MEDICAL MANAGEMENT

Ideal
Treatment for respiratory failure depends on whether the condition is acute (short-term)
or chronic (ongoing) and its severity. Treatment also depends on the condition's underlying
cause. Acute respiratory failure can be a medical emergency. It often is treated in an intensive
care unit at a hospital. One of the main goals of treating respiratory failure is to get oxygen to
your lungs and other organs and remove carbon dioxide from your body. Another goal is to treat
the underlying cause of the condition.
Diagnostic Tests
 Electrocardiogram (ECG). An electrocardiogram records electrical signals as they
travel through you heart. An ECG can often reveal evidence of a previous heart attack or
one that’s in progress.

In other cases, Holter monitoring may be recommended. With this type of ECG, you
wear a portable monitor for 24 hours as you go about your normal activities. Certain
abnormalities may indicate inadequate blood flow to your heart.

 Echocardiogram. An echocardiogram uses sound wave to produce images of your heart.

During an echocardiogram, your doctor can determine whether all parts of the heart wall
are contributing normally your hearts pumping activity.

 Pulse oximetry. For this test, a small sensor is attached to your finger or ear. The sensor
uses light to estimate how much oxygen is in your blood

 Arterial blood gas test. This test measures the oxygen and carbon dioxide levels in your
blood. A blood sample is taken from an artery, usually in your wrist. The sample is then
sent to a laboratory, where its oxygen and carbon dioxide levels are measured.
Drugs
 Furosemide (Lasix) - Administer loop diuretics such as furosemide intravenously (IV)
because this allows both superior potency and a higher peak concentration despite an
increased incidence of adverse effects, particularly ototoxicity..

 Nitroglycerin sublingual (Nitro-Bid, NitroMist, Nitrostat, Nitrolingual) - Sublingual

nitroglycerin tablets and spray are particularly useful in the patient who presents with
acute pulmonary edema with a systolic blood pressure of at least 100 mm Hg. As with
sublingual nitroglycerin tablets, the onset of action of nitroglycerin spray is 1-3 minutes,
 with a half-life of 5 minutes. Administration of the spray may be easier, and it can be
stored for as long as 4 years.

Topical nitrate therapy is reasonable in a patient presenting with class I-II congestive
heart failure (CHF). However, in patients with more severe signs of heart failure or
pulmonary edema, IV nitroglycerin is preferred because it is easier to monitor
hemodynamics and absorption, particularly in patients with diaphoresis. Oral nitrates,
because of their delayed absorption, play little role in the management of acute
pulmonary edema.

 Nitroprusside sodium (Nitropress) - Nitroprusside produces vasodilation of venous and

arterial circulation. At higher dosages, it may exacerbate myocardial ischemia by
increasing heart rate. It is easily titratable.

 Morphine sulfate (Duramorph, Astramorph) - Morphine sulfate is the drug of choice for
narcotic analgesia because of its reliable and predictable effects, safety profile, and ease
of reversibility with naloxone. Morphine sulfate administered IV may be dosed in a
number of ways and commonly is titrated until the desired effect is obtained.

 Terbutaline (Brethaire, Bricanyl) - Terbutaline acts directly on beta2 receptors to relax

bronchial smooth muscle, relieving bronchospasm and reducing airway resistance.

 Albuterol (Proventil) - Albuterol is a beta-agonist useful in the treatment of

bronchospasm. It selectively stimulates beta2-adrenergic receptors of the lungs.
Bronchodilation results from relaxation of bronchial smooth muscle, which relieves
bronchospasm and reduces airway resistance.

 Theophylline (Elixophyllin Elixir, Theo-24) - Theophylline has a number of physiologic

effects, including increases in collateral ventilation, respiratory muscle function,
mucociliary clearance, and central respiratory drive. It partially acts by inhibiting
phosphodiesterase, elevating cellular cAMP levels, or antagonizing adenosine receptors
in the bronchi, resulting in relaxation of smooth muscle. However, its clinical efficacy is
controversial, especially in the acute setting.

 Ipratropium bromide (Atrovent HFA) -Ipratropium bromide is an anticholinergic

medication that appears to inhibit vagally mediated reflexes by antagonizing the action of
acetylcholine, specifically with the muscarinic receptor on bronchial smooth muscle.
Vagal tone can be significantly increased in COPD; therefore, this can have a profound
effect. Ipratropium can be combined with a beta-agonist because it may require 20
minutes to begin having an effect.
  Methylprednisolone (Solu-Medrol, Depo-Medrol, Medrol) -Methylprednisolone is
usually given IV in the ED for initiation of corticosteroid therapy, although in theory, oral
administration should be equally efficacious.

Procedures to restore and improve blood flow

You may be given fluids to improve blood flow throughout your body and to provide nutrition.
Your doctor will make sure you get the right amount of fluids.

Too much fluid can fill the lungs and make it hard for you to get the oxygen you need. Not
enough fluid can limit the flow of oxygen-rich blood to the body's organs.

Fluids usually are given through an intravenous (IV) line inserted in one of your blood vessels.

B. ACTUAL

DATE AND TIME DOCTOR’S ORDER JUSTIFICATION

08/04/18  Facilitate annual CT scan STAT  To identify and monitor any
7:00AM o ETA,GS/CS, AFB, KOH medical conditions of the
o Blood GS/CS x 2 sets patient and to support the
o ABG diagnosis.
 Give first dose of ceftriaxone and  To treat patient’s illness.
clindamycin
 Continue other medication  To maintain the order
prescribed by the doctor
 Salbutamol + Ipratropium; nebulize  Used as a bronchodilator to
now then q6 hrs. control and prevent reversible
airway obstruction.
 NGT feeding as ordered  To give patient proper nutrition.

 Turn to side q2 with bedsore precaution

 To ICU2 or ICU4  To prevent bedsores.
 To monitor patient’s condition
and to provide with the specific
 Refer to pulmo for cough care needed.
 For further management.
5:50PM
 Please admit patient to ICU2 or ICU4  To monitor patient’s condition
 and to provide with the specific
care needed.
 Secure consent to case  To inform the family about their
patient’s condition.
 IVF PNSS 1L to run 200cc or fast drip  For fluid and electrolyte
then regulate @ 140cc/hr. replacement and for easy access
of medications.
 Insert NGT and start OTF @ 1600  To give patient proper nutrition.
kcal/day in divided feedings
 Labs:  To identify and monitor any
o CBC & platelet count medical conditions of the
o BUN, Crea, Na, K, Ca, Mg, patient and to support the
RBS, SGPT, SGOT diagnosis.
o FBC lipid profle
o ECG – Done
o ABG – done
o CXR PAL
o Cranial CT scan plain STAT
o U/A
o Sputum GS/CS  To treat patient’s illness.
o Blood GS/CS
 Meds:
o Ceftriaxone 2g IV OD
o Clindamycin 600mg IV q8
o Salbutamol + Ipra; 1 nebulize q6
o N- Acetylcysteine 600mg/tab; 1
tab dissolve in 1 glass of water
BID
o Buclizine I tab OD
o Apply flamazine cream BID on
skin ulcers
 To provide effective
o omeprazole 40mg IV now then
oxygenation to the patient.
OD
 Hook to mechanical Ventilator
o AC mode
o Fi02 100%
o TV 420
o PEEP 5  Vasopressors that constrict
o Vmax 50 blood vessels and increase
 Standby Norepinephrine drip; 40g + blood pressure and heart rate.
40c PNSS via soluset to run @ 0.5
mkd uptitrate by 0.06 mkd to  To check fluid imbalances and
normalize BP > 90/60 mmHh dehydration
 To have baseline data and to
 I & O q hourly assess the stability of the
patient’s health status.
  VS q hourly
08/05/18  TROP I & CKMB, repeat ECG now  To identify and monitor any
9:40PM medical conditions of the
patient and to support the
diagnosis.
 IVF PNSS 1L @ 40cc/hr.  For fluid and electrolyte
replacement and for easy
access of medications.
 Continue OTF 1600 kcal in 6 divided  To give patient proper
feedings nutrition.
 Continue medication  To maintain the order
prescribed by the doctor.
 ↓ Fi02 to 80%, then decrease 10% q
 To provide effective
hourly up to 50%, then repeat ABG
oxygenation to the patient.
o Maintain mechanical ventilator
set up
o
 Titrate norepinephrine accordingly  Vasopressors that constrict
blood vessels and increase
blood pressure and heart rate.
 I & O q hourly  To check fluid imbalances and
dehydration.
 VS q hourly  To have baseline data and to
assess the stability of the
patient’s health status.

 Refer for evaluation

 For further management.

08/06/18  Review MV set up:  To provide effective

1:50PM o Shift AC mode to SIMV mode: oxygenation to the patient.
SIMV 16
 Continue medication  To maintain the order
prescribed by the doctor
 I & O q hourly  To check fluid imbalances and
dehydration.
 VS q hourly  To have baseline data and to
assess the stability of the
 Refer accordingly patient’s health status.
 For further management
08/07/18  Shift SIMV mode to spontaneous mode  To provide effective oxygenation
11:35AM to the patient.
 ABG, CXR PAL  To identify and monitor any
medical conditions of the patient
 and to support the diagnosis.
 To treat patient’s illness.
 Meds:
o Give NaHCO3 100 meqs IV
o Give salbutamol + Ipratropium;
nebulize x3 doses q 15min.
apart pre-extubation
o Hydrocortisone 250mg IV now
 To maintain the order prescribed
 Continue other medication
by the doctor
 To secure airway patency.
 Suction secretion PRN
 To check fluid imbalances and
 I & O q hourly
dehydration.
 Bedsore precaution  To prevent bedsores
 Refer accordingly  For further management
08/08/18  Transfer to ICU4  To monitor patient’s condition
10:00AM and to provide with the specific
 Hook to T-piece care needed.
 To provide effective
 ABG after 4 hrs. oxygenation to the patient
 To identify and monitor any
medical conditions of the
patient and to support the
 Continue present medication diagnosis
 To maintain the order
 I & O q hourly
prescribed by the doctor
 VS q hourly  To check fluid imbalances and
dehydration
 To have baseline data and to
1:15PM  Addendum: assess the stability of the
o Salbutamol + Ipra; 1 nebulize x patient’s health status
3 doses  To treat patient’s illness
o hydrocortisone 100mg IV now
o Bedsore precaution
o Refer accordingly

 Facilitate transfer to ICU  To monitor patient’s condition

and to provide with the specific
 Endorsed to Dr. Gatmaitan care needed.
 Endorsed for any unusualities
 Refer for further management.
5:05PM

 Please repeat the following today  For further management

o CBC with PC
 o Crea  To identify and monitor any
o BUN medical conditions of the
o Na, K patient and to support the
 Please maintain IVF at same rate diagnosis

 OTF as ordered  For fluid and electrolyte

 Please maintain on spontaneous mode
for now Fi02 11%
o Please shift back to SIMV 6,
PSV 7 if with episodes of
desaturation and dyspnea
o Please facilitate repeat CXR
PA
 Please facilitate IV antibiotics
o Please start Levetiracetam
500mg 1 tab BID
o For possible extubation
tomorrow
 I & O q hourly
 VS q hourly
replacement and for easy access
of medications.
 To give patient proper nutrition
 To provide effective
oxygenation to the patient
 To treat patient’s illness
 To check fluid imbalances and
dehydration
 To have baseline data and to
assess the stability of the
patient’s health status

08/09/18  Please repeat CXR, ABG today  To identify and monitor any
3:10PM medical conditions of the
patient and to support the
diagnosis.
 IVF @ same rate  For fluid and electrolyte
replacement and for easy access
of medications
 Mechanical ventilator; spontaneous  To provide effective
mode, PSV 7 oxygenation to the patient

 Please continue meds for now  To maintain the order

prescribed by the doctor
 Extubate patient once repeat CXR
 For further management

 Please watch for any unusualities

 To identify appropriate
 I & O q hourly interventions
 To check fluid imbalances and
 VS q hourly dehydration
 To have baseline data and to
assess the stability of the
  To secure at least 1 unit PRBC patient’s health status
 For blood transfusion
08/10/18  Please follow-up ETA GS/CS  To identify and monitor any
7:00PM *Please repeat the following tomorrow medical conditions of the
AM @ 5:00AM patient and to support the
o CBC with PC diagnosis
o Crea
o BUN
o Na, K
 To provide effective
 Mechanical Ventilator: shift to SIMV
oxygenation to the patient
6, PSV 11 – done
 To identify and monitor any
 Please repeat ABG again tonight
medical conditions of the
patient and to support the
diagnosis
 Continue present medication for now  To treat patient illness
o Please shift antibiotics once
with culture and if with ↑ WBC
o ↓ nebulization in q8 for now
o Please give furosemide 20mg
IVTT now then 20mg IVTT
BID with BP precaution
 To secure airway patency
 Suction secretions  To check fluid imbalances and
 I & O q hourly dehydration
 To have baseline data and to
 VS q hourly assess the stability of the
patient’s health status
08/11/18  ABG  To identify and monitor any
11:30AM medical conditions of the
patient and to support the
diagnosis
 Mechanical Ventilator: Please decrease  To provide effective
PSV by two q 2hrs. until PSV 7 oxygenation to the patient
 Please continue medications for now  To maintain the order
prescribed by the doctor
 Please watch for any unusualities  To identify appropriate
interventions
 I & o q hourly  To check fluid imbalances and
dehydration
 VS q hourly
 To have baseline data and to
4:30PM assess the stability of the
patient’s health status
 Please start kcl drip 40meqs + 1L
PNSS  To treat patient illness
 o ↓ salbutamol + Ipra to q12
o Start albumin drip @ 20mg q12
to run for 4 hrs.
08/12/18  Mechanical Ventilator: maintain PSV  To provide effective
12:00PM 7, switch to spontaneous oxygenation to the patient
 Please watch for any unusualities  To identify appropriate
interventions
 I & O q hourly  To check fluid imbalances and
dehydration
 VS q hourly  To have baseline data and to
assess the stability of the
patient’s health status
08/13/19  Please repeat the following today:  To identify and monitor any
3:10PM o ABG medical conditions of the
o CBC with PC patient and to support the
o Crea diagnosis.
o BUN
o Na, K
o CXR PA  To provide effective
 Mechanical Ventilator: spontaneous, oxygenation to the patient
PSV 7, Fi02 40%, if with episodes of
desaturation and dyspnea please shift
back the SIMV 6, PSV 7  To treat patient illness
 Meds. ROM:
o Clindamycin 600mg IV q8
o Ceftriaxone 2g IV OD
o Flamazine BID
o Omeprazole 40mg IV OD
o Aspirin 80mg 1tab OD  It will provides real-time
o Atorvastatin 80mg 1tab OD imaging of heart structures
 Additional: 2D echo throughout the cardiac cycle
 For further management and
evaluation
 Refer