הבדיקה הגופנית של חולה הבדיקה הגופנית של חולה נשמתית – נשמתית – במצוקהבמצוקה

פתופיזיולוגיה נשמתיתפתופיזיולוגיה נשמתית

דר' פאולו פרישו

החטיבה להרדמה

בית חולים סורוקה

The mechanical function of the respiratory system is to accomplish

Alveolar Ventilation.Its main homeostatic responsibility is the maintenance of normal levels of O2, CO2 and pH in blood.

Some Respiratory Acronyms

• PaO2 - Partial Arterial Pressure of O2• PAO2 - Partial Alveolar Pressure of O2 (BarP-47) * FiO2 - PaCO2• SpO2 - Pulse oximetry• PaCO2 - Arterial Partial Pressure of CO2• PETCO2 - End Tidal CO2 Pressure • Vt - Tidal Volume• RR - Respiratory Rate• Vm - Minute Volume• Va - Alveolar Ventilation• FiO2 – Fractioned Inspiratory O2

הבדיקה הגופנית של חולה במצוקה הבדיקה הגופנית של חולה במצוקה נשימתיתנשימתית

HistoryHistory

Physical ExaminationPhysical Examination

Use your eyes, ears, nose, hands

and devices.

DevicesDevices

Stethoscope Pulse Oximeter Capnograph

SpO2 InterpretationSpO2 Interpretation

What are the limitations of SpO2?

What is the meaning of a SpO2 of 100%?

Capnography TraceCapnography TraceWhat are its uses?What are its uses?

AuscultationAuscultation

PercussionPercussion

PalpationPalpation

Assess

Consciousness

Behavior

Color

Sweat

Speech

Work of Breath

Cyanosis InterpretationCyanosis Interpretation

Is a hypoxemic patient always cyanotic?

Can a patient with a normal PaO2 be

Cyanotic?

Work of BreathWork of Breath

Respiratory RateRespiratory RateTachypnea Bradypnea

Respiratory PatternRespiratory Pattern

What is the pattern of the respiratory disorder caused by

opiates?

What is the pattern of the respiratory change caused by metabolic Acid-Base disorder?

Respiratory Sounds 1Respiratory Sounds 1

Respiratory Sounds 2Respiratory Sounds 2

Respiratory Sounds 3Respiratory Sounds 3

Respiratory Sounds 4Respiratory Sounds 4

פתופיזיולוגיה נשימתיתפתופיזיולוגיה נשימתית

SpirometrySpirometry

Ventilation SoftwareVentilation Software

Respiratory center

• pH• PaCO2

• PaO2

• Pain (Stress)

• Drugs

Ventilation HardwareVentilation Hardware

Diaphragm and Chest wall muscles,

Lung tissue and Airway conduits

Ventilation PhysicsVentilation Physics

ΔP Compliance Resistance

Dead space

VVAA/Q Match /Q Match

DODO22 ≈ CO.Hb.SaO2 ≈ CO.Hb.SaO2

Hemoglobin Dissociation curveHemoglobin Dissociation curve

BicarbonateBicarbonatepH ≈ pH ≈ CO CO22

PathologiesPathologies

Infectious diseasesMalignanceTrauma Lung contusion, pneumothorax, hemothorax Upper airway AtelectasisMetabolic Acidosis, Sepsis, feverPulmonary Edema Cardiac CNS Post ObstructiveChemical Injury Smoke inhalation, hot air inhalation, AspirationObstruction, upper and lower airways Asthma, COPD, foreign body, malignance, allergy, laryngospasmARDSCardiac diseases Heart failure Pleural effusion Drugs Opiates, Benzodiazepines

O2

CO2

For Unicellular life it is easy!For Unicellular life it is easy!

Environment. FiO2

Barometric Pressure

Respiratory System

VA

Circulatory System

Hb, SaO2, CO

FiO2

CO2

PETCO2

VA/Q

CasesCases

An unconscious young man found in the street with a heavy snoring.

Case 1Case 1

A 70 years old lady with shortening of breath

Case 2Case 2

A 18 years old girl with tachypnea

Case 3Case 3

A 24 years old girl with tachypnea.

Case 4Case 4

A 4 years old boy with respiratory distress

Case 5Case 5

A 44 years man after an emergency cholecystectomy, with an SpO2 of 82 in the RR.

Case 6Case 6

A 20 years “Golani” after an elective arthroscopy of knee, with an SpO2 of 82 in the RR.

Case 7Case 7

A 28 years old, healthy woman, with an SpO2 that dropped down to 82 after ETT insertion for General Anesthesia.

Case 8Case 8

A chronic ill patient with worsening of his chronic condition.

Case 9Case 9

An unconscious patient immediately after MVA is breathing 20 BPM, on auscultation there is a lot of noise, but air can

be heard entering both lungs.

Case 10Case 10

A patient after MVA, 38 RPM, pulse , 8 bpm, cyanosis.

Case 11Case 11

65 years old man, shortness of breath.

Case 12Case 12

A 5 years old girl with fever and dyspnea

Case 13Case 13

A 68 years old heavy smoker with dyspnea.

Case 14Case 14

A 20 year old man found partially conscious

Case 15Case 15

A 55 YO woman in a full-blown pulmonary edema, was treated with O2 by mask with bag, high flow of 100% O2. SpO2 100%, but the she is refusing to use the mask, trying to take it off every time it is put in.Why is this patient with acute respiratory failure, cannot tolerate an oxygen mask with a high FiO2?

A 70 YO CIHD patient is in the ER for 20 minutes receiving a protocol

for Pulmonary Edema. The SpO2=100% with a respiratory rate

of 40 bpm. What to do next?