1、,Nursing Management of respiratory failure,Jiang Shenghua,呼吸： 机体与外界环境之间的气 体交换过程。,Lets Review: Respiratory Anatomy,Upper Respiratory Tract:Mouth, nose, throat (pharynx), larynx, tracheaLower Respiratory Tract:Lungs, bronchi, alveoliMedulla OblongataControls inspiration/expirationMicrosoft clipart,Ana
2、tomy Review,Used with permission: webschoolsolutions, 2007,Respiratory ReviewLets Take a Breath Together:,Air is warmed and humidified.Cilia filter out dust particles.Macrophages destroy germs.Air goes to L and R bronchi.Then to the bronchioles.Through to the Alveoli.Oxygen and CO2 exchange takes pl
3、ace.Used with permission: Jensen M.S., Webanatomy 2007,Respiratory Review:Now your Breath is,Alveoli fill with air.Oxygen diffuses thru alveoli walls.Oxygen diffuses to Capillaries and bloodstream.Hemoglobin for transport ofoxygen.Oxygen to the heart and to the body.Used with permission: Jensen, M.S
4、., Webanatomy (2007).,Respiratory ReviewLet your air out,Hemoglobin frees oxygen.O2 to cells.CO2 is the waste product.Veins return CO2 to heart.Heart pumps CO2 to lungs.CO2 passes alveoli to be exhaledUse with permission: Jensen, M.S., Webanatomy (2007),Respiratory Quiz,Respiratory Assessment:Unders
5、tanding the anatomy of the lungs, where does the exchange of oxygen and CO2 occur:A. BronchiolesB. AveoliC. Bronchial TubesClick on underlined best answer.,O2,CO2,CO2,Externalrespiration,circulation,Internalrespiration,肺通气(Pulmonary ventilation),肺通气：肺与外界环境气体交换的过程。,一、肺通气的动力,直接动力：肺内压与外界大气的压力差,原动力：呼吸运动
6、,呼吸运动,（一）呼吸运动(respiratory movement),1.概念：呼吸肌的收缩和舒张引起胸廓节律性扩大和缩小，包括吸气运动和呼气运动。,吸气肌: 膈肌和肋间外肌呼气肌: 肋间内肌和腹肌辅助吸气肌: 胸锁乳突肌 和斜角肌,呼吸运动的调节,一、 呼吸中枢与呼吸节律的形成,呼吸中枢：中枢神经系统内产生和调节呼吸运动的神经细胞群。,Apneusis长吸式呼吸,Gasping喘息样呼吸,1.自主呼吸节律的形成,延髓：产生自主呼吸节律的基本中枢脑桥上部：呼吸调整中枢(促进吸气向呼气转化),2.高位脑：控制随意呼吸(大脑皮层、边缘系统、下丘脑等处),（一）呼吸中枢(respiration c
7、enter),二、呼吸运动的反射性调节,（一）化学感受性呼吸反射,外周化学感受器: 颈动脉体和主动脉体;中枢化学感受器: 延髓腹外侧浅表部位。,1.化学感受器(Chemoreceptor),外周化学感受器,颈动脉体和主动脉体,动脉血中 PO2，H+，PCO2颈动脉体和主动脉体外周化学感受器兴奋呼吸中枢兴奋呼吸加深加快。,2.中枢化学感受器,部位：延髓腹外侧区浅表部位,中枢化学感受器的生理刺激是:,脑脊液和局部细胞外液中的H+。*注意：中枢化学感受器不感受CO2和缺O2刺激,2.CO2、H+、O2对呼吸运动的调节,CO2：动脉血中一定水平PCO2是维持呼吸中枢基本活动的必要因素。,CO2刺激呼吸
8、运动的途径：中枢化学感受器(起主要作用，但反应慢)外周化学感受器(与快速呼吸反应有关),吸入气CO2浓度适当增加(1%7%)，呼吸运动加深加快；CO2排出受限或吸入气CO2含量超标，引起动脉血PCO2显著升高(80mmHg)，将抑制中枢神经系统，出现呼吸困难,头痛,头晕,甚至昏迷称为CO2麻醉。,CO2 (正常CO2为0.04%)对呼吸的影响,吸入气中CO2 1 时呼吸开始加深；4CO2时呼吸加深加快,通气量1倍以上; 6CO2时肺通气量可增大6-7倍;7CO2时血液中PC02明显升高，可出现头昏、 头痛等症状；超过15-20，呼吸反而被抑制,可出现惊厥、 昏迷，甚至呼吸停止。,H+对呼吸运动
9、调节的途径及特点,*血液的H+不易通过血脑屏障，因此对中枢 化学感受器的影响很弱。,低氧对呼吸的兴奋是通过外周化学感受器实现。低氧对呼吸中枢直接作用是抑制。,不同程度的低氧对呼吸的影响不同,中度低氧,外周化学感受器,+,+,一,呼吸中枢,一,外周化学感受器,+,+,严重低氧,呼吸运动抑制,呼吸中枢抑制,3.CO2、H+和O2在呼吸调节中的相互作用,发生总和而加大对呼吸的影响: 例：PCO2 H+，二者作用发生总和，肺通气的增加比单因素PCO2时明显相互抵消而减弱对呼吸的影响: 例：H+肺通气量CO2排出 PCO2，肺通气的增加比单因素H+时小,三、呼吸运动的随意调节,大脑皮层控制随意呼吸运动。
10、这种控制是有一定限度的。如潜水需要屏气，但不能 无限制屏气。临床上,若自主控制通路受损，可观察到自主呼吸和随意呼吸的分离现象。即自主呼吸运动消失，患者必须“记住”要呼吸，一旦入睡或注意力转移，呼吸运动停止。,Definition and Classification,Definition,Respiratory dysfunction,oxygenation,CO2 elimination,vital organs,threaten,Key Words,Respiratory failure(RF) Acute respiratory distress syndrome(ARDS) Hypox
11、emia hypercapniaRespiratory rate(RR) Respiratory SupportMechanical ventilation Positive end-expiratory pressure (PEEP),Contents,Definition and Classification Epidemiology Physiology pathogenesis Clinical Evaluation Initial Management Advanced Management,What is respiratory failure,Respiratory failur
12、e develops when the rate of gas exchange between the atmosphere and blood is unable to match the bodys metabolic demands. It is diagnosed when the patient loses the ability to provide sufficient oxygen to the blood and develops hypoxemia or when the patient is unable to adequately ventilate and deve
13、lops hypercarbia and hypoxemia.,Respiratory failure is a syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, respiratory failure is defined as a PaO2 value of less than 60 mm Hg while breathing air or a
14、 PaCO2 of more than 50 mm Hg. （mmHg=millimeter hydrargyrum）,Definition and Classification,Definition,PaO26.66 kPa(50mmHg),Classification,acutely or chronically,In acute respiratoryfailure, a sudden, catastrophic event leads to life-threatening respiratory insufficiency.In chronic respiratory failure
15、, gradual worsening of respiratory function leads to progressive impairment of gas exchange, the metabolic effects of which are partially compensated by adaptations in other systems,EPIDEMIOLOGY,Respiratory failure is a common diagnosis among patients in medical intensive care units (ICUs) and is as
16、sociated with a poor prognosis.The incidence of respiratory failure is 137 cases per100,000 population, or 360,000 cases per year in the United States,with 36% of these individuals failing to survive the hospitalization.,流调城市: 7个城市14个调查点 (北京、上海、天津、沈阳、西安、重庆、广州),Shanghai,Tianjin,Chongqing,Shenyang,Xia
17、n,Beijing,Guangzhou,21270 subjects investigated, response rate 83.0%. Total prevalence: 8.2% Male vs female: 12.4% vs 5.1% Rural vs urban: 8.8% vs 7.8% Relatively higher COPD prevalence in Chongqing, and lower prevalence in Shanghai and Xian 死亡率：100万/年,Therapeutic advances in both mechanical ventila
18、tion and airway management have improved the prognosis for patients with respiratoryfailure over the past several decades.ventilator support systemsLung transplantation,病因,1.气道阻塞性病变2.肺组织病3.血管疾病4.胸壁及胸膜疾病5.神经肌肉系统疾病,呼吸衰竭的常见发病环节,Physiology- Nervous System,Dorsal & Ventral Nuclei, Medullary Respiratory C
19、ontrol group,Afferent & Efferent Pathways,In concert with Cerebral Cortex, determine RR and Breathing Effort,Nervous System,Respiratory failure due to diseases that cause dysfunction of the central control system can be thought of as controller dysfunction, or central apnea.Hypoventilation can be ca
20、used by disease at any of the anatomical sites involved in ventilation. Brainstem injury or disease may result in impaired functioning of the respiratory centre, which may also be suppressed by depressant drugs,Physiology-Musculature,Other Musculature Intercostals; Suprasternal; Sternocleidomastoid,
21、Physiology-Musculature,Neuromuscular blockers or disease of the neuromuscular junction (eg myasthenia gravis) may impair transmission of nerve impulses to respiratory muscles Or the problem may be in the muscle itself. Respiratory muscle fatigue, disuse atrophy and malnutrition are important causes
22、of respiratory muscle failure in the ICU,Respiratory failure due to diseases that cause ineffective function of the respiratory pump can be thought of as pump dysfunction. Under normal conditions, only elastic recoil is required for expiration, but during respiratory failure accessory muscles of exp
23、iration are required,Physiology-Airways,Upper respiratory tract： nose、pharynx、larynx,Lower respiratory tract： trachea、bronchus、bronchiole,Respiratory failure involving diseases that cause marked obstruction or dysfunction of the air passages can be thought of as airway system dysfunctionAlternativel
24、y the problem may be a problem of increased resistance to airflow. For example due to obstruction of the upper airway or bronchospasm,Physiology-Alveolar Units,Alveolar Unit: bronchioles; alveolar ducts; alveoli Function: surface area; sufficient elasticity Alveolar compartment dysfunction: collapse
25、, flooding, injury to alveolar network,O2,CO2,Alveolar epithelium,Capillary endotheliocyte,Physiology-Vasculature,0.8,Q,V,Respiratory failure as a result of disease involving the pulmonary vasculature can be thought of as pulmonary vascular dysfunction.三维医学-肺栓塞.avi,4.胸壁及胸膜疾病,脊柱疾病可以引起呼吸衰竭，常伴有肺心病，胸腔积液
26、、胸膜肥厚等亦可引起，外伤、骨折、气胸等常导致急性呼吸衰竭。,左侧液气胸,右 侧 气 胸,发病机制分类,通气性呼吸衰竭：泵衰竭（II型）换气性呼吸衰竭：肺衰竭（I型）,二、缺氧和二氧化碳潴留对人体的影响,缺氧和二氧化碳潴留引起人体各个系统、器官的功能代谢发生一系列代偿适应反应，严重时出现代偿不全，出现多器官功能和代谢紊乱直至衰竭。,具体表现,1、对中枢神经系统的影响2、对循环系统的影响3、对呼吸系统的影响4、对肾功能的影响5、对消化系统的影响6、对酸碱平衡和电解质的影响,1、 对中枢神经系统的影响,PaO260mmHg：注意力不集中、智力和视力轻度减退；PaO240-50mmHg：一系列神经系
27、统症状头痛，不安定向及记忆力障碍。PaO230mmHg：神志丧失乃至昏迷PaO220mmHg：数分钟可造成神经细胞不可逆性损伤。轻度CO2增加：间接引起皮层兴奋， CO2潴留也可以引起头痛、头晕、嗜睡、昏迷、呼吸抑制等。,肺性脑病（pulmonary encephalopathy）：由缺氧和二氧化碳潴留导致的神经精神障碍症候群。又称二氧化碳麻醉（carbon dioxide narcosis）。可能机制：,低氧血症、二氧化碳潴留、酸中毒缺氧及酸中毒 血管内皮损伤 脑间质水肿。缺氧 ATP酶生成减少 Na-Ka泵障碍 细胞内Na 脑水肿。形成恶性循环。,2、对循环系统的影响：PO2PCO2反射性
28、心率加快、心肌收缩力增强、心排出量增加(皮肤内脏血管收缩，冠脉血管扩张，局部代谢物影响）严重缺氧和CO2潴留抑制作用 血管扩张、血压下降、心律失常。严重缺氧 室颤、心脏骤停长期慢性缺氧 心肌纤维化、心肌硬化呼吸衰竭PO2 肺动脉高压、心肌受损 肺心病,3、对呼吸系统的影响：氧60mmHg 刺激颈动脉体、主动脉体，使通气加强，氧30mmHg 呼吸抑制作用（兴奋抑制）PaCO2增高兴奋呼吸中枢呼吸深快。当PaCO280mmHg 呼吸中枢抑制、麻醉作用，（低氧兴奋呼吸中枢）注意氧疗方法,4、对肾功能的影响：功能性改变，甚至发生肾功不全。,5、对消化系统的影响：缺氧直接或间接损害肝细胞导致丙氨酸氨基转
29、移酶上升呼吸衰竭引起消化功能障碍，甚至出现胃肠粘膜糜烂、坏死、出血、溃疡。,6、对酸碱平衡和电解质的影响急性呼吸衰竭Ph HCO3 - / H2CO3缺氧 无氧酵解 代谢性酸中毒高钾血症（能量障碍，Na-Ka泵障碍）慢性呼吸衰竭呼吸性酸中毒并代谢性碱中毒（肾排泄HCO3减少）低氯血症,呼吸困难判断：无严重外周体表静脉充盈、皮肤潮红、温暖多汗、球结膜充血水肿。 血压早期升高，后期下降；心率多数增快。 部分病人可见视乳头水肿、瞳孔缩小，腱反射减弱或消失、锥体束征阳性等。,2.体征,血气分析,是确定有无呼衰以及进行呼衰分型最有意义的指标。,血pH电解质测定,呼吸性酸中毒合并代谢性酸中毒时，血pH明显
30、降低可伴高钾血症；呼吸性酸中毒伴代谢性碱中毒时，常有低血钾和低血氯。,动脉采血进行动脉血气分析,呼吸衰竭病人由于出现多器官功能障碍，特别是呼吸困难，用力呼吸不能满足机体需要时，常表现为恐惧或烦躁不安，产生濒死感。,随着呼吸困难加重，采用人工气道或机械通气时，影响到情感交流，病人出现情绪低落、精神错乱，甚至拒绝配合治疗及护理。,部分病人过分依赖呼吸机，一旦脱机，可能出现情绪紧张，对自主呼吸缺少信心。由于病人长期受慢性疾病折磨，加上病情突然加重，病人及家属可能出现焦虑、恐惧等心理。,1.在保持呼吸道通畅的前提下,与呼吸道分泌物多而黏稠、呼吸肌疲劳、 咳嗽无力、意识障碍或人工气道有关。,清理呼吸道无
31、效,水、电解质紊乱及酸碱失衡、上消化 道出血、颅内出血,潜在并发症,complication,problems,Ineffective Breathing Pattern,Impaired Gas Exchange,Ineffective Airway Clearance,Anxiety,Altered Nutrition,(1)ABG values within the clients baseline;(2)baseline breath sounds;(3)no dyspnea or dyspnea at the clients baseline;(4)effectivecough an
32、d ability to clear secretions.,一般护理,对症护理,病情观察,治疗配合,并发症护理,心理护理,健康指导,1休息与体位 卧床休息。协助病人取舒适且利于改善呼吸状态的体位，一般取半卧位或坐位。 ？,一般护理,呼吸衰竭多采用半坐位,1 .Effective coughing 2 .Airway establishment3 .Airway clearance,Effective coughing,If Secretions are obstructing the airway，the client should be encouarged to cough.Therap
33、eutic techniques may be benefit to these clientsHow to do so?,Airway establishment,1. Oral endotracheal intubation2. Nasal intubation3. Tracheostomy,3 .Airway clearance,Suctioning inculde crackles and rhonchi on auscultation，frequent coughing or setting off the high-pressure alarm，increasing restles
34、sness or anxietyOthers : Percussion，vibration，and psotural drainage,1。Provide high-protein, high-calorie enteral or paxenteral nutrition as ordered to meet increased nutritional requirements.2。If able to take，nutrition oralty provide six small meals per day to decrease oxygen energy expenditure duri
35、ng digestion.,3.Provide between-meal nutritional supplements to maintain adequate caloric intake. 4 .maintain the ordered oxygen delivery system during meals to prevent shortness of breath and blood oxygen desaturation while eating. 5 .Monitor for signs of CO2 increasing with parenteral nutrition be
36、cause carbohydrates may increase CO2 levels in clients With hypercapnia.,1 .Oxygen therapy2. Mechanical ventilation,1Oxygen therapy,（1）氧疗适应证：呼吸衰竭病人PaO260mmHg，是氧疗的绝对适应证，氧疗的目的是使PaO260mmHg。,（2）氧疗的方法： 临床常用、简便的方法是应用鼻导管或鼻塞法吸氧，还有面罩、气管内和呼吸机给氧法。缺氧伴CO2潴留者，可用鼻导管或鼻塞法给氧；缺O2严重而无CO2潴留者，可用面罩给氧。 吸入氧浓度与氧流量的关系：吸入氧浓度（%
37、）=21+氧流量（L/min）。,鼻塞法 鼻导管,面罩吸氧,（3）氧疗的原则： I型呼吸衰竭：多为急性呼吸衰竭，应给予较高浓度（35%吸氧浓度50%）或高浓度（50%）氧气吸入。急性呼吸衰竭，通常要求氧疗后PaO2维持在接近正常范围。 II型呼吸衰竭：给予低流量（12L/min）、低浓度（35%）持续吸氧。慢性呼吸衰竭，通常要求氧疗后 PaO2维持在60mmHg或SaO2在90%以上。,（4）氧疗疗效的观察： 若呼吸困难缓解、发绀减轻、心率减慢、尿量增多、神志清醒及皮肤转暖，提示氧疗有效。 若发绀消失、神志清楚、精神好转、PaO260mmHg、PaCO250mmHg，考虑终止氧疗，停止前必须间
38、断吸氧几日后，方可完全停止氧疗。 若意识障碍加深或呼吸过度表浅、缓慢，提示CO2潴留加重，应根据血气分析和病人表现，遵医嘱及时调整吸氧流量和氧浓度。,吸氧及停止的护理记录,1.观察呼吸困难的程度、呼吸频率、节律和深度。 2.观察有无发绀、球结膜充血、水肿、皮肤温暖多汗及Bp升高等缺氧和CO2潴留表现。 3.监测生命体征及意识状态。 4.监测并记录出入液量，血气分析和血生化检查、电解质和酸碱平衡状态。 5.观察呕吐物和粪便性状 6.观察有无神志恍惚、烦躁、抽搐等肺性脑病表现，一旦发现，应立即报告医师协助处理。,病情观察,Positive Pressure ventilation： increas
39、es lung volume，helps redistribute fluid from the alveolar to the interstitial space，helps reduce the oxygen demand caused by increased work of breathing in many conditions leading to respiratory failure,Mechanical ventilation,Through endorracheal or nasotracheal intubation or noninvasively through a
40、 nasal or facemask.absent respiration，excessive secretions，a decreased level of consciousness，high O2 requirements，or hemodynamic instability。(no NIPPV),呼吸机,人工气道和机械通气,治疗配合,做好术前准备工作，减轻或消除紧张、恐惧情绪。 按规程连接呼吸机导管 加强病人监护和呼吸机参数及功能的监测。 注意吸入气体加温和湿化，及时吸痰。 停用呼吸机前后做好撤机护理。,治疗配合,遵医嘱选择有效的抗生素控制呼吸道感染，对长期应用抗生素病人注意有无“二重
41、感染”。遵医嘱使用支气管舒张剂。,治疗配合,在呼吸道通畅的前提下，遵医嘱使用呼吸兴奋剂，静脉输液时速度不宜过快。若412h未见效，或出现肌肉抽搐等严重不良反应时，应立即报告医师。 对烦躁不安，夜间失眠病人，禁用麻醉剂，慎用镇静剂，以防止引起呼吸抑制。,并发症护理,1水、电解质紊乱及酸碱失衡 定期监测血气分析和血生化指标。遵医嘱给予药物纠酸，或补钾。2上消化道出血 注意观察呕吐物和粪便性状，出现黑粪应给予温凉流质饮食，出现呕血时应暂禁食。,心理护理,经常巡视、了解和关心病人，特别是对建立人工气道和使用机械通气的病人。采用各项医疗护理措施前，向病人作简要说明，给病人安全感，取得病人信任和合作。指导病人应用放松技术、分散注意力。,健康指导,1疾病知识指导 向病人及家属介绍疾病发生、发展与治疗、护理过程，与其共同制定长期防治计划。指导病人和家属学会合理家庭氧疗的方法以及注意事项。,2疾病预防指导 指导病人呼吸功能锻炼和耐寒锻炼，如缩唇呼吸、腹式呼吸及冷水洗脸等；教会病人有效咳嗽、咳痰、体位引流及拍背等方法。若病情变化，应及时就诊。,健康指导,3生活指导 劝告吸烟病人戒烟，避免吸入刺激性气体；改进膳食，增进营养，提高机体抵抗力。指导病人制定合理的活动与休息计划，劳逸结合，以维护心、肺功能状态,4用药指导 遵医嘱正确用药，了解药物的用法、用量和注意事项及不良反应等。,谢谢！,
