P1: SBT
0521779407-02 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 19:18
Acute Respiratory Failure/Monitoring 61➣Agitation requiring sedation
➣Hypotension due to decreased venous return
➣Regurgitation and aspiration of gastric contents
➣Nosocomial pneumonia
Contraindications
Absolute
■Airway Maneuvers – None
■Noninvasive mechanical ventilation – severe agitation and poor
cooperation
■Endotracheal intubation – noneRelative
■Airway Maneuvers - oral airway in conscious patient may induce emesis
➣Consider cervical traction in the setting of unstable C-spine
■Noninvasive ventilation – obesity, impaired consciousness, GE
reflux, nasogastric nutrition
■Endotracheal intubation – terminal prognosis with advance direc-
tivesfollow-up
During Treatment
■Titrate pressure support levels in increments of 2–5 cm H 2 O
■Wean FiO 2 and Pressure support to keep SpO 2 >90% or PaO 2 >60
mmHg
■Modify RR and TV to keep pH >7.30 and PaCO 2 ∼40 mmHgRoutine
■Serial CXRs to assess ETT placement
■Sedation as needed with narcotics and benzodiazepines
■Treat dyspnea or tachypnea with a trial of increased ventilation sup-
port
■Resolution indicates fatigue; persistent symptoms suggest agitation
■Address etiology of failure
complications and prognosis
Complications
■Aspiration of gastric contents; chemical pneumonitis
■Nosocomial pneumonia
■Pneumothorax
■Hypoxia: Encephalopathy, MI, ARDS, arrhythmia, cardiovascular
collapse