Alterations in respiratory function


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Presentation to participants undertaking the: Critical Care Transition Program at ACT Health, 2008

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  • Bacterial: effects aged and immunosupressed, antibacterial drugs have reduced the mortality significantly and shortened illness Decreased clearance rate of common bacteria (Increased susceptability of the host or decrease work of macrophages) Pneumococcal Pneumonia : 30 – 80% of CAP Viral: mild and self-limiting by adults. May progress to bacterial pneumonia due to susccepability of person Aspiration: unconscious or decreased LOC at high risk
  • Rib #s – voluntary support, decreased TV
  • Pleural Effusion R) side – also from neoplasms, infection, PE, Normally pleural fluid is produced  absorbed  prodeced, etc… to provide a smooth line within the plueral space.
  • Pneumo: Air enters the pleural space Heamo: Blood in the plueral space
  • Mediastinal Shift - pressure builds up and pushes the mediastinal cavity to the unaffected side, the lung may collapse creating a life threatening situation Cardiac Tamponade - collection of blood in pericardial/mediastinal space may compress the myocardium compromising cardiac function and cardiac output
  • One bottle system creates seal. Air out but not in… Any positive pressure greater then 2cm H2O will expel air. Suction is not regulated. If fluid enters the bottle
  • One bottle system creates seal. Air out but not in… Any positive pressure greater then 2cm H2O will expel air. Suction is not regulated. If fluid enters the bottle
  • Spinal cord: trauma – qaud / para Motor nerve: Tick-bite paralysis, Guillain-Barre syndrome Infectious: tetanus Muscle wasting: muscular dystrophy Guillain-Baree acute toxic polyneuritis – has varying degrees of muscle weakness and paralysis: respiratory complications are threefold Paralysis of the internal and external intercostal muscles reduces functional breathing ability – breathing becomes diaphramatic paralysis of the vagal nerve – gag reflex is lost
  • Acute Bronchitis : common condition caused by infection that results in inflammation of the mucosal lining of the tracheobroncial tree
  • Asthma : Acute airway obstruction. Characterised by recurrent paroxysms of wheezing and dyspnoea (not related to cardiac disease). Bronchospasm in response to various stimuli. Not all wheezing is asthma (eg aspitation, tumour). Extrinsic or intrinsic : extrinsic – specific allergies, childhood asthma is usually self-limiting, decrease severity as person matures. IgE mast cells respond, constriction of smooth muscle, increased secretions, inflammation response (cyclic)  narrowing of airways. intrinsic – related to infection, exercise Fatigue is a major problem in asthma.
  • Bronchiectasis :irreversible dilation of the bronchi and broncioles – usually preceeded by infection and inflammation of the respiratory tract. Unknown if the disease is due to infection or abnormall structure. Common sympotoms include cough, symptoms of infection
  • Cystic Fibrosis : hereditary disorder in which large quantities of viscous material are secreted – early age onset Chronic Brobnchitits : continual bronchial inflammation and progressive increase in productive cough, not attributed to a specific cause. PATHO- thickening and rigidity of bronchial mucosa to chronic irritation. Closely related to emphysema but is usually defined as an abnormality that involves excessive secretion of mucus and bronchial inflammation.
  • Pulmonary Emphysema : most common chronic pulmonary disease and frequently classified with chronic bronchitis. Differs: CB v PE History: recurrent chest infections v not recurrent chest infections Chest exam: noisy v quiet General appearance: “blue bloater” v “pink puffer” / barrel chest Draw bell curve / continuum (Chronic bronchitis) ------------------ (majority w both) ------------------------- (pulmonary empysema)
  • Organo-phosphate poisoning: protect self!! Asbestosis Coal workers – fibrosis due to excess macrophases
  • Medications: Antibiotics Inotropes Steriods Prone positioning ( PaO2/FiO2 189±34 prone vs. 83±14 supine after 6 hours)
  • Alterations in respiratory function

    1. 1. Alterations in Respiratory Function
    2. 2. Objectives <ul><li>List the clinical manifestations of common alterations in respiratory function </li></ul><ul><li>Outline the critical care management of patients with alterations in respiratory function </li></ul>
    3. 3. Common Alterations in Respiratory Function Pulmonary Oedema Lower Respiratory Tract Infection Traumatic Injury Neurological Disease Adult Respiratory Distress Syndrome Chronic Obstructive Pulmonary Disease Upper Respiratory Tract Infection Atelectasis Industrial Diseases Obesity Acute Obstructive Airways Diseases
    4. 4. Case <ul><li>75yo ♀ BIBA w/ 1/52 HO ↑ SOB </li></ul><ul><li>Sp02 86% on RA  98% on HM @ 6LPM. HR 155, BP 105/55, peripherally cool. </li></ul><ul><li>T: 38.6 </li></ul><ul><li>GCS 14 (E: 4 V: 4 M:6) </li></ul>
    5. 5. Assessment <ul><li>Physical Assessment </li></ul><ul><li>↓ R) chest wall expansion </li></ul><ul><li>Tactile fermatas </li></ul><ul><li>↓ AE R) lower lobe </li></ul><ul><li>Blood work-up </li></ul><ul><li>↑ WCC </li></ul><ul><li>CXR </li></ul><ul><li>ECG </li></ul>
    6. 6. Case
    7. 7. Case
    8. 8. Management <ul><li>O2 therapy </li></ul><ul><li>Circulatory support </li></ul><ul><li>IVABs </li></ul><ul><li>Monitor </li></ul>
    9. 9. Lower Respiratory Tract Infection <ul><li>Pneumonia </li></ul><ul><ul><li>Bacterial </li></ul></ul><ul><ul><li>Viral </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul><ul><li>Tuberculosis </li></ul>
    10. 10. Pulmonary Oedema <ul><li>Alteration in hydrostatic and/or osmotic pressure </li></ul>
    11. 11. Traumatic Injury <ul><li>Rib #s </li></ul>
    12. 12. Traumatic Injury <ul><li>Rib #s </li></ul><ul><li>Pleural Effusion </li></ul>
    13. 13. Traumatic Injury <ul><li>Rib #s </li></ul><ul><li>Pleural Effusion </li></ul><ul><li>Pneumothorax </li></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><li>Heamothorax </li></ul>
    14. 14. Traumatic Injury
    15. 15. Chest Drains
    16. 16. Chest Drains
    17. 17. Chest Drains
    18. 18. Chest Drains
    19. 19. Chest Drains
    20. 20. Chest Drains
    21. 21. Chest Drains
    22. 22. Chest Drains
    23. 23. Chest Drains
    24. 24. Chest Drains
    25. 25. Neurological Disease <ul><li>Spinal cord disease </li></ul><ul><li>Motor nerve disease </li></ul><ul><li>Infectious disease </li></ul><ul><li>Muscle-wasting disease </li></ul>
    26. 26. Acute Obstructive Pulmonary Disease <ul><li>Acute Bronchitis </li></ul>
    27. 27. Acute Obstructive Pulmonary Disease <ul><li>Acute Bronchitis </li></ul><ul><li>Asthma </li></ul>
    28. 28. Chronic Obstructive Pulmonary Disease <ul><li>Bronchiectasis </li></ul>
    29. 29. Chronic Obstructive Pulmonary Disease <ul><li>Bronchiectasis </li></ul><ul><li>Cystic Fibrosis </li></ul><ul><li>Chronic Bronchitis </li></ul>
    30. 30. Chronic Obstructive Pulmonary Disease <ul><li>Bronchiectasis </li></ul><ul><li>Cystic Fibrosis </li></ul><ul><li>Chronic Bronchitis </li></ul><ul><li>Pulmonary Emphysema </li></ul>
    31. 31. Industrial Illness <ul><li>Organo-phosphate poisoning </li></ul><ul><li>Asbestosis </li></ul><ul><li>Coal workers’ pneumoconiosis </li></ul>
    32. 32. Adult Respiratory Distress Syndrome <ul><li>“ The acute onset of severe respiratory distress and cyanosis that was refractory to oxygen therapy and associated with diffuse CXR abnormality and decreased lung compliance”. </li></ul>
    33. 33. Adult Respiratory Distress Syndrome <ul><li>Severe hypoxemia </li></ul><ul><li>Loss of lung compliance </li></ul><ul><li>Secondary disease </li></ul><ul><ul><li>Reduced perfusion </li></ul></ul><ul><ul><li>Increased capillary permeability </li></ul></ul><ul><ul><li>Direct tissue and capillary insult </li></ul></ul><ul><ul><li>Other mechanism </li></ul></ul><ul><li>Despite primary disease, same pathology exists </li></ul>
    34. 34. Adult Respiratory Distress Syndrome <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Tachypnoea </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><ul><li>Scattered crackles </li></ul></ul><ul><ul><li>Increased work of breathing </li></ul></ul><ul><ul><li>Agitation </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Decreased LOC </li></ul></ul>
    35. 35. Adult Respiratory Distress Syndrome <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Acute onset (usually within 4 hours or 2-4 days of initial trauma) </li></ul></ul><ul><ul><li>Bilateral Infiltrates </li></ul></ul><ul><ul><li>Two Categories: </li></ul></ul><ul><ul><ul><li>PaO 2 /Fio 2 ratio < 300 (ALI) </li></ul></ul></ul><ul><ul><ul><li>PaO 2 /Fio 2 ratio < 200 (ARDS) </li></ul></ul></ul><ul><ul><ul><li>(ALI is milder than ARDS that may or may not progress onto ARDS) </li></ul></ul></ul>
    36. 36. Adult Respiratory Distress Syndrome <ul><li>Treatment </li></ul><ul><li>ABC </li></ul><ul><li>Mechanical ventilation </li></ul><ul><li>Monitor </li></ul><ul><li>Treatment of underlying disease </li></ul><ul><li>Medications </li></ul><ul><li>Prone Positioning (189±34 v 83±14) </li></ul><ul><li>Nutritional Support </li></ul>
    37. 37. Oxygen Therapy <ul><li>Nasal Prongs </li></ul><ul><ul><li>Low flow </li></ul></ul><ul><ul><li>2 – 4 LPM </li></ul></ul>
    38. 38. Oxygen Therapy <ul><li>Hudson Mask </li></ul><ul><ul><li>Variable flow </li></ul></ul><ul><ul><li>6 – 15 LPM </li></ul></ul><ul><ul><li>~40–60% </li></ul></ul>
    39. 39. Oxygen Therapy <ul><li>Non-Rebreather Mask </li></ul><ul><ul><li>High flow </li></ul></ul><ul><ul><li>Inflate bag </li></ul></ul><ul><ul><li>~90-95% </li></ul></ul>
    40. 40. Oxygen Therapy <ul><li>Venturi Mask </li></ul><ul><ul><li>High flow </li></ul></ul><ul><ul><li>Adjust oxygen to flow rate </li></ul></ul>
    41. 41. Oxygen Therapy <ul><li>Bag mask ventilation </li></ul><ul><ul><li>High flow </li></ul></ul><ul><ul><li>100% </li></ul></ul><ul><ul><li>Respiratory support </li></ul></ul>
    42. 42. Alterations in Respiratory Function