Double inhalation

Introduction Double inhalation is characterized by exhaling after two consecutive inhalations, similar to the sobbing action after crying. It is mainly seen when the intracranial pressure is increasing and the cerebral palsy is about to occur, which is a precursor to respiratory arrest. Also known as sobbing like breathing. This is also a manifestation of respiratory failure. Central respiratory failure is mainly caused by irregular breathing rhythms, such as different breathing speeds, different strengths, sighs, sobbing, double inhalation, tidal breathing and apnea. Respiratory failure is a serious disorder of lung ventilation or ventilation due to various reasons, so that effective gas exchange cannot be performed, resulting in hypoxia with or without carbon dioxide retention, resulting in a series of clinical functions of physiological functions and metabolic disorders. Sign. Respiratory failure is an important part of respiratory physiology research, an important cause of death from respiratory diseases, and the application of various types of mechanical breathing devices and respiratory physiology devices in the respiratory failure care unit (RUCU) to achieve significant therapeutic effects. Respiratory failure relies solely on clinical diagnosis of arterial blood gas analysis.

Cause

The causes of respiratory failure are many, and any factor that can damage respiratory function can lead to failure. For clinical work, it will be caused by the following three categories, namely, respiratory obstruction, pulmonary parenchymal lesions and abnormal breathing pump.

First, the airway obstruction is based on two types:

1. Upper airway obstruction: The upper respiratory tract refers to the upper part of the throat, including the nose, pharynx and throat. In the entire respiratory anatomy dead space, the upper respiratory tract is about half, the respiratory tract resistance is 45% from the nose and pharynx, and the upper airway obstruction can lead to obstructive sleep apnea syndrome. The larynx is an important part of obstruction, usually due to infection, foreign body, sputum, trauma, tumor, congenital malformation.

2. Chronic obstructive pulmonary disease: including chronic bronchitis, emphysema and some asthma, airway obstruction continues to progress, becoming the main cause of chronic respiratory failure in the elderly, and often due to the influence of certain predisposing factors leading to acute respiratory failure To make the condition worse.

Second, lung parenchymal lesions

1. General pulmonary parenchymal disorders, including various pulmonary infections, pneumonia, pulmonary edema, lung abscess, pulmonary embolism, pulmonary interstitial lesions, pulmonary vascular disease and various causes of lung parenchymal injury.

2. Acute respiratory distress syndrome; including neonatal respiratory distress syndrome and adult respiratory distress syndrome.

3, abnormal breathing pump includes the respiratory center, spinal cord to the respiratory center, resulting in hypoxia or carbon dioxide retention, and even respiratory arrest.

(1). Peripheral nerve conduction system and respiratory muscle disease: acute infectious polyradiculitis, poliomyelitis, amyotrophic lateral sclerosis, cervical spine trauma, myasthenia gravis, progressive muscular dystrophy, anticholinergic ester Enzymatic drug poisoning, hypokalemia paralysis, etc. can cause the thoracic expansion and contraction of people to lose power, weaken ventilation, and cause respiratory failure.

(2). Thoracic disorders: trauma, surgical trauma, malformation or thickening of pleural adhesions, massive pleural effusion, pneumothorax, etc. affect thoracic activity and lung expansion, resulting in reduced alveolar ventilation and/or uneven distribution of inhaled gas, degrading ventilation and Ventilation function.

an examination

Related inspection

Chest CT examination chest radiograph

First, medical history

Respiratory failure caused by chronic obstructive pulmonary disease has repeated cough, cough or wheezing, rapid death, pulmonary parenchymal diseases such as pneumonia, pulmonary infarction, lung abscess, etc., causing acute onset, cough, sputum or blood stasis. Or with fever, chills, etc., patients with central nervous system disorders, may have history of trauma, headache, nausea and vomiting, general knowledge of obstacles, etc., chest disease patients may have chest pain, chest tightness, difficulty breathing.

1. The partial pressure of carbon dioxide (PaCO) is higher than 6.7 kPa (50 mmHg). When type I respiratory failure, the partial pressure of carbon dioxide is normal or decreased.

(1) Standard bicarbonate (SB) refers to the value of HCO in plasma measured at 38 ° C, PaCOz is 5.3 kPa (40 mmHg), blood oxygen saturation is 100, that is, the respiratory factor is completely normal. Factor changes. The normal value is 24 (1-27) mmol/L. In respiratory acidosis, SB remains unchanged.

(2) Actual bicarbonate (HC0-AB is a data directly measured from plasma, reflecting the metabolic situation, but the increase or decrease of dissolved carbon dioxide has a certain effect on HCO3. Normal value 24 (21-27) mmol/L HCOi will undergo a compensatory increase in respiratory acidosis.

(3) Buffer base door (BB) refers to the sum of buffered anions in the blood. The normal value is 42 (40-44) mmoL/L.

(4) The amount of acid or alkali required for the remaining alkali gate (BE) to titrate blood to pH 7.4 at 38 ° C, carbon dioxide partial pressure 5.3 kPa (40 human blood oxygen saturation ll condition), it is human body Quantitative indication of acid-base imbalance. When the normal value is 0 (±3 mmol/L), the negative value increases in metabolic acidosis; the positive value increases in metabolic alkalosis.

(5) Blood oxygen saturation: the percentage of hemoglobin oxygen, the normal value is 97%. As an indicator of hypoxia, there is no oxygen partial pressure sensitivity, and the oxygen partial pressure is significantly lower than 8 kPa (60). The oxygen saturation has changed significantly, and it is easy to cover up the clinical symptoms of hypoxia.

(6) P50: The value of blood oxygen partial pressure at an oxygen saturation of 0.50 under the conditions of pH=7.40 and PaCOz=5.3 kPa (40 rnlnHg). It indicates the position of the oxygen dissociation curve, reflecting the ability of the bloodstream to transport oxygen and the affinity of hemoglobin for oxygen. The normal value is 3.5 (3.2-3.7 kPa [26 (24 ~ 28) mmHg]. When the oxygen dissociation curve shifts to the right, the population increases, and when the curve shifts to the left, Po decreases.

(7) PX: refers to the oxygen partial pressure of 2.3 Inlnol oxygen taken from each liter of blood at a constant pH and PaCO. The difference in oxygen content between normal arteries and veins is 2.3 rnlnndL. Therefore, the Px value reflects the oxygen partial pressure of mixed venous blood, reflecting the tissue oxygen supply.

A normal value of 4.5 kPaO4 t human Px below 4.5 kPa indicates tissue hypoxia.

2, biochemical tests may occur elevated alanine aminotransferase, elevated creatinine, blood electrolysis such as potassium, sodium, chlorine, calcium, magnesium and other plasma concentrations change.

Second, the device inspection

1. Chest X-ray examination has great significance for the diagnosis of primary disease. According to the X-ray features, the following are the following: 1 White lung: Symmetrical diffuse lesions of both lungs cause a drenched glassy change in the lung field; seen in acute respiratory distress syndrome , neonatal respiratory distress syndrome, pulmonary edema, etc. 2 Lung lobule, lung segment and lung lobe scattered in the fringe edge of the shadow, seen in pneumonia. 3 cavity and cavity in the lung, found in lung cysts, lung abscess. 4 lung gas content increased, showing signs of emphysema, found in chronic obstructive pulmonary disease, congenital large lobe emphysema in children. 5 side of the chest shadow, more common in pneumonia, pleural effusion, atelectasis J , lung dysplasia. 5 pneumothorax sign, gas accumulation in the chest, visible compression of the lung edge.

2, chest CT density resolution is high, can show chest lung lesions that can not be shown, for idiopathic pulmonary interstitial fibrosis. The diagnosis of chronic bronchitis is helpful, and animal experiments have shown that adult respiratory distress syndrome also has characteristic changes in CT. Pulmonary interstitial fibrosis in the chest CT showed a subpleural curve image, uniform wall thickness, clear honeycomb shadow J nodule shadow and small leaflet thickening. Pneumonia can be expressed in the chest CT as diffusely distributed patchy, edge-blurred high-density lesions. The lesions are connected with bronchial branches at various levels, and air-bearing bronchoscopy images can be seen in large solid areas. Chronic bronchitis in the CT manifested as bronchial branch distortion, narrowing and dilatation of the lumen, surrounded by cord-like and irregular shape high-density solid lesions. CT scan can be found in more than 2mm lobular central emphysema, which is characterized by an infinite circular low-density area; the whole lobular emphysema fuses with each other to form irregular large vesicles, in which there is no structure and the surrounding blood vessels can be displaced. Pulmonary hypertension is manifested in the chest CT image as pulmonary artery expansion above the lung segment, and the pulmonary artery in the lung is distorted.

3, B-mode ultrasound examination has a certain limit on the scanning of lung lesions, but has a higher accuracy for distinguishing pleural effusion, cystic or solid mass, cardiovascular disease, and transverse lesions.

Differential diagnosis

Differential diagnosis of double inhalation:

(1) Tachypnea refers to a respiratory rate of more than 24 beats per minute. Found in fever, painful stimuli, anemia, heart failure, hyperthyroidism and so on. The general temperature rises by 1 ° C and the breathing increases by about 4 times / min. Corrigan's respiration, also known as cerebral respiration, is seen in consumptive, debilitating, fever, physical weakness such as typhoid fever, typhus, etc., manifested as shallow breathing, fast frequency, no change in rhythm.

(2) Bradypnea means that the respiratory rate is less than 12 beats/min. Seen in anesthesia or sedative overdose and increased intracranial pressure.

(3) Apnea refers to the breathing pause that occurs during the breathing cycle. Found in critical situations such as anesthesia accidents, neonatal atelectasis. Normal people may have apnea during swallowing and defecation.

(4) shallow breathing (shallow breathing) The breathing depth becomes shallow. Found in respiratory muscle paralysis, pneumonia, pleural effusion, pneumothorax, emphysema, rib fractures, application of respiratory central inhibitors, alkalosis, severe abdominal distension, ascites, obesity and so on. In addition to the application of respiratory central inhibitors, the shallower respiratory rate caused by other causes is often accompanied by an increase in respiratory rate, resulting in shallow breathing. Hildebrandt's sign refers to the rectus abdominis tension that occurs when the lung is damaged by trauma, and the patient's abdominal breathing is weakened or disappeared.

(5) Hyperpnea refers to abnormal breathing with increased respiratory rate and deeper amplitude. It is seen in severe exercise after normal people, severe metabolic acidosis, diabetic ketoacidosis, and uremia. Kussmaul's breathing, also known as acidosis, is a big breath. It shows that the patient's breathing is faster and deeper, but the rhythm is regular and the patient has no feeling of difficulty breathing. See severe metabolic acidosis caused by various causes. Deep respiration is also seen in severe metabolic acidosis, inhalation, exhalation, sigh, respiratory rhythm, normal frequency, and the patient's feeling of difficulty breathing. This kind of breathing can also occur in hepatic coma, intracranial disorders, and alcoholism.

(6) Inspiratory dyspnea (inspiratory dyspnea) The patient showed extreme effort during inhalation, prolonged inspiratory time, and there were obvious depressions in the upper sternal fossa, supraclavicular fossa and intercostal space during inhalation (also known as three depressions sign). The patient's respiratory muscles are tense, and the head leans back when inhaling. Seen in the throat, trachea, bronchial stenosis caused by inflammation, edema, tumors, foreign bodies, etc., also seen in the vagus nerve, superior laryngeal nerve, recurrent laryngeal nerve paralysis. When the vocal cords are blocked around the vocal cords such as laryngeal edema or sputum, posterior pharyngeal abscess, throat tumor or foreign body, air entry is difficult, and a high-pitched wheezing sound occurs during inhalation, called asthmatic wheezing (asthmoid wheeze). Sometimes the sound is similar in nature to snoring, called stridulous respiration.

(7) Expiratory dyspnea (expiratory dyspnea) The patient showed exhalation effort, prolonged expiration time, and rib space bulging. It is caused by weakened lung tissue, small bronchial stenosis, and poor airflow during exhalation. Found in bronchial asthma, asthmatic bronchitis, obstructive emphysema.

(8) Mixed dyspnea (mixed dyspnea) is characterized by difficulty in exhalation and inhalation, often accompanied by increased respiratory rate. Mostly, the lung lesions or lung tissue are compressed, and the respiratory area is reduced, which affects the ventilation function. Found in large cases of atelectasis, pulmonary infarction, massive pleural effusion or pneumothorax, large area of pneumonia, pulmonary fibrosis, mediastinal tumor, pulmonary congestion caused by left heart failure. Severe cardiac insufficiency, especially dyspnea caused by left ventricular dysfunction, often manifests as orthodonnea. The patient was forced to take a sitting or semi-recumbent position, sitting on the edge of the bed, with his legs drooping, his hands on his knees or on the side of the bed, because the breathing aid muscles also participated in the breathing exercise, and the patients often could not speak because they tried their best to breathe. , eating and drinking. This position can reduce the diaphragm, increase the lung ventilation, reduce the blood flow to the lower limbs, thereby reducing the burden on the heart and pulmonary congestion, and reducing breathing difficulties.

(9) Sighing respiration On the basis of normal breathing, the patient will take a deep breath every time because of chest tightness, which is similar to sighing, and the chest tightness is relieved or subsided. More often appear in silence, shifting its focus on work, exercise, chest tightness and sigh-like breathing disappear, seen in neurasthenia, depression or mental stress.

(10) stertorous respiration A large squeak in the throat when breathing. It is caused by more viscous secretions in the trachea and bronchi. Common in patients with coma and sudden death.

(11) Nodding respiration The patient inhales deeply and leans back. When he exhales, his head returns to its original position. It appears that the head has a rhythmic back and forward tilt with the breath, like a nod, that is, nodding. The patient is mostly comatose, extremely exhausted, and is a manifestation of sudden death.

(12) Tidal respiration (also known as Cheyne-Stokes's breathing, breathing gradually changes from shallow to deep, then from deep to shallow, followed by an apnea, and then repeats the above periodic breathing. The tidal breathing cycle can be as long as 30 seconds to 2 minutes, and the pause time can be as long as 5 to 30 seconds, so it takes a long time to observe carefully to understand the whole process of periodic rhythm changes. The appearance of tidal breathing is a manifestation of decreased excitability in the respiratory center. In the apnea phase, hypoxia is aggravated, carbon dioxide retention, to a certain extent can stimulate the carotid sinus and aortic body chemoreceptors and respiratory center, so that breathing recovery and strengthening; with the increase of respiratory rate and amplitude, carbon dioxide A large number of discharges, the respiratory center lost effective excitement, the breathing slowed down again, became shallow, until the pause, carbon dioxide re-accumulated, so repeated. Tidal breathing is a manifestation of critical illness and poor prognosis. It is seen in the advanced stage of many diseases and critical illness; central nervous system diseases such as encephalitis, meningitis, cerebral hemorrhage, cerebral infarction, cerebral embolism, brain tumor, brain trauma, etc.; Chronic congestive heart failure, uremia, certain drug poisoning such as barbital poisoning, diabetes coma and so on. Mild tidal breathing can be seen in normal elderly sleep, and can also occur when the air is thin at high altitudes.

(13) Intermittent respiration (also known as Biot's breathing, meningeal inflammatory respiration). It is manifested that after a period of equal breathing, an apnea occurs, and then the same depth of breathing begins, so that the cycle begins to form a pause. It is different from tidal breathing. Each time the breathing depth is equal, instead of gradually deepening and lightening, the time of apnea is longer than that of tidal breathing, and the number of breathing is also significantly reduced. The interval between intermittent breathing is variable, and the respiratory rate and amplitude are roughly neat and sometimes irregular. Its gas production is almost the same as that of tidal breathing, and the disease is similar. However, the excitability of the patient's respiratory center is lower than that of tidal breathing, the function is worse, the condition is more serious, and the prognosis is worse. Performance before dying.

(14) Sobbing respiration Also known as double inspiration. Exhale after two consecutive inhalation exercises during breathing, similar to sobbing. Seen in patients with increased intracranial pressure or early cerebral palsy.

(15) Long-sucking breathing (apneusis) The inspiratory phase is relatively long and alternates with apnea. Found in cerebrovascular accidents, intracranial tumors.

(16) Asthmatic respiration (asthmoid respiration) The exhalation time is prolonged, and the inhalation suddenly occurs and suddenly terminates. There is a certain rhythm, but not very regular.

(17) bulbar respiration The number of breaths is reduced, the rhythm is irregular, the breathing is shallow, and there is an apnea. This is a manifestation of medullary respiratory central failure and a late manifestation of central respiratory failure. Found in the occipital foramen, cerebellar or cerebral hemorrhage, medullary trauma or bleeding and other lesions in the posterior fossa. (18) Mandibular respiration (also known as mandibular respiration). The patient's breathing is slow and superficial, and often only the mouth movement of the lower jaw occurs, like the mouth opening after the fish leaves the water. Mandibular respiration is a manifestation of respiratory center failure. The patient also has various manifestations of life dying. Once it occurs, it indicates that respiratory arrest is imminent.

(19) Central neuronic overrespiration is a manifestation of central respiratory failure. The patient was coma, the pupil was loose and fixed, the eyeball was slow or disappeared, and there was motor dysfunction. The frequency of breathing can reach 30 to 40 beats / min, the amplitude is deep, the rhythm rules, can last for several hours, but less continuous attacks throughout the day. Found in severe encephalitis, meningoencephalitis, meningitis, skull base arterial thrombosis, cerebral hemorrhage, brain stem injury. The lesion is often located in the midbrain of the diencephalon and 2/3 on the pons, which is equivalent to the midbrain aqueduct and the ventral reticular formation of the fourth ventricle. On the side of the cerebellum, there may be intermittent or tidal breathing before the cerebral palsy occurs. Once it becomes central neuron respiration, it indicates that the cerebellar incision is formed and the brain stem is compressed.

(20) The Seenwald sign is a sign of sputum pleurisy. It is characterized by deep inhalation of the rectus abdominis and even tension of the entire abdominal wall during deep inhalation.

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