美國重癥醫(yī)學(xué)(FCCM)的基礎(chǔ)教程 急性呼吸衰竭的診斷和管理課件

1、Diagnosis and Management of Acute Respiratory FailureARF 1 ObjectivesDefine and classify acute respiratory failureDescribe pathophysiology of acute respiratory failureDiscuss clinical manifestations Review oxygen supplementation strategiesDiscuss noninvasive positive-pressure ventilationARF 2 Acute

2、Respiratory FailureHypoxemicRoom air PaO2 50 torr (6.7 kPa)HypercapnicPaCO2 50 torr (6.7 kPa)Acute vs chronic Pathophysiology of HypoxemiaVentilation/perfusion mismatchShunt effectDecreased diffusion of O2 Alveolar hypoventilationHigh altitudePathophysiology of HypercapniaDecreased tidal volume and/

3、or respiratory rate Inability to sense elevated PaCO2 Inability to signal effector mechanisms Inability to effect a response from respiratory musclesIncreased Dead SpaceHypovolemiaLow cardiac outputPulmonary embolusHigh airway pressuresShort-term compensation by increasing tidal volume and/or respir

4、atory rateManifestations of Respiratory DistressAltered mental statusIncreased work of breathingTachypneaAccessory muscle use, retractions, paradoxical breathing pattern Catecholamine releaseTachycardia, diaphoresis, hypertensionAbnormal arterial blood gas valuesARF 7Acute Respiratory Failure Manage

5、mentOxygen supplementationIncrease FIO2Match flow between delivery device and inspiratory demandHigh- vs. low-oxygen systemsHigh- vs. low-flow systemsARF 8Nasal Cannula100% oxygen deliveredLow flow 0.55.0 L/minLow oxygen FIO2 15 L/min)Emergency equipmentLittle to no air entrainment with firm fit Non

6、invasive Positive-Pressure Ventilation (NPPV)Ventilatory assistance with controlled FIO2Unilevel or bilevel pressure supportNasal or face maskVolume or pressure-cycled ventilatorMost effective with alert, oriented and cooperative patientSuccessful in hypoxemic and hypercapnic failure ARF 14 Relative

7、 Contraindications for NPPVDecreased level of consciousnessPoor airway protective reflexesCopious secretionsCardiovascular instabilityProgressive pulmonary decompensationUpper gastrointestinal hemorrhageARF 15 Initiation of NPPVSet FIO2 at 1.00Hypoxemic failureInspiratory pressure (IPAP) 10 cm H2OEx

8、piratory pressure (EPAP) 5 cm H2OTitrate EPAP in 2 cm H2O incrementsVentilatory failureIPAP 10 and EPAP 2 cm H2OTitrate IPAP in 2 cm H2O incrementsInitiation of NPPVMake changes every 15-30 minutesMonitor vital signs, appearance, pulse oximetry and blood gasesHead of bed at 45 angleConsider gastric decompressionIntubation if patient deteriorat