附件王家弘主任來院指導日期暨講題. Status Asthmaticus 氣喘危症. Auto-PEEP and Dynamic Hyperinflation 內生性吐氣末端陽壓. Hemodynamic Profile Interpretation 血流動力學的判讀

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1 附件王家弘主任來院指導日期暨講題日期講題 2/18(W6) Status Asthmaticus 氣喘危症 4/21(W6) Auto-PEEP and Dynamic Hyperinflation 內生性吐氣末端陽壓 6/16(W6) Hemodynamic Profile Interpretation 血流動力學的判讀 8/18(W6) Oxygen Therapy 氧氣治療 10/20(W6) 醫病溝通技巧 12/15(W6) Aerosol Therapy 噴霧治療

2 王家弘醫師中文姓名 : 王家弘英文姓名 :JIA-HORNG WANG 性別 : 男出生年月日 : 通訊地址 : 台北市北投區石牌路二段 201 號榮民總醫院呼吸治療科 jhw@vghtpe.gov.tw 或 leejh@vghtpe.gov.tw 李瑞華代轉聯絡電話 :(02) 傳真號碼 :(02) 學歷科技專長學校名稱學位起迄年月台北醫學院醫學士醫學美國紐約大學醫學中心臨床研究員醫學美國紐約哥倫比亞長老會醫學中心臨床研究員醫學經歷服務單位職稱專或兼任工作性質起迄年月現任 : 呼吸治療科醫務科主任專任醫療教學研究至今陽明大學臨床教授兼任醫療教學 82 年 - 至今國防醫學院臨床教授兼任醫療教學 82 年 - 至今台北醫學大學臨床教授兼任醫療教學台大醫院外科部主治醫師兼任醫療教學至今中華民國急救加護醫學會理事兼任 79 年 - 至今中華民國重症醫學會理事兼任 90 年 - 至今台灣胸腔暨重症醫學會監事兼任 79 年 - 至今中華民國高壓暨海底醫學會常務理事兼任 87 年 - 至今曾任 : 胸腔部住院醫師專任醫療胸腔部住院總醫師專任醫療胸腔部專科醫師專任醫療專科醫師證照 : 內科專科醫師 ; 胸腔暨重症專科醫師 ; 急救加護醫學會專科醫師 ; 高壓氧醫學會專科醫師專長 : 呼吸治療胸腔疾病危急醫學臨床高壓氧第一可授課程 : 呼吸治療重症醫學第二可授課程 : 胸腔疾病臨床高壓氧治療醫師證書 : 醫字第 1174 號 1 李瑞華電話 : 傳真 :

3 Oxygen Therapy Jia-Horng Wang Department of Respiratory Therapy Veterans General Hospital-Taipei General Characteristics of Oxygen Colorless Odorless Tasteless Molecular weight : 32 mg Density at STP : 1.43 gm/l Boiling point at a atm : -183 C Melting point at a atm : C Critical temperature : C

4 Types of Hypoxia Anemic hypoxia Stagnant hypoxia Histotoxic hypoxia Hypoxemic hypoxia Definition and Types of Hypoxia Inadequate quantities of oxygen at the tissue level Anemic hypoxia Stagnant hypoxia Histotoxic hypoxia Hypoxemic hypoxia

5 Anemic Hypoxia Decreased carrying capacity of blood for oxygen Anemia Carbon monoxide poisoning Methemoglobinemia Shift of the oxyhemoglobin dissociation curve to the right Hypoxemia may or may not be present Stagnant Hypoxia Decreased cardiac output, resulting in increased systemic transit time Shock Cardiovascular instability Regional vasoconstriction

6 Histotoxic Hypoxia Inability of tissue to utilize available oxygen Cyanide poisoning Rarely accompanied by hypoxemia Hypoxemic Hypoxia Decrease in diffusion of oxygen across alveolar capillary membrane Low inspired oxygen concentration Ventilation/perfusion inequality Increased physiologic shunt Diffusion defects Cardiac anomalies

7 Definition of Hypoxemia Inadequate quantities of oxygen in the blood Evaluation of Hypoxemia Normal : PaO mmhg Mild hypoxemia : PaO mmhg Moderate hypoxemia : PaO mmhg Severe hypoxemia : PaO2 less than 40 mmhg For individuals more than 60 years of age PaO2 = (0.42 x age ) + 4 mmhg [supine] PaO2 = (0.27 x age ) [sitting ]

8 Clinical Manifestation of Hypoxemia Tachycardia and hypertension Tachypnea and hyperpnea Pulmonary hypertension Cyanosis Confusion, disorientation, or both Secondary polycythemia Precaution of Oxygen Therapy Fire hazard Bacterial contamination Intra-tracheal tracheal ignition during laser bronchoscopy Infant with ductal heart lesion constriction of ductus arteriosus

9 Hazards of Oxygen Therapy Retinopathy of prematurity Oxygen toxicity Oxygen-induced hypoventilation Absorption atelectasis Retinopathy of Prematurity Presence of opaque fibrotic tissue behind the lens of eye, resulting in retinal detachment and blindness Phase 1 :hyperoxia: with vasoconstriction of the retinal blood vessels. ( 3 or more days ) Phase 2 :vasoproliferation: in the immature retina

10 Retinopathy of Prematurity Seen only in neonates A PaO 2 greater than mmhg Maintaining PaO 2 value less than 80 mmhg reduces the risk of this complication in neonates Oxygen Free Radicals Hydrogen peroxide Superoxide radical Hydroxy radical Singlet excited oxygen

11 Enzymes for Cellular Defenses Against Oxygen Free Radicals Superoxide dismutase Catalase Glutathione peroxide Glutathione Cysteine Cysteamine Vitamin E in lipid membrane Vitamin C (intracellular) Effects of Oxygen Free Radicals Inhibition of glycolysis Interference with surfactant transport and production Nucleic acid damage Cross-linkage of DNA molecules Cell and organelle membrane disruption Enzyme inhibition

12 Clinical Manifestation of Oxygen Toxicity Tracheobronchitis Cough Substernal pain Nausea and vomiting Anorexia Paresthesia Refractory hypoxemia Diffuse patchy bilateral pulmonary infiltrates Alveolar atelectasis Decreased compliance Pathophysiology of Oxygen Toxicity With continued exposure to 100% O 2, type I alveolar cells are destroyed and replaced by type II cells Early or acute exudative phase Late or chronic proliferative phase

13 Prevention and Treatment of Pulmonary Oxygen Toxicity Judicious use of oxygen therapy Appropriate use of positive end- expiratory pressure therapy, diuretics, and fluids while reducing the FiO 2 to "safe" levels (0.50 or less) Factors Enhancing the Development of Oxygen Toxicity or Its Clinical Manifestation Corticosteroids Hyperthyroidism Adrenergic stimulation Hyperthermia Vitamin E deficiency Paraquat Diethyldithiocarbamate (>= 250 mg/kg) Disulfiram (>10 mg/kg) Bleomycin

14 Potentiation of Oxygen Toxicity in the Intensive Care Setting Hyperthyroidism Hyperpyrexia Dietary deficiency (protein, selenium, copper) Drugs such as disulfiram, nitrofurantoin, chemotherapeutic agents Exogenous agents such as paraquat Radiation Protection Against Oxygen Toxicity in the Intensive Care Setting Avoidance of potentiators Antioxidants such as ascorbic acid, tocopherol Superoxidase dismutase Agents to stimulate protective enzymes such as endotoxin or diethyldithiocarbamate

15 Gas Delivery System Nonrebreathing system Exhaled gases have minimal contact with inspiratory gases Rebreathing system A reservoir exists on the expiratory line with a carbon dioxide absorber Non-Rebreathing Oxygen Delivery System Low-flow oxygen delivery system High-flow oxygen delivery system

16 Non-rebreathing System Commonly used in modern oxygen therapy Expense is not prohibitive Rebreathing carbon dioxide is easily avoided High-Flow Oxygen Delivery System The gas flow of the apparatus is sufficient to meet all inspiratory requirement

17 High-Flow Oxygen Delivery System Inspired atmosphere is delivered by the system The apparatus flow exceeds the peak inspiratory flow in order to maintain a consistent FiO 2 A total flow at least 4 times the patient's minute volume High-Flow Oxygen Delivery System Air entrainment masks Mechanical aerosol systems Cascade-type humidifier

18 Air-Entrainment Mask Non-Rebreathing Circuit with a Valved Face Mask

Use of Two Nebulizers in Parallel to Provide High FiO2 at High Flow Approximate Air-to-Oxygen Ratios for Common Oxygen Concentration Percentage Oxygen 100 80

19 Use of Two Nebulizers in Parallel to Provide High FiO2 at High Flow Approximate Air-to-Oxygen Ratios for Common Oxygen Concentration Percentage Oxygen Approximate Air-to to- Oxygen Ratio 0:1 0.3:1 0.6:1 1:1 1.7:1 2:1 3:1 5:1 8:1 10:1 25;1 Total Ratio Parts

Devices Attached to High-Flow Oxygen Delivery System Aerosol mask Face hood Tracheostomy collar Briggs T piece Tracheostomic Mask or Aerosol Tee Used to deliver high humidity and aerosol to patients

20 Devices Attached to High-Flow Oxygen Delivery System Aerosol mask Face hood Tracheostomy collar Briggs T piece Tracheostomic Mask or Aerosol Tee Used to deliver high humidity and aerosol to patients with endotracheal or tracheostomy tubes Used with a large volume nebulizer May be used with air or oxygen May need reservoir tube on T-pieceT May be used with air entrainment for delivery of precise oxygen percentages

21 Low-Flow Oxygen Delivery System Total minute volume is not delivered by the apparatus FiO 2 delivered is extremely variable and unpredictable The higher the patient's minute volume, the lower the FiO 2 Determinants of FiO 2 in Low-Flow Oxygen Delivery System Flow of gas from equipment Patient's anatomic reservoir Reservoir of equipment Patient's respiratory rate, tidal volume, and minute volume

22 Low-Flow Oxygen Delivery System Oxygen cannula Oxygen catheter Trans-tracheal oxygen catheter Simple oxygen mask Partial rebreathing mask Non-rebreathing mask Oxygen Cannula

23 Nasal Cannula O2 % of 24-44% 44% O2 flow 1/2-66 L/min(LPM min(lpm) For every LPM change there is approximately 4% change in inspired O 2 fraction Patient may breathe through nose or mouth O2 % delivered will change with increases or decreases according to patient's ventilatory pattern Patient may drink, eat or speak Troubleshooting Common Problems with a Nasal Cannula Problem or Clue No gas flow coming from cannula Cause Flowmeter not on System leak Solution Adjust flowmeter Check connector Humidifier pop-off off Obstruction distal to humidifier Flow is set too high Obstructed naris Find and correct the obstruction Use alternative device Use alternative device Patient reports soreness over lip or ears Mouth breathing Irritation or inflammation caused by application straps Habitual mouth breathing Blocked nasal passages Loosen straps Place cotton balls at pressure points Use a different device Switch to simple mask or venturi mask

Nasal Cannula Advantages Lightweight Comfort Less expensive Ease of application to patient Disadvantages FiO 2 varies with changes in ventilatory pattern Not

24 Nasal Cannula Advantages Lightweight Comfort Less expensive Ease of application to patient Disadvantages FiO 2 varies with changes in ventilatory pattern Not recommended as initial modality for CO 2 retainers with unstable ABG's Unsuitable for patients with deviated nasal septum or nasal obstruction Reservoir Cannula

Pendant Reservoir Cannula Nasal Catheter FiO2 delivered same as nasal cannula Change very 8-128 hours in order to prevent infections Should be lubricated during insertion

25 Pendant Reservoir Cannula Nasal Catheter FiO2 delivered same as nasal cannula Change very hours in order to prevent infections Should be lubricated during insertion Tip just visible below soft palate Catheter should not be inserted too deeply Dilatation and rupture of stomach have occurred Time and patient trauma involved in insertion

26 Oxygen Catheter Trans-Tracheal Oxygen Catheter

Simple Oxygen Mask Oxygen Mask O 2 % of 35-55% 55% O 2 flow of 6-106 LPM O 2 flow less than 5 LPM may not flush CO 2 from mask O 2

27 Simple Oxygen Mask Oxygen Mask O 2 % of 35-55% 55% O 2 flow of LPM O 2 flow less than 5 LPM may not flush CO 2 from mask O 2 % will vary with change of ventilatory pattern When patient eats, drinks, or talks, mask is removed Not suitable for long-term use

28 Disadvantages of Oxygen Mask Low flow rate : potential for CO 2 retention Low flow rates cause "face becoming hot" or "suffocating feeling" Inspired O 2 % will change with ventilatory pattern of patient Potential for aspiration of vomitus Partial Rebreathing Mask

Partial Rebreathing Mask 35-60% O 2 O 2 flow rates of 6-106 LPM Reservoir bag added First 1/3 of exhaled gas flows into

29 Partial Rebreathing Mask 35-60% O 2 O 2 flow rates of LPM Reservoir bag added First 1/3 of exhaled gas flows into bag O 2 from flowmeter is directed into bag Adjust gas flow so bag does not collapse No valves in mask Non-Rebreathing Mask

30 Non-Rebreathing Mask O 2 percent up to 100% O 2 flow rates LPM O 2 flow must be adjusted to prevent total collapse of the bag on inspiration Patient breathe in only the gas available in the reservoir bag Valves on exhalation ports which prevents room air from being inspired Not suitable for long-term use Problem or clue Patient constantly remove mask No gas flow can be detected Humidifier pop-off off is sounding Reservoir bag collapses when the patient inhales Reservoir bag remains inflated throughout inhalation Erythema develops over face or ears Troubleshooting Common Problems with Reservoir Masks Cause Claustrophobia Confusion Flowmeter not on System leak Obstruction distal to humidifier High input flow Jammed inspiratory valve Flow is inadequate Large mask leak Inspiratory valve jammed or reversed Irritation or inflammation due to appliance or straps Solution Use alternative device Restrain patient Adjust flowmeter Check connection Find and correct obstruction Omit humidifier if therapy is short term Fix or replace valve Increase flow Correct leak Repair or replace mask Reposition mask or straps Place cotton balls over ear pressure points Provide skin care

31 Approximate FiO 2 for Low-Flow System Oxygen cannula 1L/min FiO2 : L/min FiO2: L/min FiO2: L/min FiO2: L/min FiO2: L/min FiO2: 0.44 Simple oxygen mask 5-88 L/min FiO2 : Partial rebreathing mask 7-10 L/min FiO2 : Non-rebreathing mask : oxygen flow to prevent the bag from collapsing during inspiration. FiO2 : Criteria for Use of High- and Low-Flow Oxygen Delivery System High-flow delivery system A consistent and predictable FiO 2 required Low-flow delivery system Ventilatory pattern consistent and regular Tidal volume between 300 and 700 ml Respiratory rate less than 25 bpm

32 Oxygen-Conserving Devices Reservoir cannula Pendant cannula Pulse dose oxygen or demand oxygen delivery system Oxygen Therapy Low concentration --less than 30% Nasal cannula Nasal catheter Air entrainment masks Medium concentrations --35% to 50% Oxygen mask Air entrainment mask Medium to high concentrations --50% to 60% Partial rebreathing mask High concentrations --100% Non-rebreathing mask

33 Selection of Oxygen System for Adults Patients with artificial airways Use high-flow systems With an endotracheal tube : Briggs T piece With a tracheostomy tube :a tracheostomy mask or collar FiO2 <0.4 : aerosol generators FiO2 >0.4 : Cascade large -volume nebulizer system Patients without artificial airway Oxygen cannula initially In emergency room : simple mask or partial rebreathing mask In recovery room : unheated aerosol generator Use of 100% Oxygen Indication Cardiac arrest Transport Acute cardiopulmonary instability Carbon monoxide poisoning Complication Oxygen toxicity Absorption atelectasis Oxygen-induced hypoventilation

34 Overall Goals of Home Respiratory Care Extend life Enhance the quality of life Reduce morbidity associated with disease Arrest the progress of chronic disease Improve overall physiologic and psychologic function Provide an environment to enhance individual potential Provide cost-effective medical care Primary Forms of Home Respiratory Care Oxygen therapy Aerosol therapy Mechanical ventilation Positive pressure Negative pressure CPAP

35 Chronic Hypoxemia PaO 2 55 mmhg or less PaO 2 59 mmhg or less with Dependent edema or Cor pulmonale or Hematocrit 55% or more Hemoglobin saturation 85% or less Hemoglobin saturation 86% to 89% and: Dependent edema or Cor pulmonale or Hematocrit 55% or more Physiologic Effects of Long-Term Oxygen Therapy Increased exercise capacity Decreased work of the myocardium Decreased pulmonary hypertension Normalization of the hemoglobin level

36 Oxygen Containment Systems Used in the Home Oxygen concentrator Liquid oxygen system Oxygen tank Oxygen Therapy Equipment Simple oxygen cannula Oxygen -conserving devices Oxygen reservoir system Reservoir cannula Pendant cannula Pulse dose or demand system Trans-tracheal oxygen

37 Patient Education for Oxygen Therapy For patients discharged on oxygen therapy, there should be documentation in the medical record, prior to discharge, of instructions and/or comprehension by the patient and/or family regarding Indications for use Dosage Complications of misuse Maintenance of equipment Arrangement for follow-up care Indications/Justification for Initiation of Oxygen Therapy A. Any one of the following diagnoses or conditions Acute asthma Acute cerebrovascular accident Acute respiratory failure, documented by PaO2=< 60 mmhg on room air Adult respiratory distress syndrome Atelectasis, documented by chest x-rayx

38 Indications/Justification for Initiation of Oxygen Therapy A. Any one of the following diagnoses or conditions Bronchiolitis or laryngotracheobronchitis in children Chest trauma ( flail chest) Chronic obstructive pulmonary disease Congestive heart failure Head injury or spinal cord injury Indications/Justification for Initiation of Oxygen Therapy A. Any one of the following diagnoses or conditions Infant respiratory distress syndrome Interstitial lung diseases Myocardial infarction or suspected myocardial infarction Pneumonia or pneumonitis Postanesthesia recovery Postcardiopulmonary arrest

39 Indications/Justification for Initiation of Oxygen Therapy A. Any one of the following diagnoses or conditions Pulmonary embolism Pulmonary edema Sepsis Severe anemia ( Hgb < 7.0 gm/dl dl) Shock Indications/Justification for Initiation of Oxygen Therapy B.. Hypoxemia documented by invasive or noninvasive blood gas analysis ( PO2 level or % saturation to be determined locally ) C.. Patient exhibits clinical signs or symptoms of tissue hypoxia, such as tachycardia, tachypnea, dyspnea, cyanosis, acute neurologic dysfunction, or acute myocardial irritability

40 Duration and Frequency Of Oxygen Therapy Documentation of continuing reassessment of need for oxygen therapy at least every four days Blood gas analysis in any patient treated with oxygen for more than 24 hours at FiO2 > 0.4 for more than 8 hours at any FiO2 for more than 2 hours in newborns at any FiO2 for more than 2 hours in patients with COPD All "prn" prn" " orders for oxygen should be reviewed

2) an acute situation in which hypoxemia is suspected.

2) an acute situation in which hypoxemia is suspected. I. Subject: Oxygen Therapy II. Policy: Oxygen therapy shall be initiated upon a physician's order by health care professionals trained in the set-up and principles of safe oxygen administration. Oxygen

附件 王家弘主任來院指導日期暨講題. Status Asthmaticus 氣喘危症. Auto-PEEP and Dynamic Hyperinflation 內生性吐氣末端陽壓. Hemodynamic Profile Interpretation 血流動力學的判讀

附件王家弘主任來院指導日期暨講題. Status Asthmaticus 氣喘危症. Auto-PEEP and Dynamic Hyperinflation 內生性吐氣末端陽壓. Hemodynamic Profile Interpretation 血流動力學的判讀