【正文】 ia associated with a variety of etiologies: ? Progressive dyspnea and hypoxia which can not be relieved by oxygen therapy ? Bilateral infiltrates on chest radiograph ? PaO2/FiO2 200 ? Excluding patients with signs of heart failure or a pulmonary capillary wedge pressure (PCWP) 18 mmHg 38 Treatment (outline of principle) ? Etiology Management ? Keep airway open ? Oxygen therapy ? Ensure adequate alveolar ventilation, correct CO2 retention ? Respiratory stimulant ? Mechanical Ventilation ? General supportive care ? Transfer to ICU for critical care and treatment ? Infection control ? Management of electrolyte and acidbase disturbance ? Management of cor pulmonale, pulmonary encephalopathy, multian dysfunction syndrome(MODS). ? Nutrition support 39 Treatment Etiology Management ? Management of any underlying diseases : upper airway obstruction, severe pneumothorax, massive pleural effusions ? Eliminate any factors that cause respiratory failure secondary to infection or shock ? Any inducement leading to acute deterioration of chronic respiratory failure： infection, malnutrition, inappropriate medication usage 40 Causes of Upper Airway Obstruction ? CNS depressionanesthesia, drug overdose ? Cardiac arrest ? Loss of consciousness ? Foreign body or tumor 41 Treatment Keep airway open 保持氣道通暢 Importance of airway open : ? Airway obstruction: resistance ↑ → WOB↑ ? respiratory muscle fatigue ? difficult to clear airway secretion → infection deteriorate ? atelectasis → the surface area of gas exchange ? ? Complete airway obstruction → apnea, death Clear airway secretion : ? mucolytics ? manual suction 42 A: Airway (氣道通暢嗎？ ) ? Open airway, blind sweep inside mouth ? Look, listen, and feel ? Assist if patient is not breathing adequately (watch for neck injury) ? Head tilt ? Jaw thrust ? Intubation – best protection ? Airway confirmation: CO2 + BBS ? CO2 may be absent if patient has no circulation 43 Maneuvers to Open the Airway ? Head tilt ? Jaw thrust (preferred in trauma) ? Triple airway maneuver: chin lift, head tilt, separation of teeth 44 Treatment Keep airway open保持氣道通暢 ? Bronchodilators for patients with bronchospasm: ?β2adrenoreceptor agonist, anticholinergic, glucocorticoid, theophylline ?Mode of administration : parenteral first and then inhale ?Mechanical ventilation+ medications delivery ?Airway humidify 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