Respiratory Flashcards
Haemoptysis
Management:
Oxygenate
- Sit up right, HFNP 60L/min, max FiO2 100% (will not tolerate face mask)
2x large bore suction devices
Staff wearing PPE
Early CXR to locate side of bleeding if unilateral
Blood transfusion
Reverse coagulopathy
Tranexamic acid 1g iv, 500mg nebulised for small bleeds
Early intubation!
Difficult airway – call for help from anaesthetist
Use standard laryngoscope – video laryngoscope camera will be covered in blood
Use the largest size ETT possible >7.5 – blood will occlude small ETT’s, need to be able to perform fibre optic bronchoscopy
Consider selective lung intubation if severe haemoptysis and unilateral bleeding
Foley catheter occlusion
- ETT into affected side main bronchus
- Foley catheter through ETT and inflate in bronchus
- Withdraw ETT to normal position to ventilate normal lung
Post intubation – lateral decubitus position with bleeding lung down to prevent soiling of non-bleeding lung
Localise source of bleeding:
CXR
CTA
Bronchoscopy
Definitive treatment:
Interventional radiology - Bronchial artery embolization - if CT angio shows blush amenable to emblization, if available
Bronchoscopy (adrenaline or balloon tamponade)
- minimal bleeding
Surgery – lobectomy or pneumonectomy
- cardithoracic surgeon available
- ongoing bleeding not amenable to IR
Covid 19
Ref Tintinalli’s
a)
Resuscitation/intubation should occur in a NEGATIVE PRESSURE ROOM
Limit who is present (only those needed)
All staff involved in full airborne, droplet and contact precaution PPE
Provider protective equipment (PPE)
- bonnet
- fitted N95 mask
- eye protection/goggles
- face shield
- impervious gown
- double gloved
Aerosol producing procedures:
- intubation
- nebulizer
- mouth/airway suctioning
- NIV
Equipment:
Intubation hoods - reduce aerolizing the virus
Video Laryngoscopy as opposed to direct laryngoscopy
- increases chance of first pass success
- the airway doctor is farther away from the patients oropharynx, reducing the risk of transmission
ETT suctioning - closed circuit inline suction
Viral filter - between and ETT and Y-connector of the ventilator
ETT clamp with gauze
Pre-oxygenation:
Give induction agent with the paralytic
Passive oxygenation with face mask with tight seal - no positive pressure ventilation, no apnoeic BVM ventilation
In the event of failed intubation, reoxygenate using LMA with viral filter instead of BVM ventilation
Once intubated, place straight onto the ventilator. The cuff must be fully inflated before ventilating and there must be a Viral filters between the ETT and Y-connector of the ventilator
ETT tube needs to clamped before disconnecting from the ventilator
CPR
The patient’s mouth and nose should be covered by an oxygen mask (tight seal) with flow of up to 10 L/min.
Cover oxygen mask with a towel - this helps prevent droplet contamination
Look for signs of breathing as oppose to listening or feeling for breathing
No open source suction until in a negative pressure room with all staff in PPE
Provide passive oxygenation - no positive pressure ventilation until the patient in negative pressure room with all staff in PPE
Lung Protective Ventilation in ARDS: (Tintinalli’s)
- low tidal volumes 4-6ml/kg of predicted body weight
- plateau pressures <30cmH2O
- low RR 16-18
- permissive hypercapnoea (pH >7.2, PCO2 45-55)
- higher PEEP to maintain open lung physiology
- lower FiO2 to maintain SaO2 88-90%
- prone position
- prolonged neuromuscular blockade
ECMO is last resort
Covid 19 Pharmacotherapy (Tintinalli’s)
- dexamethasone 6mg daily
- monoclonal antibodies “mabs” for patients at high risk of disease progression (T2DM, CRF, obesity, chronic lung disease)
- anti-virals - remdesivir
- anticoagulation to prevent VTE
Asthma
Steroids:
Prednisolone 2mg/kg stat then 1mg/kg daily
Methylprednisolone 1 mg/kg (max 60 mg) 6 hourly OR
Hydrocoristone 4 mg/kg (max 300 mg) 6 hourly
Bronchodilators
salbutamol 100mcg/puff 6 puffs via MDI or spacer every 20min x3
salbutamol 5mg nebulised if covid negative and requiring oxygen
continuous nebulised salbutamol 2x 5mg undiluted
Ipratropium bromide 21mcg/puff 4puffs via MDI or spacer every 20min x3
Nebulised ipratropium added to salbutamol, every 20 minutes for 3 doses only
<6 years old: 250 microg
≥6 years old: 500 microg
Magnesium sulfate 0.2 mmol/kg over 20 mins (maximum 8 mmol). This may be continued with 0.12 mmol/kg/hour by infusion
Aminophylline - loading dose: 10 mg/kg (max 500 mg) IV over 60 min, then Q6h
Adrenaline 10 mcg/kg or 0.01 mL/kg of 1:1000 (maximum 0.5 mL) IM, into lateral thigh which should be repeated after 5 min if the child is not improving
NIV BIBAP
Oxygen requirement – will drive PEEP setting
Degree of hypoxia – will determine initial FiO2 setting
Work of breathing and tidal volume – will drive initial IPAP – EPAP differential (pressure support)
Haemodynamics – PEEP will compromise preload and precipitate hypotension
Patient tolerance/anxiety – may choose to start with lower settings for tolerance
Pt usual settings
c)
Increase EPAP – for refractory hypoxia
Increase IPAP – inadequate tidal volumes or poor clearance of CO2
Decrease FiO2 – hyperoxia
Increase FiO2 – hypoxia despite EPAP increase
Decrease trigger flow rate – patient unable to trigger machine to achieve synchrony
