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use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” MCGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill Education and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise Dedication For Susan, Terri, Rob, Max, Abby, Lauren, and Matt—who make every day enjoyable D.R.H For my children Robert, Julia, Katie, and Callie, who make it all worthwhile R.M.K Contents Preface Abbreviations Part 1 Principles of Mechanical Ventilation Chapter Physiologic Effects of Mechanical Ventilation Chapter Physiologic Goals of Mechanical Ventilation Chapter Ventilator-Induced Lung Injury Chapter Ventilator-Associated Pneumonia Chapter Ventilator Mode Classification Chapter Traditional Modes of Mechanical Ventilation Chapter Pressure and Volume Ventilation Chapter Advanced Modes of Mechanical Ventilation Chapter Flow Waveforms and I:E Ratios Chapter 10 High Frequency Ventilation Chapter 11 Noninvasive Ventilation Chapter 12 Humidification and the Ventilator Circuit Chapter 13 FIO2, Positive End-Expiratory Pressure, and Mean Airway Pressure Chapter 14 Initial Settings for Mechanical Ventilation Chapter 15 Patient-Ventilator Asynchrony Chapter 16 Ventilator Liberation Part 2 Ventilator Management Chapter 17 Acute Respiratory Distress Syndrome Chapter 18 Obstructive Lung Disease Chapter 19 Chest Trauma Chapter 20 Head Injury Chapter 21 Postoperative Mechanical Ventilation Chapter 22 Neuromuscular Disease Chapter 23 Cardiac Failure Chapter 24 Burns and Inhalation Injury Chapter 25 Bronchopleural Fistula Chapter 26 Drug Overdose Part 3 Monitoring During Mechanical Ventilation Chapter 27 Blood Gases Chapter 28 Pulse Oximetry, Capnography, and Transcutaneous Monitoring Chapter 29 Hemodynamic Monitoring Chapter 30 Basic Pulmonary Mechanics During Mechanical Ventilation Chapter 31 Advanced Pulmonary Mechanics During Mechanical Ventilation Chapter 32 Nutritional Assessment Part 4 Topics Related to Mechanical Ventilation Chapter 33 Airway Management Chapter 34 Airway Clearance Chapter 35 Inhaled Drug Delivery Chapter 36 Emergency Ventilation and Ventilation in a Disaster Chapter 37 Mobilization and Portable Ventilation Chapter 38 Extracorporeal Life Support Index flow, 153-157 mode, 161-162, 162f trigger, 153 interaction and equation of motion, 48 schematic representation, 152f mobilization, 371-372 challenges of, 374 limiting factor, 372 ventilator-associated pneumonia risk, 37 synchrony, 17-18 system checks, 129 PCV+ See Airway pressure-release ventilation (APRV) Peak alveolar pressure, 5 mechanical ventilation, 301-302 Peak inspiratory pressure (PIP), 301-302 pressure ventilation, 62 Pediatrics, ECMO indication for, 381t, 382 Pendelluft, 97 Penetrating chest trauma, 204 Permissive hypercapnia, 272 adverse effects, 14t, 15 bronchopleural fistula, 258 burns and inhalation injury, 251 chest trauma, 207 physiologic effects, 14-16, 14t pH See also Acid-base balance and blood gases, 278 temperature adjustment, 278 Phase variables, 44, 46, 47f criteria to determine, 46f Physiologic effects, mechanical ventilation, 2-10 Physiologic goals, of mechanical ventilation, 13-18 alveolar distending pressure, 13-14 gas exchange targets, 16-17 oxygen toxicity, 16 patient-ventilator synchrony, 13 PEEP, 14 permissive hypercapnia, 14-16 tidal volume, 13 Plateau pressure (Pplat), 301, 302f burns and inhalation injury, 251 chest trauma, 207 neuromuscular disease, 233 overdistention, avoidance in ARDS, 184 ventilator-induced lung injury, avoidance in ARDS, 179 Pleural pressure change, auto-PEEP assessment, 319f Pleural space, transmission of PEEP to, 297 Pneumatic system, 41-42 Pneumonia, 129, 349 PEEP, 141 ventilator-associated See Ventilator-associated pneumonia (VAP) Pneumothorax, 5, 207, 255 chest trauma, 204 tracheobronchial injuries, 204 Portable ventilators, 372-374 characteristics, 373 for critically ill, 372-373 microprocessor controlled, 374 transport equipment and supplies, 373t Positioning, 350 Positive end-expiratory pressure (PEEP), 14, 136-140, 141 ARDS, 140, 185, 318, 318f bronchopleural fistula, 258 burns and inhalation injury, 251 cardiac failure, 239, 240 chest trauma, 206-207 and FIO2 combination in ARDS, 184t heart-lung interactions, 292 hemodynamic measurements, effect on, 297-298 indications, 138-140, 139t initial ventilator settings, 148 intracranial pressure and, 212 level and atelectrauma, 25 neuromuscular disease, 233 open lung approach, ARDS, 180, 182 overcoming auto-PEEP, COPD, 195 physiologic effects, 137, 137t procedures to select, 316t pulmonary mechanics, 137, 138 recruitment maneuvers, 183f, 184-185, 315 stress index, in ARDS, 185 transmission to pleural space, 297 use in spontaneous breathing trial, 169 in ventilator-associated pneumonia prevention, 37 Positive-feedback control, in ventilators, 48 Positive pressure ventilation, 298 active inspiration during, 309, 310f cardiovascular system response, 238, 239t intrathoracic pressure, 2, 238 pulmonary capillary wedge pressure and, 297 shunt, 3 Positive pressure ventilators, 42 Postoperative atelectasis, PEEP, 139 Postoperative patients, 221-226 algorithm for, 223f CPAP, 225 initial ventilator settings, 224t mechanical ventilation, 221-226 NIV, 225 overview, 221 Postpolio syndrome, 230 Postural drainage therapy, 348 Preload, derived measurements, 295 Pressure changes, respiratory cycle, 296-297, 297f Pressure-controlled inverse ratio ventilation (PCIRV), 95 Pressure-controlled ventilation (PCV), 53, 53f, 61-64 adaptive pressure control, 75-78 ARDS, open lung approach, 180 asthma, 196 auto-PEEP, 67, 141 bronchopleural fistula, 257 COPD, 193 drug overdose, 264 end-inspiratory pause, 64-65, 65f flow and flow pattern, 64 flow asynchrony, 154 gas flow delivery pattern, 65 inspiratory flow pattern, 93, 94f, 95 inspiratory time, 66, 67 peak inspiratory pressure and alveolar pressure, 301-302 pressure-controlled CMV (assist/control), 64 transition to controlled ventilation, 67 vs volume-controlled ventilation, 51-52, 62t waveforms, 93-94, 93f airflow, 302f pressure, 309 work-of-breathing, 67 Pressure sores, NIV and, 116 Pressure support ventilation (PSV), 54-55, 56f, 59, 62, 63, 95-96 ARDS, 180 bronchopleural fistula, 258 changes in flow termination criteria, 96, 96f COPD, 195 cycle asynchrony, 160-161, 162f sigh volume, 98, 99f Pressure-supported breath, design characteristics, 63f Pressure transmission to alveolar level, high frequency ventilation, 107 to pleural space, 297, 320-321 Pressure triggering, 44, 47 Pressure-volume curves dynamic, 314f hysteresis, 315f lung volume and PEEP, 315f mechanical ventilation, 312-315 Pressure waveforms, 309, 310f airway volume waveform, 311 Prolonged mechanical ventilation (PMV) chronic critical illness and, 172-173 neuromuscular disease and, 173 Prone positioning, 350 refractory hypoxemia, 186 Proportional-assist ventilation (PAV), 80-82, 81f, 96, 161-162 Pulmonary ARDS, 179 Pulmonary artery cannulation, 293t Pulmonary artery catheters, 294, 295f ARDS, 186 zone 1, signs that catheter is wedged in, 297 Pulmonary artery pressure (PAP), 294 Pulmonary capillary wedge pressure (PCWP), 294, 295 fluid management in ARDS, 298 positive pressure ventilation and, 297 Pulmonary complications, inhalation injury, 245 Pulmonary contusion, chest trauma, 203-204, 207 Pulmonary edema, liberation, left ventricular failure, 240 Pulmonary effects, mechanical ventilation, 3-7 Pulmonary embolism burns and inhalation injury, 251 chest trauma, 207 Pulmonary infection, burns and inhalation injury and, 252 Pulmonary mechanics during mechanical ventilation advanced, 309-323 basic, 301-307 Pulmonary shunt, oxygenation and, 271 Pulmonary time constant, 191t Pulmonary vascular resistance (PVR), 292 positive pressure ventilation, 7 Pulse oximetry, 282-286, 289 accuracy limits, 283 carboxyhemoglobin levels, 251 and hemodynamics, 284-286, 284f-285f in mobilization and ambulation, 372 Pulse pressure variation (PPV), 298, 298f Pumps, ECMO, 379 R Rapid-onset neuromuscular weakness, 228, 230 Rapid-shallow breathing index (RSBI), 168 Rate, initial ventilator settings, 148 Recruitment maneuvers ARDS, 184-185 decremental PEEP trial, 183f Rectangular-wave ventilation, 90 Regurgitation and aspiration, drug overdose, 264-265 Reintubation, 37, 336, 337 Renal effects, mechanical ventilation, 7-8 Resistance, 128, 304-305 lungs, 48 passive humidifiers, 126 Respiration and nutrition, relationship between, 327f Respiratory cycle, pressure changes during, 296-297, 297f Respiratory distress See Acute respiratory distress syndrome (ARDS) Respiratory drive, and respiratory failure, 145 Respiratory dysfunction and central nervous system diseases, 229t and peripheral nervous system diseases, 229t Respiratory elastance and resistance, 48 See also Compliance, lung and chest wall Respiratory failure acute, NIV in, 111, 112t, 113, 118f burns, 245 hypercapnic, 111, 144-145, 145t hypoxemic, 144, 145-146, 146t Respiratory muscle catabolism, 327t dysfunction, chronic pulmonary disease, 190-191 Respiratory quotient and metabolism, relationship between, 326 Respiratory rate, in bronchopulmonary fistula, 258 Respiratory tract inhalation injury, 247 moisture and heat loss, 122 temperature and humidity levels, 124, 124f Retinol binding protein, nutritional status, 328 Reverse-triggered breaths, 153, 156f Rib fractures, 203 Right ventricular stroke work index, 296f Rise time asynchrony, 156 pressure-controlled ventilation, 95, 95f pressure support, 63 S Saline instillation, 346 Scalars, advanced pulmonary mechanics, mechanical ventilation, 309-312 Secretions, clearance of, 339 Sedation, of mechanically ventilated patients, 371 Sedatives drug overdose, 263, 266 effect on ventilator discontinuation, 167 Self-inflating manual ventilators, 362-365, 364t Sellick maneuver, bag-valve-mask ventilation, 364 Sepsis, burns and smoke inhalation, 246 Set point targeting, in ventilators, 47-48 Severe refractory hypoxemia, management in ARDS, 185-186 Shunt, 3-4, 133-134, 134f Sigh volume, 98 Single-circuit ventilators, 42 Single lung transplant, 222, 224, 225 Sleep effects, mechanical ventilation, 8 SmartCare/PS, 78 Smoke inhalation See Inhalation injury Sodium bicarbonate, for permissive hypercapnia, 16 Speaking tracheostomy tube, 340-341 Spinal cord injuries, high, 228 liberation, 233 Spontaneous awakening trial (SAT), for ventilator discontinuation, 167 Spontaneous breathing trials (SBT), 168-169 failed, approaches to, 169, 170 NIV, 111 obstructive lung disease, liberation, 199 PEEP, use in, 169 Starvation, effect of, 326-327 Steam, inhalation injury, 247 Stewart’s approach, acid-base disturbances, 275-276, 276f Strain, lung, 22-23 Stress index in mechanical ventilation, 316, 317f PEEP, 185 Stress ulcers, 8 Stroke volume, derived measurements, 294-295 Strong Ion Difference (SID), 275-276 Suctioning, 345-346, 346t techniques to avoid complications, 346t Super-syringe, pressure-volume curve measurement, 313, 314f Surface burns, 245, 246 Synchronized intermittent mandatory ventilation (SIMV), 51t, 56, 58, 58f asynchrony, 161, 161f pressure waveform, 57f Synchrony, vs comfort and dyspnea, 162 Systemic toxins, inhalation injury, 248 T T-piece trials, spontaneous breathing, 168 Tension pneumothorax, penetrating chest trauma, 204 Thermal injury, inhalational, 247 Thermodilution cardiac output, 294 Thoracic burns, full-thickness circumferential, 246 Thoracic deformities, 145, 230 initial ventilator settings, 233 Thoracic surgery, preexisting pulmonary disease, 221 Thoracic vasculature, injuries, chest trauma, 204 Thyroxine-binding prealbumin, 328 Tidal volume, 4, 13 asynchrony, 156-157 bag-valve manual ventilators, 364t delivered, 127 inspiratory time fraction, relationship to, 66f monitoring in ARDS, 184 pressure-controlled ventilation, 75, 76f waveform, inspiratory and expiratory airways resistance calculation, 305f Time constant, 89-90 Time controller, 43 Total facemask, NIV, 114 Total physiologic dead space fraction, 4 Tracheal injuries, artificial airways, 337 Tracheobronchial injuries, 204 Tracheostomy, 339-341 advantages, 340t neuromuscular disease and chest deformity, 234 Tracheostomy tube speaking valve, 341 types, 340 Transcutaneous PO2 and PCO2, 289 Transdiaphragmatic pressure, 321 Transferrin, nutritional status, 328 Translaryngeal intubation, advantages, 340t Translocation of cells, 26 Transplant recipients, 222 single lung transplant, 224-225 Transpulmonary pressure, 2 effect of stiff chest wall, 246f Transtentorial herniation, brainstem compression, 212 Transthyretin, 328 Trauma See Chest trauma; Head injury Tricyclic antidepressants, 263 Trigger asynchrony, 153 Tube compensation (TC) advanced modes in mechanical ventilation, 82-83 pressure waveforms from trachea and proximal airway, 83f U Unilateral lung disease lateral positioning, 350 single lung transplant, 224-225 Unilateral pulmonary contusion, 207 Upper airway obstruction after extubation, 172, 339-340 inhalation injuries, 247, 249, 252 V mismatch, 134, 135f Venoarterial (VA) ECMO, 378-379, 379f Venous oximetry, 277 Venovenous (VV) ECMO, 378-379, 378f Ventilation alveolar, 273 blood gases and, 272-273 dead space, 272-273 distribution of, 4f gas exchange targets, 17 PaCO2, 272 Ventilator-associated conditions (VACs), 32-33, 33f Ventilator-associated events (VAEs), 32-34 Ventilator-associated pneumonia (VAP), 6, 30-38, 30f, 35f, 129 aspiration and, 31, 31f CDC guidelines, 32-34 early vs late, 32 etiology, 31-32 identification of, 32-34 IVAC, 32-34, 33f-34f NIV, 111 PEEP, 139-140 prevention, 34-37 artificial airway, care, 35-36 bacterial load, 37 bundle, 36t hand hygiene and related precautions, 34-35 noninvasive ventilation, 37 oral hygiene, 37 patient positioning, 37 PEEP, 37 ventilation duration, 37 ventilator circuit, care of, 36 ventilator-associated conditions, 32-33, 33f ventilator-associated events, 32-34 Ventilator circuit, 126-130, 127f See also Barotrauma; Oxygen(O2), toxicity; Volutrauma alarms, 130 humidification, 121-130 leaks, 129 troubleshooting, 129 Ventilator discontinuation assessing readiness for, 165-167 initiating breath, 167 extubation, 171-172 indication for ventilator support, reversal, 165 protocols, 170-171 weaning parameters, 168 Ventilator-induced lung injury (VILI), 5, 6, 21-28, 179 spectrum, 24t types, 21t Ventilator powering system generic block diagram, 42f postoperative patients, 41-42 Ventilator settings ARDS, 180-183, 180t bronchopleural fistula, 257-258 burns and inhalation injury, 249-251 cardiac failure, 240 chest trauma, 205-206 drug overdose, 264, 264t neuromuscular disease, 231, 233 postoperative patients, 222-226 Ventilator waveform manipulation, 348-349 Ventilatory failure, impending, 146 Ventilatory load, excessive, 145 Ventilatory muscles, function, inadequate, 145 Ventilatory pump, 144 Ventilatory support, full vs partial, 58, 59 Visceral protein status, indicators of, 327 Volume and pressure, levels, initial ventilator settings, 147-148, 147t Volume-controlled continuous mandatory ventilation, 54f Volume-controlled ventilation (VCV), 52, 52f, 61 air-trapping and auto-PEEP, 67 airway pressure, 310 asthma, 196 auto-PEEP, 141 bronchopleural fistula, 257 COPD, 193, 195 descending ramp, 90 double triggering, 158 end-inspiratory pause, 64-65, 65f flow and flow pattern, 64 flow asynchrony, 154, 157f gas flow delivery pattern, 65 inspiratory flow waveforms, 311 inspiratory time and air-trapping, 65-67 monitoring, 68 neuromuscular disease, 231 pressure waveforms, 309 transition to controlled ventilation, 67 volume control, 74 vs pressure-controlled ventilation, 51-52, 62t waveforms, 90 work-of-breathing, 67 Volume-controller, 43 Volume of lung unit, rate of change in, 89-90 Volume support (VS), 77, 77f auto-PEEP, 77 AutoMode, 77 Volumetric capnometry, 288-289 Volutrauma, 23-24, 23f W Waveforms flow, 90-96 physiologic effects of manipulations, 97 pressure-controlled ventilation, 93-94, 95 pressure support ventilation, 95-96 pressure waveform with the use of a sigh, 99 Weaning automated, gradual reduction of support and, 170 parameters for, 167-168 Weir method, indirect calorimetry, 329 Work-of-breathing, 67 adaptive support ventilation, 78 auto-PEEP in COPD, 191 Campbell diagram, 321, 321f dual-control modes, 73 estimation, mechanical ventilation, 306 patient vs ventilator, 319 PEEP, 138 proportional-assist ventilation, 81-82 and resistance, 128 ... A thorough understanding of the essentials of mechanical ventilation is requisite for respiratory therapists and critical care physicians A general knowledge of the principles of mechanical ventilation is also required of critical care nurses and... Preface Abbreviations Part 1 Principles of Mechanical Ventilation Chapter Physiologic Effects of Mechanical Ventilation Chapter Physiologic Goals of Mechanical Ventilation Chapter Ventilator-Induced Lung Injury... There have been many advances in the practice of mechanical ventilation over the past 10 years Hence, much of the book is rewritten Like previous editions, the book is divided into four parts Part 1, Principles of Mechanical Ventilation, describes basic principles of mechanical ventilation and then