Internal Medicine

P1: SBT

0521779407-02 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 19:18

Acute Respiratory Failure/Monitoring 59

Advanced Studies

■RR/TV >105 (“Tobin Index”) – likely requires mechanical ventilation

■PaO 2 /FiO 2 <300 – Acute Lung Injury

■PaO 2 /FiO 2 <200 – ARDS

Other Tests

■ECG – signs of ischemia, MI

■CXR – Infiltrate, increased heart size, pulmonary edema, pneumoth-

orax

differential diagnosis

■Agitation: Sepsis, “sundowning”, cerebral vascular accident, drug

toxicity, renal or hepatic encephalopathy, acute somatic pain.

■Cardiac: Pulmonary edema, CHF

■Pulmonary: Acute exacerbation of obstructive or restrictive disease,

asthma, COPD, pneumonia.

management

What to Do First

■Secure airway

➣If upper airway is obstructed – Chin lift/Jaw Thrust maneuver

➣Oral Nasal Airway, or Laryngeal Mask Airway

■Monitor oxygenation with pulse oximetry

■Treat airflow obstruction with albuterol MDI or nebulizer and IV

steroids

■Endotracheal intubation if mental status altered

➣Institute respiratory support with bag-valve mask ventilation

■Serial ABGs with arterial catheter

General Measures

■Monitor in an intensive care setting

■Consider noninvasive ventilation with CPAP or BiPAP by nasal or

facemask

■Consider mechanical ventilation with Assist Control, Intermittent

Mandatory Ventilation or Pressure Support Ventilation

■Prompt resuscitation is essential to avoid end organ damage

specific therapy

Indications for Treatment

■Institute therapy upon diagnosis while etiology is sought

■Treat hypoxic and hypercarbic failure with positive pressure assis-

tance