#Fishman TM

[xxweirdtripxx]

Hey, posting a cute doodle & confessing I'm in fact, down bad for the fish man-

Anyways, the OC shown here is named Oleander and is infused with Olm + Axolotl DNA, but more on her later. This piece took 24 hours total, so enjoy! <3

(PS - If you dislike OCxCanon, just ignore me please,,, <3)

[guhroovi]

Been wanting to redraw old drawings and decided to go after my sasaki brainrot. I posted the original piece here on my old self shipping blog.

And yes this drug me back into said sasaki brainrot.

[ratkingsocks]

Misc. Heart Pirates Head Canons

So, when I'm bored out of my brain at work I've been thinking about my silly little beloveds the Heart Pirates! So here are some thoughts I've had about them and the crew structure! Crew Structure

Not a traditional first mate or incredibly strict hierarchy. I figure Law's authority issues extend to how he runs his crew!

There's four "departments" basically where one of the core-four preside over.

Bepo is in charge of all the helm stuff: navigation, steering, general operations (maintenance of equipment, engineering)

Penguin is in charge of personnel: finances, crew schedules, supplies (clothes, food, yatta yatta)

Shachi is on weapons: armory & procurement of, training the crew, and any like recon they do is planned by him

Law handles all the medical stuff: yearly exams, extensive charts/notes on the crew, any on-going treatments, and the supplies for this specifically goes through him

As captain, Law does oversee/supervise the others if he feels it relevant but after like 13 years he's pretty confident his favorite idiots can handle themselves!

The tang runs on two shifts so someone is always around to keep the sub running in case of emergencies, as such there's often multiple crew members capable of a job (ex chef, helmsman, engineering, nurses)

All the crew knows how to handle alarms, any gauge or sonar readouts, and just generally keep everyone from dying

Most of the crew knows basic triage and first aid

Any Big Decisions (TM) are normally talked over. The crew has a lot of say in most scenarios... One of the few times this was not the case was Law ordering them to Zou when he went to Punk Hazard.

It was an intentional choice on Law & the crew's part that none of them were spotted on jobs and don't have bounties. A lot of the crew's work, especially early on in Law's plotting against Doffy, was gathering information and other covert work. Them being well known or recognizable would've made it impossible for this to get done... It also would've made hiding from Doffy that much harder.

The crew splits proceeds evenly! 50% goes to the Tang's upkeep and supplies, 50% is split equally between everyone else.

Named Crew Jobs

Law- Captain, Doctor

Penguin- Quartermaster

Shachi- Armsmaster

Bepo- Navigator

Jean Bart- Helmsman

Ikkaku- Head Engineer

Uni- Head Nurse

Clion Chef

Hakugan- Helmsman

The unnamed crew I do plan to flesh out eventually, but I haven't made a whole lot of headway in that direction yet... Some day I shall!

Silly HCs

Other than Bepo, everyone is older than Law

Penguin likes to sing

He also has collected rocks & shells from every island they've stopped at to make a living map of their travels.

I personally like to think of Shachi & Peng as some sort of fishman-human hybrid or perhaps a few generations removed from a fishman ancestor? Not super sure on how it works exactly, but I think they both look a lil odd and that's why they hide their eyes and such with hats.

Ikkaku handles Law 2nd best only to the Core 4. She knows when he needs space and when he needs to be pushed pretty well, and so they're pretty close.

Uni loves to sew; it's how he relaxes and passes time while they're underwater for long stretches of time. He is also the person who customizes most of Law's clothes with their jolly roger

Law did said customization before they recruited Uni and still helps, but Uni shoves him off often and says this is his therapy time alone

Clione takes to new members the best

He's also a great fighter and definitely yeeted Shachi into a wall one day; Shachi was delighted with this

He can drink most of the crew under the table

Hakugan is enby! And uses they/them pronouns

They also communicate with sign language, so the entire crew is relatively fluent

Hakugan is never lost; they have a 6th sense for where north is at all times

Much like their namesake, Hakugan is a volatile creature prone to violence

Shachi likes to keep up with psychology journals in his free time, so sometimes he & Law will have a little "medical journal book club" to hang out

Bepo is more an astronomy & weather guy... there was, however, a tragic mix-up with the news coo one time that resulted in Bepo getting an astrology magazine.

He likes to torment Law by teasing him with a well placed "That's so very libra of you, captain."

Law actually likes his coffee absurdly, disgustingly sweet

Penguin, however, takes his coffee black

Shachi & Bepo are 2 of 3 members of the Hearts without a caffeine addiction. Hakugan is the third

Penguin has given up trying to get Law on a schedule... It has never worked in their 13 years sailing together

Law had to implement a "no gambling on the tang" rule shortly after Hakugan joined; They were absolutely taking everyone else's money

Law does, however, actively encourage fleecing marines & rival pirate crews

The crew has picked up some Mink social behaviors! As such they're very physically affectionate... Yes, even Law. Though he tends to contain his affection to when they're in private or on the Polar Tang

It's super common to see the crew swap undershirts, jewelry, or other accessories

Bepo has a collection of his crewmates' shirts! Uni made it into a quilt for him since he can't exactly wear them properly

Everyone else has a "Bepo shirt"

Ikkaku tends to forget she's wearing hers while working on the Tang or to sleep then walks about. Whenever Bepo sees this he gets all flustered & teary-eyed

Law, similarly, wears his to sleep in regularly. He would rather be caught dead than wearing though. That's way too mushy for him.... but if there are days where he's still wearing it when Bepo comes to check on him in the morning, well, nobody has to know but them right?

Shachi & Penguin one time wore their Bepo shirts and attempted to force Bepo into their shirts which... obviously did not fit. Undetered they stitched the two together to the ultimate-bros-shirt. Bepo loves this shirt & wears it regularly.

Shachi & Penguin remake this shirt whenever the old one starts wearing down or falling apart every few years

(I took this one from a fic cuz I thought it was just so good) Between more junior members of the crew, it's a running gag that Law, Shachi, & Penguin are more "lesser mink" than "human" after 13 years with Bepo.

Law finds this absolutely hysterical, Bepo says they're all lesser minks

Law is, in fact, capable of a variety of animal noises such as growling, hissing, or purring. He normally makes this noises on accident when startled or particularly relaxed. He did not intentionally learn to make these noises. He was just an incredibly weird child and like many weird children before and after him, mimicked animals

Shachi & Penguin may or may not make fun of him for this

They may or may not have started the rumor that one of Law's parents was a mink; a rumor that Law has unintentionally perpetuated with his general wet cat behavior

Penguin's family were whalers! He uses a harpoon & is a fantastic fisher as a result

The above makes him Clione's favorite

Penguin often threatens Shachi with the harpoon so he may join his bretheren. Shachi shrieks back that orcas are not whales but dolphins. This is a near weekly song & dance.

Each of the "core four" have a way to show they accept a newbie into the crew!

Shachi carves a little wooden animal

Penguin embroiders their name inside their boiler suits

Bepo trades clothes with them

Law procures a custom mug decorated to their taste

Law normally gives his first, actually. Firstly, if he invited you to his crew he already likes you well enough. Two, he knows he can be an unapproachable dick and sees it as a bit of a peace offering. Three, to show the rest of the crew this new person is approved!

Shachi & Penguin gives theirs whenever they feel the new member has "earned" it. Normally 2nd/3rd in whatever order they deem.

Bepo basically always gives his last. He's a very anxious lil guy and doesn't want to disturb or weird anyone out.

Jean Bart is, ironically, the only crew member to not have concussed himself on the doorways in the Tang

Law had a few problem years after his sudden growth spurt, but it hasn't been a problem since he got used to being taller

After reuniting on Zou there was a crew wide cuddle puddle

Law is surprisingly tactile so long as it's on his terms. A head pat there, brushing his hands against a cheek or shoulder there... That kind of thing

This is generally the best indicator of how much he actually likes you

Law often stims using Bepo's fur or paws. Bepo loves this very much

[moonpaw]

"What crimes could an elephant possibly commit" I say, knowing full well Zunesha is big enough to hold an entire village of furries on his back and walk without issue in the ocean but never mind that because I think Zunasha's crime was carrying Laugh Tale to it's Super Secret Location(tm) and also you guys know of Jaya right? of course you know of Jaya

Jaya is in the shape of a skull and missing an eye, Jaya where the city of gold resided and the residents were protecting a poneglyph but never mind about the poneglyph, what really catches my attention is THIS

why was this just randomly here, not on a poneglyph? outside of joyboy's apology on fishman island, (and even that was on a poneglyph, even if its purpose was different) I don't believe any other area had something like this

whether it's because the shandians protected this area well, or because it being in the sky for 400 years made it safe from getting ruined, as far as i know, this is the only place where the writings are on stone, not the a poneglyph

would that make shandora even more special? i think so! especially since skypiea is the first hint and mention of the sun god! and from what we can just barely see, the first joyboy wore a similar style of outfit to that of the shandanians

[mamamittens]

Platonic Yandere Arlong with AFAB Half human half fishman reader who was abandoned by her bio parents

Ngl, I'm not super familiar with Arlong's character, so take this with a grain of salt as it's powered by Vibe Check (TM). Also, I have no idea what the hell a hybrid would look like, so I'm assuming human enough to pass but obvious enough to need like, a scarf to cover gills and gloves or smt.

Okay, he strikes me as someone that would, in this situation, struggle in the early years with his hatred of humans. Ultimately, though, he'll settle for a strange mix of "You're the only exception and only, like, by half" and "You're cool cause I say you are but all other humans are trash". Does lean heavily into abandonment issues and encourages the reader to attach to him and seek his approval for everything. Don't get me wrong, he gives it pretty freely for a bastard, but he rewards the instant head turn to double check thing.

Violently explodes if anyone tries to start shit with HIS baby. Might prop them up as a cautious example of what Tiger King and Otohime were working for if anyone questions his racist ass actions. A real "I can't be racist AF, my adopted daughter is half human!" completely ignoring how angry he gets if she hides her fishman heritage for any reason other than extreme safety concerns. Not that she's likely to be allowed out and about without Top Men or Arlong himself.

If she's ever feeling self conscious for being a hybrid Arlong immediately wants to fight whoever inspired this feeling. He's not super good at consoling her so it mostly boils down to "You believe me, right? Then believe me when I say you're perfect exactly as you are. Be proud of your heritage" while lowkey propping up fishmen as the better half cause he's always hating at least a little. For good reason on his part, but he's worked astonishingly hard to ensure she never experiences it herself.

Not sure if he'll teach her to fight or just enough for him to get there and take care of business. Definitely anything involving fishmen heritage though. He really wants her first thought to be "I'm half fishman" rather than "I'm half human". Lowkey ignores anything specific to human heritage unless it's pressing. Does quietly shuffle her towards Nami for these issues so he doesn't have to learn for himself or confront his toxic ideas.

If her bio parents ever show up to insert themselves, he's quietly shuffling them to the side to either get rid of them or manufacture a situation where Reader will hate them and want nothing to do with them forever.

RIP anyone that tries to date her. Even fishmen will have to work very hard for his approval and, ironically, not hate humans. He doesn't want to risk his daughter in a relationship where her partner would hate literally any part of her.

I... genuinely can't remember if he's arrested or breaks out or what but in case he's indisposed for the future, he sends her to Jinbe, trusting that he can keep her safe (without any prejudice) or at least take her somewhere she will be until Arlong is free again.

[katyspersonal]

KATY!!!!

You muppet

Gimme your top 5 non-boss Bloodborne enemies 🔪🔪

Hahaha! This is a hard question, because, like... Do I judge the design? The concept? The (presumed) pleasure of fighting them? xD Or, maybe, how good they are from raw gameplay standpoint, without any of our Tumblr sentimental values added? ...so, in the end, I decided to judge on raw personal enjoyment. Here goes!

Five - Edgar, Choir Intelligencer!

Yeah, yeah, NPCs are a weird grey area since they're no regular enemies, blablabla. But, first, I wanted to include at least one Hunter NPC. Two - if I am choosing, it is DEFINITELY Edgar. I enjoyed fighting him on that moonlit bridge..... But, more importantly, I enjoy what this character entails. A player that was only yet to be educated would, soon enough, learn that Micolash has a friend. And then, some time later, the fandom would learn from official materials the character's name and get confirmation for his affiliation with the Choir! I just think that he is THE coolest NPC. Whereas others (looking at the no-dialogue ones in this) would be self-explanatory, with Edgar, there is a mystery that only people with imagination could solve! What else you could've asked for!

Also, I am totally weak for the fact that he does the 'Joy' gesture when he kills us. Way to kill the potential drama of "sparing us from the worse fate" and confirm that you are a simp insane, you lil shit! :pensive: Yet, despite saying less, it is saying more..... Anyways, onto the REAL enemies!

Four - Old Hunter enemy!

They are fuckin' SOMETHING ELSE in terms of aesthetic and behaviour, you know? The bastards have far too much of a healthbar, I will admit, but it is more about the lore... And the vibe. When they are attacking in unhinged, terrifying rage - the beasts (Beast Patient type) cover in fear, that leaves the whole "who is the REAL beast here?" message! They have various weapons and fighting styles. And they have yellow or red eyes variants, that helped me to resolve the mystery of what is under Chester's mask, since he is heavily implied to be from Yharnam and teleported by an Amygdala!

Three - Fishman Mage!

LOVE these guys! ...yes, despite the fact that they keep spamming me with DARN bolt spells and DARN purple homing skulls. But... At the same time, this is so BADASS. I can only speculate and bounce off ideas on why their magic has "wrong" colors; with this type of skulls normally being red and the bolt in Bloodborne normally being blue. But, I love the aesthetic and the cool magic nonetheless. Not to mention the Mystery TM of what is up with their "elongated" heads.

I thought of something akin Lumenweed but more coral-like instead of plant-like, since they seem to pray for other Great Ones to avenge Kos that they "failed" to protect (and since one of Fishmen variants has something similar anyways), but we just don't know! Could be a polyp, could be a fin, could be a Cool Hat...

Two - Clocktower Patient!

The amount of lore per pixel kills me! They have interesting VARIANTS - the regular, the naked, the completely tied-up one, the just-head one, the one behaving like a beast, the fuckin headless walking bodies... The HUGE one, that I fucking bet would be Pthumerians pushed into experiments too, all that.

And, although sometimes they can be frustrating to fight, ESPECIALLY when they come in a crowd, I just love how... "informative" they are? I have not learned more from any other enemy than from these people. They demand a keen eye to decipher no matter what. Like how it is easy to miss that their heads are covered so we can't know what is UNDER the fabric, or the tentacles... But yes, at the same time, the designs and the variations alone are pretty interesting AND scary!

One - Loran Cleric!

Fuckin'. BEST. Display of the fact that what Yharnam is going through already plagued Loran once. Fuckin' AWESOME design. Fuckin' EXTREMELY on-the-nose way to show the "history repeats itself" sentiment. They have ROBES, and they have horns. And they have PYROMANCY... Like other Pthumerians, some Vilebloods (Maria) and, interestingly, Laurence in his beast form, have.

I always found it hard to kill them, because I just could not have enough of their moveset and appearances. They are the enemies I tried to NOT kill for as long as I could afford. Their pyromancy staff gave me idea that Laurence would be using one as soon as he'd get his hands on it, probably in Byrgenwerth + early Church era. I also remember having killed one and spending good 20 minutes just taking pictures, including their cool twisted smiles! I also think that Blood-Possessed Soul is their final transformation form!

_________________

Honorable mention: Church Servants. Of course.

Thank you for the 'some things can only harm you if you are smart enough to PERCEIVE them' delivery, guys.

Thank you for the ask! It was insightful for me too! x)

[xanthezhou]

oda is so deeply unserious. it's crazy too because in fishman island the widely hated "joke" of Sanji's Nosebleeds TM shares the same blood motif with the arc's much more poignant racism allegory.

[doctortonytchopper]

Hey didn't anyone, literally anyone at all, talk to literally anyone else after Wano. Like wasn't there an entire week worth of Partying and Hanging Out (tm) during which Any of the characters could have exchanged Any of the extremely important information they received during the raid

I only ask because at first I thought about how Zoro hasn't told anyone he has conquerors, but not for any reason I can fathom.

But now we have Luffy going "lol who's Joyboy"

But like Zunesha LITERALLY told Momo (who told Yamato), like in words, "that's Joyboy", right? Like he said "Joyboy is here." and then Momo said "Joyboy's here???" and then Yamato said "Luffy is Joyboy?????"

And neither of them thought that was, I dunno, worth mentioning? Even in passing? Not even a small thing like Yamato, walking by the buffet table where Luffy is cramming an entire roast sea king into his mouth and swallowing without chewing: "Hey Joyboy I mean Luffy, lollllll" Robin, who was passing by from the other direction, overhears this and her eyeballs fall clean out of her skull in astonishment.

Momo didn't ever go "hey wow I can't believe I've been sailing with Joyboy" in earshot of anyone?

Maybe those two should have told Kin like maybe the boys were too young and just didn't know to do it and should have told an adult. Who would probably know to mention to literally any Strawhat at literally any point in the long week they hung out after getting that info that he was actually a prophesied hero of legend

Then again I'm pretty sure Robin has talked about Joyboy at length before esp on Skypeia and Fishman Island and Luffy still said "who's Joyboy" so maybe they told him about it in extended rich and vibrant detail and he just immediately forgot

[baumguy]

I've been rewatching One Piece on Netflix in my spare time, and it's been such a WILD ride.

On the one hand, the loss of the Pirate Rap(tm) and Sanji's ridiculous Brooklyn accent is heartbreaking, BUT "We Are" is somehow even better as an intro (it's so good!!!), and not having to watch Sanji suck on a lollipop all the time is so cathartic.

And as much as people say that Arlong Park is really what hooked them into watching One Piece, I didn't remember how much BETTER Arlong Park is then everything that came before it. I actually cried twice during that arc (during The Walk to Arlong Park, and again when Nami got that last little "push" from Bellemere before leaving), because it's so good!!!

I'm getting through Loguetown now, and while the new intro is... Not great in comparison, seeing everyone's reactions to Luffy's first bounty was amazing, plus every Zoro and Tashigi scene is amazing.

Also, something I noticed in Arlong Park: When Sanji was fighting the karate fishman underwater, the thing that gave Sanji the spark to ultimately win was the fishman saying "If you didn't have any feelings for that girl, you wouldn't have ended up dead by my hand!" It wasn't until his opponent insisted that Sanji would be better off without feelings that he REALLY went all out, and considering what we now know about Germa 66, that's some GOD tier foreshadowing.

It's also heartbreaking that Netflix ends after Alabasta, because Water 7 and Enies Lobby is just as good as Arlong Park if not way, way better.

[timothy-z3r0]

Geedis!

Geedis,

There...I said it. Atlas Obscura is talking about it. And there's a big Reddit Thread for it too. (But then there's a Reddit Thread on which way people put their toilet paper on the dispenser and how the people that put the toilet paper with the tissue going under the roll, are refugees from an alternate reality that has collapsed onto our own. I made that last part up. C'mon! You think Reddit is that cool?)

Comedian and writer for The Late Show with James Corden, Nate Fernald, Tweeted one day about he found an enamel pin when looking for a pin for the band, "The Jam", and then went down the ol' google hole. Fernald has brought a lot of attention to this creature named Geedis. This little monkey-like creature can be found on a sheet of stickers in 1981 from a company called Dennison. It appears that the company made some fantasy stickers from 1981 to 1982. Also on the top of the sticker sheet, next to the name "Zoltan"  it says, "The Land of Ta".  Also, notice that does not have a "TM" next to it, nor does it have copyright symbol either. That is the give away for me, that this is not a failed toyline or prototype cartoon or any kind of conceptual art.

These stickers came out around the time That Gary Gygax's Dungeons and Dragons was making headway in our society. It was spreading through schools like wildfire and running away with our imaginations. Dennison made stickers to sort of cash in on that streak. I mean, if I would have seen them, back then, I would literally throw money at it while it was hanging on a peg next to the scratch and sniff stickers!

The creature known as Geedis has a look that evokes a general sense of a forgotten picture of something that you can't put a finger on. He brings to mind the look of the robotic daggit (dog) on Battlestar Galactica called, "Muffit" (I would put a “I” or “II” after the “it” but..semantics). And it very well could be where the artist of this creature got his inspiration from. Also, the very first picture of a daggit came from veteran sci-fi artist Ralph Mcquarrie.

Daggit played by a 3-year-old female chimpanzee named Eve.

Looks Geedis-esque to me!

But in my opinion, I believe that it was just a run of stickers just like Dennison's knockoff of Star Wars, Buck Rogers sticker sheet. (See below)

We can see from the above picture here that there is a knock-off X-wing fighter from Star Wars on the top left of the sticker sheet. And if you look at the "A" shaped ship below the saucer-shaped one, you would say that it looks similar to the A-wing fighter. Now please direct your attention down to the very bottom of the right side. One could argue that the ship there puts you in mind of the Draconian Marauder from the TV series Buck Rogers. These stickers were just a way to issue a prescribed response for those that had seen these things and related or identified with them and then begged your parents to buy them for you.

X-wing fighter from Star Wars (for those of you that have lived in a bomb shelter for the last 40+ years)

A-wing fighter from Star Wars

Draconian Marauder From the Buck Rogers TV series  

The knockoff stickers are familiar enough to picture the real ships in your mind's eye, without actually saying something negative about the whole thing. Sure they're riding on the coattails of other giants but sometimes you can't help what influences you, I mean in the 90's I drew characters with pouches all over them. It was a dark time in my life and I'd like to not talk about it anymore.

So where does the Geedis pin come into this whole thing? My answer would be since it was an obscure sticker that wasn't very mainstream, then it was considered fair game to some random bootleg enamel pin maker who could make some easy cash on them.

My point is that there's no more story to those stickers. That's all they were. But I am staying open to new developments though. And just like Atlas Obscura and Fernald, I contacted, neigh, called people! I know right?! Who even uses a phone to call people anymore unless you are over the age of 50.

I even talked to a bigwig named Eva Fishman and told her what I was doing. She told me that she couldn't help because all the people that worked back then are retired and it would be pretty hard to get a hold of them but that I should call corporate and try to talk to someone in cataloging. So I called corporate in Glendale Ca, and they told me to fill out the "contact us"  part on their website and they would try to get back to me as soon as possible.

I may come back and do updates on this if I ever find out anything more on it. So stay tuned!                                                                        

[khamgiodau]

Thông khí nhân tạo không xâm nhập

1. ĐẠI CƯƠNG Đợt cấp bệnh phổi tắc nghẽn mạn tính (BPTNMT) là một tình trạng bệnh từ giai đoạn ổn định trở nên xấu đi đột ngột ngoài những biến đổi thông thường hàng ngày và đòi hỏi thay đổi cách điều trị thường quy ở người bệnh đã được chẩn đoán BPTNMT. 2. CHẨN ĐOÁN a) Chẩn đoán xác định Người bệnh đã được chẩn đoán bệnh phổi tắc nghẽn mạn tính đột nhiên xuất hiện một trong ba triệu chứng theo phân loại của Anthonisen 1987: - Tăng khó thở. - Tăng số lượng đờm. - Thay đổi màu sắc đờm: xanh, vàng và đờm mủ. b) Chẩn đoán phân loại đợt cấp - Type I (mức độ nặng): Nếu có đầy đủ cả ba triệu chứng. - Type II (mức độ trung bình): Nếu có hai trong ba triệu chứng. - Type III (mức độ nhẹ): Nếu có một triệu chứng và kèm theo một trong các triệu chứng phụ sau: Triệu chứng nhiễm khuẩn hô hấp trên trong vòng 5 ngày trước đó, sốt không do nguyên nhân khác, tăng ho hoặc khò khè hoặc tăng nhịp tim hay nhịp thở 20% so với trạng thái bình thường. c) Chẩn đoán nguyên nhân gây đợt cấp 72 - Nguyên nhân trực tiếp thường gặp nhất gây đợt cấp là nhiễm khuẩn khí phế quản phổi cấp do virus hoặc vi khuẩn (các vi khuẩn thường gặp là Streptococcus pneumoniae, Hemophilus influenzae và Moraxella catarrhalis). - Các nguyên nhân khác: Nhiễm lạnh, bụi ô nhiễm, khói, khí độc. - Không rõ nguyên nhân: 1/3 các trường hợp. 3. ĐIỀU TRỊ a) Kháng sinh - Chỉ định dùng kháng sinh: Theo hướng dẫn của GOLD 2013, khuyến cáo chỉ sử dụng kháng sinh trong các trường hợp sau: + Người bệnh typ I (Bằng chứng B). + Người bệnh typ II (Bằng chứng C). + Người bệnh cần thông khí nhân tạo (xâm nhập hoặc không xâm nhập) (Bằng chứng B). - Thời gian điều trị kháng sinh: Thời gian dùng kháng sinh 5 - 10 ngày (Bằng chứng D). - Lựa chọn kháng sinh theo mức độ nặng của đợt cấp BPTNMT và cân nhắc trên tính kháng của vi khuẩn tại địa phương. Đường dùng của kháng sinh (uống hoặc tĩnh mạch) tùy vào tình trạng người bệnh có uống được không và dược động học của kháng sinh. Các phác đồ kinh nghiệm có thể sử dụng nhau sau: + Đợt cấp mức độ nhẹ: Beta-lactam phối hợp với chất ức chế beta-lactamase (amoxicilin-clavulanat; ampicilin-sulbactam) 3g/ngày hoặc cefuroxim 1,5g/ngày hoặc moxifloxacin 400mg/ngày hoặc levofloxacin 750mg/ngày. + Đợt cấp mức độ trung bình: Cefotaxim 1g x 3 lần/ngày hoặc ceftriaxon 1g x 3 lần/ngày và phối hợp với amikacin 15mg/kg/ngày hoặc fluoroquinolon (ciprofloxacin 1g/ngày uống, levofloxacin 500mg/ngày uống hoặc truyền TM...). + Đợt cấp mức độ nặng và nguy kịch: Dùng kết hợp kháng sinh: nhóm cephalosporin thế hệ 3 (ceftazidim 3g/ngày) hoặc imipenem 50mg/kg/ngày kết hợp amikacin 15mg/kg/ngày hoặc ciprofloxacin 800mg/ngày truyền TM chia 2 lần, levofloxacin 750mg/ngày truyền TM. (Lưu ý: Liều lượng ở trên cần cân nhắc điều chỉnh phù hợp theo chức năng thận của người bệnh). - Trong trường hợp không đáp ứng (vẫn sốt, đờm vẫn vàng, tình trạng khó thở không cải thiện...) cần phải cấy đờm làm kháng sinh đồ. b) Điều trị đợt cấp mức độ nhẹ - Cho điều trị và tăng (nếu cần) liều thuốc giãn phế quản phun hít (ventolin, berodual, combivent) đến 4 - 6 lần/ ngày. 73 - Dùng thuốc giãn phế quản đường uống nếu không có thuốc đường phun hít: salbutamol 4 mg x 4 viên/ngày chia 4 lần hoặc terbutalin 5 mg x 2 viên/ngày. - Prednisolon uống 40 mg/ngày nếu tình trạng không cải thiện sau 1 giờ kể từ lúc tăng các loại thuốc giãn phế quản tác dụng nhanh. - Sử dụng kháng sinh cho đợt cấp mức độ nhẹ xin xem ở mục a phía trên. c) Điều trị đợt cấp mức độ trung bình - Tiếp tục các biện pháp điều trị đã nêu ở trên. Theo dõi mạch huyết áp, nhịp thở, SpO 2 . - Thở oxy 1 - 2 lít/phút sao cho SpO 2 > 90% và thử lại khí máu sau 30 phút nếu có điều kiện. - Tăng số lần xịt hoặc khí dung các thuốc giãn phế quản lên 6 - 8 lần với các thuốc giãn phế quản cường b 2 -adrenergic phối hợp với kháng cholinergic (albuterol/ipratropium, fenoterol/ipratropium). - Nếu không đáp ứng với các thuốc khí dung thì dùng salbutamol, terbutalin truyền tĩnh mạch với liều 0,5 - 2mg/giờ, điều chỉnh liều thuốc theo đáp ứng của người bệnh. Truyền bằng bơm tiêm điện hoặc bầu đếm giọt. - Methylprednisolon: 2 mg/kg/ngày tiêm tĩnh mạch chia 2 lần. - Nếu người bệnh chưa dùng theophylin, không có rối loạn nhịp tim và không có salbutamol hoặc terbutalin thì có thể dùng aminophylin 0,24g x 1 ống + 100 ml glucose 5% truyền tĩnh mạch trong 30 phút, sau đó chuyển sang liều duy trì. Tổng liều theophylin không quá 10mg/kg/24 giờ. Trong quá trình điều trị bằng theophylin cần lưu ý dấu hiệu ngộ độc của thuốc: buồn nôn, nôn, rối loạn nhịp tim, co giật, rối loạn tri giác. - Thông khí nhân tạo không xâm nhập (TKNTKXN) (BiPAP) khi có ít nhất hai tiêu chuẩn sau: + Khó thở vừa tới nặng có co kéo cơ hô hấp phụ và hô hấp nghịch thường. + Toan hô hấp nặng (pH: 7,25 - 7,30) và PaCO 2 45 - 65 mmHg. + Tần số thở > 25 lần/phút. - Nếu sau 60 phút TKNTKXN, các thông số PaCO 2 tiếp tục tăng và PaO 2 tiếp tục giảm hoặc các triệu chứng lâm sàng tiếp tục xấu đi thì cần chuyển sang thông khí nhân tạo xâm nhập. - Chống chỉ định TKNTKXN: + Ngừng thở, ngủ gà, rối loạn ý thức, không hợp tác. + Rối loạn huyết động: tụt huyết áp, loạn nhịp tim, nhồi máu cơ tim. + Nguy cơ hít phải dịch dạ dày, đờm nhiều, dính. + Mới phẫu thuật răng hàm mặt hoặc mổ dạ dày. + Bỏng, chấn thương đầu, mặt, béo phì quá nhiều. - Sử dụng kháng sinh cho đợt cấp mức độ trung bình xin xem ở mục a phía trên. 74 d) Đợt cấp bệnh phổi tắc nghẽn mạn tính có suy hô hấp nặng và nguy kịch - Thở oxy qua gọng kính oxy, giữ SpO 2 90% - 92%. - Dùng thuốc giãn phế quản tại chỗ: + Thuốc cường hai giao cảm, khí dung qua mặt nạ 5 mg (salbutamol, terbutalin), nhắc lại tuỳ theo tình trạng bệnh nhân, có thể khí dung nhiều lần. + Thuốc kháng cholinergic: Ipratropium (0,5 mg) khí dung qua mặt nạ, nhắc lại nếu cần thiết. - Kết hợp truyền tĩnh mạch các thuốc cường hai giao cảm (salbutamol, terbutalin). + Tốc độ khởi đầu 0,1 mg/kg/phút, điều chỉnh liều theo đáp ứng của người bệnh (tăng tốc độ truyền 5 - 10 phút/lần cho tới khi có đáp ứng). + Có thể dùng aminophylin 0,24g pha với 100ml dịch glucose 5%, truyền trong 30-60 phút, sau đó truyền duy trì với liều 0,5 mg/kg/giờ. - Methylprednisolon 2 mg/kg/24 giờ tiêm tĩnh mạch chia 2 lần. Thở máy không xâm nhập - Nếu không có chống chỉ định. - Thường lựa chọn phương thức BiPAP: + Bắt đầu với IPAP = 8 - 10 cmH 2 O; EPAP = 4 - 5 cmH 2 O. + FiO 2 điều chỉnh để có SpO 2 > 92%. + Điều chỉnh thông số: Tăng IPAP mỗi lần 2 cmH 2 O. - Mục tiêu: Người bệnh dễ chịu, tần số thở 92%, xét nghiệm không có nhiễm toan hô hấp. - Nếu thông khí không xâm nhập không hiệu quả hoặc có chống chỉ định: Đặt ống nội khí quản và thông khí nhân tạo qua ống nội khí quản. Thở máy xâm nhập - Phương thức: Nên chỉ định thông khí nhân tạo hỗ trợ/điều khiển thể tích. + Vt = 5 - 8 ml/kg. + I/E = 1/3. + Trigger 3-4 lít/phút. + FiO 2 lúc đầu đặt 100%, sau đó điều chỉnh theo oxy máu. + PEEP = 5 cmH 2 O hoặc đặt bằng 0,5 auto-PEEP. - Các thông số được điều chỉnh để giữ Pplat 92%, pH máu trên 7,20. Duy trì tần số thở ở khoảng 20 lần/phút bằng thuốc an thần. 75 - Trong trường hợp người bệnh khó thở nhiều, không thở theo máy, có thể chuyển sang thông khí điều khiển (thể tích hoặc áp lực). Tuy nhiên việc dùng an thần liều cao hoặc giãn cơ có thể làm khó cai thở máy. - Đánh giá tình trạng người bệnh hàng ngày để xem xét cai thở máy khi các yếu tố gây mất bù đã được điều trị ổn định. - Sử dụng kháng sinh cho đợt cấp mức độ nặng và nguy kịch xin xem ở mục a phía trên. Nếu người bệnh suy hô hấp nguy kịch - Bóp bóng qua mặt nạ với oxy 100%. - Đặt ống nội khí quản, thông khí nhân tạo xâm nhập. - Hút đờm qua nội khí quản. - Dùng thuốc giãn phế quản truyền tĩnh mạch. - Tiêm tĩnh mạch corticoid. - Dùng thuốc kháng sinh theo hướng dẫn trong mục a ở trên. TÀI LIỆU THAM KHẢO 1. Celli BR (2008), “Update on the management of COPD”, Chest, 133(6):1451-62. 2. Chronic Obstructive Pulmonary Disease (2010), The Washington Manual of Medical Therapeutics (33 rd ed), Lippincott Williams & Wilkins, 271-282. 3. Maclay JD, Rabinovich RA, MacNee W (2009), “Update in chronic obstructive pulmonary disease 2008”, Am J Respir Crit Care Med, 179(7):533-41 4. Robert A. Wise (2008), “Obstructive lung diseases”, Fishman’s Pulmonary Diseases and Disorder (4th ed), McGraw-Hill, 749–747. 5. Global Initiative for Chronic Obstructive Lung Disease (2013): Management of COPD (Component 4: Manage Exacerbations), in: Global Strategy for Diagnosis, Management, and Prevention of COPD (Internet version, updated 2013). Available in https://ift.tt/2HPEARU management.html Stoller J.K. (2010): Management of acute exacerbations of chronic obstructive pulmonary disease. UpToDate online 18.3 [last updated: October 7, 2010], Available in: https://ift.tt/2vulfTw e=1~39&source=search_result. 76.Bài viếtThông khí nhân tạo không xâm nhập xuất hiện lần đầu tại website http://khamgiodau.com