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How to Approach a Patient With
Respiratory Failure at Ward or
ICU
KJC
Dyspnea - difficult or labored respiration
¡ symptom - (medicine) any sensation or change
in bodily function that is experienced by a patient
and is associated with a particular disease
¡ orthopnea - form of dyspnea in which the person
can breathe comfortably only when standing or
sitting erect; associated with asthma and
emphysema and angina pectoris
¡ breathlessness, shortness of breath, SOB - a
dyspneic condition
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Management of severe dyspneaBasic Principles
¡ It is medical emergency- Be careful and
alert in managing these patients.
¡ You need caution, good knowledge,
experience, skill and specialist
consultation and member assistant to
handle this big problem immediately.
¡ Sent to ICU as soon as possible if
unstable vital signs, hypoxemia and
disturbed consciousness.
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History Reviews of Underlying Disease
A. Non-pulmonary diseases:
1. Cardiovascular disease: AMI, CAD,
arrhythmia, deep vein thrombosis, CHF,
valvular heart disease
2. Others: anxiety or neurosis, drugs
(chemotherapy, morphine), anemia, liver
cirrhosis, renal disease or failure (uremia),
cancer (lung metastasis ?), DM(DKA),
alcoholism (ketoacidosis), neuro-muscular
disease, CVA.
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History Reviews of Underlying Disease
B. Pulmonary diseases:
Smoking Hx ( ? Pack-year), COPD (chronic
brochitis or empysema), asthma, TB with
sequele, bronchiectasis, intubation history
(sequeles of intubation:tracheal stenosis),
tracheostomy, lung fibrosis, inhalation injury
(burn, toxic gas), occupation history
(pneumoconiosis, silicosis), aspiration
pneumonia (old CVA, ICH, head injury, NG
feeding), chest injury Hx (flail chest,
hemothorax, pneumothorax)
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Rapid and Accurate Systemic
Reviews and Physical Examination-1
1. Conscious level, conjuntiva (pale or edema),
jaundice?
2. Vital signs: BP, HR, rhythm, BT, RR, SaO2.
3. Respiratory patterns (deep or shallow, rapid or
slow, regular or irregular) and chest wall
deformity ?
4. Accessary muscle use? Paradoxical breathing
pattern and pulse?
5. Jugular veins engorgement? (CHF, SVC
syndrome), lymphadenopathy?
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COPD with air-trapping
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SVC Syndrome
臉部潮紅，
脖子腫脹，
呼吸喘，
呈端坐呼吸。
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Neck Veins are distended.
They were non-pulsatile and did not collapse with
inspiration.
History coupled with this finding suggests superior vena
caval obstruction.
Lung Cancer with SVC syndrome.
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Severe COPD with cor-pulmonale and right heart failure
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Severe emphysema with body weight loss
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Rapid and Accurate Systemic
Reviews and Physical Examination-2
6. Heart sound: regular or irregular, S3 or S4,
diminished or not?, murmur (systolic or
diastolic murmurs)? pericardial friction rub?
7. Lung sound: stridor, wheezing, rhonchi,
crackles, diminished or not?, bronchial sound
or vesicular sound?
Percussion and Palpation: tenderness?
Dullness or hyperresonance? Symmetric chest
wall expansion? Intercostal muscle retraction?,
suprasternal retraction? Chest wall vescular
dilation? (SVC syndrome), subcutaneous
emphysema?
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如何自我評估氣喘發作嚴重度？
輕度
中度
重度
1.喘息程度
走路會喘，
可以躺下來
說話會喘，
坐著較舒服
休息也會喘，
向前彎腰會稍
微好些
2.說話長度
可以說一整
個句子
只能說片語
只能說單字
3.意識狀態
可能略微焦
慮
經常焦慮
明顯焦慮
4.呼吸速率
略增加
增加
>30次/分
5.哮喘聲
中度
大聲
很大聲
變小聲或聽不到
6.心跳數/分
<100
100-200
>120
心跳變慢
呼吸衰竭;緊急
嗜睡或意識不清
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Rapid and Accurate Systemic
Reviews and Physical Examination-3
8. Abdomen: soft or rigid, distended?
tenderness? Muscle guarding? ascites?
(shifting dullness), hepatosplenomegaly?, bowel sound
(hyperactive or hypoactive?)
9. Extremities: muscle power? cold or warm?
skin: dry or edema? cyanosis? Arterial
pulse (PAOD or DVT)? clubbing fingers?
Purple mottle of skin (sepsis)?
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Systemic reviews for respiratory failure or
distress in ICU or critical patients (1)
¡ Check vital signs, including BP, HR, RR, SpO2 ,
coma scale, body temperature, ABG first, then
keep airway patent, maintain normal breathing
and circulation or perfusion.
¡ Review past history as soon as possible,
including major diseases: CHF, CAD, COPD,
asthma, TB, DM, hypertension, CVA, occupation,
smoking, alcohol, drug history, operation history,
cancer history.
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Systemic reviews for respiratory failure
or distress in ICU or critical patients (2)
¡ Check CBC, ABG, biochemistry and sugar, electrolytes,
CXR, EKG immediately. Pulmonary function test or peak
flow rate in asthma or COPD patients. Chest CT scan,
MRI, perfusion lung scan if needed.
¡ Perform physical examination systemically as soon as
possible:
¡ 1) Inspection: cyanosis, chest motion with paradoxical
motion, accessory respiratory muscle use, edema, skin
turgor, skin lesion, rash or mass, extremity motion,
clubbing fingers, spider angioma, conjunctiva and sclera
(edema, pale, icteric?), jugular vein engorgement.
¡ 2) Palpation: trachea position, skin crepitation
(subcutaneous emphysema), heart beat and heave or
thrill, cold or warm skin, neck stiffness.
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Systemic reviews for respiratory failure
or distress in ICU or critical patients (3)
¡ Percussion of lung fields: dullness (consolidation,
collapse, pleural effusion) or hyperresonance
(emphysema, pneumothorax). Abdomen
percussion: shifting dullness (ascites).
¡ Heart size and the range of lung volume.
¡ Auscultation: a) Lung sound: bronchial sound or
vesicular sound, crackles, wheezing, rhonchi,
stridor,decreased or increased transmission of
breathing sound. b) Heart sound: S3 gallop,
systolic or diastolic murmur, regular or irregular
beat. C) Bowel soung: hypoactive or hyperactive
bowel sound.
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Is Patient Receiving Mechanical
Ventilation?
¡ YES→common causes of sudden onset of
dyspnea with acute hypoxemia: SPO2 <
90%, PO2<60mmHg:
¡
¡
¡
¡
ARDS
Pneumonia progression
Pneumothorax
Acute pulmonary embolism
Pulmonary lung edema (CHF, fluid overload,
malnutrition, Uremia)
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Continued common causes of
severe dyspnea
¡
¡
¡
¡
¡
¡
¡
Sepsis
Bilateral pleural effusing
Pericardial tamponade
COPD + AE
Asthma + AE
Pulmonary hemorrhage
Acute massive blood loss ( esp, G-I tract or
intra-abdominal bleeding) with anemia
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Ventilator setting and monitoring
¡ Check Peak airway pressure, plateau
pressure, alarm causes, auto-PEEP level,
air-leak or not, tubing connection is correct
or not, humidifier is OK or not? Cuff
pressure? ET tube position by CXR for
adjustment.
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Evaluate Ventilator Setting and
Monitoring Ventilator Parameters
¡ VT, Flow rate, Frequency, I:E ratio, PEEP
level, Pressure control level (setting)
¡ Monitor expiratory tidal volume, RR, peak
airway pressure, plateau pressure
¡ Ventilator waveforms (graphs) and the
causes of alarms.
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Emergent Laboratory Tests or Radiological
Studies for Severe Dyspnea-1
1. ABG:
pH: acidosis or alkalosis (pH< 7.25)
PO2: hypoxia or not (PaO2< 60mmHg)
PCO2: hypercapnia (PaCO2>60mmHg) or
hyperventilation (respiratory acidosis or alkalosis)
HCO3-: (metabolic acidosis or alkalosis)
ARDS: PaO2 / FiO2 ≤ 200, Bilateral alveolar
infiltration, PAWP ≤ 18 mmHg.
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Emergent Laboratory Tests or Radiological
Studies for Severe Dyspnea-2
Calculate
a. A-a gradient: PAO2-PaO2
PAO2: FiO2 X (760-47 mmHg)-PaCO2/RQ (0.8)
Normal range: 8-15 mmHg
> 15 mmHg-V/Q mismatch or shunt.
Normal A-a gradient: FiO2 (21%): 2-25 mmHg, FiO2
(100%): <150 mmHg
b. Shunt: CcapO2/CcapO2-CvO2
CcapO2: (1.39 X ScapO2 X Hb + 0.0031X PaO2)
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Emergent Laboratory Tests or Radiological
Studies for Severe Dyspnea-3
2. Electrolytes: Na+, K+, (Cl-, Ca++, Mg++,
Phosphate if necessary.)
3. CXR:
-
pneumonia, lung edema, ARDS, pleural effusion or
pericardial effusion, lung collapse, pneumothorax,
pneumomediastena, lung fibrosis, bronchiectasisi,
tumors, lymphodenopathy, pulmonary hypertension,
subdiaphramation free air or abnormal gas
formation (liver abscess), the position of ET tube,
CVP line, Swang-Ganz catheter, chest tube or
pigtail catheter.
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CXR reading principles
¡ Good expansion, position and exposure
condition.
¡ Name, bed number, correct date and time, sex,
age. (correct or not?)
¡ Check the position of various lines or tubes,
including CVP, Swan-Ganz catheter, ET tube,
chest tube, pigtail catheter, draining tube, NG
tube.
¡ Compared with previous CXR films or CT
findings, repeat CXR follow-up if condition
needed.
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CXR reading sequences
¡ Extra-pulmonary area: neck, soft tissue mass,
including breast shadow, bones (sternum,
clavicles, ribs, scapula, humerous), pleura
(effusion or air), mediastinum, trachea position.
¡ Intra-pulmonary area: pulmonary vessels,
bronchial trees, lung field lesions (mass, nodule,
pneumonia, collapse, cardiomegaly with lung
edema, pericardial effusion).
¡ Diaphragm position and subphrenic lesion:
including stomach air, colon gas (paralytic ileus
or obstructive ileus), free air (PPU or colon
rupture)
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RUL lobar
pneumonia
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RUL Klebsiella pneumonia
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LUL TB pneumonia
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Staphylococcus septic
emboli with right
empyema, drug
addiction with heroin
injection
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PCP
pneumonia
from AIDS
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RUL collapse from patient
with endotracheal intubation
and ventilator support
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Liver cirrhosis with massive
right pleural effusion
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RLL Lung cancer with
bilateral pleural effusion and
pericardial effusion
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Bilateral
pneumothorax with
pneumotoceles from
staphylococcus
sepsis
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Pneumomediastinum
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Status asthmaticus with
severe air-trapping
(emphysematous
change)
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Uremia with lung edema and
pericardial effusion
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Morphine overdose
with pulmonary
edema
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CHF with pulmonary edema
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Severe pneumonia with ARDS
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Lymphoma
with SVC
syndrome
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Liver abscess with right
subphrenic air
accumulation
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Liver
abscess
by
Klebsiella
pneumoni
a infection
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Pneumoconiosis
PMF with
emphysema
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Colon cancer with
lung metastasis
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Emergent Laboratory Tests or Radiological
Studies for Severe Dyspnea-4
4. CBC: Hb? MCV? WBC? Neutrophil %,
Eosinophil %? Lymphocyte %? Platelet count ?
5. Blood sugar level? hyperglycemia or
hypoglycemia?
6. BUN, Creatinine (R/O renal failure with
acidosis)
7. Pulmonary function test, PEFR ( for COPD and
asthma attack)
8. Perfusion lung scan and angiography (r/o
acute pulmonary embolism)
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Emergent Laboratory Tests or Radiological
Studies for Severe Dyspnea-5
9.
10.
11.
12.
13.
Cardiac echo and radionuclotide LV scan
Abdomen echo
Chest or abdomen CT scan
Brain CT for disordered conscious
Sepsis study if fever or metabolic acidosis
a. Blood culture, urine routine and culture, sputum
smear for Gram¡s stain and Acid-Fast stain, and for
bacterial and TB cltures.
b. Other infections source ?(CVP line, Foley, wound,
abscess?¡ )
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Emergent Laboratory Tests or Radiological
Studies for Severe Dyspnea-6
14. Bronchoscope study: for the diagnosis of
stridor, hemoptysis, lung collapse;
endobronchial TB or tumor, and
treatment for sputum impaction, stopping
bleeding, or foreign body removal.
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Immediate Approaches for
dyspnea-1
1. Oxygen supply:
a. nasal cannula: (3-5l/min), keep SaO2>92%
b. Simple O2 mask: (> 5L/min)(FiO2: 40-80%)
c. Non-rebreathing mask: (10-15L/min),
(FiO2:80-100%)
d. Venturi mask (FiO2 24-50%) for COPD
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Classification of Asthma
Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
Nocturnal
Symptoms
Continuous
Limited physical
activity
Frequent
Daily
Attacks affect activity
> 1 time week
> 1 time a week
but < 1 time a day
FEV1 or PEF
 60% predicted
Variability > 30%
60 - 80% predicted
> 2 times a month
Variability > 30%
 80% predicted
Variability 20 - 30%
< 1 time a week
STEP 1
Intermittent
Asymptomatic
and normal PEF
between attacks
 2 times a month
 80% predicted
Variability < 20%
The presence of one feature of severity is sufficient to place patient in that category.
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Part 4: Long-term Asthma Management
Stepwise Approach to Asthma
Therapy - Adults
Outcome: Best
Possible Results
Outcome: Asthma Control
Controller:

Controller:
Controller:
None
Controller:
Daily inhaled
corticosteroid



Daily inhaled
corticosteroid
Daily longacting inhaled
β2-agonist


Daily inhaled
corticosteroid
Daily long ¡
acting inhaled
β2-agonist
plus (if needed)
-Theophylline-SR
-Leukotriene
-Long-acting inhaled
β2- agonist
-Oral corticosteroid

When
asthma is
controlled,
reduce
therapy

Monitor
Reliever: Rapid-acting inhaled β2-agonist prn
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate
Persistent
STEP 4:
Severe
Persistent
STEP Down
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Immediate Approaches-2
2. Bronchodilator inhalation for
bronchospasm
a.
b.
c.
d.
Bricanyl 1amp + NS 2ml, Nebulizer q1h-q6h
Atrovent 1amp + NS 2ml, Nebulizer q1h-q6h
Berotec (MDI) 2-4 puffs q30min-q6h
Salamol (MDI) 2-4 puffs q30min-q6h (add
spacer or aerochamber for MDI)
e. Symbicort (turbuhaler)(Formoteral +
Budesonide) 2-4 actuations q12h
f. Bosmin 1cc + NS 3cc Nebulizer for stridor
(vocal cord edema after extubation) q1h-q6h
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Speed of
onset
Classes of 2-agonists
RESCUE MEDICATION
fast onset, short duration
fast
inhaled terbutaline
inhaled salbutamol
fast onset, long duration
inhaled formoterol
slow onset, short duration slow onset, long duration
slow
oral terbutaline
oral salbutamol
oral formoterol
short
inhaled salmeterol
oral bambuterol
long
Politiek MJ et al European Respiratory Journal 1999; 13; 988 - 992
M
A
I
N
T
E
N
A
N
C
E
Duration
of action
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Formoterol has unique pharmacological
properties compared with other long-acting
2-agonists
Formoterol
Salmeterol
Long duration (>12 hours)
Long duration (>12 hours)
Rapid onset of action
Delayed onset of action
Full receptor agonist
Partial receptor agonist
Dose¡ response within
labelled doses
No dose¡ response at
labelled doses
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氣喘合併式療法新趨勢
¡ Flixotide (輔舒酮) + Serevent (使
立穩) (SeretideR使肺泰胖胖魚吸
入劑)
¡ Pulmicort (可減喘) + Oxis (優吸
舒) (SymbicortR吸必擴都保吸入
劑)
¡ 同時具抗發炎與氣管擴張作用
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Hypothesis of Adjustable Treatment for
Asthma
Asthma control may be improved by providing
the right dose of Symbicort at the right time
Asthma
worsening
Symbicort
inhalations
Asthma control
Quickly
gain
control
2 inh.
bid
Maintain
control
1 inh.
bid
Step down to adequate
dose that maintains control
4 inh.
bid*
1 inh. or
bid
2 inh.
od
Time
(months, weeks, days)
inh. = inhalation(s)
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First-line treatments of acute asthma
Agent
Administration
Oxygen (level IIIA)
High flow to maintain SaO2>92-95%; by
nasan prongs, mask or ET tube
β2-Agonists ( level IA)
MDI: initial 4-8 puffs, can be repeated
every 15-20 minutes up to 3 times, it can
be increased to 1 puff every 30-60 s, up to
20 puffs ( level IA).
Wet nebulizer: 5-10 mg of salbutamol (1-2
mL plus 3 mL of saline) every 15-20 min, or
can be run continuously in severe attack
Corticosteroid (level IA)
Prednisolone 50 mg orally or
methylprednisolone 125 mg IV stat then
40-120 mg IV daily if PO not possible, or
hydrocortisone 500 mg IV, repeat every 8
hrs for 24 hrs
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Adjunct therapy in acute asthma
Agent
Administration
Anticholinergics ( level IA for reducing
hospitalization and with additive
bronchodilation effect)
Atrovent: MDI: 4-8 puffs every 15-20 min,
to be repeated 3 times. Increased to 1 puff
every 30-60 s, to amaximum of 20 puffs
MgSO4 (level IA in reducing hospitalization
and increasing FEV1 with co-treatment of
β2-agonists)
IV infusion 25 mg/kg/h
Adrenaline (seldom use in asthma, but is
the drug of choice in anaphylaxis with
prominent bronchoconstriction)
0.3-0.5 mL (1:1000) subcutaneously every
15-20 min, as required. Infusion: 4-8
µg/min
Intravenous β2-agonists (level IC)
Salbutamol 4 µg/kg, over 2-5 min, or
infusion at 0.1-0.2 µg/kg/min
Aminophylline (level ID)
Loading dose: 3-6 mg/kg IV over 30 min;
the dose should be halved if the patient is
already on theophylline; followed by an
infusion at 0.2-1 mg/kg/h; blood level
monitoring is recommended
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Immediate Approaches-3
3. Intravenous steroid for COPD with
AE or status asthmaticus:
a. Loading dose:
1) Medason (125mg methylprednisolone) 1
vail iv st
2) Saxizon (300mg hydrocortisone) 1 vail iv
st
b. Maintenance dose:
1) Solumedrol (40mg methyprednisolone) 1
vial iv q12h-6h
2) Saxizone 100mg iv q8h-q6h
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Immediate Approaches-4
4. Aminophylline infusion (0.1-0.5 mg/hr/kg)
[2amps + NS 500cc, set 30cc/hr (≒
0.5mg/hr/kg) , adjust infusion dose
according to coexisted underlying
disease or medications], monitoring
serum level after 24-48 hours of infusion.
5. Diuretic for lung edema
6. Adequate antibiotic for sepsis or infection.
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Immediate Approaches-5
7. Heparin ihfusion for thrombo-embolism, or
thrombolytic agent for life threatening case.
8. Hemodialysis for uremia acidosis, lung edema,
or hyperkalemia.
9. Insulin and fluid replacement for DKA, HHNK
10. Chest tube for pneumothorax or massive
pleural effusion.
11. Non-invasive ventilation (BiPAP, CPAP mask)
for COPD + AE or Ac pulmonary edema.
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Immediate Approaches-6
12. Emergent intubation and Mechanical
Ventilation
-
pH < 7.2
PO2 < 60 mmHg despite O2 mask or NIPPV
PCO2 > 60 mmHg
Unstable vital signs or drowsy consciousness.
→ ICU care
13. 急會外科 (PPU, peritonitis, ICH, emergent
tracheostomy for difficult intubation)
14. 會心臟科 for cardiovascular problems
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Immediate Approaches-7
15.
16.
17.
18.
會腎臟科 for hemodialysis
會胸腔科 for chest and airway diseases
會腸胃科 for G-I and Liver diseases
Use sedation or paralyzed agents with
cautions : IV Dormicum (Midazolam), Diprivan
(Propofol), morphine, valium, atracurium or
pancuronium: need good airway protection
(with ET tube) and need intensive blood
pressure monitoring in ICU.
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