Additional Information
Book Details
Abstract
Applying mechanical ventilation principles to patient care, Pilbeam's Mechanical Ventilation: Physiological and Clinical Applications, 5th Edition helps you provide safe, appropriate, and compassionate care for patients requiring ventilatory support. A focus on evidence-based practice includes the latest techniques and equipment, with complex ventilator principles simplified for optimal learning. This edition adds new case studies and new chapters on ventilator-associated pneumonia and on neonatal and pediatric mechanical ventilation. Starting with the most fundamental concepts and building to the most advanced, expert educator J. M. Cairo presents clear, comprehensive, up-to-date coverage of the rapidly evolving field of mechanical ventilation.
- Excerpts of Clinical Practice Guidelines developed by the AARC (American Association for Respiratory Care) make it easy to access important information regarding indications/contraindications, hazards and complications, assessment of need, assessment of outcome, and monitoring.
- Case Studies with exercises and Critical Care Concepts address situations that may be encountered during mechanical ventilation.
- Learning objectives at the beginning of each chapter help in accurately gauging your comprehension and measuring your progress.
- Chapter outlines show the "big picture" of each chapter's content.
- Key terms are listed in the chapter opener, then bolded and defined at their first mention in the text.
- Key Point boxes highlight need-to-know information.
- NBRC exam-style assessment questions at the end of each chapter offer practice for the certification exam.
- NEW Neonatal and Pediatric Mechanical Ventilation chapter covers the latest advances and research relating to young patients.
- Additional case studies in each chapter present "real-life" scenarios, showing the practical application of newly acquired skills.
- End-of-chapter summaries help with review and in assessing your comprehension with a bulleted list of key content.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | cover | ||
| Abbreviations | BM_1 | ||
| Half title page | i | ||
| Evolve page | ii | ||
| Pilbeam's Mechanical Ventilation, 5/e | iii | ||
| Copyright page | iv | ||
| Dedication | v | ||
| Contributors | vi | ||
| Foreword | viii | ||
| Acknowledgments | ix | ||
| Preface | x | ||
| Organization | x | ||
| Features | x | ||
| New to this Edition | x | ||
| Learning Aids | xi | ||
| Workbook | xi | ||
| For Educators | xi | ||
| Table of Contents | xiii | ||
| 1 Basic Concepts and Core Knowledge in Mechanical Ventilation | 1 | ||
| 1 Basic Terms and Concepts of Mechanical Ventilation | 2 | ||
| Outline | 2 | ||
| Learning Objectives | 2 | ||
| Key Terms | 2 | ||
| Physiological Terms and Concepts Related to Mechanical Ventilation | 3 | ||
| Normal Mechanics of Spontaneous Ventilation | 3 | ||
| Ventilation and Respiration | 3 | ||
| Gas Flow and Pressure Gradients During Ventilation | 3 | ||
| Units of Pressure | 4 | ||
| Definition of Pressures and Gradients in the Lungs | 4 | ||
| Transairway Pressure | 4 | ||
| Transthoracic Pressure | 4 | ||
| Transpulmonary Pressure | 4 | ||
| Transrespiratory Pressure | 5 | ||
| Lung Characteristics | 5 | ||
| Compliance | 5 | ||
| Resistance | 7 | ||
| Measuring Airway Resistance | 8 | ||
| Time Constants | 8 | ||
| Types of Ventilators and Terms Used in Mechanical Ventilation | 9 | ||
| Types of Mechanical Ventilation | 10 | ||
| Negative-Pressure Ventilation | 10 | ||
| Positive-Pressure Ventilation | 10 | ||
| High-Frequency Ventilation | 11 | ||
| Definition of Pressures in Positive-Pressure Ventilation | 11 | ||
| Baseline Pressure | 12 | ||
| Peak Pressure | 12 | ||
| Plateau Pressure | 12 | ||
| Pressure at the End of Exhalation | 13 | ||
| Summary | 14 | ||
| Review Questions | 14 | ||
| References | 16 | ||
| 2 How Ventilators Work | 17 | ||
| Outline | 17 | ||
| Learning Objectives | 17 | ||
| Key Terms | 17 | ||
| Historical Perspective on Ventilator Classification | 17 | ||
| Internal Function | 18 | ||
| Power Source or Input Power | 18 | ||
| Electrically Powered Ventilators | 18 | ||
| Pneumatically Powered Ventilators | 18 | ||
| Combined-Power Ventilators: Pneumatically Powered, Electronically or Microprocessor-Controlled Models | 18 | ||
| Positive- and Negative-Pressure Ventilators | 20 | ||
| Control Systems and Circuits | 21 | ||
| Open- and Closed-Loop Systems to Control Ventilator Function | 21 | ||
| Control Panel (User Interface) | 21 | ||
| Pneumatic Circuit | 21 | ||
| Internal Pneumatic Circuit | 21 | ||
| External Pneumatic Circuit | 23 | ||
| Power Transmission and Conversion System | 23 | ||
| Compressors (Blowers) | 23 | ||
| Volume-Displacement Designs | 25 | ||
| Flow-Control Valves | 26 | ||
| Summary | 27 | ||
| Review Questions | 27 | ||
| References | 28 | ||
| 3 How a Breath Is Delivered | 29 | ||
| Outline | 29 | ||
| Learning Objectives | 29 | ||
| Key Terms | 29 | ||
| Basic Model of Ventilation in the Lung During Inspiration | 30 | ||
| Factors Controlled and Measured During Inspiration | 30 | ||
| Pressure-Controlled Breathing | 30 | ||
| Volume-Controlled Breathing | 32 | ||
| Flow-Controlled Breathing | 32 | ||
| Time-Controlled Breathing | 32 | ||
| Overview of Inspiratory Waveform Control | 32 | ||
| Four Phases of a Breath and Phase Variables | 33 | ||
| Beginning of Inspiration: The Trigger Variable | 33 | ||
| Time Triggering | 34 | ||
| Patient Triggering | 34 | ||
| The Limit Variable During Inspiration | 36 | ||
| Pressure Limiting | 36 | ||
| Volume Limiting | 37 | ||
| Flow Limiting | 37 | ||
| Maximum Safety Pressure: Pressure Limiting Versus Pressure Cycling | 37 | ||
| Termination of the Inspiratory Phase: The Cycling Mechanism (Cycle Variable) | 38 | ||
| Volume-Cycled Ventilation | 38 | ||
| Set Volume Versus Actual Delivered Volume | 38 | ||
| Tubing compressibility. | 38 | ||
| System leaks. | 38 | ||
| Time-Cycled Ventilation | 38 | ||
| Flow-Cycled Ventilation | 39 | ||
| Pressure-Cycled Ventilation | 39 | ||
| Inflation Hold (Inspiratory Pause) | 39 | ||
| Expiratory Phase: The Baseline Variable | 40 | ||
| Definition of Expiration | 40 | ||
| Baseline Pressure | 40 | ||
| Time-Limited Expiration | 40 | ||
| Continuous Gas Flow During Expiration | 40 | ||
| NEEP and Subambient Pressure During Expiration | 40 | ||
| Expiratory Hold (End-Expiratory Pause) | 41 | ||
| Expiratory Retard | 41 | ||
| Continuous Positive Airway Pressure (CPAP) and Positive End-Expiratory Pressure (PEEP) | 42 | ||
| Types of Breaths | 43 | ||
| Summary | 43 | ||
| Review Questions | 44 | ||
| References | 45 | ||
| 2 Initiating Ventilation | 47 | ||
| 4 Establishing the Need for Mechanical Ventilation | 48 | ||
| Outline | 48 | ||
| Learning Objectives | 48 | ||
| Key Terms | 48 | ||
| Acute Respiratory Failure | 49 | ||
| Recognizing the Patient in Distress | 49 | ||
| Definition of Respiratory Failure | 50 | ||
| Recognizing Hypoxemia and Hypercapnia | 50 | ||
| Patient History And Diagnosis | 51 | ||
| Central Nervous System Disorders | 51 | ||
| Neuromuscular Disorders | 52 | ||
| Increased Work of Breathing | 53 | ||
| Physiological Measurements in Acute Respiratory Failure | 53 | ||
| Bedside Measurements of Ventilatory Mechanics | 53 | ||
| Maximum Inspiratory Pressure | 53 | ||
| Vital Capacity | 54 | ||
| Peak Expiratory Flow Rate and Forced Expiratory Volume in 1 Second | 54 | ||
| Respiratory Rate and Minute Ventilation | 55 | ||
| Failure of Ventilation and Increased Dead Space | 55 | ||
| Failure of Oxygenation | 55 | ||
| Overview Of Criteria For Mechanical Ventilation | 56 | ||
| Possible Alternatives To Invasive Ventilation | 56 | ||
| Noninvasive Positive-Pressure Ventilation (NIV) | 58 | ||
| Intubation Without Ventilation | 58 | ||
| Ethical Considerations | 58 | ||
| Summary | 60 | ||
| Review Questions | 61 | ||
| References | 62 | ||
| 5 Selecting the Ventilator and the Mode | 63 | ||
| Outline | 63 | ||
| Learning Objectives | 63 | ||
| Key Terms | 63 | ||
| Noninvasive and Invasive Positive-Pressure Ventilation: Selecting the Patient Interface | 64 | ||
| 3 Monitoring in Mechanical Ventilation | 123 | ||
| 8 Initial Patient Assessment | 124 | ||
| Outline | 124 | ||
| Learning Objectives | 124 | ||
| Key Terms | 124 | ||
| Documentation of the Patient-Ventilator System | 125 | ||
| The First 30 Minutes | 126 | ||
| Mode | 128 | ||
| Sensitivity | 129 | ||
| Tidal Volume, Rate, and Minute Ventilation | 129 | ||
| Correcting Tubing Compliance | 129 | ||
| Alveolar Ventilation | 130 | ||
| Dead Space | 130 | ||
| Added Mechanical Dead Space | 130 | ||
| Final Alveolar Ventilation | 131 | ||
| Monitoring Airway Pressures | 131 | ||
| Peak Inspiratory Pressure | 131 | ||
| Plateau Pressure | 131 | ||
| Set Pressure | 132 | ||
| Transairway Pressure: PIP Minus Pplateau | 132 | ||
| Mean Airway Pressure | 132 | ||
| End Expiratory Pressure | 132 | ||
| Pressure Limit | 133 | ||
| Low-Pressure Alarm | 133 | ||
| Checking the Circuit: Checking for Leaks | 133 | ||
| Vital Signs, Blood Pressure, and Physical Examination of the Chest | 134 | ||
| Heart Rate | 135 | ||
| Temperature | 135 | ||
| Systemic Arterial Blood Pressure | 135 | ||
| Central Venous Pressure | 135 | ||
| Pulmonary Artery Pressure | 135 | ||
| Physical Examination of the Chest | 135 | ||
| Management of Endotracheal and Tracheostomy Tube Cuffs | 136 | ||
| Cuff Pressure Measurement | 136 | ||
| High Cuff Pressure | 137 | ||
| Nonexistent or Low Cuff Pressure | 138 | ||
| Cut in the Pilot Tube | 138 | ||
| Tube and Mouth Care | 140 | ||
| Monitoring Compliance and Airway Resistance | 140 | ||
| Static Compliance | 140 | ||
| Dynamic Characteristic (Dynamic Compliance) | 140 | ||
| Airway Resistance | 142 | ||
| Bedside Measurement of Pressure-Volume Curves | 142 | ||
| Comment Section of the Ventilator Flow Sheet | 144 | ||
| Summary | 144 | ||
| Review Questions | 145 | ||
| References | 146 | ||
| 9 Ventilator Graphics | 148 | ||
| Outline | 148 | ||
| Learning Objectives | 148 | ||
| Key Terms | 148 | ||
| Relationship of Volume, Flow, Pressure, and Time | 149 | ||
| Volume-Controlled Ventilation with Constant Flow | 150 | ||
| Producing Ventilator Graphics | 150 | ||
| Calculations | 150 | ||
| A Closer Look at the Flow-Time Scalar in Volume-Controlled Continuous Mandatory Ventilation | 151 | ||
| Variation One | 152 | ||
| Variation Two | 153 | ||
| Variation Three | 154 | ||
| Changes in the Pressure-Time Curve | 155 | ||
| Volume Scalar | 155 | ||
| Volume-Controlled Ventilation with Varying Gas Flow Waveforms | 157 | ||
| Volume-Controlled Spontaneous Intermittent Mechanical Ventilation | 157 | ||
| Key Points of Volume-Controlled Ventilation Graphics | 157 | ||
| Pressure-Controlled Ventilation | 158 | ||
| Pressure-Controlled Ventilation with a Constant Pressure Waveform | 158 | ||
| Comparison of Pressure-Controlled Ventilation and Volume-Controlled Ventilation | 159 | ||
| Changes in Compliance during Pressure-Controlled Continuous Mechanical Ventilation | 159 | ||
| Active Inspiration and Expiration | 159 | ||
| Inspiratory Rise Time Control: Sloping or Ramping | 159 | ||
| Pressure-Controlled SIMV plus CPAP | 160 | ||
| Key Points of Pressure- Controlled Ventilation Graphics | 160 | ||
| Pressure Support Ventilation | 161 | ||
| Details of the Pressure-Time Waveform in Pressure-Support Ventilation | 161 | ||
| Flow Cycling During Pressure-Support Ventilation | 162 | ||
| Automatic Adjustment of the Flow-Cycle Criterion | 163 | ||
| Use of Pressure-Support Ventilation with Simv | 165 | ||
| Pressure-Volume Loops | 165 | ||
| Components of the Pressure-Volume Loop | 165 | ||
| Changes in the Pressure-Volume Loop with Changes in Flow | 165 | ||
| Pressure-Volume Loop with Changes in Compliance | 166 | ||
| Pressure-Volume Loop with Increased Airway Resistance | 167 | ||
| Spontaneous Breaths and Pressure-Volume Loops | 167 | ||
| Pressure-Volume Loop and Work of Breathing | 168 | ||
| Troubleshooting a Pressure-Volume Loop | 169 | ||
| Flow-Volume Loops During Mechanical Ventilation | 169 | ||
| Components of a Flow-Volume Loop with Mandatory Breaths | 169 | ||
| Varying Flow Waveforms and Varying Flows with Flow-Volume Loops During Volume Ventilation | 169 | ||
| Airway Resistance and Evaluation of Bronchodilator Therapy with the Flow-Volume Loop | 170 | ||
| Troubleshooting with Flow- Volume Loops During Mechanical Ventilation | 171 | ||
| Summary | 172 | ||
| Review Questions | 172 | ||
| References | 174 | ||
| 10 Assessment of Respiratory Function | 175 | ||
| Outline | 175 | ||
| Learning Objectives | 175 | ||
| Key Terms | 175 | ||
| Noninvasive Measurements of Blood Gases | 175 | ||
| Pulse Oximetry | 175 | ||
| Physiologic and Technical Concerns | 176 | ||
| Low Perfusion States | 177 | ||
| Dysfunctional Hemoglobins and Dyes | 177 | ||
| Nail Polish | 177 | ||
| Skin Pigmentation | 178 | ||
| Ambient Light | 178 | ||
| Clinical Applications | 178 | ||
| Capnography (Capnometry) | 179 | ||
| Technical Considerations | 179 | ||
| Chemical Methods | 179 | ||
| Infrared Spectroscopy | 180 | ||
| Physiologic Considerations | 181 | ||
| Clinical Applications | 182 | ||
| Capnograph Contours | 182 | ||
| Arterial to Maximum End-Expiratory PCO2 Difference | 183 | ||
| Volumetric Capnometry | 184 | ||
| Description of the Single Breath CO2 Curve | 184 | ||
| Single-Breath CO2 Loop of Inspiration and Exhalation | 185 | ||
| Trending CO2 Production and Alveolar Minute Ventilation Over Time | 185 | ||
| Exhaled Nitric Oxide Monitoring | 186 | ||
| Transcutaneous Monitoring | 186 | ||
| Transcutaneous PO2 | 186 | ||
| Transcutaneous PCO2 | 186 | ||
| Technical Considerations | 187 | ||
| Indirect Calorimetry and Metabolic Measurements | 187 | ||
| Overview of Indirect Calorimetry | 187 | ||
| Technical Considerations | 188 | ||
| Obtaining Indirect Calorimetry Measurements | 189 | ||
| Clinical Applications of Metabolic Measurements | 189 | ||
| Assessment of Respiratory System Mechanics | 190 | ||
| Measurements | 190 | ||
| Airway Pressure Measurements | 190 | ||
| Flow Measurements | 191 | ||
| Clinical Applications | 192 | ||
| Measured Variables | 192 | ||
| Derived Variables | 193 | ||
| Mean airway pressure. | 193 | ||
| Dynamic and static compliances. | 193 | ||
| Airway resistance. | 193 | ||
| Work of breathing. | 193 | ||
| Work of breathing defined. | 194 | ||
| Graphic representation of WOB. | 194 | ||
| Pressure-time product. | 195 | ||
| Occlusion pressure measurements. | 195 | ||
| Summary | 196 | ||
| Review Questions | 196 | ||
| References | 197 | ||
| 11 Hemodynamic Monitoring | 199 | ||
| Outline | 199 | ||
| Learning Objectives | 199 | ||
| Key Terms | 199 | ||
| Review of Cardiovascular Principles | 200 | ||
| Factors Influencing Cardiac Output | 200 | ||
| Obtaining Hemodynamic Measurements | 202 | ||
| Hemodynamic Monitoring Systems | 202 | ||
| Fluid Pressures | 202 | ||
| Systemic Artery Catheterization | 203 | ||
| Central Venous Lines | 204 | ||
| Pulmonary Artery Catheterization | 204 | ||
| Interpretation of Hemodynamic Profiles | 207 | ||
| Heart Rate | 207 | ||
| Systemic Arterial Pressure | 207 | ||
| Right Atrial and Pulmonary Artery Pressures | 208 | ||
| Atrial Pressures | 208 | ||
| Pulmonary Artery Pressure | 209 | ||
| Cardiac Output | 210 | ||
| Fick Principle and Cardiac Output Measurements | 211 | ||
| Indirect Fick Method | 211 | ||
| Mixed Venous Oxygen Saturation | 212 | ||
| Oxygen Delivery | 212 | ||
| Shunt Fraction | 212 | ||
| Vascular Resistance | 213 | ||
| Ejection Fraction | 213 | ||
| Cardiac Work | 213 | ||
| Clinical Applications | 214 | ||
| Summary | 217 | ||
| Review Questions | 217 | ||
| References | 219 | ||
| 4 Therapeutic Interventions—Making Appropriate Changes | 221 | ||
| 12 Methods to Improve Ventilation in Patient-Ventilator Management | 222 | ||
| Outline | 222 | ||
| Learning Objectives | 222 | ||
| Key Terms | 222 | ||
| Correcting Ventilation Abnormalities | 223 | ||
| Common Methods of Changing Ventilation Based on PaCO2 and pH | 223 | ||
| Respiratory Acidosis: Volume and Pressure Ventilation Changes | 223 | ||
| Respiratory Alkalosis: VC-CMV and PC-CMV Changes | 225 | ||
| Metabolic Acidosis and Alkalosis | 226 | ||
| Metabolic Acidosis | 226 | ||
| Metabolic Alkalosis | 226 | ||
| Mixed Acid-Base Disturbances | 227 | ||
| Increased Physiological Dead Space | 228 | ||
| Increased Metabolism and Increased Carbon Dioxide Production | 228 | ||
| Intentional Iatrogenic Hyperventilation | 229 | ||
| Permissive Hypercapnia | 229 | ||
| Procedures for Managing Permissive Hypercapnia | 229 | ||
| Contraindications of Permissive Hypercapnia | 230 | ||
| Airway Clearance During Mechanical Ventilation | 230 | ||
| Secretion Clearance from an Artificial Airway | 230 | ||
| Hazards and Complications of Suctioning | 232 | ||
| Closed-Suction Catheters (In-line Suction Catheters) | 232 | ||
| Continuous Aspiration of Subglottic Secretions | 234 | ||
| Normal Saline Instillation | 234 | ||
| Assessment Following Suctioning | 235 | ||
| Administering Aerosols to Ventilated Patients | 235 | ||
| Types of Aerosol-Generating Devices | 235 | ||
| Ventilator-Related Factors | 235 | ||
| Patient-Related Factors | 235 | ||
| Circuit-Related Factors | 236 | ||
| Use of pMDIs During Mechanical Ventilation | 236 | ||
| Use of SVNs During Mechanical Ventilation | 238 | ||
| Technical Problems Associated with Continuous Nebulization Using an External Gas Source | 239 | ||
| Nebulization Provided by the Ventilator | 239 | ||
| Use of Nebulizers During Noninvasive Positive-Pressure Ventilation | 240 | ||
| Patient Response to Bronchodilator Therapy | 240 | ||
| Postural Drainage and Chest Percussion | 241 | ||
| Flexible Fiberoptic Bronchoscopy | 241 | ||
| Additional Patient Management Techniques and Therapies in Ventilated Patients | 244 | ||
| Importance of Body Position and Positive-Pressure Ventilation | 244 | ||
| Positioning in a Patient with ARDS: Prone Positioning | 244 | ||
| Potential Mechanisms of Improved Oxygenation in Prone Positioning | 245 | ||
| Technical Aspects of Prone Positioning | 245 | ||
| Patient Position in Unilateral Lung Disease | 246 | ||
| Sputum and Upper Airway Infections | 247 | ||
| Fluid Balance | 247 | ||
| Psychological and Sleep Status | 248 | ||
| Patient Safety and Comfort | 249 | ||
| Patient Safety | 249 | ||
| Patient Comfort | 249 | ||
| Patient-Centered Mechanical Ventilation | 249 | ||
| Transport of Mechanically Ventilated Patients within an Acute Care Facility | 250 | ||
| Summary | 251 | ||
| Review Questions | 252 | ||
| References | 253 | ||
| 13 Improving Oxygenation and Management of Acute Respiratory Distress Syndrome | 257 | ||
| Outline | 257 | ||
| Learning Objectives | 257 | ||
| Key Terms | 257 | ||
| Basics of Oxygenation Using FiO2, Peep Studies, and Pressure-Volume Curves for Establishing Optimum Peep | 258 | ||
| Basics of Oxygen Delivery to the Tissues | 258 | ||
| Evaluating PaO2, SpO2, and FIO2 in Ventilator Patients | 259 | ||
| Adjusting FIO2 | 259 | ||
| Selection of FIO2 or Adjustment of Mean Airway Pressures | 260 | ||
| Introduction to Positive End-Expiratory Pressure and Continuous Positive Airway Pressure | 261 | ||
| Pathophysiology of Atelectasis | 261 | ||
| Goals of PEEP and CPAP | 262 | ||
| Terminology | 262 | ||
| Technical Aspects of PEEP and CPAP | 262 | ||
| Application of CPAP and PEEP Devices to the Patient’s Airway | 262 | ||
| Mask CPAP | 262 | ||
| Nasal CPAP | 262 | ||
| Endotracheal or Tracheostomy Tubes | 262 | ||
| Flow and Threshold Resistors | 262 | ||
| Circuitry for Spontaneous CPAP with Freestanding Systems and Mechanical Ventilators | 263 | ||
| PEEP Ranges | 263 | ||
| Minimum or Low PEEP | 263 | ||
| Therapeutic PEEP | 263 | ||
| Optimum PEEP | 263 | ||
| Indications for PEEP and CPAP | 263 | ||
| Initiating PEEP Therapy | 264 | ||
| Selecting the Appropriate PEEP/CPAP Level (Optimum Peep) | 264 | ||
| Application of PEEP Above 5 cm H2O | 264 | ||
| Optimum PEEP Study | 266 | ||
| Performing an Optimum PEEP Study. | 267 | ||
| Patient Appearance. | 267 | ||
| Blood Pressure. | 267 | ||
| Breath Sounds. | 267 | ||
| Ventilator Parameters. | 267 | ||
| Static Compliance. | 267 | ||
| Arterial PO2, FIO2, and PaO2/FIO2. | 269 | ||
| Arterial PaCO2 and pH. | 269 | ||
| Alveolar-to-Arterial Oxygen Tension [P(A − a)O2]. | 269 | ||
| Arterial to End-Tidal CO2 Tension Gradient [P(a − et)CO2]. | 269 | ||
| Hemodynamic Data. | 269 | ||
| Arterial-to-Venous Oxygen Difference. | 269 | ||
| Mixed Venous Oxygen Tension or Saturation. | 270 | ||
| Cardiac Output. | 270 | ||
| Use of Pulmonary Vascular Pressure Monitoring with PEEP | 270 | ||
| Contraindications and Physiological Effects of Peep | 271 | ||
| Contraindications for PEEP | 271 | ||
| Pulmonary Effects of PEEP | 272 | ||
| Transmission of Airway Pressure to Pleural Space | 272 | ||
| Uses of PEEP for Problems Other Than Acute Lung Injury | 273 | ||
| PEEP and Congestive Heart Failure | 273 | ||
| Mask CPAP as a Treatment for Postoperative Atelectasis and Hypoxemia | 273 | ||
| Sleep Apnea | 273 | ||
| Cystic Fibrosis | 273 | ||
| Airway Suctioning with PEEP | 273 | ||
| Weaning from Peep | 273 | ||
| Acute Respiratory Distress Syndrome | 275 | ||
| Pathophysiology | 275 | ||
| Changes in Computed Tomogram with Ards | 275 | ||
| Ards as an Inflammatory Process | 276 | ||
| Two Categories of ARDS | 277 | ||
| ARDS: A Heterogeneous Disorder—Normal Lung vs. ARDS | 277 | ||
| PEEP and the Vertical Gradient in Ards | 278 | ||
| Lung-Protective Strategies: Setting Tidal Volume and Pressures in Ards | 278 | ||
| Long-Term Follow-Up on Ards | 279 | ||
| Pressure-Volume Loops and Recruitment Maneuvers in Setting Peep in Ards | 279 | ||
| Patient Evaluation for Lung Recruitment | 280 | ||
| Pressure-Volume Loops in Setting PEEP | 280 | ||
| Super-Syringe Technique | 280 | ||
| Low-Flow (Quasi-Static) Technique | 280 | ||
| Features of the SPV Loop | 281 | ||
| Recruitment Maneuvers | 282 | ||
| Illustration of a Recruitment Maneuver | 282 | ||
| The Function of Lung Recruitment | 282 | ||
| Hazards of Recruitment Maneuvers | 283 | ||
| Variability Among Patients | 284 | ||
| Effects of Chest Wall Compliance on Lung Recruitment | 284 | ||
| Potential Complications During Lung Recruitment | 285 | ||
| Types of Recruitment Maneuvers | 285 | ||
| Sustained Inflation. | 285 | ||
| PC-CMV with a High PEEP Level. | 285 | ||
| PC-CMV with Increased PEEP. | 285 | ||
| Recruitment and Decremental PEEP. | 285 | ||
| Sigh Techniques. | 285 | ||
| Derecruitment Maneuver | 286 | ||
| Summary of Recruitment Maneuvers in Ards | 286 | ||
| Patient Cases | 286 | ||
| Summary | 288 | ||
| Review Questions | 288 | ||
| References | 290 | ||
| 5 Effects and Complications of Mechanical Ventilation | 293 | ||
| 14 Ventilator-Associated Pneumonia | 294 | ||
| Outline | 294 | ||
| Learning Objectives | 294 | ||
| Key Terms | 294 | ||
| Epidemiology | 295 | ||
| Causes and Risk Factors | 295 | ||
| Pathogenesis of Ventilator-Associated Pneumonia | 297 | ||
| Diagnosis of Ventilator-Associated Pneumonia | 297 | ||
| Clinical Diagnosis | 297 | ||
| Bacteriologic (Quantitative) Diagnosis | 298 | ||
| Treatment of Ventilator-Associated Pneumonia | 298 | ||
| Strategies to Prevent Ventilator-Associated Pneumonia | 299 | ||
| Nonpharmacologic Interventions | 300 | ||
| Handwashing | 300 | ||
| Semirecumbent Patient Positioning and Enteral Feeding | 300 | ||
| Noninvasive Ventilation | 302 | ||
| Selection, Changing, and Suctioning of the Endotracheal Tube | 302 | ||
| Care of the Tracheostomy Tube | 302 | ||
| Continuous Aspiration of Subglottic Secretions (CASS) | 302 | ||
| Ventilator Circuit Management Strategies | 303 | ||
| Kinetic Therapy | 303 | ||
| Pharmacologic Interventions | 303 | ||
| Oropharyngeal Decontamination | 303 | ||
| Stress Ulcer Prophylaxis | 303 | ||
| Selective Digestive Tract Decontamination | 304 | ||
| Prophylactic Antibiotics | 304 | ||
| Summary | 304 | ||
| Review Questions | 304 | ||
| References | 305 | ||
| 15 Sedatives, Analgesics, and Paralytics | 307 | ||
| Outline | 307 | ||
| Learning Objectives | 307 | ||
| Key Terms | 307 | ||
| Sedatives and Analgesics | 308 | ||
| Monitoring the Need for Sedation and Analgesia | 308 | ||
| Benzodiazepines | 308 | ||
| Diazepam | 309 | ||
| Midazolam | 309 | ||
| Lorazepam | 310 | ||
| Neuroleptics | 310 | ||
| Anesthetic Agents | 310 | ||
| Opioids | 310 | ||
| Morphine | 311 | ||
| Fentanyl | 311 | ||
| Paralytics | 312 | ||
| Monitoring Neuromuscular Blockade | 313 | ||
| Depolarizing Agents | 313 | ||
| Succinylcholine | 313 | ||
| Nondepolarizing Agents | 313 | ||
| Pancuronium | 313 | ||
| Vecuronium | 313 | ||
| Atracurium/Cisatracurium | 314 | ||
| Summary | 314 | ||
| Review Questions | 314 | ||
| References | 315 | ||
| 16 Extrapulmonary Effects of Mechanical Ventilation | 316 | ||
| Outline | 316 | ||
| Learning Objectives | 316 | ||
| Key Terms | 316 | ||
| Effects of Positive-Pressure Ventilation on the Heart and Thoracic Vessels | 316 | ||
| Adverse Cardiovascular Effects of Positive-Pressure Ventilation | 317 | ||
| The Thoracic Pump Mechanism During Normal Spontaneous Breathing and During Positive-Pressure Ventilation | 317 | ||
| Increased Pulmonary Vascular Resistance and Altered Right and Left Ventricular Function | 317 | ||
| Coronary Blood Flow with Positive-Pressure Ventilation | 318 | ||
| Factors Influencing Cardiovascular Effects of Positive-Pressure Ventilation | 318 | ||
| Compensation in Individuals with Normal Cardiovascular Function | 318 | ||
| Effects of Lung and Chest Wall Compliance and Airway Resistance | 319 | ||
| Duration and Magnitude of Positive Pressures | 319 | ||
| Beneficial Effects of Positive-Pressure Ventilation on Heart Function in Patients with Left Ventricular Dysfunction | 319 | ||
| Minimizing the Physiological Effects and Complications of Mechanical Ventilation | 319 | ||
| Mean Airway Pressure and PaO2 | 320 | ||
| Reduction in Airway Pressure | 320 | ||
| Inspiratory Flow | 320 | ||
| Inspiratory : Expiratory Ratio | 321 | ||
| Inflation Hold | 321 | ||
| Positive End-Expiratory Pressure | 321 | ||
| High Peak Pressures from Increased Airway Resistance | 321 | ||
| Intermittent Mandatory Ventilation and Synchronized Intermittent Mandatory Ventilation | 321 | ||
| Effects of Mechanical Ventilation on Intracranial Pressure, Renal Function, Liver Function, and Gastrointestinal Function | 322 | ||
| Effects of Mechanical Ventilation on Intracranial Pressure and Cerebral Perfusion | 322 | ||
| Renal Effects of Mechanical Ventilation | 323 | ||
| Renal Response to Hemodynamic Changes | 323 | ||
| Endocrine Effects of Positive-Pressure Ventilation on Renal Function | 323 | ||
| Arterial Blood Gases and Kidney Function | 323 | ||
| Implications of Impaired Renal Effects | 324 | ||
| Effects of Mechanical Ventilation on Liver and Gastrointestinal Function | 324 | ||
| Nutritional Complications during Mechanical Ventilation | 324 | ||
| Summary | 325 | ||
| Review Questions | 325 | ||
| References | 326 | ||
| 17 Effects of Positive-Pressure Ventilation on the Pulmonary System | 327 | ||
| Outline | 327 | ||
| Learning Objectives | 327 | ||
| Key Terms | 327 | ||
| Lung Injury With Mechanical Ventilation | 328 | ||
| Ventilator-Associated Lung Injury Versus Ventilator-Induced Lung Injury | 328 | ||
| Barotrauma or Extra-Alveolar Air | 328 | ||
| Subcutaneous Emphysema | 328 | ||
| Pneumomediastinum | 329 | ||
| Pneumothorax | 329 | ||
| Pneumoperitoneum | 329 | ||
| Barotrauma or Volutrauma | 329 | ||
| Atelectrauma | 330 | ||
| Shear Stress | 331 | ||
| Surfactant Alteration | 331 | ||
| Biotrauma | 331 | ||
| Multiple-Organ Dysfunction Syndrome | 332 | ||
| Vascular Endothelial Injury | 332 | ||
| Historic Webb and Tierney Study | 332 | ||
| Role of PEEP in Lung Protection | 333 | ||
| Ventilator-Induced Respiratory Muscle Weakness | 333 | ||
| Effects Of Mechanical Ventilation On Gas Distribution And Pulmonary Blood Flow | 333 | ||
| Ventilation to Nondependent Lung | 333 | ||
| Ventilation-to-Lung Periphery | 334 | ||
| Increase in Dead Space | 334 | ||
| Redistribution of Pulmonary Blood Flow | 334 | ||
| Effects of Positive Pressure on Pulmonary Vascular Resistance | 334 | ||
| Respiratory And Metabolic Acid-Base Status In Mechanical Ventilation | 335 | ||
| Hypoventilation | 335 | ||
| Hyperventilation | 335 | ||
| Metabolic Acid-Base Imbalances and Mechanical Ventilation | 336 | ||
| Air Trapping (Auto-Peep) | 336 | ||
| How Auto-PEEP Occurs | 337 | ||
| Physiological Factors That Lead to Auto-PEEP | 337 | ||
| Identifying and Measuring Auto-PEEP | 338 | ||
| Effect on Ventilator Function | 339 | ||
| Measuring Static Compliance with Auto-PEEP | 339 | ||
| Methods of Reducing Auto-PEEP | 339 | ||
| Potential Benefits of Auto-PEEP | 339 | ||
| Hazards Of Oxygen Therapy With Mechanical Ventilation | 339 | ||
| Oxygen Toxicity and the Lower Limits of Hypoxemia | 339 | ||
| Absorption Atelectasis | 339 | ||
| Depression of Ventilation | 340 | ||
| Increased Work Of Breathing | 340 | ||
| System-Imposed Work of Breathing | 340 | ||
| Work of Breathing During Weaning | 340 | ||
| Measuring Work of Breathing | 340 | ||
| Steps to Reduce Work of Breathing During Mechanical Ventilation | 341 | ||
| Reducing Work Imposed by the Artificial Airway | 341 | ||
| Setting Machine Sensitivity and Inspiratory Flow | 341 | ||
| Patient-Ventilator Synchrony | 341 | ||
| Trigger asynchrony. | 341 | ||
| Flow asynchrony. | 343 | ||
| Cycle asynchrony. | 343 | ||
| Mode asynchrony. | 344 | ||
| PEEP asynchrony. | 344 | ||
| Closed-loop ventilation asynchrony. | 344 | ||
| Other types of asynchrony. | 345 | ||
| Reducing Minute Ventilation Demands | 345 | ||
| Ventilator Mechanical and Operational Hazards | 345 | ||
| Complications Of The Artificial Airway | 347 | ||
| Summary | 348 | ||
| Review Questions | 349 | ||
| References | 350 | ||
| 18 Troubleshooting and Problem Solving | 353 | ||
| Outline | 353 | ||
| Learning Objectives | 353 | ||
| Key Terms | 353 | ||
| Definition of the Term Problem | 354 | ||
| Solving Ventilation Problems | 354 | ||
| Protecting The Patient | 354 | ||
| Identifying The Patient In Sudden Distress | 355 | ||
| Patient-Related Problems | 356 | ||
| Airway Problems | 356 | ||
| Pneumothorax | 357 | ||
| Bronchospasm | 357 | ||
| Secretions | 357 | ||
| Pulmonary Edema | 357 | ||
| Dynamic Hyperinflation | 357 | ||
| Abnormalities in Respiratory Drive | 358 | ||
| Change in Body Position | 358 | ||
| Drug-Induced Distress | 358 | ||
| Abdominal Distention | 358 | ||
| Pulmonary Embolism | 358 | ||
| Ventilator-Related Problems | 358 | ||
| Leaks | 359 | ||
| Inadequate Oxygenation | 359 | ||
| Inadequate Ventilatory Support | 359 | ||
| Trigger Sensitivity | 359 | ||
| Inadequate Flow Setting | 359 | ||
| Other Examples of Patient-Ventilator Asynchrony | 359 | ||
| Common Alarm Situations | 360 | ||
| Low-Pressure Alarm | 360 | ||
| High-Pressure Alarm | 361 | ||
| Low PEEP/CPAP Alarms | 362 | ||
| Apnea Alarm | 362 | ||
| Low-Source Gas Pressure or Power Input Alarm | 363 | ||
| Ventilator Inoperative Alarm and Technical Error Message | 363 | ||
| Operator Settings Incompatible with Machine Parameters | 363 | ||
| Inspiratory-to-Expiratory Ratio Indicator and Alarm | 363 | ||
| Other Alarms | 363 | ||
| Use Of Graphics To Identify Ventilator Problems | 363 | ||
| Leaks | 368 | ||
| Inadequate Flow | 368 | ||
| Inadequate Sensitivity Setting for Patient Triggering | 368 | ||
| Overinflation | 368 | ||
| Auto-PEEP | 368 | ||
| Inadequate Inspiratory Time During Pressure Ventilation | 368 | ||
| Waveform Ringing | 369 | ||
| Expiratory Portion of Volume-Time Curve Below Baseline | 370 | ||
| Patient-Ventilator Asynchrony | 370 | ||
| Unexpected Ventilator Responses | 370 | ||
| Unseated or Obstructed Expiratory Valve | 371 | ||
| Excessive CPAP/PEEP | 371 | ||
| Nebulizer Impairment of Patient’s Ability to Trigger a Pressure-Supported Breath | 371 | ||
| High Tidal Volume Delivery | 371 | ||
| Altered Alarm Function | 371 | ||
| Electromagnetic Interference | 371 | ||
| Other Ventilator Problems | 372 | ||
| Summary | 372 | ||
| Review Questions | 372 | ||
| References | 375 | ||
| 6 Noninvasive Positive Pressure Ventilation | 377 | ||
| 19 Basic Concepts of Noninvasive Positive-Pressure Ventilation | 378 | ||
| Outline | 378 | ||
| Learning Objectives | 378 | ||
| Key Terms | 378 | ||
| Types Of Noninvasive Ventilation Techniques | 379 | ||
| Negative-Pressure Ventilation | 379 | ||
| Positive-Pressure Ventilation | 379 | ||
| Goals Of And Indications For Noninvasive Positive-Pressure Ventilation | 380 | ||
| Acute-Care Setting | 380 | ||
| Acute Exacerbation of Chronic Obstructive Pulmonary Disease | 380 | ||
| Asthma | 381 | ||
| Hypoxemic Respiratory Failure and Acute Respiratory Distress Syndrome | 381 | ||
| Community-Acquired Pneumonia | 381 | ||
| Cardiogenic Pulmonary Edema | 381 | ||
| Chronic-Care Setting | 381 | ||
| Restrictive Thoracic Disorders | 382 | ||
| Chronic Stable Chronic Obstructive Pulmonary Disease | 382 | ||
| Cystic Fibrosis | 382 | ||
| Nocturnal Hypoventilation | 382 | ||
| Other Indications For NIV | 382 | ||
| Facilitation of Weaning from Invasive Ventilation | 382 | ||
| “Do Not Intubate” Patients | 383 | ||
| Patient Selection Criteria | 383 | ||
| Acute-Care Setting | 383 | ||
| Chronic-Care Setting | 384 | ||
| Equipment Selection For NIV | 384 | ||
| Types of Ventilators | 384 | ||
| Pressure-Targeted Ventilators | 384 | ||
| Portable Homecare Ventilators | 386 | ||
| Adult Acute-Care Ventilators | 387 | ||
| Humidification Issues During NIV | 388 | ||
| Patient Interfaces | 388 | ||
| Nasal Interfaces | 389 | ||
| Full (Oronasal) and Total Face Mask and Helmet | 390 | ||
| Oral Interfaces | 391 | ||
| Setup And Preparation For NIV | 392 | ||
| Monitoring And Adjustment Of NIV | 393 | ||
| Aerosol Delivery In NIV | 394 | ||
| Complications Of NIV | 394 | ||
| Weaning from And Discontinuing NIV | 396 | ||
| Patient Care Team Concerns | 396 | ||
| Summary | 397 | ||
| Review Questions | 397 | ||
| References | 398 | ||
| 7 Discontinuation from Ventilation and Long-Term Ventilation | 401 | ||
| 20 Weaning and Discontinuation from Mechanical Ventilation | 402 | ||
| Outline | 402 | ||
| Learning Objectives | 402 | ||
| Key Terms | 402 | ||
| Weaning Techniques | 403 | ||
| Methods of Titrating Ventilator Support During Weaning | 403 | ||
| Synchronized Intermittent Mandatory Ventilation | 404 | ||
| Pressure-Support Ventilation | 405 | ||
| T-Piece Weaning | 405 | ||
| Comparison of Traditional Weaning Methods | 406 | ||
| Closed-Loop Control Modes for Ventilator Discontinuation | 406 | ||
| Automatic Tube Compensation | 406 | ||
| Arguments Against the Use of Automatic Tube Compensation | 407 | ||
| Summary of Automatic Tube Compensation | 407 | ||
| Volume-Targeted Pressure-Support Ventilation | 407 | ||
| Automode and Variable Pressure Support/Variable Pressure Control | 407 | ||
| Mandatory Minute Ventilation | 408 | ||
| Adaptive Support Ventilation | 408 | ||
| Artificial Intelligence Systems | 408 | ||
| Evidence-Based Weaning | 409 | ||
| Evaluation of Clinical Criteria for Weaning | 409 | ||
| Recommendation 1: Pathology of Ventilator Dependence | 409 | ||
| Weaning Criteria | 409 | ||
| Patient Ventilatory Performance and Muscle Strength | 409 | ||
| Measurement of Drive to Breathe | 412 | ||
| Work of Breathing | 413 | ||
| Adequacy of Oxygenation | 413 | ||
| Recommendation 2: Assessment of Readiness for Weaning Using Evaluation Criteria | 413 | ||
| Recommendation 3: Assessment During a Spontaneous Breathing Trial | 413 | ||
| Recommendation 4: Removal of the Artificial Airway | 414 | ||
| Postextubation Difficulties | 415 | ||
| Noninvasive Positive-Pressure Ventilation After Extubation | 416 | ||
| Factors in Weaning Failure | 417 | ||
| Recommendation 5: Spontaneous Breathing Trial Failure | 417 | ||
| Nonrespiratory Factors that may Complicate Weaning | 417 | ||
| Cardiac Factors | 417 | ||
| Acid-Base Factors | 417 | ||
| Metabolic Factors | 417 | ||
| Effect of Pharmacologic Agents | 419 | ||
| Nutritional Status and Exercise | 419 | ||
| Psychological Factors | 419 | ||
| Recommendation 6: Maintaining Ventilation in Patients with Spontaneous Breathing Trial Failure | 420 | ||
| Final Recommendations | 420 | ||
| Recommendation 7: Anesthesia and Sedation Strategies and Protocols | 420 | ||
| Recommendation 8: Weaning Protocols | 420 | ||
| Recommendation 9: Role of Tracheostomy in Weaning | 422 | ||
| Recommendation 10: Long-Term Care Facilities for Patients Requiring Prolonged Ventilation | 422 | ||
| Recommendation 11: Clinician Familiarity with Long-Term Care Facilities | 422 | ||
| Recommendation 12: Weaning in Long-Term Ventilation Units | 422 | ||
| Ethical Dilemma: Withholding and Withdrawing Ventilatory Support | 423 | ||
| Summary | 423 | ||
| Review Questions | 423 | ||
| References | 424 | ||
| 21 Long-Term Ventilation | 428 | ||
| Outline | 428 | ||
| Learning Objectives | 428 | ||
| Key Terms | 428 | ||
| Goals of Long-Term Mechanical Ventilation | 429 | ||
| Sites for Ventilator-Dependent Patients | 430 | ||
| Acute-Care Sites | 430 | ||
| Intermediate-Care Sites | 430 | ||
| Long-Term Care Sites | 430 | ||
| Patient Selection | 430 | ||
| Disease Process and Clinical Stability | 430 | ||
| Psychosocial Factors | 431 | ||
| Financial Considerations | 432 | ||
| Preparation for Discharge to the Home | 432 | ||
| Geographic and Home Assessment | 433 | ||
| Family Education | 433 | ||
| Additional Preparation | 435 | ||
| Follow-Up and Evaluation | 435 | ||
| Adequate Nutrition | 435 | ||
| Family Issues | 435 | ||
| Equipment Selection for Home Ventilation | 436 | ||
| Tracheostomy Tubes | 437 | ||
| Ventilator Selection | 437 | ||
| Examples of Home Care and Transport Ventilators | 437 | ||
| First-generation portable volume ventilators. | 437 | ||
| Second-generation portable ventilators. | 438 | ||
| Complications of Long-Term Positive-Pressure Ventilation | 440 | ||
| Alternatives to Invasive Mechanical Ventilation at Home | 441 | ||
| Noninvasive Positive-Pressure Ventilation | 441 | ||
| Negative-Pressure Ventilation | 441 | ||
| Tank Ventilators/Iron Lungs | 441 | ||
| The Chest Cuirass | 442 | ||
| The Body Suit | 442 | ||
| Additional Noninvasive Devices | 442 | ||
| Diaphragm Pacing | 444 | ||
| Continuous Positive Airway Pressure for Obstructive Sleep Apnea | 444 | ||
| CPAP systems. | 444 | ||
| Potential complications of CPAP. | 445 | ||
| Glossopharyngeal Breathing | 445 | ||
| Expiratory Muscle Aids and Secretion Clearance | 445 | ||
| Assisted Coughing | 446 | ||
| Mechanical Oscillation | 446 | ||
| Mechanical Insufflation-Exsufflation | 446 | ||
| Tracheostomy Tubes, Speaking Valves, And Tracheal Buttons | 447 | ||
| Trachesotomy Tube Selection and Benefits | 447 | ||
| Loss of Speech | 447 | ||
| Speaking with Tracheostomy Tubes During Ventilation | 447 | ||
| Electrically Activated Speaking Devices | 448 | ||
| Speaking Tracheostomy Tubes | 448 | ||
| Tracheostomy Speaking Valves | 448 | ||
| Concerns with Speaking Tubes and Valves | 451 | ||
| Tracheal Buttons and Decannulation | 451 | ||
| Ancillary Equipment and Equipment Cleaning for Home Mechanical Ventilation | 452 | ||
| Disinfection Procedures | 452 | ||
| Ventilator Circuit Disinfection | 452 | ||
| Humidifiers | 452 | ||
| Summary | 453 | ||
| Review Questions | 453 | ||
| References | 455 | ||
| 8 Neonatal and Pediatric Respiratory Support | 459 | ||
| 22 Neonatal and Pediatric Mechanical Ventilation | 460 | ||
| Outline | 460 | ||
| Learning Objectives | 460 | ||
| Key Terms | 460 | ||
| Recognizing the Need for Mechanical Ventilatory Support | 461 | ||
| Clinical Indications for Respiratory Failure | 461 | ||
| Neonate | 461 | ||
| Pediatric | 461 | ||
| Determining Effective Oxygenation and Ventilation | 462 | ||
| Goals of Newborn and Pediatric Ventilatory Support | 462 | ||
| Noninvasive respiratory Support | 462 | ||
| Nasal Continuous Positive Airway Pressure in Neonates | 463 | ||
| Indications and Contraindications | 463 | ||
| Application of Nasal CPAP | 464 | ||
| Complications of CPAP | 466 | ||
| Noninvasive Positive-Pressure Ventilation in Neonates | 466 | ||
| Nasal Intermittent Mandatory Ventilation in Neonates | 467 | ||
| Nasal “Sigh” Positive Airway Pressure in Neonates | 467 | ||
| Noninvasive Nasal High-Frequency Ventilation in Neonates | 467 | ||
| CPAP and BiPAP in Pediatric Patients | 468 | ||
| Conventional Mechanical Ventilation | 469 | ||
| Indications for Ventilatory Support of Neonates | 469 | ||
| Indications for Ventilatory Support of Pediatric Patients | 470 | ||
| The Pediatric Ventilator | 470 | ||
| Pressure-Control Mode | 473 | ||
| Inspiratory Pressure | 474 | ||
| Positive End-Expiratory Pressure | 474 | ||
| Inspiratory Time, Expiratory Time, and Inspiratory-to-Expiratory Ratio | 474 | ||
| Tidal Volume | 477 | ||
| Frequency | 478 | ||
| Mean Airway Pressure | 478 | ||
| Inspired Oxygen Concentration | 478 | ||
| Volume Control Mode | 479 | ||
| Pressure-Support Ventilaton | 479 | ||
| Dual-Controlled Mode | 480 | ||
| Pressure-regulated volume control. | 481 | ||
| Machine volume with volume bracketing. | 481 | ||
| Volume-assured pressure support. | 481 | ||
| Volume guarantee. | 482 | ||
| Volume-Support Ventilation | 482 | ||
| Airway Pressure Release Ventilation | 482 | ||
| Neurally Adjusted Ventilatory Assist | 483 | ||
| Lung-Protective Strategies in Conventional Ventilation | 483 | ||
| High-Frequency Ventilation | 485 | ||
| Indications for High-Frequency Ventilation | 485 | ||
| Contraindications and Complications of High-Frequency Ventilation | 485 | ||
| High-Frequency Ventilation Techniques | 486 | ||
| High-Frequency Positive-Pressure Ventilation | 486 | ||
| High-Frequency Flow Interruption | 486 | ||
| High-Frequency Percussive Ventilation | 486 | ||
| High-Frequency Oscillatory Ventilation | 487 | ||
| High-Frequency Jet Ventilation | 488 | ||
| Physiology of High-Frequency Ventilation | 489 | ||
| Management Strategies for High-Frequency Ventilation | 489 | ||
| Management of High-Frequency Oscillatory Ventilation in Infants | 490 | ||
| Weaning and Extubation | 491 | ||
| Adjunctive Forms of Respiratory Support | 493 | ||
| Surfactant Replacement Therapy | 493 | ||
| Prone Positioning | 494 | ||
| Inhaled Nitric Oxide Therapy | 494 | ||
| Summary | 495 | ||
| Review Questions | 496 | ||
| References | 498 | ||
| 9 Special Applications in Ventilatory Support | 503 | ||
| 23 Special Techniques in Ventilatory Support | 504 | ||
| Outline | 504 | ||
| Learning Objectives | 504 | ||
| Key Terms | 504 | ||
| Airway Pressure-Release Ventilation | 505 | ||
| Other Names | 505 | ||
| ADVANTAGES Of APRV Compared With Conventional Ventilation | 506 | ||
| Preserving Spontaneous Ventilation | 506 | ||
| APRV and Airway Pressures During Spontaneous Breathing | 507 | ||
| Disadvantages | 507 | ||
| Initial Settings | 507 | ||
| Setting High Pressure | 508 | ||
| Setting Low Pressure | 508 | ||
| Setting High Time | 508 | ||
| Setting Low Time | 508 | ||
| Adjusting Ventilation And Oxygenation | 508 | ||
| Discontinuation | 509 | ||
| High-Frequency Oscillatory Ventilation in the Adult | 509 | ||
| Technical Aspects | 510 | ||
| Initial Control Settings | 510 | ||
| Maximum Airway Pressure | 510 | ||
| Amplitude | 511 | ||
| Frequency | 512 | ||
| Inspiratory Time Percent | 512 | ||
| Bias Flow | 512 | ||
| Additional Settings | 512 | ||
| Indication And Exclusion Criteria | 512 | ||
| Monitoring, Assessment, And Adjustment | 513 | ||
| Adjusting Settings To Maintain Arterial Blood Gas Goals | 514 | ||
| Returning To Conventional Ventilation | 515 | ||
| Heliox Therapy and Mechanical Ventilation | 515 | ||
| Gas Flow Through The Airways | 516 | ||
| Heliox In Avoiding Intubation And During Mechanical Ventilation | 516 | ||
| Postextubation Stridor | 517 | ||
| Devices For Delivering Heliox In Spontaneously Breathing Patients | 517 | ||
| Mask Heliox | 517 | ||
| Cost and Gas Consumption During Heliox Therapy | 517 | ||
| Heliox and Aerosol Delivery | 518 | ||
| Manufactured Heliox Delivery System | 518 | ||
| Heliox And Aerosol Delivery During Mechanical Ventilation | 519 | ||
| Heliox with a Mechanical Ventilator | 519 | ||
| Technical Considerations in Heliox Delivery | 521 | ||
| Heliox and NIV | 521 | ||
| Monitoring the Electrical Activity of the Diaphragm and Neurally Adjusted Ventilatory Assist | 522 | ||
| Review Of Neural Control Of Ventilation | 522 | ||
| Diaphragm Electrical Activity Monitoring | 522 | ||
| History of Diaphragm Electrical Activity Monitoring | 522 | ||
| The Edi Catheter: Its Characteristics and Placement | 522 | ||
| Detecting Patient-Ventilator Asynchrony Using the Edi Catheter | 524 | ||
| Using the Edi Waveform to Interpret Ventilator Synchrony | 524 | ||
| Neurally Adjusted Ventilatory Assist | 527 | ||
| Using NAVA Ventilation | 527 | ||
| Alarms and Safety Features in NAVA | 528 | ||
| Results of Initiating NAVA Ventilation | 528 | ||
| Weaning from NAVA | 528 | ||
| Evaluating NAVA | 528 | ||
| Summary | 529 | ||
| Review Questions | 529 | ||
| References | 531 | ||
| Appendix A Answer Key | 534 | ||
| Part 1: Review Questions Answer Key | 534 | ||
| Chapter 1 | 534 | ||
| Basic Terms and Concepts of Mechanical Ventilation | 534 | ||
| Chapter 2 | 534 | ||
| How Ventilators Work | 534 | ||
| Chapter 3 | 534 | ||
| How a Breath is Delivered | 534 | ||
| Chapter 4 | 535 | ||
| Establishing the Need for Mechanical Ventilation | 535 | ||
| Chapter 5 | 535 | ||
| Selecting the Ventilator and the Mode | 535 | ||
| Chapter 6 | 535 | ||
| Initial Ventilator Settings | 535 | ||
| Chapter 7 | 536 | ||
| Final Consideration in Ventilator Setup | 536 | ||
| Chapter 8 | 536 | ||
| Initial Patient Assessment | 536 | ||
| Chapter 9 | 537 | ||
| Ventilator Graphics | 537 | ||
| Chapter 10 | 538 | ||
| Assessment of Respiratory Function | 538 | ||
| Chapter 11 | 538 | ||
| Hemodynamic Monitoring | 538 | ||
| Chapter 12 | 538 | ||
| Methods to Improve Ventilation and Other Techniques in Patient-Ventilator Management | 538 | ||
| Chapter 13 | 538 | ||
| Improving Oxygenation and Management of Acute Respiratory Distress Syndrome | 538 | ||
| Chapter 14 | 539 | ||
| Ventilator-Associated Pneumonia | 539 | ||
| Chapter 15 | 539 | ||
| Sedatives, Analgesics and Paralytics | 539 | ||
| Chapter 16 | 539 | ||
| Extrapulmonary Effects of Mechanical Ventilation | 539 | ||
| Chapter 17 | 539 | ||
| Effects of Positive Pressure Ventilation | 539 | ||
| Chapter 18 | 539 | ||
| Troubleshooting and Problem Solving | 539 | ||
| Chapter 19 | 541 | ||
| Basic Concepts of Noninvasive Positive Pressure Ventilation | 541 | ||
| Chapter 20 | 541 | ||
| Discontinuation and Weaning from Mechanical Ventilation | 541 | ||
| Chapter 21 | 541 | ||
| Long-Term Ventilation | 541 | ||
| Chapter 22 | 541 | ||
| Neonatal and Pediatric Ventilation | 541 | ||
| Chapter 23 | 541 | ||
| Special Techniques in Ventilatory Support | 541 | ||
| Answer Key to Appendix C: Graphing Exercises | 543 | ||
| Answer Key for Problem 1 | 543 | ||
| Part 2: Case Study Answer Key | 542 | ||
| Chapter 1: Basic Terms and Concepts of Mechanical Ventilation | 542 | ||
| Case Study 1-1 | 542 | ||
| Determine Static Compliance (CS) and Airway Resistance (Raw) | 542 | ||
| Chapter 2: How Ventilation Works | 542 | ||
| Case Study 2-1 | 542 | ||
| Ventilator Selection | 542 | ||
| Chapter 3: How a Breath is Delivered | 542 | ||
| Case Study 3-1 | 542 | ||
| Patient Triggering | 542 | ||
| Case Study 3-2 | 542 | ||
| Premature Breath Cycling | 542 | ||
| Chapter 4: Establishing the Need for Mechanical Ventilation | 542 | ||
| Case Study 4-1 | 542 | ||
| Stroke Victim | 542 | ||
| Case Study 4-2 | 542 | ||
| Unexplained Acute Respiratory Failure | 542 | ||
| Case Study 4-3 | 542 | ||
| Ventilation in Neuromuscular Disorders | 542 | ||
| Case Study 4-4 | 542 | ||
| Asthma Case | 542 | ||
| Chapter 5: Selecting the Ventilator and the Mode | 542 | ||
| Case Study 5-1 | 542 | ||
| What Type of Breath Is It? | 542 | ||
| Case Study 5-2 | 544 | ||
| Pressure-Control (PC-CMV) or Volume-Control Ventilation (VC-CMV) | 544 | ||
| Chapter 6: Initial Ventilator Settings | 544 | ||
| Case Study 6-1 | 544 | ||
| Minute Ventilation () Needs | 544 | ||
| Case Study 6-2 | 544 | ||
| Minute Ventilation (), Tidal Volume (VT), and Respiratory Rate | 544 | ||
| Case Study 6-3 | 544 | ||
| Inspiratory: Expiratory Rate (I:E) and Flow | 544 | ||
| Case Study 6-4 | 544 | ||
| Tidal Volume (VT) During Pressure-Control Continuous Mandatory Ventilation (PC-CMV) | 544 | ||
| Case Study 6-5 | 544 | ||
| Inspiratory Flow Termination in Pressure Support Ventilation (PSV) | 544 | ||
| Case Study 6-6 | 544 | ||
| Pressure-Regulated Volume Control (PRVC) | 544 | ||
| Chapter 7: Final Considerations in Ventilator Setup | 544 | ||
| Case Study 7-1 | 544 | ||
| Auto-PEEP and Triggering | 544 | ||
| Case Study 7-2 | 544 | ||
| Key Questions for ARDS Patient | 544 | ||
| Case Study 7-3 | 545 | ||
| Troubleshooting: The Pulse Oximeter | 545 | ||
| Chapter 8: Initial Patient Assessment of the Mechanically Ventilated Patient | 545 | ||
| Case Study 8-1 | 545 | ||
| The Importance of Documentation | 545 | ||
| Case Study 8-2 | 545 | ||
| Circuit Disconnect | 545 | ||
| Case Study 8-3 | 545 | ||
| Cuff Inflation Techniques | 545 | ||
| Case Study 8-4 | 545 | ||
| Patient Assessment Cases | 545 | ||
| Case Study 8-5 | 545 | ||
| Evaluating CS and Raw During Ventilation | 545 | ||
| Chapter 9: Ventilator Graphics | 545 | ||
| Case Study 9-1 | 545 | ||
| Calculation of Pta, CS, and Raw | 545 | ||
| Case Study 9-2 | 545 | ||
| Problem Solving in PC-CMV | 545 | ||
| Chapter 10: Assessment of Respiratory Function | 545 | ||
| Case Study 10-1 | 545 | ||
| Causes of Cyanosis | 545 | ||
| Case Study 10-2 | 546 | ||
| Capnography During Intubation | 546 | ||
| Case Study 10-3 | 546 | ||
| Dead-Space Ventilation | 546 | ||
| Chapter 11: Hemodynamic Monitoring of the Ventilated Patient | 546 | ||
| Case Study 11-1 | 546 | ||
| Evaluation of Pressure Tracing | 546 | ||
| Case Study 11-2 | 546 | ||
| Cardiac Index and Stroke Index | 546 | ||
| Case Study 11-3 | 546 | ||
| Application of the Fick Principle | 546 | ||
| Case Study 11-4 | 546 | ||
| Stroke Work | 546 | ||
| Case Study 11-5 | 546 | ||
| Hemodynamic Monitoring After Open-Heart Surgery | 546 | ||
| Case Study 11-6 | 546 | ||
| Hemodynamic Monitoring—Chest Injury | 546 | ||
| Case Study 11-7 | 546 | ||
| Patient Case—ICU and Hemodynamic Assessment | 546 | ||
| Chapter 12: Methods to Improve Ventilation and Other Techniques in Patient-Ventilator Management | 546 | ||
| Case Study 12-1 | 546 | ||
| Hyperventilation | 546 | ||
| Case Study 12-2 | 546 | ||
| Assessment During Suctioning | 546 | ||
| Case Study 12-3 | 546 | ||
| Evaluation of Bronchodilator Therapy | 546 | ||
| Case Study 12-4 | 546 | ||
| Changing Patient Position | 546 | ||
| Case Study 12-5 | 547 | ||
| Evaluating Fluid Status | 547 | ||
| Chapter 13: Improving Oxygenation and Management of Acute Respiratory Distress Syndrome | 547 | ||
| Case Study 13-1 | 547 | ||
| Patient Case—Myasthenia Gravis | 547 | ||
| Case Study 13-2 | 547 | ||
| Changing FIO2 | 547 | ||
| Case Study 13-3 | 547 | ||
| Problem Solving: Infant CPAP | 547 | ||
| Case Study 13-4 | 547 | ||
| Selecting Optimum PEEP | 547 | ||
| Chapter 14: Ventilator-Associated Pneumonia | 547 | ||
| Case Study 14-1 | 547 | ||
| Patient Case—VAP | 547 | ||
| Case Study 14-2 | 547 | ||
| Patient Care—Methicillin-resistant Staphylococcus aureus | 547 | ||
| Chapter 15: Frequently Used Pharmacological Agents in Ventilated Patients: Sedatives, Analgesics, and Paralytics | 547 | ||
| Case Study 15-1 | 547 | ||
| Patient Case—Discontinuing Lorazepam | 547 | ||
| Case Study 15-2 | 547 | ||
| Patient Case—Agitated Patient | 547 | ||
| Case Study 15-3 | 547 | ||
| Patient Case—Asynchrony | 547 | ||
| Case Study 15-4 | 547 | ||
| Patient Case—Neuromuscular Blocking Agent | 547 | ||
| Chapter 16: Extrapulmonary Effects of Mechanical Ventilation | 547 | ||
| Case Study 16-1 | 547 | ||
| The Effects of Ventilator Changes on Blood Pressure | 547 | ||
| Chapter 17: Effects of Positive-Pressure Ventilation on the Pulmonary System | 548 | ||
| Case Study 17-1 | 548 | ||
| Peak Pressure Alarm Activating | 548 | ||
| Case Study 17-2 | 548 | ||
| Patient Case—Acute Pancreatitis | 548 | ||
| Case Study 17-3 | 548 | ||
| Appropriate Ventilator Changes | 548 | ||
| Case Study 17-4 | 548 | ||
| Difficulty Triggering in a Patient with COPD | 548 | ||
| Chapter 18: Troubleshooting and Problem Solving | 548 | ||
| Case Study 18-1 | 548 | ||
| Evaluating Severe Distress in a Ventilated Patient | 548 | ||
| Case Study 18-2 | 548 | ||
| Evaluating PIP and Pplateau in Volume Control Ventilation | 548 | ||
| Case Study 18-3 | 548 | ||
| Evaluating PIP and Volume in Pressure Control Ventilation | 548 | ||
| Case Study 18-4 | 548 | ||
| Problem Solving Using Ventilator Graphics | 548 | ||
| Case Study 18-5 | 548 | ||
| Evaluating Ventilator Problem | 548 | ||
| Chapter 19: Basic Concepts on Noninvasive Positive Pressure Ventilation | 548 | ||
| Case Study 19-1 | 548 | ||
| Patient Selection for NIV | 548 | ||
| Case Study 19-2 | 549 | ||
| Monitoring and Adjusting NIV | 549 | ||
| Case Study 19-3 | 549 | ||
| Common Complications of NIV | 549 | ||
| Chapter 20: Discontinuation and Weaning From Mechanical Ventilation | 549 | ||
| Case Study 20-1 | 549 | ||
| Evaluation of Weaning Attempt | 549 | ||
| Case Study 20-2 | 549 | ||
| Calculation of Rapid Shallow Breathing Index | 549 | ||
| Case Study 20-3 | 549 | ||
| Failed Weaning Attempt | 549 | ||
| Chapter 21: Long-Term Ventilation | 549 | ||
| Case Study 21-1 | 549 | ||
| Patient Case—Difficulty Weaning | 549 | ||
| Case Study 21-2 | 549 | ||
| Patient Case—Communication Difficulty | 549 | ||
| Chapter 22: Neonatal and Pediatric Ventilation | 549 | ||
| Case Study 22-1 | 549 | ||
| Assessment and Treatment of a Newborn | 549 | ||
| Case Study 22-2 | 550 | ||
| Adjustments to Home Therapy | 550 | ||
| Case Study 22-3 | 550 | ||
| Acute Status Asthmaticus | 550 | ||
| Case Study 22-4 | 550 | ||
| Recommending Changes in Ventilator Settings | 550 | ||
| Case Study 22-5 | 550 | ||
| Evaluation of Volume-Assured Pressure Support | 550 | ||
| Case Study 22-6 | 550 | ||
| Evaluation of Volume Guarantee Dual-Control Mode | 550 | ||
| Case Study 22-7 | 550 | ||
| Interpretation and Response to Monitored Data | 550 | ||
| Case Study 22-8 | 550 | ||
| Patient Case—Acute Respiratory Distress Syndrome Managed with HFO | 550 | ||
| Case Study 22-9 | 550 | ||
| Determining Appropriateness of Nitric Oxide Therapy | 550 | ||
| Chapter 23: Special Techniques in Ventilation | 551 | ||
| Case Study 23-1 | 551 | ||
| Patient Assessment During HFOV | 551 | ||
| Case Study 23-2 | 551 | ||
| Calculating Gas Flows During Heliox Therapy | 551 | ||
| Part 3: Critical Care Concepts Answer Key | 551 | ||
| Chapter 1: Basic Terms and Concepts of Mechanical Ventilation | 551 | ||
| Critical Care Concept 1-1 | 551 | ||
| Calculate Pressure | 551 | ||
| Chapter 2: How Ventilators Work | 551 | ||
| Critical Care Concept 2-1 | 551 | ||
| Open Loop or Closed Loop | 551 | ||
| Chapter 3: How A Breath is Delivered | 551 | ||
| Chapter 4: Establishing the Need for Mechanical Ventilation | 551 | ||
| Chapter 5: Selecting the Ventilator and the Mode | 551 | ||
| Critical Care Concept 5-1 | 551 | ||
| Volume-Controlled Breaths with Changing Lung Characteristics | 551 | ||
| Critical Care Concept 5-2 | 551 | ||
| Pressure-Controlled Breaths with Changing Lung Characteristics | 551 | ||
| Chapter 6: Initial Ventilator Settings | 551 | ||
| Critical Care Concept 6-1 | 551 | ||
| Tidal Volume and Ideal Body Weight | 551 | ||
| Critical Care Concept 6-2 | 551 | ||
| Inspiratory Flow in a Time-Cycled Ventilator | 551 | ||
| Chapter 7: Final Consideration in Ventilator Setup | 551 | ||
| Critical Care Concept 7-1 | 551 | ||
| Changes in Relative Humidity | 551 | ||
| Chapter 8: Initial Patient Assessment of the Mechanically Ventilated Patient | 552 | ||
| Chapter 9: Ventilator Graphics | 552 | ||
| Chapter 10: Assessment of Respiratory Function | 552 | ||
| Critical Care Concept 10-1 | 552 | ||
| Indirect Calorimetry | 552 | ||
| Chapter 11: Hemodynamic Monitoring of the Ventilated Patient | 552 | ||
| Chapter 12: Methods to Improve Ventilation and Other Techniques in Patient-Ventilator Management | 552 | ||
| Chapter 13: Improving Oxygenation and Management of Acute Respiratory Distress Syndrome | 552 | ||
| Chapter 14: Ventilator-Associated Pneumonia | 552 | ||
| Chapter 15: Frequently Used Pharmacologic Agents in Ventilated Patients: Sedatives, Analgesics, and Paralytics | 552 | ||
| Chapter 16: Extrapulmonary Effects of Mechanical Ventilation | 552 | ||
| Critical Care Concept 16-1 | 552 | ||
| Calculating Cardiac Transmural Pressure | 552 | ||
| Chapter 17: Effects of Positive Pressure Ventilation on the Pulmonary System | 552 | ||
| Chapter 18: Troubleshooting and Problem Solving | 552 | ||
| Chapter 19: Basic Concepts of Noninvasive Positive Pressure Ventilation | 552 | ||
| Chapter 20: Discontinuation and Weaning From Mechanical Ventilation | 552 | ||
| Chapter 21: Long-Term Ventilation | 552 | ||
| Chapter 22: Neonatal and Pediatric Ventilation | 552 | ||
| Chapter 23: Special Techniques in Ventilation | 552 | ||
| Appendix B Review of Abnormal Physiological Processes | 553 | ||
| Mismatching of Pulmonary Perfusion and Ventilation | 553 | ||
| Physiological Dead Space and Its Clinical Monitoring | 553 | ||
| Calculation of Mechanical Dead Space Volume Needed to Increase PaCO2 | 554 | ||
| Some Causes of Hypoxemia | 554 | ||
| Shunt | 555 | ||
| Calculation of Shunt | 556 | ||
| Ventilation/Perfusion Abnormalities | 556 | ||
| Diffusion Defects | 557 | ||
| References | 557 | ||
| Appendix C Graphics Exercises | 558 | ||
| Graphing Ventilator Waveforms | 558 | ||
| Problem 1 | 558 | ||
| Changes in Waveforms with Changes in Lung Characteristics | 558 | ||
| Ventilator Working Pressure | 558 | ||
| Constant Flow Volume Ventilation with High Working Pressure | 558 | ||
| Constant Flow Volume Ventilation with Low Working Pressure | 562 | ||
| Glossary | 563 | ||
| Index | 569 | ||
| A | 569 | ||
| B | 571 | ||
| C | 571 | ||
| D | 573 | ||
| E | 574 | ||
| F | 575 | ||
| G | 575 | ||
| H | 575 | ||
| I | 577 | ||
| K | 578 | ||
| L | 578 | ||
| M | 579 | ||
| N | 580 | ||
| O | 581 | ||
| P | 582 | ||
| R | 585 | ||
| S | 586 | ||
| T | 587 | ||
| U | 588 | ||
| V | 588 | ||
| W | 590 | ||
| Y | 591 | ||
| Z | 591 |