RespiratoryCareforSevereHFMD

. .

Clinical course of fatal HFMD

Clinicalcourseoffatal
Abrieffebrileillness
A brief febrile illness
Subtleneurologicsign
Acuterefractorymyocardialdysfunction
Acutefulminantpulmonaryedemalaterwithinhours
Theexactdiseasemechanismofcardiopulmonary
failure : not well defined linked to brain stem
failure:notwelldefined,linkedtobrainstem
encephalitis
(ClinicalInfectiousDiseases2002;34Suppl 2:s5257.)

A predictive of CNS involvement in HFMD

ApredictiveofCNSinvolvementinHFMD
Temp>
T
38 5 C
38.5C
Fever>3days
Fever > 3 days
Lethargy
gy
Recurrentvomiting
Limbweakness
Myoclonicjerks
(BMCInfectiousDisease2009;9:3.)

Risk of rapid progression to cardiopulmonary failure

Riskofrapidprogressiontocardiopulmonaryfailure
Inchildrenwithautonomicnervoussystem(ANS)
dysregulations,including
Coldsweating
Mottleskin
Mottle skin
Tachycardia
Tachypnea
T h
Hypertension
hyperglycemia

Continuousmonitorofhemodynamicstatusfor
cardiopulmonaryfailure
WhenANSdysregulation
HR,RR,BP,SpO2,ABG
arterialBP(arterialline)
CVP
echocardiography

(Pediatr Cardiol 2006;27:577.)

Table : HFMD and cardiopulmonary complications

Table:HFMDandcardiopulmonarycomplications

Intubationwithmechanicalventilator
support
Airwaymanagement:mentalchange
Hyperventilation:encephalitis
Decreasedcardiacworkload:heartfailure
ApplyPEEP:pulmonaryedema

(ExpertReviewofAntiInfectiveTherapy2009;7:73542.)

Critical care management

Criticalcaremanagement

CriticalmanagementinsevereEV71

IVIG :neutralizingAb,immunomodulatoryeffect
Midazolam,phenytoin:myoclonicjerk,seizure
Inotropes (milrinone,doputamine,dopamin,
p p
)
,
epinephrine):heartfailure,shock
ECMO :cardiopulmonaryfailure
: cardiopulmonary failure
(ExpertReviewofAntiInfectiveTherapy2009:7:73542.)
(Pediatr Int 2006;48:25056.)

CriticalmanagementinsevereEV71
Conclusion:
1) IVfluidadjustedaccordingtoCVPandBP
2) Earlysupportwithventilatorandlowdoseinotropic
E l
t ith
til t
dl d
i t i
drugs:Milrinone,dobutamine
g
,
3) Hemodynamicfunctionmonitoredby
Echocardiography,CPVandarterialline
4) Cardiopulmonaryfunctionreturnedtonearnormal
in 3 5 days
in35days.
(Pediatr Int 2006;48:25056.)

CXR in severe HFMD with cardiopulmonary failure

ALI/ARDS

Pressure vs Volume assist/control ventilation

Ventilatorstrategiesfor
VentilatorstrategiesforARF
ARF
Acute
Acutehypoxemicrespiratoryfailure:hypoxiafrom
hypoxemic respiratory failure : hypoxia from
intrapulmonaryshunt(consolidation,atelectasis),
refractory hypoxemia small lung volume
refractoryhypoxemia,smalllungvolume
Ventilatorstrategy:decreaseshuntandoxygen
toxicity
,
yg
InitialPEEP8cmH2O,titratePEEPforthebestoxygen
saturationandkeepplateaupressure<30cmH2O
Figure9
Figure
9:
:(Top
(Topdown)flow
down)flowtime,pressure
time,pressuretimeandvolume
timeandvolumetimeinconstantflow(VCV)
whencomparedwithexponentialdeceleratingflow(PCV,PRVC)
h
d ith
ti l d l ti fl (PCV PRVC)
PIPindeceleratingflow<PIPinconstantflowwiththesameTV

Optimum
OptimumPEEP:2cmH
PEEP : 2 cmH2O>lowerinflectionpointof
O >lower inflection point of
inflationpressurevolumecurve(openlungapproach)

Ventilator strategies for ARF

VentilatorstrategiesforARF
Ventilatorstrategiesfor
Pressurecontrolmodewithdeceleratingflowcan
P
l
d i hd l
i fl
limit peak alveolar pressure
limitpeakalveolarpressure
TV~6ml/kg,permissivehypercapnia
Ti andI:Eratio:increaseTitoincreasemeanairway
pressureandthenoxygenation
IfTi>Te ,pressurecontrolinverseratioventilation
mode (PCIRV)
mode(PC
IRV):toimproveoxygenation
: to improve oxygenation

Fi
Figure:
P
Pressure-volume
l
curve show
h
lower
l
and
d
upper inflection points (LIP and UIP)
LIP: opening pressure,
pressure PEEP >LIP
UIP: overdistension,

TV <UIP

Table 5 : Show decremental/incremental PEEP titration for ARDS patients

Table5:Showdecremental/incrementalPEEPtitrationforARDSpatients
PEEP
(cmH2O)

PIP
(cmH2O)

TV
(mL)

Heart rate
(min)

BP
(mmHg)

SpO2
(%)

20

35

200

100

90/60

96

18

33

220

100

90/60

96

16

31

220

95

90/60

97

14

29

230

95

90/60

98

12

27

230

90

90/60

98

10

25

190

85

90/60

95

23

190

90

90/60

90

21

180

87

90/60

88

19

170

89

90/60

90

HEPA filter at expired limb of ventilator circuit

HEPAfilteratexpiredlimbofventilatorcircuit