good estimate of alveolar pressure </li></ul></ul><ul><ul><li>Determined by PEEP and PIP </li></ul></ul><ul><ul><li>Also influenced by inspiratory time (It) </li></ul></ul>
    72. 74. Oxygenation – Getting O 2 In <ul><li>Mean Airway Pressure (MAP) </li></ul><ul><ul><li>In CMV majority of MAP is determined by PEEP </li></ul></ul><ul><ul><li>As rate increases, larger contribution from PIP </li></ul></ul><ul><ul><li>Too little, not enough open alveoli (and thus lung); too much, inhibit pulmonary blood flow </li></ul></ul><ul><li>Inspiratory Time (I t ) </li></ul>
    73. 75. Monitoring – How Are We Doing? <ul><li>Physical exam </li></ul><ul><ul><li>Chest rise </li></ul></ul><ul><ul><li>Color </li></ul></ul><ul><ul><li>Examination of the chest: </li></ul></ul><ul><ul><ul><li>Breath sounds </li></ul></ul></ul><ul><ul><ul><li>Air exchange </li></ul></ul></ul><ul><ul><ul><li>Extra sounds, i.e., crackles, wheezes, rhonchi… </li></ul></ul></ul><ul><li>Radiographic studies </li></ul>
    74. 76. Monitoring – How Are We Doing? <ul><li>Gasses </li></ul><ul><ul><li>pH, PO 2 , PCO 2 , serum bicarbonate (calculated) </li></ul></ul><ul><ul><li>TcCO 2 monitoring </li></ul></ul><ul><ul><li>In vivo monitoring </li></ul></ul>
    75. 77. Now Let’s Talk About Ventilation
    76. 78. Some Terms <ul><li>Peak End Expiratory Pressure (PEEP) </li></ul><ul><ul><li>Maintains open alveoli </li></ul></ul><ul><ul><li>Distending pressure across airways </li></ul></ul><ul><li>Peak Inspiratory Pressure (PIP) </li></ul><ul><ul><li>Highest pressure reached during breath </li></ul></ul><ul><ul><li>Provides pressure to move gas into lungs in positive pressure ventilation </li></ul></ul><ul><li>∆P = PIP - PEEP </li></ul><ul><ul><li>In general, determines tidal volume </li></ul></ul>
    77. 79. PEEP
    78. 80. PEEP <ul><li>PEEP 0 5 12 20 </li></ul>
    79. 81. Modes of Ventilation <ul><li>Assist Control (A/C, CMV) </li></ul><ul><li>Synchronized Intermittent Mandatory Ventilation (SIMV) </li></ul>
    80. 82. Modes of Ventilation <ul><li>Assist Control (A/C, CMV) </li></ul><ul><ul><li>The ventilator has a number of preset machine breaths, at a set tidal volume or inspiratory pressure level (Vt or I P ) each minute. </li></ul></ul><ul><ul><li>The patient is capable of initiating their own spontaneous breaths in between machine breaths </li></ul></ul><ul><ul><ul><li>Spontaneous breaths will be equal to preset ventilator breaths </li></ul></ul></ul>
    81. 83. <ul><li>Synchronized Intermittent Mandatory Ventilation (SIMV) </li></ul><ul><ul><li>The ventilator has a number of preset machine breaths, at a set tidal volume or inspiratory pressure level (Vt or I P ) each minute. </li></ul></ul><ul><ul><li>The patient is capable of initiating their own spontaneous breaths in between machine breaths </li></ul></ul><ul><ul><ul><li>Spontaneous breath will be whatever size the patient wants to take </li></ul></ul></ul><ul><ul><ul><li>Used most often in conjunction with Pressure Support (PS) </li></ul></ul></ul>Modes of Ventilation
    82. 84. Breath Delivery Types <ul><li>Volume Control </li></ul><ul><li>Pressure Control </li></ul><ul><li>Pressure Regulated Volume Control </li></ul><ul><li>Spontaneous Breath Types </li></ul><ul><ul><li>CPAP (Continuous Positive Airway Pressure) </li></ul></ul><ul><ul><li>Pressure Support </li></ul></ul><ul><ul><li>Volume Support </li></ul></ul><ul><ul><li>BiPAP (Biphasic Positive Airway Pressure) </li></ul></ul>
    83. 85. Breath Delivery types <ul><li>Volume Control </li></ul><ul><ul><li>Preset Vt, Respiratory Rate and sometimes flow </li></ul></ul><ul><ul><li>Peak Pressure (PIP) is variable while the volume remains constant. </li></ul></ul>
    84. 86. Breath Delivery Types (cont) <ul><li>Pressure Control Ventilation (PCV) </li></ul><ul><ul><li>Preset RR, Inspiratory Time and Inspiratory Pressure </li></ul></ul><ul><ul><li>Vt is variable while pressure remains constant </li></ul></ul>
    85. 87. Breath Delivery Types (cont) <ul><li>Pressure Regulated Volume Control (PRVC) </li></ul><ul><ul><li>Preset RR, Inspiratory Time and Vt </li></ul></ul><ul><ul><li>Pressure is variable yet limited while Vt remains constant </li></ul></ul>
    86. 88. <ul><li>Continuous Positive Airway Pressure (CPAP) </li></ul><ul><ul><li>Preset level of pressure added to the circuit as the patient exhales. </li></ul></ul><ul><ul><li>The patient does all the work </li></ul></ul><ul><ul><li>No set RR or tidal volume </li></ul></ul><ul><ul><li>Used most often with Pressure Support </li></ul></ul>Spontaneous Breath Delivery Types
    87. 89. Spontaneous Breath Delivery Types <ul><li>Pressure Support (PS) </li></ul><ul><ul><li>Preset level of pressure added to the spontaneous breath during inspiration only </li></ul></ul><ul><ul><li>This helps augment the patients tidal volume </li></ul></ul><ul><ul><li>Pressure is constant but tidal volume varies </li></ul></ul>
    88. 90. Spontaneous Breath Delivery Types <ul><li>Volume Support (VS) </li></ul><ul><ul><li>Variable pressure support added to the ventilator during inspiration only, to deliver a preset Vt </li></ul></ul><ul><ul><ul><li>Tidal volume is constant but pressure varies </li></ul></ul></ul>
    89. 91. Spontaneous Breath Delivery Types <ul><li>Biphasic Positive Airway Pressure (BiPAP) </li></ul><ul><ul><li>Preset level of pressure added to the circuit during both inspiratory and expiratory phases. </li></ul></ul><ul><ul><li>Differing levels of inspiratory and expiratory support </li></ul></ul><ul><ul><li>The patient does all the work </li></ul></ul><ul><ul><li>No set RR or tidal volume </li></ul></ul>
    90. 92. The Alphabet Game <ul><li>Combined Modes of Ventilation </li></ul><ul><ul><li>PRVC (pressure regulated volume control) </li></ul></ul><ul><ul><li>APRV (airway pressure release ventilation) </li></ul></ul><ul><ul><li>BiVent </li></ul></ul><ul><ul><li>BiLevel </li></ul></ul><ul><ul><li>VAPS (volume assured pressure support) </li></ul></ul><ul><ul><li>VS (volume support) </li></ul></ul><ul><ul><li>Automode </li></ul></ul>
    91. 93. Determination of Ventilator Settings <ul><li>Mode </li></ul><ul><ul><li>Depends on patient </li></ul></ul><ul><li>Breath Delivery Type </li></ul><ul><ul><li>Depends on patient </li></ul></ul><ul><li>Vt </li></ul><ul><ul><li>6-10cc’s/kg </li></ul></ul><ul><li>RR </li></ul><ul><ul><li>12 – 40 bpm’s (depending on age & desired Minute Ventilation) </li></ul></ul><ul><li>FiO2 </li></ul><ul><ul><li>Usually start at 100% </li></ul></ul><ul><ul><li>Less if patient has been on a vent for a while </li></ul></ul><ul><li>PEEP </li></ul><ul><ul><li>Depends on patient </li></ul></ul><ul><li>PS </li></ul><ul><ul><li>Depends on patient </li></ul></ul>
    92. 94. Patient Consideration <ul><li>Humidification </li></ul><ul><ul><li>HME </li></ul></ul><ul><ul><li>Heated (37 ◦ C & 44mg/L Water Vapor) </li></ul></ul><ul><li>Suctioning </li></ul><ul><ul><li>Saline </li></ul></ul><ul><li>Nutrition </li></ul><ul><ul><li>Enteral (Gavage) </li></ul></ul><ul><ul><li>Parenteral (TPN) </li></ul></ul>
    93. 95. Sedatives, Analgesics, and Paralytics
    94. 97. Sedatives <ul><li>Benzodiazepines </li></ul><ul><li>Opioids </li></ul><ul><li>Neuroleptics </li></ul>
    95. 98. Benzodiazepines <ul><li>Drugs of choice for treatment of anxiety </li></ul><ul><ul><li>Relatively low cost </li></ul></ul><ul><ul><li>Muscle-relaxing </li></ul></ul><ul><ul><li>Anticonvulsant </li></ul></ul><ul><ul><li>Amnesiac effects </li></ul></ul><ul><li>May cause respiratory depression if administered to COPD patients on opioids </li></ul><ul><li>Minimal cardiovascular effects, BP depression possible in hemodynamically unstable patients </li></ul>
    96. 99. Most common benzos in ICU <ul><li>Generic Name (Trade Name) ½ life </li></ul><ul><li>Diazepam (Valium) 20- 120 hrs </li></ul><ul><ul><li>Rapid onset </li></ul></ul><ul><li>Midazolam (Versed) 3 – 11 hrs </li></ul><ul><ul><li>Onset 2-3 minutes </li></ul></ul><ul><li>Lorazepam (Ativan) 8 – 15 hrs </li></ul><ul><ul><li>Onset 5 – 20 minutes </li></ul></ul>
    97. 100. Opioids <ul><li>Primarily used for pain relief </li></ul><ul><li>Secondarily used for as anxiolytic and sedation </li></ul><ul><li>Many serious side effects </li></ul><ul><ul><li>Respiratory Depression </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Cardiovascular depression </li></ul></ul><ul><ul><li>Reduced GI motility </li></ul></ul><ul><ul><li>Convulsions </li></ul></ul><ul><ul><li>High physical dependence </li></ul></ul>
    98. 101. Opioids <ul><li>Recovery period lengthened in renal/hepatic insufficiency </li></ul><ul><li>May cause histamine release and bronchoconstriction </li></ul><ul><li>Reversal medication </li></ul><ul><ul><li>Naloxone Hydrochloride (Narcan) </li></ul></ul><ul><ul><ul><li>30 minutes half life </li></ul></ul></ul><ul><ul><ul><li>May require IV infusion for opioid withdrawal </li></ul></ul></ul>
    99. 102. Most common Opioids in ICU <ul><li>Generic name (Trade name) </li></ul><ul><li>Fentanyl Hydrochloride (Sublimaze) </li></ul><ul><ul><li>Synthetic </li></ul></ul><ul><ul><li>1 - 4 hours duration with fast onset </li></ul></ul><ul><ul><li>100 – 150 times more potent than MS </li></ul></ul><ul><ul><li>Less cardiac side effects than MS </li></ul></ul><ul><li>Morphine Sulfate (Duramorph) </li></ul><ul><ul><li>1- 6 hours duration with slower onset </li></ul></ul><ul><ul><li>Preferred for lower cost </li></ul></ul>
    100. 103. Neuroleptics <ul><li>Used to treat extreme agitation and delirium (increased in elderly and burn patients) </li></ul><ul><li>Side effects </li></ul><ul><ul><li>Decreased seizure threshold </li></ul></ul><ul><ul><li>Cardiac dysrhythmias </li></ul></ul><ul><ul><li>Parkinson’s-type symptoms </li></ul></ul><ul><ul><ul><li>Muscle rigidity </li></ul></ul></ul><ul><ul><ul><li>Lethargy </li></ul></ul></ul><ul><ul><ul><li>Drowsiness </li></ul></ul></ul>
    101. 104. Most common Neuroleptic Drug in ICU: <ul><li>Generic name (Trade name) </li></ul><ul><li>Haloperidol (Haldol) </li></ul><ul><ul><li>3 - 5 minute onset </li></ul></ul><ul><ul><li>5 - 24 hours half-life </li></ul></ul>
    102. 105. Anesthetics <ul><li>Used for sedative, hypnotic & amnesiac properties </li></ul><ul><li>NO analgesic effects </li></ul><ul><li>Many hemodynamic effects </li></ul><ul><ul><li>Decreased SVR </li></ul></ul><ul><ul><li>Decreased BP </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><li>Good for IC bleeds </li></ul><ul><ul><li>Neurosurgical patients = decreases ICP </li></ul></ul><ul><li>Rapid “wake-up”… no hangover </li></ul><ul><li>Painful on injection </li></ul><ul><li>Used in OR, ICU </li></ul><ul><li>Lipid based solution prone to contamination </li></ul>
    103. 106. Anesthetics <ul><li>Generic name (Trade name) </li></ul><ul><li>Diprivan (Propofol) </li></ul><ul><ul><li>Onset 1 minute, </li></ul></ul><ul><ul><li>Half-life <30 minute </li></ul></ul><ul><ul><li>Expensive </li></ul></ul>
    104. 107. Paralytics <ul><li>Used to: </li></ul><ul><ul><li>Facilitate mechanical ventilation </li></ul></ul><ul><ul><li>Treat extreme agitation </li></ul></ul><ul><ul><li>Facilitate intubation and other procedures </li></ul></ul><ul><ul><li>Manage tetanus </li></ul></ul><ul><ul><li>Extreme hyperventilation </li></ul></ul><ul><ul><li>Reduction of O 2 consumption & CO 2 production </li></ul></ul><ul><li>Can cause </li></ul><ul><ul><li>Decreased BP </li></ul></ul><ul><ul><li>Cardiac dysrhythmias </li></ul></ul><ul><ul><li>Prolonged paralysis in patients with renal/hepatic insufficiency </li></ul></ul>
    105. 108. Paralytics <ul><li>NO SEDATIVE EFFECTS </li></ul><ul><li>NO ANALGESIC EFFECTS </li></ul><ul><li>Essentially it paralyzes your patient - MUST be given WITH analgesic and sedative!! </li></ul>
    106. 109. Paralytics <ul><li>Generic name (Trade name) </li></ul><ul><li>Panacuronium (Pavulon) </li></ul><ul><li>“ Vec” Vecuronium (Norcuron) </li></ul><ul><li>“ Rock” Rocuronium (Zemuron) </li></ul><ul><li>“ Sux” Succinylcholine (Anectine) </li></ul>
    107. 110. Respiratory Diseases <ul><li>Pneumonia </li></ul><ul><li>PE </li></ul><ul><li>ARDS </li></ul><ul><li>Chest Trauma </li></ul>
    108. 111. Pneumonia <ul><li>Definition: </li></ul><ul><ul><li>Inflammation process that primarily effects the gas exchange area’s of the lung </li></ul></ul><ul><li>Etiology: </li></ul><ul><ul><li>Bacteria, viruses, fungi, TB, etc. </li></ul></ul><ul><li>Clinical Manifestation: </li></ul><ul><ul><li>Initially dry cough, turning productive with blood streaked sputum, crackles, rhonchi, dyspnea, cyanosis </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>O 2 therapy, bronchial hygiene, bronchodilators, antibiotics </li></ul></ul>
    109. 112. Pulmonary Embolism <ul><li>Definition: </li></ul><ul><ul><li>Complete or partial obstruction of the pulmonary artery blood flow to a distal portion of the lung by a plug brought by the blood </li></ul></ul><ul><li>Etiology: </li></ul><ul><ul><li>Blood clots (blood stasis, vessel wall abnormalities, abnormal blood coagulation), Fat, Tumors, Air </li></ul></ul><ul><li>Clinical Manifestation: </li></ul><ul><ul><li>Asymptomatic to death, dyspnea and sharp chest pain most common, </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>O 2 therapy, anticoagulation therapy, steroids, embolectomy </li></ul></ul>
    110. 113. ARDS <ul><li>Definition: </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>Etiology: </li></ul><ul><ul><li>Shock (severe hemorrhage, trauma, MI, CVA, CABG) </li></ul></ul><ul><ul><li>Inhalation (O 2 , aspiration, near drowning, burns) </li></ul></ul><ul><ul><li>Infection (viral pneumonia, sepsis) </li></ul></ul><ul><ul><li>Over-hydration, chemical injury, blood infusion, etc. </li></ul></ul><ul><li>Clinical Manifestation: </li></ul><ul><ul><li>Rapid onset, dyspnea, hypoxia, tachypnea, tachycardia, ↓ed compliance, </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Treat underline cause, O 2 , PEEP, CPT, Sx, diuretics, ventilator </li></ul></ul>
    111. 114. Chest Trauma <ul><li>Account for ¼ of all trauma deaths </li></ul><ul><li>Blunt Trauma </li></ul><ul><ul><li>Steering wheels </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><li>Penetrating Trauma </li></ul><ul><ul><li>Knife wounds </li></ul></ul><ul><ul><li>Gunshots </li></ul></ul><ul><li>Primary concern </li></ul><ul><ul><li>ABC </li></ul></ul><ul><ul><li>C-Spine </li></ul></ul>
    112. 115. Chest Trauma <ul><li>Fractures/Flail chest </li></ul><ul><ul><li>High or low fx, watch for concurrent injuries </li></ul></ul><ul><li>Pneumothorax </li></ul><ul><ul><li>Spontaneous or trauma, < or >20%, 2 nd ICS MCL or 5 th ICS MAL </li></ul></ul><ul><li>Hemothorax </li></ul><ul><ul><li>Mild <300cc, Moderate b/w 300-1400cc, Severe >1400cc </li></ul></ul><ul><ul><li>Drain, surgery for >200cc/hr, transfusions </li></ul></ul><ul><li>Sucking chest wound </li></ul><ul><ul><li>Open flap in chest wall, sucking sound, tension pneumo ?, sterile dressing over 3 sides </li></ul></ul>
    113. 116. Questions?
    114. 117. Thank you