Acute respiratory failure

Management of acute postoperative respiratory failure.

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‘Non Invasive Positive Pressure Ventilation (NIPPV) is becoming the treatment of choice for patients with type 1 and type 2 respiratory failures in both the Emergency Department and general medical wards. Non Invasive Positive Pressure Ventilation is an overarching term to describe two different ventilation modes, Continuous Positive Pressure Ventilation (CPAP), and Non Invasive Ventilation (NIV). However, the choice of ventilation mode to treat the respiratory failure appears to be driven by personal opinion’, (Wright, 2015).

This talk will offer information for nurses to make informed clinical decisions regarding the appropriate mode of NIV to use.

Evidence suggests that respiratory failure can be divided in to two groups.

Type 1: which includes acute pulmonary odeama (APO) and acute respiratory depression syndrome (ARDS)

Type 2: which includes chronic obstructive pulmonary disease (COPD)

Clinical interpretation is often difficult and should be supported by arterial blood gas (ABG) analysis.

Type 1 is represented by low SPO2 and normal or reduced CO2

Type 2 is represented by low SPO2 and high CO2

Treatment:

Type 1

Non-Cardiogenic Oedema

In non-cardiogenic oedema, there is usually minimal elevation of pulmonary capillary pressure, except in volume overload due to oliguric renal failure.

It may reflect altered alveolar-capillary membrane permeability, such as Acute Respiratory Distress Syndrome (ARDS), and also lymphatic insufficiency following lung transplant.

Causes of Acute Pulmonary Oedema

The causes of acute exacerbation of congestive cardiac failure are conveniently summarized by the

acronym MADHATTER – Myocardial infarct, Anaemia, Drugs or dietary high fluid or salt intake,

Hypertension, Arrhythmias, Thyrotoxicosis, Toxic i.e. infection,

Endocarditis or embolism (pulmonary),

R enal failure or pregnancy (‘ruptured placenta’)

􀂃 M yocardial infarct,

􀂃 A naemia,

􀂃 D rugs or d ietary high fluid or salt intake,

􀂃 H ypertension,

􀂃 A rrhythmias,

􀂃 T hyrotoxicosis,

􀂃 T oxic i.e. infection,

􀂃 E ndocarditis or embolism (pulmonary),

􀂃 R enal failure or pregnancy (‘ruptured placenta’)

Type 1 should be treated by applying Continuous Positive Pressure ventilation (CPAP) and oxygen concentration used to regulate SPO2.

Type 2 by Bi-level NIV using a defined inspiratory positive airway pressure (IPAP) to increase ventilation, and a defined expiatory positive airway pressure (EPAP) to increase oxygenation.

The recommended starting pressures are: IPAP= 12-14 EPAP 6-8

The IPAP can be titrated upwards to reduce high CO2

And EPAP titrated upwards to increase oxygenation.

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 Duncan Wright. RID: I-3810-2015

 

References

Beringer, R. (2006). Non Invasive ventilation in the Intensive care unit. Anaesthesia UK. from http://www.frca.co.uk

Chawla, R., Chaudhry, D., Kansal, S., Khilnani, G., Mani, R., Nasa, P., . . . Suri, J. (2013). Guidelines for noninvasive ventilation in acute respiratory failure. Indian Journal of Critical Care Medicine, 17, 42-70.

Hannan, L. M., Dominelli, G. S., Chen, Y.-W., Darlene Reid, W., & Road, J. (2014). Systematic review of non-invasive positive pressure ventilation for chronic respiratory failure. Respiratory Medicine, 108(2), 229-243. doi: http://dx.doi.org/10.1016/j.rmed.2013.11.010

Purwar, S., Venkataraman, R., Senthilkumar, R., Ramakrishnan, N., & Abraham, B. (2014). Noninvasive ventilation: Are we overdoing it? Indian Journal of Critical Care Medicine, 18(8), 503-507. doi: http://dx.doi.org/10.4103/0972-5229.138147

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