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C H A P T E R 11 EARLY MANAGEMENT OF RESPIRATORY FAILURE RICHARD HODDER, PIERRE CARDINAL, AND Lois CHAMPION While in the emergency department (ED) assessing an intubated patient with a sedative overdose prior to transfer to the ICU, you are asked to see another patient who is not doing well Mr. Puffer is a 63year -old heavy smoker with known COPD who visits the ED two or three times ayear with a COPD exacerbation. His last admission to hospital was two months ago, during which he was successfully managed on the ward and discharged home after five days. He has known coronary artery disease as he had an MI threeyears ago but does not have angina, The rest of his past history is unremarkable. He takes salbutamol, ipratropium and budesonide inhalers, atenolol, and enteric-coated aspirin. He has not been on oral corticosteroids since his last admission and is not on long-term oxygen therapy, Prior to discharge from hospital two months ago,his pulmonary function tests were:FVC 68% predicted, FEV135% paredicted, FEV1/FVC 0,40, Pao 2 78 mm Hg breathingair,PaCO2 47 mm Hg, pH 739, and a hemoglobin level of 124 g/L For the past week, Mr. Puffer has had an increase in his usual cough and mucoid phlegm, and he has been getting more breathless withhis usual activities. Yesterday the phlegm turned yellow and was stickier and moredifficult to cough up. He started taking some amoxicillin left over from his last admission, but last night could not sleep because ofbreathlessness. This morning he called 911 and came to the ED, During the ambulance ride he was put on oxygen at 2 l/min and upon arrival this was continued. He underwent a chest radiograph,received 8 puffs each ofsalbutamol and ipratropium, and was started on IV cefuroxime and dexamethasone. An arterial stab was attempted, but it was presumed venous, as the results were: pH 7.23,PaCQ2 69, PaO2 45, SaO2 76%. When you examine Mr, Puffer, you note that he is drowsy, but able to carry on an accurate conversation punctuated withpausesfor breath. He says that he is very breathless and a bit frightened. He cannot get comfortable and issitting upright on thestretcher. His respiratory rate is 30 bpm, his heart rate is irregular 93 test were; FVC 68%predicated, FEVI 35% predicared between 119-130bpm. The remainder of his vitalsigns include a BP 0/165/60, temperature ofB6J°C and an oxygen saturation (Sao2) of 85% on O2 at 2 l/min via nasal cannulae, The ECG monitor shows atrial fibrillation but there are no obvioussigns of ischemia. He is a thin man and is using both his accessory inspiratory neck musclesand his abdominal expiratory muscles with each breath. There is indrawing in the supraclavicular region and his costal margins move inward during inspiration (Hoover's sign). Inspiratory breath sounds can be heard throughout the lung fields, but almost no sounds can be heard over the lung fields during exhalationexcept perhaps an intermittent,faint, high-pitched wheeze. While listening over the trachea however,expiratory breath sounds can be heard and they persist right up until the next inspiration.Heart tonesarefaint but normal There is neither central nor peripheral cyanosis. The patient, Mr. Puffer, certainly appears to be quite sick. Severalquestions about what to do for him are apparent. Does Mr. Puffer have acute respiratory failure? What are your immediate concerns? What are your initial management goals and how will you accomplish them? The goal of this chapter is to use this case is to illustrate an approach to a patient in respiratory failure. • Respiratory Failure Acute respiratory failure may be simply defined as "any impairment of O2 uptake or CO2 elimination or both that is severe enough to be a threat to life/' This definition implies that the delivery of oxygen to the tissues is an important factor and emphasizes the important interrelationship of the pulmonary and cardiac systems (Equation 11.1). Although this definition describes a fundamentalconcept, it is not likely to be very helpful at the bedside, where we are concerned primarily with treating our patients' symptoms and ensuring their safety and not with labelling them asbeing either in or out of "respiratory failure." Nevertheless, it is important to have an understanding of what constitutes a dangerous gas exchange abnormality, so we can act to prevent or correct it. What then is a dangerous level of hypoxia or hypoxemia, and what is a dangerous level of hypercapnia? The...

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