急診醫學核心課程編號 :E7 呼吸困難 急診部何政軒醫師 / 施長志醫師 104 年 12 月 15 日第二版

Transcription

1 急診醫學核心課程編號 :E7 呼吸困難 急診部何政軒醫師 / 施長志醫師 104 年 12 月 15 日第二版

2 學習目標

3 評估呼吸困難嚴重程度, 知道 呼吸窘迫與呼吸衰竭的臨床表 徵

4 Definition A subjective experience of breathing that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors. It may induced secondary physiological and behavioral responses.

5 Mechanisms of Dyspnea N Engl J Med 333: , 1995

6 How to Quantify Dyspnea?

7 焦點式病史詢問及理學檢查, 同時給予初步治療

8 Diagnostic approach: History Taking Comprehensive medical history Persistence or variability of the symptoms Precipitating factors Time of day Position Physical activity:

9 Diagnostic approach: Physical Examination Pattern of breathing Body habitus Posture Skeletal deformity Emotional state Cough on deep respiration or expiration Decrease in the intensity of breath sounds Jugular venous distension, right-sided S3 gallop, edema of the lower extremities Clubbing of the digits

10 Clubbing of the digits

11 Oxygen therapy Low Flow Nasal cannula Simple mask Partial rebreath mask Non-rebreath mask High Flow Venturi All-purpose T-piece

12 利用各種實驗室及放射學影像 檢查, 鑑別診斷呼吸因難原因

13 Laboratory Evaluation CBC Blood biochemistry BUN/Cr, calcium, electrolytes Arterial blood gases (pulse oximetry) Hypoxemia, hypercapnia, increased (A-a) gradient Chest radiograph Electrocardiography, EKG Brain natriuretic peptide (BNP) Distinguishing CHF from the other causes of dyspnea Pulmonary function test Restrictive or obstructive

14 Special Studies Cardiopulmonary exercise testing Bronchial challenge Ventilation-perfusion lung scanning CT of chest (HRCT) Gallium scanning Diaphragmatic fluoroscopy Thallium scan Echocardiography Cardiac catheterization Psychogenic assessment

15 Differential Diagnosis Dyspnea Respiratory Cardiovascular Gas Exchanger Pulmonary embolism Pneumonia Interstitial lung disease Pump COPD Asthma Kyphoscoliosis Controller Pregnancy Metabolic acidosis Low output Congestive heart failure Myocardial ischemia Constrictive pericarditis Normal output Deconditioning Obesity Diastolic dysfunction High output Anemia Hyperthyroidism Arteriovenous shunt

16 Hypercapnic Respiratory Failure PaCO 2 >45mmHg Not compensation for metabolic alkalosis (PAO 2 -PaO 2 ) normal increased Alveolar Hypoventilation V/Q abnormality Central Hypoventilation Neuromuscular Problem V/Q Abnormality Hypermetabolism Overfeeding PI max

17 Hypoximic Respiratory Failure Is PaCO 2 increased? Yes No Hypoventilation (PAO 2 -PaO 2 )? (PAO 2 -PaO 2 ) Yes No Hypoventilation alone Hypovent plus another mechanism Is low PO 2 correctable with O 2? Inspired PO 2 No Yes Shunt V/Q mismatch

18 各種呼吸道緊急處置及解救措 施 Emerg Med Clin N Am 30 (2012)

19 Mechanical Ventilation NIPPV Non-invasive Positive Pressure Ventilation CPAP or BiPAP COPD, CHF Contraindication Conventional Mechanical Ventilation Volume control, Pressure control (Assist-Control) SIMV Pressure support

20 Mechanical Ventilation Adequate oxygenation PaO2 > 60 mmhg or SaO2 > 90% Optimal ventilation (PaCO2) Permissive hypercapnea for ARDS and Obstructive lung diseases ph is more important; consider giving bicarbonate for ph less than 7.2 Hyperventilation for IICP Rest the respiratory muscles of patients

21 LMA Fastrach Special design features facilitate intubation, blind or fiberoptic, include: Rigid, anatomically curved. One-handed operated. Epiglottic elevating bar (elevates the epiglottis) reduce the risk of arytenoid trauma.

22 LMA in Place, 有時可以救命!

23 NONSURGICAL: Direct laryngoscopy Digital tactile intubation Nasotracheal intubation Bougie-assisted endotracheal intubation Supraglottic airway devices Supraglottic devices: Lighted stylets Fiberoptic-guided intubation/video-assisted devices

24 Surgical techniques Translaryngeal-guided retrograde intubation Percutaneous transtracheal jet ventilation Cricothyroidotomy

25 基本的快速順序性插管 Emerg Med Clin N Am 30 (2012)

26 快速麻醉誘導插管的 7 P 事前準備 Check BVM, Laryngoscopes, ETT, Stylets, Suction, ETCO 2 detector, Esophageal Detection Device (EDD), all medications, Difficult Airway devices Zero 10 min Zero 05 min Zero 03 min Preparation Monitoring (SpO 2, ECG, BP), IV 路徑 ( 最好打上 2 條 lines) Preoxygenation Bagging 到 SaO2 100% for 2~3 分鐘 Pretreatment (LOAD) Lidocaine Opioid Atropine Defasciculation

27 Zero Paralysis ( 打癱 ) with Induction ( 打昏 ) Zero + 15 sec. Protection + Positioning( 插管 ) Sniffing position ( Align axes) Zero + 45 sec. Placement with Proof( 確認位置 ) Consider BURP, Evaluate ETCO 2 ( purple yellow), EDD Consider ETCO 2 in cardiac arrest Zero + 1 min. Post-Intubation Management( 插管後照顧 ) Sedation and paralysis Hemodynamic and oxygen monitoring Appropriate ventilator settings

28 Medications: induction agents Hypotensive/normotensive patient scenario: Ketamine/etomidate/midazolam Hypertensive patient scenario:propofol/etomidate/midazolam/thiop ental

29 Medications: paralyzing agents