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The Critically Ill PatientStuart ConquerAdvanced Physiotherapist Paediatric ICU, Surgery & MedicineSheffield Childrens Hospital
Aims of sessionRecap of essentials of assessment:Respiratory FailureAuscultationCXRFBCReview of treatment options:PositioningBreathing TechniquesSecretion clearanceAdjunctsOn call:Case StudiesAppropriate/inappropriateQuestions to ask
Assessment
DefinitionsVentilation:
Respiratory Failure:
Ventilation is the drive to get CO2 out not to get O2 in
An inability to sufficiently eliminate carbon dioxide from, or provide oxygen to the organ systems during spontaneous respiration.
Cant get oxygen in
+/-
Cant get carbon dioxide out
Respiratory FailureInability to get oxygen inHypoxaemiaCardiac:
Resp:
Inability to get carbon dioxide outHypercapnoeaCauses:
Type I Type IIPulmonary OedemaEmbolismPneumoniaAsthmaARDSFibrosisAirway obstructionChest injuryNeurological lesionsMuscle/neuromuscular junction problemsChronic lung disease
AuscultationThyroid cartilageCricoid cartilageTracheal cartilageLeft upper lobeLeft main bronchusOblique fissureBronchiolesLeft lowerlobeRight lowerlobeOblique fissureRight middlelobeHorizontal fissureRight mainbronchusRight upper lobe
AuscultationBronchialVesicularBreath sounds:NormalEqualComplete
Crackles:Inspiratory/ExpiratoryCoarse/FineAll or partWhere is it?Wheeze:Inspiratory/ExpiratoryAll or partMonophonic/PolyphonicWhere is it?
Chest X-raysBe methodicalDemographicsType of filmExposurePositionHeartLungsRibsAnything AddedAbnormal:Too whiteToo DarkToo Big/smallIn the wrong place
Left upper lobe
Left lower lobe Right upper lobe
Right middle lobe
Right lower lobe
Blood CountHbWCC:Royal Marines:
Royal Marine Commandos:
SAS:
SBS:
CRP
PlateletsUreaCreatinineAlbuminLactateSodiumPotassiumOthers at a later date if required
NeutrophilsLymphocytesMacrophagesEosinophils
Treatment
OptionsPositioningBreathing TechniquesSecretion Clearance TechniquesAdjuncts
BE METHODICAL
On callTREAT?RUN?MANUAL TECHNIQUES?COMPUTER SAYS NO!SLEEP
Case Study 1Capt. C CavemanRetired Colonel BAFICU admission with AAA repair (emergency)CV Instability post-opReduced air entry L LZsType I respiratory failureSecretion retention
Case Study 2Ms P PittstopRacing DriverCrash sustaining # Ribs and pneumothorax L Blood Stained secretionsPain++Oxygen requirement
Case Study 3Mr H K PhooeyJanitor (mild Mannered of course!)Keeps exotic birdsAtypical pneumoniaIncreased WOBSecretion Retention
Case Study 4Dame Crystal Tipps85 year old millionaire Smokes 60 park-drive/day COPDIncreased WOBThick green secretionsType II respiratory failure