The treatment of respiratory failure

The treatment of respiratory failure
Chronic respiratory failure more than a certain diseases, but in acute decompensated respiratory failure, can be directly life threatening, must take timely and effective rescue. Respiratory failure is to maintain the principle of respiratory smooth conditions, improve and rectify O2 missing CO2 retention, and metabolic dysfunction, which is based on disease and treatment-induced factors for time and create the conditions, but the specific measures should be combined with the actual situation Set.

First, the establishment of the airway patency

In improving the ventilation and oxygen therapy before, we must take various measures to maintain smooth enable respiratory tract. Such as porous catheter through the mouth, throat, or secretion of gastric reflux aspiration. Kechu viscous phlegm difficult, the new spray of bromine has been inhaled, can also retain a ring of plastic membrane puncture, the injection of saline diluted secretions, or bronchial spasm of bronchial β2 doping expansion, if necessary, to adrenal cortex Inhaled steroid ease bronchospasm; bronchoscopy can be used to suction secretions. If the effect of the poor, the use of nasal intubation or tracheotomy, the establishment of artificial airway.

Second, oxygen therapy

By enhancing alveolar oxygen (PaO2), an increase O2 diffusing capacity, improve PaO2 and oxygen saturation, increasing the use of oxygen.

(A) hypoxia without carbon dioxide retention of the low-oxygen therapy oxygen therapy alveolar ventilation, oxygen consumption increased, and the diffusion of dysfunction can be better to correct missing O2; ventilation / imbalance in the ratio of blood flow in patients with increased concentration of oxygen after inhaling , To increase ventilation alveolar oxygen shortage, improve its surrounding capillary blood oxygen intake so that the PaO2 increased. The site of chronic pulmonary interstitial pneumonia, interstitial pulmonary fibrosis, pulmonary edema, alveolar cell carcinoma of the lymphatic cancer and inflammation of the patients, mainly for the diffusion damage, ventilation / flow ratio imbalance caused by hypoxia And stimulate the carotid sinus, the aorta of chemical receptors cause excessive ventilation, PaCO2 low absorption can be given a higher oxygen concentration (35% -45%), to correct missing O2, then improve ventilation. But late in patients with high concentrations of oxygen absorption less effective.

The pneumonia is caused by the change, pulmonary edema and atelectasis caused by ventilation / flow ratio imbalance and lack of pulmonary artery shunt O2, and can not increase due to oxygen therapy diversion of blood oxygenation, such as the flow is less than 20 hours %, Inhaled high concentrations of oxygen (> 50%) corrected missing O2; if more than 30 percent of its bad effects, such as long-term inhalation of high concentrations of oxygen will cause oxygen poisoning.

(B) hypoxia with the obvious carbon dioxide retention of its oxygen therapy oxygen therapy should be given to the principle of low concentration (<35%) continued to oxygen, its principles are as follows.

Decompensated chronic respiratory failure, lack O2 with CO2 retention is the consequences of inadequate ventilation, because of hypercapnia of patients with chronic respiratory failure, the respiratory center of chemical receptors on the CO2 response of the poor, relying mainly on the maintenance of respiratory O2 hyperlipidemia on the low-neck Sinus artery, the aorta of chemical receptors in the driving role. If inhaled high concentrations of oxygen, PaO2 rising rapidly, so that the loss of peripheral chemical receptors to stimulate low O2 hyperlipidemia, patients with the slow and shallow breathing, PaCO2 go up, when a serious CO2 anesthesia, which often change consciousness and PaCO2 Increase the speed; inhaled high concentrations of low-O2 lifting O2 pulmonary vasoconstriction, allowing high pulmonary ventilation and blood flow than the (VA / QA) units in the lung blood flow to the low-VA / QA than lung units, increase ventilation and blood Flow ratio imbalance caused physiological dead space and tidal volume ratio (VD / VT) increase, thereby reducing alveolar ventilation, PaCO2 further increased in accordance with hemoglobin oxygen dissociation of the characteristics of the serious shortage O2 when, PaO2 and SaO2 The relationship between oxygen in the dissociation of the steepness of the curve, PaO2 slightly higher, SaO2 will be more, but there are still missing O2, can stimulate the chemical receptors, the ventilation to reduce the impact of low concentration of O2 therapy to correct low alveolar Ventilation (VA) of the alveolar oxygen tension (PaO2), and this inhaled oxygen concentration at different alveolar oxygen and alveolar ventilation of the curve, has earlier steep, after the characteristics of the flat, see Figure 2-6 -4. When inhaled oxygen concentration in more than 30 percent, although the alveolar ventilation is less than 1.5 L / min, alveolar oxygen maintained at 10.67 kPa (80mmHg), and alveolar partial pressure of carbon dioxide (PaCO2) will exceed 13.3 kPa (100mmHg). Generally low concentration of respirable O2, PaCO2 rise no more than 17/21, PaO2 rose 2.8 kPa (21mmHg), while PaCO2 rise no more than 2.26 kPa (17mmHg).

(C) the method commonly used oxygen therapy oxygen therapy for nasal catheter or nasal oxygen, the oxygen concentration of respirable (F1O2) and the inhaled oxygen flow was broadly following relations: F1O2 = 21 +4 × inhaled oxygen flow (L / min). It should be noted the same flow, with nasal inhalation of oxygen concentration of respirable per minute ventilation volume changes and changes. As to the low ventilation inhalation, the actual oxygen concentration higher than the calculation of the value of the high ventilation when inhaled oxygen concentration than the calculated values to lower.

Through oxygen masks Venturi principle, the use of oxygen jet produced negative pressure, inhaled air to dilute oxygen, into the air-conditioning control of oxygen concentration in the 25% -50% within the sub-grade structure of regulation 2-6-5, face masks Oxygen concentration in the stable, free from the respiratory rate and tidal volume impact. Is the consumption of its shortcomings, expectoration inconvenience.

Oxygen therapy to the general physical and clinical needs to regulate the concentration of oxygen inhalation, PaO2 of more than 8 kPa, or SaO2 for more than 90 percent. Oxygen consumption increases, such as fever can increase the concentration of oxygen inhalation. Reasonable oxygen therapy increased the effect of respiratory failure, respiratory failure in patients with COPD such as long-term low concentrations of oxygen therapy (especially at night) can reduce pulmonary circulation of resistance and pulmonary artery pressure, increased cardiac contraction, with activities to enhance and extend the survival time of endurance .

Third, increase ventilation and reduce CO2 retention

Alveolar CO2 retention is caused by inadequate ventilation, only to increase alveolar ventilation to effectively discharge CO2. Mechanical ventilation in the treatment of respiratory failure effect has affirmed and the application of respiratory stimulants, because of their different effect, the surviving in the controversy. Profile is as follows:

(A) a reasonable application of respiratory stimulants, respiratory stimulants stimulate the respiratory center or around the chemical receptors, through enhanced respiratory center of excitement, increased respiratory rate and tidal volume to improve ventilation. At the same time, patients with oxygen consumption and CO2 output also increased, and ventilation and a positive correlation. Because of its use of simple, economic, and a certain effect, it was still widely used in clinical, but should have their clinical indications. Patients with low ventilation mainly because of the central inhibition, respiratory stimulant effect of better chronic obstructive pulmonary disease, respiratory failure due to bronchial - lung disease, the response of the central or lower respiratory muscle fatigue caused by low ventilation, at this time of breath Doping should be the pros and cons of the three factors of primary and secondary may be. In nerve conduction system and the respiratory muscle lesions, and pneumonia, pulmonary edema and pulmonary fibrosis of the extensive ventilation dysfunction, respiratory stimulants are no disadvantages benefit and should not be used.

In the application of respiratory stimulants at the same time, should attach importance to reduce the chest, lungs and airway mechanical load, such as the secretion of drainage, the application of bronchial spasm, the elimination of pulmonary edema and other factors affecting the chest compliance. Otherwise, ventilation drive will add to short breath and breathing to increase power, and the need to increase the concentration of oxygen inhalation. In addition, we must make full use of some stimulants respiratory consciousness back to the Soviet Union, to encourage patients to cough, sputum elimination, and maintain the airway open. If necessary, nose or mouth and nose mask with mechanical ventilation support.

Nikethamide is the common respiratory center stimulants, increase ventilation, have a certain role Su-Ti. Patients can sleepiness of the first slow intravenous injection 0.375 g-0.75g, then to 3-3.75 g adding 500 ml of liquid, drop by 25-30 / min infusion. Close observation of patients with the lash response to change consciousness, and respiratory rate, the rate and rhythm, the follow-up of arterial blood gas, in order to regulate dosage. If a skin itching, irritability and other side effects, must be slowed down Disu. If the 4 h-12h did not bear fruit, or a muscle twitch serious reactions, should be suspended, if necessary, a change of mechanical ventilation support.

(B) a reasonable application of mechanical ventilation with respiratory physiology and pathophysiology of the development, nose and mouth masks, artificial airway, breathing and respiratory-care properties of continuous improvement, mechanical ventilation will enable patients with respiratory failure to grow. Practice has proved that mechanical ventilation for the success or failure of respiratory failure, in addition to the breathing machine and related properties, is more important to the medical staff to keep respiratory failure in patients with pathological changes in physiological and reasonable application of mechanical ventilation. By increasing ventilation and provide appropriate oxygen concentration, to a certain extent, improve the ventilation function and reduce the power consumption of breath, respiratory failure in patients with missing O2, CO2 retention and acid-base balance disorders can be different degrees of improvement and corrected, General will not die of respiratory failure. Attention should be paid to prevention and treatment may be lethal infection of the airway, obstructive airway secretions, high-pressure pulmonary complications such as trauma. Even in some serious respiratory failure complicated by multiple organ failure patients, after treatment by mechanical ventilation, because of improved patient heart, brain, kidney, liver and other organs of oxygen the body and internal environment, and then to nasal feeding or intravenous Nutritional support, create the conditions for the resumption of patients, save a lot of dying patient's life.

Shang-qing consciousness of mild to moderate, in line with the patients with respiratory failure, nose or mouth and nose mask for mechanical ventilation; serious condition, although the consciousness-but uncooperative, coma or respiratory secretions of the large number of patients, the timely establishment of gas Road, such as the nose (or mouth) intubation mechanical ventilation, the choice of organizations with good compatibility of high-capacity low-pressure air bags (<3.3 kPa) of PVC or silicone catheter, the catheter can retain more than half a month, to avoid Low capacity use latex rubber high-pressure balloon catheter, because of their reaction, can cause the airway mucosa clear congestion, edema, erosion, and ulcers. In very poor lung function, recurrent respiratory failure, secretions, the body extremely weak, malnutrition, need long-term support of patients with mechanical ventilation, for tracheotomy, the long-term retention of mechanical ventilation trachea casing.

In the use of breathing machine before the medical staff must understand the pathophysiology of patients with respiratory, to suit the tidal volume, respiratory rate and breathing, such as the ratio of various parameters, such as a blockage of the ventilation to be too large tidal volume, frequency slow breath longer Breathing, and restrictive ventilated patients is the opposite. Through simple hand pinch capsule breathing respirator for the transition, followed by a mechanical ventilation and monitoring of patients with clinical manifestations, such as the activities of the thorax, airway pressure and oxygen saturation changes in the general follow-up after 20 min blood gas again Further adjustments breathing machine parameters. In the different periods of mechanical ventilation, ventilation should use different approaches, such as respiratory or manual control capsule ventilation or assisted intermittent positive pressure ventilation (IPPV), PEEP ventilation (PEEP), synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV). Ventilation can also be different forms of composition, such as PEEP + PSV for the integration of bi-level positive airway pressure (BiPAP). PEEP improve the ventilation function, SIMV and PSV benefit from the breathing machine, so as to achieve avoid excessive ventilation or inadequate ventilation. Reduce the impact of the heart cycle. During the mechanical ventilation should strengthen management of respiratory and breathing machine. As to the wetlands of the respiratory tract, secretions to attract and maintain respiratory unobstructed; breathing machine disinfection and maintenance of clean, avoid cross-infection. Particularly want to emphasize is the need to strengthen the respiratory and cardiovascular care, early detection of problems, analyse problems and to properly resolve to give full play to mechanical ventilation in the treatment of respiratory failure of the active role so that a reasonable and effective application of mechanical ventilation, improve Its efficacy and reduce complications.

40, to correct acid-base balance disorders and electrolyte imbalance

Diagnosis and treatment of respiratory failure in the process, there are several common types of acid-base balance disorders.

(A) of respiratory acidosis due to lack of pulmonary ventilation, CO2 produced in the body retention hypercapnia, changed the BHCO3/H2CO3 the normal ratio of 1 / 20, acute respiratory acidosis. Patients with chronic respiratory failure, blood-buffer system and the role of the kidney adjustment (secretion of H +, Na + absorption and HCO3-integration into NaHCO3), to near normal pH. Respiratory failure stolen generation acid poisoning can use alkaline agent (5% NaHCO3) temporarily to correct the pH value, but will reduce the ventilation to further increase the CO2 retention, there is no acid poisoning have removed the root causes. Only increase alveolar ventilation can be corrected respiratory acidosis.

(B) respiratory acidosis merger metabolic acidosis due to low O2 levels, insufficient blood volume, cardiac output and reduce cycle around obstacles, such as lactic acid in fixed, such as increased renal damage impact from acid metabolites. Therefore, on the basis of respiratory acid can be complicated with metabolic acidosis. Anions in the fixed acid increased, HCO3-reduction, pH value dropped. Acidosis potassium ions from cell to cell within the transfer of blood K + increase, HCO3-reduced blood CI-expansion of the higher, Na + cells to move. Treatment, in addition to acid poisoning due to serious impact on blood pressure, or pH <7.25 when added alkaline agent, as NaHCO3 will add CO2 retention risk (NaHCO3 + HAC → NaAC + H2O + CO2). At this point should be raised to correct ventilation of CO2 retention and treatment of metabolic acidosis the cause.

(C) respiratory acidosis merger metabolic alkalosis in chronic respiratory acidosis in the course of treatment, often because of mechanical ventilation, so that CO2 emission too fast; added alkaline drug overdose; application of glucocorticoid, diuretics, which Pai increase in potassium, or because the correct acid poisoning, potassium to the cell transfer, have hypokalemia. Vomiting blood or diuretics to reduce the chlorine can produce metabolic alkalosis, pH High, BE is positive. Treatment should be more than a base to prevent the poisoning iatrogenic factors and avoid excessive CO2 emission, and to give adequate chlorination Kushiro, to alleviate the alkali poisoning, the event should be promptly dealt with.

(D) of this respiratory alkalosis for patients with respiratory diseases, respiratory a heartbeat to stop using mechanical ventilation, ventilation because of the excessive emission of CO2 caused by excessive respiratory alkalosis.

(5) respiratory alkalosis metabolic alkalosis merger of chronic respiratory failure in patients with mechanical ventilation, in the short term from too much CO2, and lower than normal, because of compensatory kidney, the body bicarbonate is due to increased volume.

Can also be due to improper handling, respiratory failure in patients with respiratory and metabolic acidosis basis, because of low potassium, low chlorine and alkali from the triple acid-base balance disorders.

5, the rational use of diuretics

Respiratory failure, because of interstitial lung, pulmonary and bronchial mucous membrane thin bronchial pulmonary edema caused wilting depression, atelectasis affect ventilation function, because of respiratory failure at the aldosterone increase in the use of mechanical ventilation and increase the antidiuretic hormone Shuinazhuliu due to the increase. Therefore, in heart failure, respiratory failure, the trial furosemide (furosemide) 10-20mg, if oxygen saturation increased, the use of diuretics proved to be the indication. But we must electrolyte disturbance without the use of the situation, and promptly give added potassium chloride, sodium chloride (mainly gastrointestinal administration) to prevent alkali poisoning.

To sum up, in dealing with respiratory failure, as long as the rational application of mechanical ventilation, oxygen, diuretics and alkaline agent, nasal feeding and intravenous nutritional supplements and electrolyte, particularly in the longer-term COPD pulmonary heart disease rarely eat, the use of diuretics Patients with more attention should be paid. Therefore, respiratory failure of the acid-base balance disorders and electrolyte imbalance is a reason to be investigated, nor is the prevention and treatment.

6, anti-infection treatment

Respiratory infections often induced respiratory failure, because the infected secretions Jizhi increase, particularly in the artificial airway mechanical ventilation and immunocompromised patients can be repeated infections, and difficult to control infection. Therefore, patients with respiratory failure must maintain the smooth drainage of respiratory conditions, according to the sputum culture and sensitivity test, the choice of effective drug control respiratory infections. Must also be pointed out that COPD patients with pulmonary heart disease repeated infection, and often without fever, high blood poisoning symptoms interleukin not only increase the sense of short breath, Weina diminish, if not handled timely, mild infection can also lead to respiratory failure decompensated Occurred.

7, control gastrointestinal bleeding

A serious lack of O2 and CO2 retention patients should be given to conventional oral cimetidine or ranitidine, to prevent gastrointestinal bleeding. If a large number of hematemesis or tar-like stools, should lose new blood, or stomach Guanru norepinephrine ice water. Must vein to the H2 receptor antagonists, or omeprazole. Gastrointestinal bleeding prevention is the key to correct missing O2 and CO2 retention.

8, shock

The shock caused numerous reasons, such as acidosis and electrolyte imbalance, severe infections, gastrointestinal bleeding, the lack of blood volume, heart failure and mechanical ventilation, such as airway pressure too high, should be cause to take corresponding measures. No improvement in the treatment should be given to vasoactive drugs such as dopamine, Ala Ming, and so in order to maintain blood pressure.

9, nutritional support

Patients with respiratory failure due to insufficient calorie intake and increased respiratory Gong, fever and other factors, resulting in increased energy consumption, a negative body metabolism. A long time and will reduce the body's immune function, difficult to control infection, breathing machine fatigue, resulting in respiratory pump failure, or failure to rescue the extension course. Therefore, rescue, to the conventional nasal feeding high-protein, high-fat and low carbohydrate, and a variety of vitamins and trace elements of the diet, when necessary, in a vein of high-nutrition, general daily calories to 14.6 k / kg.