A very large proportion of Intensive Care Patients. Discussed in detail about causes diagnosis and management pearls of neuromuscular respiratory failure. Intensive Care Physicians will find this presentation very useful and informative.
Bronchial Thermoplasty (BT) Novel Treatment for Patients with Severe AsthmaBassel Ericsoussi, MD
Do our Asthma Patients Know What They Are Missing?Now, A Revolutionary Procedure Can Help Them Lead A Fuller Life.
Bronchial Thermoplasty (BT) Novel Treatment For Patients With Severe Asthma
Presentation of Dr. Dean Hess at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
Bronchial Thermoplasty (BT) Novel Treatment for Patients with Severe AsthmaBassel Ericsoussi, MD
Do our Asthma Patients Know What They Are Missing?Now, A Revolutionary Procedure Can Help Them Lead A Fuller Life.
Bronchial Thermoplasty (BT) Novel Treatment For Patients With Severe Asthma
Presentation of Dr. Dean Hess at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
MECHANICAL VENTILATION IN NEUROLOGICAL AND NEUROLOGICAL CASES.pptxNeurologyKota
20% of all patients requiring mechanical ventilation suffer from neurological dysfunction.
Major contributor to prolongation of mechanical ventilation in over a third of patients admitted in ICU.
Managing Respiratory Symptoms in Advanced MS by Rachael Mosesmiranda olding
Advanced MS & neuromuscular disease cause respiratory problems leading to problems with talking, eating and chest infections, which can be fatal. Rebreathe bags & airway clearance machines / cough machines can enhance quality of life, and prove cost-effective in preventing unplannned hospital admissions for chest infection.
How to manage a case of acute exacerbation of COPD according to GOLD guidelines. Sincere thanks to Dr. Amardeep Toppo who has prepared most of this presentation.
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
A simplified description of basal ganglia stroke to help understand the clinical scenarios where patients present with neurological symptoms not clearly pointing towards possibility of stroke.
Vertebral artery pseudo-aneurysms and dissections are known to occur as a result of mechanical
manipulations of the cervical region, traumatic injury, spontaneously and iatrogenic injury because of central
venous catheterization. Central venous lines have become an integral part of patient care, but they are
not without complications. Vertebral artery injury (leading to pseudo-aneurysm and dissection) is one of
the rarer complications of central venous catheter placement. We report a case of inadvertent vertebral
artery catheterization during a dialysis catheter placement which subsequently demonstrated arterial
blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery catheterization.
It was successfully treated with open surgical technique by the vascular surgeon because of the size of
catheter and subsequent requirement of artery repair. There were no neurological sequelae. Open surgical
repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudo-aneurysms
has been described with promising outcomes, but long-term results are lacking. This case report describes
the rare iatrogenic event of vertebral artery injury and reviews its etiology, diagnosis, complications, and management.
From eye drops to icu, a case report of three side effects of ophthalmic timo...Muhammad Asim Rana
Timolol Maleate (also called Timolol) is a nonselective beta-adrenergic blocker and a class II antiarrhythmic drug, which is used
to treat intraocular hypertension. It has been reported to cause systemic side effects especially in elderly patients with other
comorbidities.These side effects are due to systemic absorption of the drug and it is known that Timolol is measurable in the serum
following ophthalmic use. Chances of life threatening side effects increase if these are coprescribed with other cardiodepressant
drugs like calcium channel or systemic beta blockers. We report a case where an elderly patient was admitted with three side
effects of Timolol and his condition required ICU admission with mechanical ventilation and temporary transvenous pacing.The
case emphasizes the need of raising awareness among physicians of such medications about the potential side effects and drug
interactions. A close liaison among patient’s physicians is suggested.
Congenitally absent Inferior Vena Cava: A rare cause of recurrent DVT and non...Muhammad Asim Rana
In search of a cause for the so-called idiopathic Deep Vein Thrombosis (DVT), researchers have
pointed towards association between recurrent DVT and absent IVC
The best use of systemic corticosteroids in the intensive care units, reviewMuhammad Asim Rana
Corticosteroids are one of the most common medications that are used in the intensive care units (ICUs);
corticosteroids are used for a variety of indications, including septic shock, acute respiratory distress syndrome
(ARDS), bacterial meningitis, tuberculous meningitis, lupus nephritis, severe chronic obstructive pulmonary disease
(COPD) exacerbations and many others.
Corticosteroids are associated with many severe side effects that affect morbidity and mortality of the patients like
increased risk of infections, glucose intolerance, hypokalemia, sodium retention, edema, hypertension, myopathy
etc. In order to make the best use of these medications and to minimize the unwanted side effects we should follow
some particular protocol. Please keep in our mind that there is controversy about dosing and tapering of steroids, so
effort has been made to include the best available evidence.
This review discusses mainly the most common indications of corticosteroids in ICU, dosing of corticosteroids in
those indications and how to taper corticosteroids according to the best evidence that recommends their use.
Literature search was done using Medline, BMJ, Uptodate, Chochrane database, Google scholar and the best
evidence based guidelines in which steroids are recommended to treat ICU related disorders. Sex hormones are not
discussed in this review since its use is rare in the intensive care units.
A very effective, precise and focused presentation for Calcium abnormalities and approach towards management. Targeted to teach the to the point diagnosis and treatment.
It is requested to download the presentation to run the animation as it is a very interactive presentation
A detailed discussion and description on fungal diseases and management. The focus is kept on those facts which frequently come across an intensivist but it is also important for the Internist.
A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
A detailed discussion on a very much in demand topic. Covered all aspects of the procedure which are important for an Emergency, Medical and Intensive Care physician should know. Nurses can also benefit from the presentation as we have tried to keep it as simple and straight forward as possible.
Transorbital stab injury with retained knife. A narrow escapeMuhammad Asim Rana
An interesting case report about a patient who was admitted with a 13 cm long knife stabbed in his eye and has gone across the mid line. The interesting thing to note is that patient did not develop any neurological deficit.
Multi drug resistant bacteria are a big problem in ICUs now a days. This is a successful case report where we treated an pleural infection b directly instilling the drug colistin in the pleura.
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
A brief yet comprehensive description of a very common problem faced in KSA especially during hajj season. It is meant to enhance the awareness among ER and ICU physicians.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
Ethnobotany and Ethnopharmacology:
Ethnobotany in herbal drug evaluation,
Impact of Ethnobotany in traditional medicine,
New development in herbals,
Bio-prospecting tools for drug discovery,
Role of Ethnopharmacology in drug evaluation,
Reverse Pharmacology.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
2. Introduction
•
•
•
•
Respiratory Failure… definition
Types…. I & II
Why this distinction is important?
Causes & Classification
– Pulmonary
– Non pulmonary
• Nonpulmonary causes of respiratory failure
include diverse group of disorders….
• Pathophysiologic hallmark….. Hypoventilation
• Approx 20% cases of respiratory failure
3. Introduction
• Hypoventilation
• Theoretical definition:
– Deviation from the usual state of ventilatory
control resulting in decreased minute ventilation
relative to metabolic requirements
• Operational definition:
– Hypoventilation exists when alveolar or arterial
PaCO2 exceeds normal upper limit (44 mmHg)
4. Single compartment lung model
PaCO2= VCO2/VE (1-VD/VT)
PAO2= FiO2(Patm-P H2O)-1.2(PaCO2)
–
–
–
–
VCO2= CO2 elimination rate
VE= minute ventilation
VD= dead space
VT= tidal volume
5. EtiologicalClassification
Plum & Leigh & Phillipson
Nonpulmonary causes of respiratory failure
Ventilatory control
Neuromuscular Disorders
↓Peripheral
Chemosensitivity
Anterior horn cells
Brain stem neurons
Phrenic neuropathies
Spinal Cord pathways
NMJ disorders
Respiratory muscles
In all these conditions the lungs are normal !!!!
Chest wall & Other
disorders
Obesity-hypovent
Syndrome
Kyphoscoliosis
Fibrothorax
Thoracoplasty
Ankylosing
spondylitis
Flail chest
Metabolic alkalosis
6. Primary disorders of ventilatory control
↓Peripheral
Chemosensitivity
Carotid body
surgery
Prolonged hypoxia
Metabolik alkalosis
Brain stem neurons
Bulbar polio
Syringobulbia
Encephalitis
Infarction
Neoplasm
Demyelinating
disorders
Drugs
Neoplasms
Spinal Cord pathways
Trauma
Bilateral high
cervical cordotomy
Anterior spinal
cord surgery
Transverse myelitis
Encephalomyelitis
9. Neurogenic Respiratory Failure
• Definition
– Respiratory failure due to difficulties with
•
•
•
•
Cortical, Brainstem respiratory centers
Motor neurons (Cell bodies)
Axons
Neuromuscular junction
– Pre synaptic
– Post synaptic
• Muscle
– Not due to primary pulmonary problems
10. Clinical Recognition
Signs and Symptoms
• The initial manifestation of respiratory failure & the
age at presentation can vary….
• Primary disorders of ventilatory control
–
–
–
–
Excessive day time somnolence
Pulmonary HTN
Corpulmonale
Severe respiratory failure following sedatives
• Neuromuscular disorders
–
–
–
–
Unexplained hypercapnia
Dyspnea
Sleep disruption
Recurrent pneumonia
11. Manifestation of Respiratory Muscles Involvement
• Tachypnea …. (expression of muscle fatigue)
• Signs of diaphragmatic weakness
–
–
–
–
Orthopnea
Paradoxical abdominal wall movement
Respiratory alternans
REM associated hypoventilation
• Signs of abdominal muscle weakness
– Decreased cough effort
• Signs of bulbar muscle weakness
–
–
–
–
–
Dysarthria
Dysphonia
Dysphagia
Aspiration
Obstructive sleep apnea
12. Functional Assessment
Disorders of ventilatory control
Chronic neuromuscular disorders
•
•
•
•
•
•
• Lung mechanics & muscles
Lung mechanics
Respiratory muscle strength
Gas exchange
Arterial PaCO2
Central apneas
Response to exogenous
hypoxia
• Polycythemia & ↑ HCO3
• Voluntary breath-holding
• Response to elastic & resistive
load..(Borg scale of dyspnea)
– Restricted lung volumes
– Decline in vital capacity
– PI max & PE max (
– Electromyography
• Gas exchange
– Mild hypoxemia
– Normal diffusion capacity
• Contribution of additional
factors
– Microatelactasis
– Alteration in surfactant
– Progressive deformity of thorax
13. Laboratory Values in Monitoring
Acute Neuromuscular Failure
Normal
value
Measurement
Procedure
Vital capacity
Max exhalation
45-70 mL/kg
Maximal Inspiratory
pressure (PI max)
Max inhalation
M >-100 cm H2O
F >-70 cm H2O
Maximal expiratory pressure
(PE max)
Max blowing out
M >200 cm H2
F >140 cm H2O
15. Respiratory weakness
• Arterial blood gases
– Initial changes
• Subtle drop in oxygen levels with the development of
atelectasis
– Later changes
• Mild hypercapnia with normal ph
• Rapid deterioration with apnea
16. Respiratory weakness
• Respiratory parameters
– Forced vital capacity
• Generally intubate if <10 ml/kg
• May be underestimated by respiratory technician
• Similar flow volume loops as COPD
– Prolonged tail due to extended exhalation time
• Count to 30 on one breath
– Cheap but effective way to estimate VC
– Approximately 2 Liters
• Neck flexors and proximal muscle strength correlate
best with respiratory strength
17. Guillain-Barre Disease
(Acute Inflammatory demyelinating polyneuropathy)
• Autoimmune process
– Effects myelin sheath of
peripheral nerves
– Humoral attack may be
induced by viruses,
vaccinations
– Demyelination slows
conduction along nerves
• Leads to progressive
weakness
– Axonal variant
18. MGH Series
Retrospective Series
n=169
Upper
respiratory
tract infection
36%
No prior
illness
38%
Prospective Series
n=120
Upper respiratory
tract infection
49%
No prior
illness
27%
Diarrhea
10%
Diarrhea
8%
Malaise
6%
Surgery
6%
Ropper, Wijdicks, Truax, 1991
EBV
5%
Pregnancy
1%
Hodgkin’s
disease,
surgery, SLE,
vaccination
3%
CMV
Malaise 3%
3%
EBV
3%
Pneumonia
2%
CP1142597-8
19. Diagnostic Criteria for GBS
• Strongly supportive features
–
–
–
–
Progression of symptoms over 4 weeks
Symmetric legs greater than arms weakness
Mild sensory symptoms
Cranial nerve involvement especially bilateral facial
weakness
– High protein content in the CSF with < 10 cells
– EMG/ NCV: Conduction block, increased F waves and distal
latencies
20. Treatment for GBS
• Supportive
– Respiratory
• Intubate Early
• No role for BiPap in GBS
– Treat dysautonomia
• Deafferented cardiac and baroreceptors
• Pseudoobstruction
• DVT prophylaxis
• Plasma Exchange
• IVIG
• Steroids not helpful
– Evaluate for CIDP
21. Plasma Exchange Trials in GBS
North American study
Plasma
exchange
n=122
Conventional
n=123
Days to reach grade 2 (median)
53
85
Patient improved at least 1 grade at 6 months (%)
97
87
Patients walking independently at 6 months (%)
82
71
French study
Days to onset motor recovery (median)
n=111
n=109
6
13
Days weaning (median)
18
31
Days to recover walking without
assistance (median)
70
111
CP1142597-47
22. Prognosis GBS
• Depends upon degree and extent of Axonal
damage
– Demyelination alone will recover within days to
weeks
– Axonal damage with intact myelin sheaths will
recover within months
– Most patients will make a complete recovery
• Psychological support
• GBS Support groups
24. Respiratory weakness
• Clinical findings
(Not all patients will have)
– Dyspnea
• VC is half of predicted
– Brow sweating
– Accessory muscle use
• INTUBATION SHOULD NOT BE BASED
UPON THE CLINICAL PRESENTATION
ALONE BUT ON THE RATE OF
RESPIRATORY DECLINE, AND
PULMONARY FUNCTION TESTS
25. Acute Respiratory Failure
• Inspiratory and expiratory muscles
involvement is variable
• Inspiratory muscle fatigue occurs because….
• Work of breathing is increased because….
• Blood flow to respiratory muscles is
compromised because….
• Inspiratory muscles weakness → atelactasis
26. Acute Respiratory Failure
• Risk of respiratory failure increases when VC falls
below 15 mL/kg
• Watch the trend….. Serial measurements
• The question of when to start ventilatory
support….
• An anticipatory approach avoids risks associated
with emergent intubation and minimizes
complications
• The mode of ventilation..
• Supportive care is important
27. Chronic Respiratory Failure
• Prolonged mechanical ventilation is defined by
the Centers for Medicare and Medicaid Services
in the United States as greater than 21 days of
mechanical ventilation for at least 6 hours per
day.
• Most patients requiring prolonged mechanical
ventilation will have a tracheostomy placed to
facilitate comfort, communication, and chronic
ventilator facility or home ventilation placement.
28. Chronic Respiratory Failure
• Common problems among patients undergoing
prolonged mechanical ventilation
– Infections (e.g., pneumonia,line sepsis, Clostridium difficile
colitis
– Ileus
– Renal failure
– Pneumothorax
– Seizures
– Tracheal bleeding
– Laryngeal edema
– Development of tracheal granulation tissue
– Tracheoesophageal fistula formation
– Loss of airway patency because of unplanned extubation
or decannulation
35. Conclusions
• A normal P(A - a)O2 difference should not be
required as a diagnostic criterion for
nonpulmonary causes of respiratory failure.
• The etiologic classification of nonpulmonary
disorders causing respiratory failure consists
of the following broad categories:
– disorders of ventilatory control,
– neuromuscular disorders
– disorders of the chest wall, and upper airway
obstruction.
36. Conclusions
• Clinical recognition of these disorders depends on
familiarity with the physiologic consequences of
chronic hypoxia and hypercapnia, the signs and
symptoms of respiratory muscle weakness, and their
effects on pulmonary function tests.
• The approach to the management of acute
respiratory failure does not differ in principle from
the approach used in lung diseases.
• Noninvasive nocturnal ventilatory support has gained
acceptance as a means of controlling diurnal
hypercapnia and providing respiratory muscle rest.
Resp failure def from 3rd ed. Introductory line from 2nd ed. First paragraph.
Any given patient may have more than one process leading to respiratory failure. Example hypothyroidism… poliomyelitis… muscular dystrophies…A series of responsis is elicited by chronic hypoxemia and hypercapnia….
Now as a physician you should have a wide index of suspicion, awareness of the possible involvement of muscles of respiration in particular the diaphragm and the ability to recognize its clinical expression areoften the most important elements in the diagnosis.