Respiratory failure

Acute respiratory failure: Tachypnea (>30), use of accessory muscles, hypoxia, already of BiPAP but struggling

  • STAT orders: ABG, BNP, EKG, chest x-ray, Troponin. Consider D-dimer if want to r/o PE.
    • ABG: Interpretation help – http://www.medcalc.com/acidbase.html
  • Call ICU and talk with attending about possible ICU transfer – Critical Care to manage intubation if necessary.
  • Look at urine output (I/O) – important if fluid overload. Look at Cr.
  • Treat underlying cause:
    • Infection – Community acquired PNA: IV Rocephin plus IV Azithromycin/Doxycycline
    • STEMI: Stat consult Cardiology for stat LHC
      • Continue Aspirin and Clopidogrel (Plavix)
    • PE: Also order CT spiral of chest per PE protocol – Start anticoagulation (therapeutic Lovenox or Heparin)
    • Fluid overload – CHF: IV Lasix.

Respiratory failure:

  • Consult Critical Care to manage BiPAP
    • Admit patient to ICU (if chance of need for intubation) vs PCU
      • Oxygenation options:
        • Oxygen via high-flow nasal cannula
        • Non-rebreather mask
          • 100% oxygen given
          • Has small clear air bladder/bag attached to mask
        • Venti-Mask:
          • If chronic CO2 retainer, alert pt
          • Has different color caps for different oxygen levels device can deliver.
        • BiPAP: If retaining CO2acute, lethargic pt (do NOT use if patient is vomiting as patient will aspirate!)
          • BiPAP [COPD] Initial Settings: IPAP: 10-12 cmH2O, EPAP: 5 cmH2O, Rate: 12, and FiO2 to maintain O2 saturation > 88
          • CPAP [OSA] Initial Settings: 8-10 cmH2O and FiO2 to maintain O2 saturation > 88%
  • Start DuoNeb breathing treatments q4hrs.
  • IV Solu-Medrol (methylprednisolone) 125mg (2ml) IV X 1 dose and then 60mg (.96ml) IV q12hrs                           Prednisone 40mg PO qd
  • Monitor with continuous pulse oximetry and telemetry.

Assess for home oxygen: PaO2 less than or equal to 55mmHg or a SpO2 less than or equal to 88% on room air.

Assess need for CPAP:

  • Formal outpatient polysomnography study (sleep study).
  • Screen: Perform overnight pulse ox: >5 minutes of <80% SpO2.
    • Recommend that the patient lie on lateral side while sleeping
    • Exercise and lose weight
  • Note: OSA can lead to insulin resistance.

Sleep Apnea [Obstructive sleep apnea: CPAP at night]:

STOP Questionnaire: Sleep Apnea Pre-Operative Risk Assessment

  • S: Do you Snore loudly?
  • T: Do you often feel Tired, fatigued, or sleepy during the daytime? Headaches first thing in the morning?
  • O: Has anyone Observed you stop breathing during sleep?
  • P: Do you have or are you being treated for high blood Pressure?
  • Additional OSA risk factors:
    • High BMI
    • Age over 50 years old
    • Male gender
    • Large neck circumference

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