1. Respiratory Failure Immediate Assessment & Treatment Indications For Intubation Non-Invasive Ventilatory Options Therapeutic Thoracentesis Initial Ventilator Settings Tempo:seconds…Reflex Reaction 1 – 5 minutes..…Emergency Assessment 20 minutes….Additional Therapy Goal:Stabilize the Patient within 20 minutes!

2. “Doctor…Your patient is in Respiratory Distress….?” “Reflex” Reaction….. Vitals –Including pulse ox Oxygen…. –50% face mask “Albuterol Neb” –0.5 cc solution mixed with 2.5 cc NS (= 2.5mg)

3. “Emergency” Assessment Focused Exam / Important Labs / Differential DOES THIS PATIENT NEED TO BE INTUBATED!!! “The Look” vs “VOPS”

4. “The Look” Speech Pattern Vital Signs Breathing Pattern –Accessory Muscles –Retractions –Thoraco-Abdominal Paradox –Hoover’s Sign –Pulsus Paradox Air Movement Cyanosis Patient’s Own Assessment

5. Assessment and Treatment - Continued Focused Physical –Wheezing vs Crackles vs No Breath Sounds Pulse Oximeter/ABG CXR –CHF –Pneumonia –Effusions –Atelectasis –Pneumothorax –Clear what should you think of? Therapeutic Thoracentesis Oxygen Bronchodilators Adequate Nursing / Monitoring ? Non-Invasive Ventilation –“CPAP” or “BiPAP”

6. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds Bronchospasm Pneumonia Pneumothorax Atelectasis Pulmonary Edema Effusion

7. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia Pneumothorax Atelectasis Pulmonary Edema Effusion

8. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia Pneumothorax Atelectasis Pulmonary Edema Effusion

9. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull(Crackles) Pneumothorax Atelectasis Pulmonary Edema Effusion

10. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull(Crackles) Pneumothorax Atelectasis Pulmonary Edema Effusion

11. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull(Crackles) Pneumothorax  Hyper- resonant Atelectasis Pulmonary Edema Effusion

12. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull(Crackles) Pneumothorax  Hyper- resonant Atelectasis Pulmonary Edema Effusion

13. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull(Crackles) Pneumothorax  Hyper- resonant Atelectasis  Dull Pulmonary Edema Effusion

14. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull(Crackles) Pneumothorax  Hyper- resonant Atelectasis  Dull Pulmonary Edema Crackles Effusion

15. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull(Crackles) Pneumothorax  Hyper- resonant Atelectasis  Dull Pulmonary Edema Crackles Effusion

16. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull Crackles, Egophony Pneumothorax  Hyper- resonant Atelectasis  Dull Pulmonary Edema Crackles Effusion  DullEgophony

17. Focused Exam Breath Sounds Fremitus Pectoriloquy PercussionExtra Sounds BronchospasmWheezing Pneumonia  (Bronchial)  Dull Crackles, Egophony Pneumothorax  Hyper- resonant Atelectasis  Dull Pulmonary Edema Crackles Effusion  DullEgophony

18. Common CXR Dilemmas White Out Three Major Causes: 1. 2. 3. How to Distinguish: Pneumo vs Skin Fold How to Distinguish:

30. Emergency Needle Decompression Prepare area (i.e., Betadine). Technique: –14 or 16-gauge IV catheter –Second intercostal space –Superior to the third rib –Midclavicular line –1-2 cm from the sternal edge –hold perpendicular to the chest wall –listen for the hissing sound of air escaping –remove the needle while leaving the catheter in place. Prepare the patient for tube thoracostomy.

31. Therapeutic Thoracentesis If effusion is large and symptoms are significant. –Otherwise, if non-urgent, call the Pulmonary Procedure Fellow in the morning (63893) Technique –http://content.nejm.org/misc/videos.shtml?ssource+recentVideoshttp://content.nejm.org/misc/videos.shtml?ssource+recentVideos Common Mistakes –Preparation Location (specific rib) Comfort –Angle –Volume

32. Oxygen How Much? –Once Saturated is More Better? –? Blunting Drive to Breath ? Type of Delivery Device

33. Oxygen Delivery Devices Nasal Cannula –24-44% F I O 2 –? F I O 2 per liter

34. Oxygen Delivery DevicesC Nasal Cannula –24-44% FiO2 Simple Face Mask –40 –60% FiO2

35. Oxygen Delivery Devices Nasal Cannula –24-44% FiO2 Simple Face Mask –40 –60% FiO2 Non-Rebreather Mask –“resevoir” with one- way valve –60-100% FiO2

36. Oxygen Delivery Devices Venturi Mask –Includes a valve allowing precise FiO2 delivery (? Advantage for COPD patients) –24-40% FiO2

37. Oxygen Delivery Devices Nasal Cannula –24-44% FiO2 Simple Face Mask –40 –60% FiO2 Non-Rebreather Mask –“resevoir” with one- way valve –60-100% FiO2 Venturi Mask –Includes a valve allowing precise FiO2 delivery (? Advantage for COPD patients) –24-40% FiO2

38. Bronchodilators Indication –Any Wheezing –Any “Silent” Chest –? Other Which One(s)? –Albuterol – 2.5 to 5 mg (0.5 to 1 cc of 0.5% sltn) –Ipratropium – 500 mcg (one vial)

39. CPAP / BiPAP CPAP Continuous Positive Airway Pressure CPAP  PEEP –Redistributes Edema Fluid –Reduces Atelectasis –Reduces WOB in COPD by Counterbalancing auto- PEEP BiPAP Bilevel Positive Airway Pressure EPAP  CPAP  PEEP IPAP  PS –Augments TV –Reduces Atelectasis –Reduces WOB

40. BiPAP Indications Acute Pulmonary Edema –PEEP/CPAP redistributes the alveolar edema COPD Exacerbation –reduces WOB caused by auto-PEEP Pulmonary Infiltrates in the BMTU Post-Extubation Failures –reduces atelectasis…...buys time…maybe

41. BiPAP Initial Settings: –EPAP = 5 cm H 2 O –IPAP = 3 cm H 2 O Titrate to Effect: –Get rid of “The Look”  EPAP to improve oxygenation and counter-balance auto- PEEP (hard to assess!)  IPAP to  TV &  RR Requires Close Nursing Supervision

42. Initial Vent Settings Initial Goal… –Get rid of “The Look” –aka “Rest” the patient A good place to start: –a/c, TV = 500 cc, RR = 12 –FiO2 = 100%, PEEP = 5 cm H 2 O

43. ?’s