Pulmonary In-service Bassem Srour, MD, FCCP. Pulmonary, Critical - PowerPoint PPT Presentation

Pulmonary In-service Bassem Srour, MD, FCCP. Pulmonary, Critical Care & Sleep Medicine. Jameson Health System.

To Go over list 1. Respiratory rate. 2. Pulmonary myths and Science. 3. Oxygen. 4. ABGs, Acid base disturbances. 5. Nebulizers. 6. CPAP/BIPAP. 2

Respiratory Rate. 1. What is Normal ? 2. What dictates how fast we should breath. 3. Why should we care ? 4. What does it tell us about the patient? 3

What is Normal ?? Small Hint NOT 20 4

Respiratory Rate.  CO2 dictates our Minute ventilation as the PH needs to be maintained at around 7.40 Our body have 2 ways to buffer acids:  HCO3 that takes days for kidney to make more or get rid off  Changing our CO2 . That takes minutes. 5

Respiratory Rate.  Minute Ventilation = RR x Tidal Volume.  Normal MV 6 L ± 2 L .  Tidal volume is affected by many variables such as Weight, Height, muscle weakness...  Normal VT is around 500cc for 70 kg male.  5 Ft obese elderly F with Kyphosis 300cc.  6” 5’ young Male Athlete 900cc . 6

Respiratory Rate.  VT 900 cc x RR 10 = 9L MV  VT 300 cc x RR 30 = 9L MV  They are both Ventilating the same.  As we grow our lungs get bigger and our Vt gets larger so our RR go down. 7

Textbook Normal !!! 8

What about not perfectly healthy patients 9

So what is Normal ??  A single value is of little clinical importance unless its in the extremes. (RR 5 or 40)  A trend is far more Valuable such as a patient has been breathing at 10-16 and now is breathing at 26 something has changed. 10

We measure the saturation isn't that the same thing?  No The lung has 2 functions oxygenate and ventilate. They are not related.  Patient with one lung after pneumonectomy could have a saturation near 100% but around double the normal respiratory rate. We need only about half a lung to maintain a “normal” Sat. 11

Why Should we care !!! 1. Any changes in the lung such as worsening pneumonia or CHF will lead to an increase dead space leads to increase in the minute ventilation and respiratory rate to maintain the same PCO2 and blood PH. 2. Any patient that turns septic will have more lactic acid and will have a higher respiratory rate to buffer the acidosis 12

Why Should we care !!!  Respiratory rate is a VITAL sign because its an early predictor of VITAL changes in the patient physiology and when early interventions are done the complications and bad patient outcomes can be avoided.  The reason why the patients are not treated home is to be observed for these complications !!! 13

BREATHING MYTHS & FACTS 14

Myths #1 Breathing is regulated by need for oxygen  Breathing is regulated by the CO2 concentration in the arterial blood and the brain. Whatever we do (sit, walk, eat, run, sleep, etc.), CO2 concentration is kept within a narrow range (0.1% accuracy) by the breathing centre located in the medulla oblongata of the brain 15

Myth #2 CO2 is a poisonous or toxic waste gas and a waste product to get rid off.  CO2 is a powerful vasodilator and regulates blood and oxygen supply to the brain, heart and all other vital organs.  Another CO2 effect is to regulate the release of oxygen by the blood in the tissues. 16

Myth #3 More breathing means better body oxygenation  Hyperventilation REDUCES oxygen supply to the brain, heart, liver, kidneys, and all other vital organs due to low CO2 induced vasoconstriction.  “Take a deep breath, get more oxygen”, or “Breathe deeper for better oxygenation” is nothing more than a myth. 17

Myth #3 More breathing means better body oxygenation  That’s why the recommended ACLS Bag rate in arrest in 10-12 / min.  Hyperventilating a cardiac arrest patient will worsen his vital tissues blood supply and cause worse gastric distention and increase the chance of aspiration. 18

Myth #3 More breathing means better body oxygenation  Applying PEEP valve on the bag mask is the right way to increase the saturation if needed in an intubation.  Synchronizing bagging and patient spontaneous ventilation is another way

Myth # 4 Oxygen is good for you  “All chronic pain, suffering and diseases are caused from a lack of oxygen at the cell level." Prof. A.C. Guyton, MD.  It was thought to be the cause of all illnesses so giving it to patients was the treatment of all diseases !!! 20

Oxygen  Name derives from the Greek roots (oxys) ("acid", literally "sharp") and ( gοnos ) ("producer").  The acid producing gas was never intended to be part of the Tender, Love and care. 21

Oxygen toxicity  Pulmonary toxicity occurs with exposure to concentrations of oxygen greater 50%.  Signs of pulmonary toxicity begins with evidence of tracheobronchitis, or inflammation of the upper airways, after an asymptomatic period between 4 and 22h. 22

Oxygen toxicity  Lead to decline in lung function as quickly as 24h of continuous exposure to 100% oxygen, with evidence of diffuse alveolar damage and the onset of ARDS usually occurring after 48 h on 100%.  Breathing high concentration of oxygen also leads to collapse of the alveoli (Atelectasis). 23

So what's the worse that can happen with giving too much oxygen to a patient as long as its less than 50%. Hyper - oxygenating a patient will make us loose the ability to detect early physiologic changes. 24

Example  Patient Sat is 98 % on RA and was placed on 4L NC in the ER. We kept it the same and his Sat now is 99%.  Patient has worsening CHF from a silent MI or worsening pneumonia on poor antibiotics selection. By the time he desaturates on 4L oxygen the condition is much worse and we might be too late to intervene and prevent intubation. 25

Who think this is a problem?  Combine this practice: Not accurately documenting RR over 30 S 1. Giving oxygen while the Sat on RA >90% 2. Titrating oxygen up without investigating 3. what caused it and what can we do to prevent the future worsening. NEXT Rapid response, intubation or arrest !!

ABGs 27

ABGs Made simple  Its useful in assessing Acid/base status.  Measure the PCO2 level.  Determine the PO2 and the A-a Gradient.  Not needed for oxygenation in general as pulse ox saturation is very accurate if we have a good pulse wave. 28

ABGs Made simple  PH 7.4 (7.35 – 7.45) in normal.  > 7.45 Alkalosis.  <7.35 Acidosis.  PCO2: 40 mmhg ( 35 – 45) normal.  HCO3 on ABG is calculated and CO2 on BMP is measured and its more accurate. 24 (22 -26 ) normal. PCO2 and CO2 (Bicarb) are not the same 29

ABGs Made simple  PCO2 is Lung/CNS problem.  HCO3 is kidney/GI/Perfusion problem.  Condition is either too much or too low.  Usually it’s a combination and a compensatory mechanism.  The condition can also be acute or chronic. 30

Is it Respiratory or Metabolic? Respiratory Acidosis  Increased pCO2 >45 1. Decreased pCO2<35 Respiratory Alkalosis  2. Metabolic Acidosis  Decreased HCO3 <20 3. Metabolic Alkalosis  Increased HCO3 >28 4.

Common Conditions  Metabolic Acidosis: PH HCO3 PCO2 1. Septic shock with high lactic acid. 2. Ingestion of an external acid like anti freeze 3. Diabetic Keto-acidosis 4. Diarrhea and loss of GI Bicarb. 5. Renal failure cause lack of production of bicarb and no clearing acids by the kidneys. 32

Common Conditions Respiratory Acidosis:  Acute: PH, N HCO3, PCO2.  Chronic: PH, HCO3, PCO2. The Kidney needs time to make changes and get increase the HCO3 to try to get the PH as close to 7.4 as possible. 33

Common Conditions  Common causes for Acute Resp Acidosis: Acute drug overdose that suppress respiratory drive such as Benzo and opiates. Acute COPD, Asthma attack.  Common causes for Chronic Resp Acidosis: Chronic advance COPD, Severe Muscular weakness, Severe Kyphosis, Untreated OSA 34

Common Conditions  Metabolic alkalosis : PH HCO3 PCO2 1. Vomiting and loss of gastric acids 2. Excessive NG suctioning and loss of gastric acids 3. External ingestion of large amounts of alkaline antacids. 35

Common Conditions Respiratory Alkalosis : Acute: PH, N HCO3, PCO2. 1. Chronic: PH, HCO3, PCO2. 2. The Kidney needs time to make changes and get rid off the HCO3 to try to get the PH as close to 7.4 as possible. 36

Common Conditions  Common causes for Acute Resp Alk : Pain, Anxiety, Psychosis, Sepsis, PE, Asthma, Pneumonia.  Common causes for Chronic Resp Alk : Progesterone during pregnancy. Toxins in patients of chronic liver disease. 37

Bronchodilators Not part of our Tender, Love and Care. They are not Harmless.

Bronchodilators They can worsen the patient oxygenation. 1. Linked to a worse ARDS mortality. 2. Prolong the time on ventilator in ARDS. 3. They can induce tachyarrhythmia's. 4. They can induce ischemia in CAD Pts. 5. USE ONLY WHEN INDICATED !!!! 39

Bronchodilators  BALTI-2 and ALTA large studies. Both showed detrimental effects of the use of B agonist in patients with ARDS/ALI. They are indicated to treat Bronchospasm not lung disease. 40