【正文】 ? Irritation caused by increased PaCO2 in early stage: insomnia at night, drowsiness during the day ? Depression caused by pulmonary encephalopathy in late stage: apathy, convulsion, a, tendon reflex weakened or disappear Circulatory system: ? Peripheral vesodilation, skin congestion, warm and sweaty extremities, BP↑, CO↑, pulsus magnus, HR↑, pulsatile headache 36 Diagnostic criteria ? History of respiratory dysfunction that severely affects the lung’s ability to maintain arterial oxygenation or carbon dioxide elimination ? Clinical manifestation of dyspnea and cyanosis ? Blood gas analysis ? PaO2 60 mmHg, or plus ? PaCO2 50 mmHg ? Breathing air on sea level and standard atmosphere pressure at rest ? Exclude intracardiac shunt and decreased cardiac output, such as ventricular septal defect ? In fact it is a pathophysiology amp。 nebulize ? Establishing artificial airway ?Endotracheal intubation ?Tracheostomy 45 Intubation Procedure ? Obtain a brief history ? Oxygenate ? Position ? Align the oral with the pharyngeallaryngeal axis ? Have suction ready ? Sedation and neuromuscular blockade 46 Intubation Procedure ? Perform laryngoscopy ? Introduce on the right side, sweeping the tongue left ? Straight blade under the epiglottis ? Curved blade in the vallecula 47 CO2 Detection 測定證實 48 B: Breathing 呼吸 ? Identify: He is not breathing! ? Mouthtomouth: slow, low pressure ? Evidence: expired O2 is sufficient ? Evidence: Breathless CPR is still beneficial ? Intubation + Ambu Bag = Best ? Connect O2 when possible 49 Barrier Breathing Devices 呼吸保護屏障裝置 50 B: Breathing 呼吸 ? New airway equipment guidelines: ? Endotracheal intubation = Gold standard ? Laryngeal Mask Airway (LMA) and Combitube are easier to use by less skilled personnel ? Don’t fet cricoid pressure ? Use 67 mL tidal volume over 2 sec. if O2 is available ? 15 chest pressions / 2 ventilations increase coronary perfusion pressure and reduce risk of aspiration 51 B: Breathing 呼吸 Airway Alternatives “ FastTrach” LMA (Laryngeal Mask Airway) 52 C: Circulation 循環(huán) ? Start IV (antecubital（肘前靜脈） is the 1st choice) ? Femoral and internal jugular lines may be necessary ? Chest pressions: 80100 bpm, rate is more important than actual pressions ? Confirm effectiveness: feel pulse, arterial waveform 53 D: Diagnosis 診斷 ? Work with internal medicine and cardiology ? Start with 5H and 5T 54 Chain of Survival 生還之鏈 ? The sequence of events (Call first ? A? B?C ?D) ? “The chain is only as strong as its weakest link” 55 Treatment Oxygen therapy Indications of oxygen therapy : ? Pump failure: improve ventilation ? Pneumonia, Pulmonary embolism, acute attack of asthma ? Severe pulmonary edema, ARDS ? Acute deterioration or worsening of COPD (pay attention to CO2 retention when giving oxygen therapy! ) 56 Treatment Oxygen therapy Inspired oxygen concentration: ? Inspired oxygen concentration should be the lowest value that results in an oxygen saturation of over 90% (PaCO2 about 60mmHg). ? High concentrations of inspired oxygen (35%) are safe in patients with type Ⅰ respiratory failure, as there is no risk of CO2 retention. ? While in patients with type Ⅱ respiratory failure, who are dependent on hypoxic drive for ventilation, oxygen therapy must be carefully controlled so that sufficient oxygen is supplied but without precipitating severe respiratory acidosis. 57 Oxygen delivery device: ① Nasal cannula/prongs: ? Advantage: allow patients to eat, drink, expectorate and speak ? Disadvantage: FiO2 delivered is not stable and affected by breathing。 FiO2 (%)=21+4 oxygen flow rate (L/min) ? Flow rates should be limited to less than 7L/min. ② Mask: ? Simple oxygen mask, nonrebreathing mask with reservoir bag, Venturi mask. ? Advantage: FiO2 delivered is paratively stable and is adjustable。 59 Simple oxygen mask 常規(guī)面罩 ? 常規(guī)面罩可提供較穩(wěn)定的氧濃度，其輸送的氧濃度大約為70% 80% ? 但是這兩種方法都不能精確地監(jiān)測 FiO2。故影響糾正低氧血癥并防止高碳酸血癥的發(fā)生的治療觀察。 ? improve pulmonary gas exchange。 ? upper airway obstruction。 ? inadequate handling of secretions。 ? severe hypoxem