2016 pilbeam s mechanical ventilation physiological and clinical applications 6th edition

ABBREVIATIONS Δ µ µg µm µV AARC ABG(s) A/C ACBT ADH Ag AgCl AI AIDS ALI ALV anat ANP AOP APRV ARDS ARF ASV ATC ATM ATPD ATPDS ATS auto-PEEP AV AVP BAC BE bilevel PAP BiPAP BP BPD BSA BTPS BUN C C ° C CaO2 C(a- v) O2 CC cc Cc’O2 CD CDC CDH CHF CI CL cm cm H2O CMV CNS CO CO2 COHb COLD COPD CPAP CPG CPP CPPB CPPV CPR CPT CPU CRT Cs CSF CSV CT CT CV CvO2 C v O2 CVP DL change in micromicrogram micrometer microvolt American Association for Respiratory Care arterial blood gas(es) assist/control active cycle of breathing technique antidiuretic hormone silver silver chloride airborne infection isolation acquired immunodeficiency syndrome acute lung injury adaptive lung ventilation anatomic atrial natriuretic peptide apnea of prematurity airway pressure release ventilation acute respiratory distress syndrome acute respiratory failure adaptive support ventilation automatic tube compensation atmospheric pressure ambient temperature and pressure, dry ambient temperature and pressure saturated with water vapor American Thoracic Society unintended positive end-expiratory pressure arteriovenous arginine vasopressin blood alcohol content base excess bilevel positive airway pressure registered trade name for a bilevel PAP device blood pressure bronchopulmonary dysplagia body surface area body temperature and pressure, saturated with water vapor blood urea nitrogen compliance pulmonary-end capillary degrees Celsius arterial content of oxygen arterial-to-mixed venous oxygen content difference closing capacity cubic centimeter oxygen content of the alveolar capillary dynamic characteristic or dynamic compliance Centers for Disease Control and Prevention congenital diaphragmatic hernia congestive heart failure cardiac index lung compliance (also CLung) centimeters centimeters of water pressure controlled (continuous) mandatory mechanical ventilation central nervous system carbon monoxide carbon dioxide carboxyhemoglobin chronic obstructive lung disease chronic obstructive pulmonary disease continuous positive airway pressure Clinical Practice Guideline cerebral perfusion pressure continuous positive-pressure breathing continuous positive-pressure ventilation cardiopulmonary resuscitation chest physical therapy central processing unit cathode ray tube static compliance cerebrospinal fluid continuous spontaneous ventilation computerized tomogram tubing compliance (also Ctubing) closing volume venous oxygen content mixed venous oxygen content central venous pressure diffusing capacity DC DC-CMV DC-CSV DIC DO2 DPAP DPPC Dm DVT E ECG ECCO2R ECLS ECMO Edi EDV EE EEP EIB EPAP ERV est ET EtCO2 F ° F f FDA FEF FEFmax FEFX FETX FEVt FEV1 FEV1/VC FICO2 FIF FIO2 FIVC FRC ft f/VT FVC FVS Gaw g/dL [H+] HAP Hb HCAP HCH HCO3− H2CO3 He He/O2 HFFI HFJV HFO HFOV HFPV HFPPV HFV HHb HMD HME HMEF H2O HR ht Hz IBW I IC ICP ICU ID IDSA I:E discharges, discontinue dual-controlled continuous mandatory ventilation dual-controlled continuous spontaneous ventilation disseminated intravascular coagulation (DIV no longer used) oxygen delivery demand positive airway pressure dipalmitoylphosphatidylcholine diffusing capacity of the alveolar-capillary membrane deep venous thrombosis elastance electrocardiogram extracorporeal carbon dioxide removal extracorporeal life support extracorporeal membrane oxygenation electrical activity of the diaphragm end-diastolic volume energy expenditure end-expiratory pressure exercise-induced bronchospasm (end-)expiratory positive airway pressure expiratory reserve volume estimated endotracheal tube end-tidal CO2 fractional concentration of a gas degrees Fahrenheit respiratory frequency, respiratory rate Food and Drug Administration forced expiratory flow maximal forced expiratory flow achieved during an FVC forced expiratory flow, related to some portion of the FVC curve forced expiratory time for a specified portion of the FVC forced expiratory volume (timed) forced expiratory volume at second (or FEV1/SVC) forced expiratory volume in second over slow vital capacity fractional inspired carbon dioxide forced inspiratory flow fractional inspired oxygen forced inspiratory vital capacity functional residual capacity foot rapid shallow breathing index (frequency divided by tidal volume) forced vital capacity full ventilatory support airway conductance grams per deciliter hydrogen ion concentration hospital-acquired pneumonia hemoglobin healthcare-associated pneumonia hygroscopic condenser humidifier bicarbonate carbonic acid helium helium/oxygen mixture, heliox high-frequency flow interrupter high-frequency jet ventilation high-frequency oscillation high-frequency oscillatory ventilation high-frequency percussive ventilation high-frequency positive-pressure ventilation high-frequency ventilation reduced or deoxygenated hemoglobin hyaline membrane disease heat moisture exchanger heat moisture exchange filter water heart rate height hertz ideal body weight inspired inspiratory capacity intracranial pressure intensive care unit internal diameter Infectious Diseases Society of America inspiratory-to-expiratory ratio ILD IMV iNO IPAP IPPB IPPV IR IRDS IRV IRV ISO IV IVC IVH IVOX kcal kg kg-m kPa L LAP lb LBW LED LFPPVECCO2R LV LVEDP LVEDV LVSW m2 MABP MalvP MAP MAS max mcg MDI MDR mEq/L MEP metHb mg mg% mg/dL MI-E MIF MIP mL MLT mm MMAD mm Hg mmol MMV MOV mPaw - Paw MRI ms MV MVV NaBr NaCl NAVA NBRC NEEP nHFOV NICU NIF NIH NIV nM nm NMBA nmol/L NO NO2 NP NPO NPV NSAIDS nSIMV interstitial lung disease intermittent mandatory ventilation inhaled nitric oxide inspiratory positive airway pressure intermittent positive-pressure breathing intermittent positive-pressure ventilation infrared infant respiratory distress syndrome inverse ratio ventilation inspiratory reserve volume International Standards Organization intravenous inspiratory vital capacity intraventricular hemorrhage intravascular oxygenator kilocalorie kilogram kilogram-meters kilopascal liter left atrial pressure pound low birth weight light emitting diode low-frequency positive-pressure ventilation with extracorporeal carbon dioxide removal left ventricle left ventricular end-diastolic pressure left ventricular end-diastolic volume left ventricular stroke work meters squared mean arterial blood pressure mean alveolar pressure mean arterial pressure meconium aspiration syndrome maximal microgram metered-dose inhaler multidrug-resistant milliequivalents/liter maximum expiratory pressure methemoglobin milligram milligram percent milligrams per deciliter mechanical insufflation-exsufflation maximum inspiratory force minute maximum inspiratory pressure milliliter minimal leak technique millimeter median mass aerodynamic diameter millimeters of mercury millimole mandatory minute ventilation minimal occluding volume mean airway pressure magnetic resonance imaging millisecond mechanical ventilation maximum voluntary ventilation sodium bromide sodium chloride neurally adjusted ventilatory assist National Board of Respiratory Care negative end-expiratory pressure nasal high-frequency oscillatory ventilation neonatal intensive care unit negative inspiratory force (also see MIP and MIF) National Institutes of Health noninvasive positive-pressure ventilation (also NPPV) nanomolar nanometer neuromuscular blocking agent nanomole/liter nitric oxide nitrous oxide nasopharyngeal nothing by mouth negative-pressure ventilation nonsteroidal anti-inflammatory drugs nasal synchronized intermittent mandatory ventilation N-SiPAP O2 O2Hb OH− OHDC OSA P ΔP P50 P100 Pa PA P(A–a)O2 P(A–awo) PACO2 PaCO2 Palv PAO2 PaO2 PaO2/FIO2 PaO2/PAO2 PAOP PAP PAP P(a–et)CO2 PAGE Paug PAV Paw Paw Pawo PAWP PB Pbs PC-CMV PCEF PCIRV PCO2 PC-IMV PC-SIMV PCV PCWP PCWPtm PDA PE PEmax P E CO2 PEEP PEEPE PEEPI PEEPtotal PEFR Pes PetCO2 PFT Pflex Pga Phigh pH PHY PIE PImax Pintrapleural PIO2 PIP PL Plow PLV PM pMDI Pmus nasal positive airway pressure with periodic (sigh) bilevel positive airway pressure breaths or bilevel nasal continuous positive airway pressure oxygen oxygenated hemoglobin hydroxide ions oxyhemoglobin dissociation curve obstructive sleep apnea pressure change in pressure PO2 at which 50% saturation of hemoglobin occurs pressure on inspiration measured at 100 milliseconds arterial pressure pulmonary artery alveolar-to-arterial partial pressure of oxygen pressure gradient from alveolus to airway opening partial pressure of carbon dioxide in the alveoli partial pressure of carbon dioxide in the arteries alveolar pressure partial pressure of oxygen in the alveoli partial pressure of oxygen in the arteries ratio of arterial PO2 to FIO2 ratio of arterial PO2 to alveolar PO2 pulmonary artery occlusion pressure pulmonary artery pressure mean pulmonary artery pressure arterial-to-end-tidal partial pressure of carbon dioxide (also a–et PCO2) perfluorocarbon associated gas exchange pressure augmentation proportional assist ventilation airway pressure mean airway pressure airway opening pressure pulmonary artery wedge pressure barometric pressure pressure at the body’s surface pressure-controlled continuous mandatory ventilation peak cough expiratory flow pressure control inverse ratio ventilation partial pressure of carbon dioxide pressure-controlled intermittent mandatory ventilation Pressure-controlled synchronized intermittent mandatory ventilation pressure control ventilation pulmonary capillary wedge pressure transmural pulmonary capillary wedge pressure patent ductus arteriosus pulmonary embolism maximal expiratory pressure partial pressure of mixed expired carbon dioxide positive end-expiratory pressure extrinsic PEEP (set-PEEP, applied PEEP) intrinsic PEEP (auto-PEEP) total PEEP (the sum of intrinsic and extrinsic PEEP) peak expiratory flow rate esophageal pressure partial pressure of end-tidal carbon dioxide pulmonary function test(ing) pressure at the inflection point of a pressure– volume curve gastric pressure high pressure during APRV relative acidity or alkalinity of a solution permissive hypercapnia pulmonary interstitial edema maximum inspiratory pressure (also MIP, MIF, NIF) intrapleural pressure (also Ppl) partial pressure of inspired oxygen peak inspiratory pressure (also Ppeak) transpulmonary pressure low pressure during APRV partial liquid ventilation mouth pressure pressurized metered-dose inhaler muscle pressure PO2 Ppeak PPHN Ppl Pplateau ppm PPST PPV PRA PRVC PS PSB psi psig Pset PSmax Pst PSV Pta PtcCO2 PtcO2 Ptm Ptr PTSD Ptt P-V PV PVC(s) Pv O2 PVR PVS Pw q2h Q Q Q C′ QT QS / Q t QS R RAM RAP Raw RCP RDS Re REE RI RICU ROM RM RQ RSV RT Rti RV RV/TLC% RVP RVEDP RVEDV RVSW SA SaO2 SBCO2 SCCM S.I SI SIDS SIMV Sine SiPAP SpO2 STPD SV SVC partial pressure of oxygen peak inspiratory pressure (also PIP) primary pulmonary hypertension of the neonate intrapleural pressure plateau pressure parts per million premature pressure-support termination positive-pressure ventilation plasma renin activity pressure regulated volume control pressure support protected specimen brush pounds per square inch pounds per square inch gauge set pressure maximum pressure support static transpulmonary pressure at a specified lung volume pressure support ventilation transairway pressure transcutaneous PCO2 transcutaneous PO2 transmural pressure transrespiratory pressure posttraumatic stress disorder transthoracic pressure (also Pw) pressure–volume pressure ventilation premature ventricular contraction(s) partial pressure of oxygen in mixed venous blood pulmonary vascular resistance partial ventilatory support transthoracic pressure (also Ptt) every two hours blood volume blood flow pulmonary capillary blood volume cardiac output shunt physiologic shunt flow (total venous admixture) resistance (i.e., pressure per unit flow) random access memory right atrial pressure airway resistance respiratory care practitioner respiratory distress syndrome Reynold’s number resting energy expenditure total inspiratory resistance respiratory intensive care unit read-only memory lung recruitment maneuver respiratory quotient respiratory syncytial virus respiratory therapist tissue resistance residual volume residual volume to total lung capacity ratio right ventricular pressure right ventricular end-diastolic pressure right ventricular end-diastolic volume right ventricular stroke work sinoatrial arterial oxygen saturation single breath carbon dioxide curve Society for Critical Care Medicine Système International d’Unités stroke index sudden infant death syndrome synchronized intermittent mandatory ventilation sinusoidal positive airway pressure with periodic (sigh), bilevel positive airway pressure breaths, or bilevel continuous positive airway pressure oxygen saturation measured by pulse oximeter standard temperature and pressure (zero degrees Celsius, 760 mm Hg), dry stroke volume slow vital capacity S v O2 SVN SVR t T TAAA Tc tcCO2 TCT TE TGI TGV TI TI% TID TI/TCT Thigh Tlow TJC TLC TLV TOF torr TTN U UN USN V v V V VE VA VA VAI VALI VAP VAPS VC VCT VC-CMV VC-IMV VCIRV VCO2 VD VD VDanat VDAN VDalv VDmech VD/VT VE VEDV VI VILI VL VLBW VO2 VS VT VTalv VTexp VTinsp vol% V/Q VSV W WOB WOBi wye X X Y yr ZEEP mixed venous oxygen saturation small volume nebulizer systemic vascular resistance time temperature thoracoabdominal aortic aneurysm time constant transcutaneous CO2 total cycle time expiratory time tracheal gas insufflation thoracic gas volume inspiratory time inspiratory time percent three times per day duty cycle time for high pressure delivery in APRV time for low pressure delivery in APRV The Joint Commission total lung capacity total liquid ventilation tetralogy of Fallot measurement of pressure equivalent to mm Hg transient tachypnea of the neonate unit urinary nitrogen ultrasonic nebulizer gas volume venous mixed venous flow expired minute ventilation alveolar ventilation per minute alveolar gas volume ventilator-assisted individuals ventilator-associated lung injury ventilator-associated pneumonia volume-assured pressure support vital capacity volume lost to tubing compressibility volume-controlled continuous mandatory ventilation volume-controlled intermittent mandatory ventilation volume-controlled inverse ratio ventilation carbon dioxide production per minute volume of dead space physiologic dead space ventilation per minute anatomic dead space ventilation per minute volume of anatomic dead space alveolar dead space mechanical dead space dead space-to-tidal volume ratio expired volume ventricular end-diastolic volume inspired volume per minute ventilator-induced lung injury actual lung volume (including conducting airways) very low birth weight oxygen consumption per minute volume support tidal volume alveolar tidal volume expired tidal volume inspired tidal volume volume per 100 mL of blood ventilation/perfusion ratio volume-support ventilation work work of breathing imposed work of breathing wye- or Y-connector any variable mean value connects patient ET to 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Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products  C H A P T E R Mechanical Ventilation Physiological and Clinical Applications  PILBEAM’S Mechanical Ventilation Physiological and Clinical Applications J.M Cairo, PhD, RRT, FAARC Dean of the School of Allied Health Professions Professor of Cardiopulmonary Science, Physiology, and Anesthesiology Louisiana State University Health Sciences Center New Orleans, Louisiana C H A P T E R 3251 Riverport Lane St Louis, Missouri 63043 Pilbeam’s Mechanical Ventilation, Physiological and Clinical Applications, Sixth edition Copyright © 2016 by Elsevier, Inc All rights reserved ISBN: 978-0-323-32009-2 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Previous editions copyrighted 2012, 2006, and 1998 Library of Congress Cataloging-in-Publication Data Cairo, Jimmy M., author   Pilbeam’s mechanical ventilation : physiological and clinical applications / J.M Cairo.—Sixth edition    p ; cm   Mechanical ventilation   ISBN 978-0-323-32009-2 (pbk : alk paper)   I.  Title.  II.  Title: Mechanical ventilation   [DNLM:  1.  Respiration Disorders—therapy.  2.  Respiration, Artificial.  3.  Ventilators, Mechanical WF 145]   RC735.I5   615.8′36—dc23    2015016179 Content Strategist: Sonya Seigafuse Content Development Manager: Billie Sharp Content Development Specialist: Charlene Ketchum Publishing Services Manager: Julie Eddy Project Manager: Sara Alsup Design Direction: Teresa McBryan Cover Designer: Ryan Cook Text Designer: Ryan Cook Printed in the United States of America Last digit is the print number:  9  8  7  6  5  4  3  2  To Palmer Grace Wade For reminding us what is truly important in life  C H A P T E R Contributors Robert M DiBlasi, RRT-NPS, FAARC Seattle Children’s Hospital Seattle, Washington Terry L Forrette, MHS, RRT, FAARC Adjunct Associate Professor of Cardiopulmonary Science LSU Health Sciences Center New Orleans, Louisiana Christine Kearney, BS, RRT-NPS Clinical Supervisor of Respiratory Care Seattle Children’s Hospital Seattle, Washington ANCILLARY CONTRIBUTOR Sandra T Hinski, MS, RRT-NPS Faculty, Respiratory Care Division Gateway Community College Phoenix, Arizona REVIEWERS Allen Barbaro, MS, RRT Department Chairman, Respiratory Care Education St Luke’s College Sioux City, Iowa J Kenneth Le Jeune, MS, RRT, CPFT Program Director, Respiratory Education University of Arkansas Community College at Hope Hope, Arkansas Tim Op’t Holt, EdD, RRT, AE-C, FAARC Professor University of South Alabama Mobile, Alabama Stephen Wehrman, RRT, RPFT, AE-C Professor University of Hawaii Program Director Kapiolani Community College Honolulu, Hawaii Richard Wettstein, MMEd, FAARC Director of Clinical Education University of Texas Health Science Center at San Antonio San Antonio, Texas Mary-Rose Wiesner, BS, BCP, RRT Program Director Department Chair Mt San Antonio College Walnut, California Margaret-Ann Carno, PhD, MBA, CPNP, ABSM, FNAP Assistant Professor of Clinical Nursing and Pediatrics School of Nursing University of Rochester Rochester, New York vii  C H A P T E R Acknowledgments A number of individuals should be recognized for their contributions to this project I wish to offer my sincere gratitude to Sue Pilbeam for her continued support throughout this project and for her many years of service to the Respiratory Care profession I also wish to thank Terry Forrette, MHS, RRT, FAARC, for authoring the chapter on Ventilator Graphics; Rob DiBlasi, RRT-NPS, FAARC, and Christine Kearney, BS, RRT-NPS, who authored the chapter on Neonatal and Pediatric Ventilation; Theresa Gramlich, MS, RRT, for her contributions in earlier editions of this text to the chapters on Noninvasive Positive Pressure Ventilation and Long-Term Ventilation; Paul Barraza, RCP, RRT, for his contributions to the content of the chapter on Special Techniques in Ventilatory Support I also wish to thank Sandra Hinski, MS, RRT-NPS, for authoring the ancillaries that accompany this text, and Amanda Dexter, MS, RRT, and Gary Milne, BS, RRT, for their suggestions related to ventilator graphics As in previous editions, I want to express my sincere appreciation to all of the Respiratory Therapy educators and students who provided valuable suggestions and comments during the course of writing and editing the sixth edition of Pilbeam’s Mechanical Ventilation I would like to offer special thanks for the guidance provided by the staff of Elsevier throughout this project, particularly Content Development Strategist, Sonya Seigafuse; Content Development Manager, Billie Sharp; Content Development Specialist, Charlene Ketchum; Project Manager, Sara Alsup; and Publishing Services Manager, Julie Eddy Their dedication to this project has been immensely helpful and I feel fortunate to have had the opportunity to work with such a professional group My wife, Rhonda, has provided loving support for me and for all of our family throughout the preparation of this edition Her gift of unconditional love and encouragement to our family inspires me every day ix INDEX Inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP), 40f insufficient, 379 presence of, 39f settings of, 452 Inspiratory pressure, 80, 457 Inspiratory pressure-volume curve, 264f Inspiratory rise time, control, sloping or ramping, 156, 156f Inspiratory time (TI), 62b, 457-460 determination of, 86-87 reduction of, 123 tidal volume and, interrelation of, 86b time constants and, Inspiratory time percentage (TI%), 494 Inspiratory-to-expiratory ratio, 457-460 calculation of, 86 case study on, 87b expression of, 86 indicator for, alarms and, 351 inverse, 86 tidal volume and, relationship of, 85-87 Inspiratory waveform control, overview of, 30, 31f ventilator maintenance of, 30f Inspiratory WOB, 325 Inspired air, carbon dioxide (absence), 167 Inspired oxygen concentration, 461-462 Inspired tidal volume (VTinsp), 127f InSURE, 446-447 Integrated ventilator, 155, 155f Intensive care unit (ICU) in acute care sites, 415 hemodynamic assessment, case study, 203b paralytics, usage, 300b Intensive care unit (ICU) ventilators, 17 built-in oxygen analyzers, 242 control variables, availability, 81 end-expiratory pause buttons, 326 oxygen analyzers and, 122 Intentional iatrogenic hyperventilation, 214 Interface, establishment of, 105 Intermediate care sites, 415 Intermittent abdominal pressure ventilator, 428-429 Intermittent mandatory ventilation (IMV), 67-69, 309f, 389-390 advantages, risks and disadvantages of, 70t differences in, 68f periodic volume/pressure-targeted breaths in, 67 synchronized, 69b system, for home use, 422 use of, successful, 69b Intermittent positive-pressure breathing (IPPB), 17 history of, 65 use of mask or mouthpiece in, 365 Intermittent positive-pressure ventilation (IPPV), 365 Internal maximum safety pressure, 35 Internal pneumatic circuit, 20 Internal respiration, Interstitial emphysema, development of, 317f Intracranial pressure effects of mechanical ventilation on, 310f increased in, 46 Intracranial pressure (ICP) elevated, 253-254 increased, 110 reduction in, 65 Intrapleural pressure (Ppl), 3, 3f, 197 positive-pressure ventilation and, 305f spontaneous inspiration and, 305, 305f Intrapulmonary pressure, 3, 3f, 12 Intrapulmonary shunts, occurrence, 201 Intrathoracic pressures increased, 381 positive-pressure ventilation and, 305, 305f Intravascular line, fever, 192 Intravascular volume, cardiovascular assessment on, 475 Intraventricular hemorrhage, 470 Intrinsic PEEP, 11, 325 definition of, 99b tidal volume and, 83-84 Intubated patient, resistance values for, 7b Intubation avoidance, heliox, 498, 498b capnography, usage (case study), 170b without ventilation, 53 Invasive mechanical ventilation clinical indications for, 453b home alternatives to, 426-430 indications for, 51b switching to, 379b Invasive positive-pressure ventilation (IPPV), 47 selecting patient interface for, 59-60 tracheostomy tube for, 416 Invasive vascular monitoring system, 190 catheter connection, 190f Invasive ventilation alternatives to, 51-53 change, 53b indication of, 53 indicator for, 51b tracheostomy as, 368 weaning from, facilitation of, 368-369 Inverse I:E ratios, 86 ventilation, 467 Inverse-ratio alarm, 351, 353f-356f Inverse ratio ventilation (IRV), 243b Inverse ratios, 86 IPAP see Inspiratory positive airway pressure (IPAP) Iron lungs, 9, 365, 426-427 Isothermic saturation boundary (ISB), 101 position, 101f J Jejunostomy tube, 420 Jet mixing, 473 K Kidney, function of, arterial blood gases and, 311 Kinetic therapy, 290 Klebsiella pneumoniae, 281 L Laminar flow, 498 Laryngeal cough reflex (depression), narcotics and, 228 Laryngeal injury, from long-term ventilation, 425b Larynx, damage to, 335b-336b Late-onset pneumonia, 280 Leaks, 346-347, 351 checks for, 347 559 Left ventricular dysfunction PEEP effects in, 114b positive pressure ventilation and, 307, 307b Left ventricular end-diastolic pressure (LVEDP), 188 right ventricular (RV) dilation and, 305-306 Left ventricular function, altered, 305-306 Left ventricular stroke work, calculation, 201-202 Left ventricular stroke work index (LVSWI), 201-202 Length tension relationship, 188 Light-emitting diode (LED) technology, advances in, 164 Limit variable, 33-35 Linear drive piston, 24b, 24f Lips, damage to, 335b-336b Liver function, mechanical ventilation effects on, 312 Long-term acute care hospitals, 415 Long-term care facilities clinician familiarity with, 407 weaning goals in, 407 Long-term care sites, 415 Long-term mechanical ventilation (LTMV), 414 goals of, 414 medical conditions appropriate for, 416b patient groups requiring, 416b Long-term positive-pressure ventilation, complications of, 425-426 Long-term ventilation, 413-442 airway complications of, 425b discharge and plan, components of, 421b preparation for, 417-420, 417b family education in, 418-420 financial considerations with, 417 follow-up and evaluation for, 420-421 geographic and home assessment for, 418 preparation for, 420 psychosocial factors in, 416 units, weaning in, 395b, 407-408 Long-term ventilator-assisted patients, ACCP definition of, 414b Long-term ventilatory support, alternative sites for, 407b Loops, normal, 146-147 Lorazepam (Ativan), 296-297 adverse drug interactions of, 297 discontinuation, case study, 297b Low birth weight (LBW) neonates, 452 VT target in, 468-469 Low cuff pressure, 132-133 Low-flow (quasi-static) technique, 264 Low lung volume, drawing, 260f Low PEEP, 245 Low PEEP/CPAP alarms, 350 Low perfusion states, pulse oximeter, 163 Low pressure, setting, 490 Low-pressure alarm, 127, 348 common causes of, 349b setting of, 103 Low-source gas alarms alert, 103 silencing, 103b Low-source gas pressure alarm, 351 Low time, setting, 490 Low-volume/high-pressure cuff, 132f LP10, 422 ventilator internal circuit, 423f 560 INDEX LTMV see Long-term mechanical ventilation (LTMV) LTV 1000 flow on, 88b ventilator, 373f CareFusion, 424f Lung injury measures, 261b mechanical ventilation for, 316-321 from overdistention, 318 ventilator-associated versus ventilatorinduced, 316, 316b Lung-protective strategies, 261-262, 262b in conventional ventilation, 467-469 for neonatal lung disorders, 468t Lung recruitment case report, 269b chest wall compliance on, effects of, 267-268 function of, 265-266 patient evaluation for, 262-263 potential complications during, 268 use of, success, 104-105 Lung units, fast, 8-9 filling of, 8f slow, 8-9 Lungs ARDS, inspiratory pressure-volume curve in, 267f characteristics of, 5-7 change in, 62b in patient, 62b collapse, pneumothorax and, 317 compliance, 5-6, 5b effects of, 306-307 positive-pressure breath volume, 113f disease, acute phase of, 468 electron micrograph of, 320f focal obstruction of, 470 histology of, under normal conditions, 258f intrapleural pressures and, 305, 305f mechanics, negative-pressure ventilation and, 10f nondependent position of, 273f ventilation to, 321-322, 322f normal, vs ARDS, 260-261 overdistention of, 254b, 478-479 perfusion of, 168-170, 253f pressure, 3, 3f pressure-volume curves, 138f pressures and gradients, definition of, 2-4, 3t protection of, PEEP and, 321 recruitment, 495b regions of, ARDS and, 253f resistance, 6-7 tissue involvement, 45b ventilation, 253f model of, 27-28 volume increase in, 44b volume of, effect of, 260f volutrauma of, 478-479 West’s zones of, 194t LVEDP see Left ventricular end-diastolic pressure (LVEDP) M Machine breaths, 68b Machine-triggered breath types, during N-IMV, 450 Malignant hyperthermia, 300 Malnutrition, mechanical ventilation and, 312, 312b Mandatory breath, 40-41, 60, 60b delivery, patient effort, 348f Mandatory minute ventilation (MMV), 18, 73, 389 advantages of, 393b description of, 393 as weaning technique, clinical studies on, 393 Manometer aneroid, 177 usage of, 11 Manual ventilation, 105 Maquet Servo-i ventilator, 89 MAS see Meconium aspiration syndrome (MAS) Masimo Signal Extraction Technology (SET), pulse oximeter, 163 Mask CPAP, 244 complications associated with, 382t, 430t Mask discomfort, 380 Mask heliox, 499 Mask pressure, 2, 3f Mask systems, aspects of, 499 Maximum airway pressure (mPaw), 492-493 establishment of, 493 wide swings in, 492b Maximum expiratory pressure (MEP), 182 Maximum inspiratory pressure (MIP), 48-49 bedside measurement of, 49b measurement of, 182 alternative technique for, 49b device for, 48f use of, 46 Maximum pressure limit, 66 Maximum safety pressure, 35 McKhann, Charles, 365 MDI see Metered-dose inhaler (MDI) Mean airway pressure (Paw ), 125, 180, 461 adjustment of, 242 calculation of, method for, 243b concerns about, 88 illustration of, 243f PaO2 and, 307-308 selection of, 242-243 Mean arterial pressure (MAP), 195-196 increased, 218 Mean intracranial pressure (MICP), increased, 218 Mean left atrial pressure, 201 Mean pulmonary artery pressure (MPAP), 201-202 Measured variables, 179 clinical applications, 179-183 Mechanical dead space (VDmech), 124 addition, 124, 124b considerations, 85 definition of, 85 volume, measurement of, 124b Mechanical insufflation-exsufflation, 430-431 Mechanical insufflator-exsufflator, 431f Mechanically ventilated patients acute care facility transport, 233-234 anesthetic agents, usage, 299b malnourishment, effects of, 312b management of sudden severe respiratory distress in, 344b neuroleptics, usage, 299b Mechanically ventilated patients (Continued) nosocomial pneumonias, risk reduction methods of, 287b opioids, usage, 299b sedatives, usage, 299b Mechanical oscillation, 430 Mechanical positive-pressure breath, airway pressure graph, 12f Mechanical ventilation accidental disconnections, 334b acute and chronic complications of, 425f adults and children, artificial airways, endotracheal suctioning (AARC clinical practice guidelines), 221b airway clearance during, 216-230 alarm levels during, 103b capnography/capnometry during, 168b cerebral perfusion and, 310-311, 310f clinical objectives of, 44b complications of, 334b minimization of, 307-310 conventional, 452-469 criteria overview for, 51 development of, 65 discontinuation from, 387-412 esophageal pressure curves in, 506f establishing need for, 43-57 events during, 103b extrapulmonary effects of, 304-314 flow in, 506f heliox delivery during, 501-503 indications for, 108b indirect calorimetry during, 176b initial connection (first 30 minutes), 122-124 initiation of, ethical considerations for, 53 injury during, volutrauma and, 317-318 institution of, standard criteria for, 51b intracranial pressure and, 310-311, 310f intubation avoidance, heliox and, 498, 498b lung injury with, 316-321 measurements, 177-178 medication administration protocol nebulizers, 226b metabolic acid-base imbalances and, 324 metabolic acid-base status in, 323-324 mode of, 197 neonatal and pediatric, 443-485 nutritional complications during, 312-313 physician’s orders for, 119b physiological effects of, minimization of, 307-310 physiological objectives of, 44b physiological terms and concepts, 2-9 pMDIs during, usage, 224 potential mechanical failures with, 333b pressure in, 506f pressure-volume curves, 137f renal effects of, 311 impaired, implications of, 311 respiratory status in, 323-324 sudden respiratory distress causes of, 343b management of, 344b SVN usage, 224, 224b terms used in, 9-12 types of, 9-11 weaning from, 387-412 work of breathing, reduction of, steps for, 328-333 INDEX Mechanical ventilators, 501 connections of, 326f and equipment, 422b spontaneous CPAP with, 245 Mechanical ventilatory support, 47t recognizing need for, 444-445 Meconium aspiration syndrome (MAS), 446, 457 Medically stable, term, definition of, 370 Medication administration protocol nebulizers, 226b Men, ideal body weight for, calculating, 83b Mental status, assessment of, 107 MEP see Maximum expiratory pressure (MEP) Metabolic acid-base imbalances, mechanical ventilation and, 324 Metabolic acid-base status, in mechanical ventilation, 323-324 Metabolic acidosis, 212 blood chemistry in, 324t respiratory alkalosis, combined (clinical scenario), 213b Metabolic alkalosis, 213 acid loss and, 324 blood chemistry in, 324t Metabolic carts/monitors, 174-175 Metabolic disturbances, clinical scenario, 213b Metabolic factors, in respiratory failure, 396b Metabolic measurements, 174-177 clinical applications of, 175-177, 177b Metabolic monitoring system, major components, 175f Metabolic rate, 81 factors, 176 Metabolism, increased, 214 clinical scenario, 214b Metered-dose inhaler (MDI), 500 use of, 102 ventilator circuit adaptation, 223f Methemoglobin (MetHb), 163 as types of hemoglobin, 162f Methemoglobinemia, 479 Methicillin-resistant Staphylococcus aureus, patient case of, 285b MICP see Mean intracranial pressure (MICP) Microprocessor-controlled ventilators, 123 Microprocessors, 17 random access memory (RAM), usage of, 17-18 read-only memory (ROM), updating, 17-18 usage, ventilators controlled by, waveform display capability of, 30 Midazolam, 296, 296b Minimal sedation, 295b Minimum leak techniques, 128b Minimum minute ventilation, 73 Minimum occlusion techniques, 128b Minimum PEEP, 245 Minute ventilation ( VE) case study, 83b constant, 74t demands in, reduction of, 333 determining, 81b display of, 123 improvement of, 491 increase in, 353f-356f Minute ventilation ( VE) (Continued) measurement, respirometer technique for, 123b needs, case study, 82b reductions in, 46 respiratory rate and, 49-50 setting of, 81-89 special considerations on, 89-90 MIP see Maximum inspiratory pressure (MIP) Mixed acid-base disturbances, 213 Mixed-mode ventilation, 456 Mixed venous oxygen saturation, 200, 251-252 Mixed venous oxygen tension, 251-252 Mode, worksheet for reviewing, 76f-77f Mode asynchrony, 332 Moderate sedation (conscious sedation), 295b Monitoring equipment, 233b Morphine, 298 effects of, 298 Motion, production of, energy requirement of, 28 Motor nerve damage, 46 Mouth care, 134 Mouth pressure (PM), 2, 3f Mouthpiece headgear or straps, requirement (absence), 377 interface, 368 MPAP see Mean pulmonary artery pressure (MPAP) Multidrug-resistant (MDR) infections, risk factors for, 282b Multidrug-resistant (MDR) microorganisms, 281, 281b Multidrug-resistant (MDR) pathogens, development of, risks for, 287t Multiple organ dysfunction syndrome, 259, 320 Multisystem organ failure, 259 Muscle dysfunction, 46 Muscle function, impaired, 45b Muscle strength, 394-397 Muscles, respiratory, inactivity of, 28 Myasthenia gravis case study, 240b initial ventilator settings, 110 Myocardial function, 129 Myocardial ischemia, borderline, 105 N Nail polish, pulse oximeter impact on, 163 Naloxone hydrochloride (Narcan), 53 Nasal CPAP, 244 application of, 447-449 indications and contraindications for, 446-447, 446b in neonates, 445-446, 448b usage, 499 Nasal headgear, disposable, 375f Nasal high-frequency ventilation, in neonates, 450-451 Nasal interfaces, 374-377 Nasal intermittent mandatory ventilation (nasal IMV), in neonates, 450 Nasal mask disadvantages of, 374 disposable, 375f fitting of, 375f indications for CPAP via, 446b meeting criteria for, 416 problems with, 380 561 Nasal mini-mask, 375 and headgear, 376f Nasal passages, damage to, 335b-336b Nasal pillows, 375 and headgear, 376f use of, 380 Nasal prongs fit of, 447 indications for CPAP via, 446b usage, 449b Nasal “sigh” positive airway pressure, in neonates, 448f, 450 Nasopharyngeal injury, from long-term ventilation, 425b Nasopharyngeal tube indications for CPAP via, 446b usage, 449b NAVA see Neurally adjusted ventilatory assist (NAVA) Nebulization, provided by ventilator, 225 Nebulizers impairment, 357-358 usage, 226 protocol, 226b NEEP see Negative end-expiratory pressure (NEEP) Negative end-expiratory pressure (NEEP), 37, 38f advocacy for, 38 subambient pressure and, 38-39, 38f Negative inspiratory force (NIF), 48, 397 Negative-pressure ventilation (NPV), 4, 426-427 airtight garments for, 428f cuirass shell for, 427f lung mechanics after, 10f use of, 365 rarely, 109 Negative-pressure ventilators, 18 use of, 10 Neonatal lung disorders, lung-protective ventilation strategies for, 468t Neonatal ventilator advancement in, 455 circuit, schematic for, 454f features of, 455b Neonates, 444 cuffless ETs in, use of, 460 data of, interpretation and response to, case study on, 469b extubation in, 447, 475-478 graphical waveform in, 456f heart rates of, 195 HFOV management in, 475 high-frequency ventilation for, 469-475 INO therapy for, 479 invasive mechanical ventilation in, clinical indications for, 453b management of, with respiratory failure, 452 nasal CPAP in, 446-449, 448b application of, 447-449 indications and contraindications for, 446-447, 446b nasal intermittent mandatory ventilation in, 450 nasal “sigh” positive airway pressure in, 448f, 450 noninvasive nasal high-frequency ventilation in, 450-451 noninvasive positive-pressure ventilation in, 449-451 oxygenation and ventilation in, determining, 445 562 INDEX Neonates (Continued) patient-triggered pressure-controlled intermittent mandatory ventilation in, 456f PEEP in, 457 prone positioning of, 479 prophylactic therapy for, 478 rescue therapy for, 478 respiratory distress in, 444, 445f magnitude assessment of, Silverman Score for, 445f respiratory support for, adjunctive forms of, 478-479 TCPL/IMV asynchrony and, 454 ventilators for, features of, 454b ventilatory support for, indications for, 452 weaning in, 475-478 Neural control, review of, 504 Neurally adjusted ventilatory assist (NAVA), 467, 507-510 alarms in, 509-510 breath, inspiration during, 509 development, motivation, 508 electrical activity, monitoring of, 503-511 evaluation of, 510 level, accidental setting, 509 monitoring of, 503-511 safety features in, 509-510 ventilation initiation, results, 510 Servo-i ventilator, main screen, 509f usage, 508-509 weaning from, 510 Neuroleptics, 297, 297b usage, in mechanically ventilated patients, 299b Neurologic factors, in respiratory failure, 396b Neuromuscular blockade, monitoring of, 300 accomplishment of, 300 Neuromuscular blocking agents (NMBAs), 300b administration, SCCM recommendation, 300 case study, 301b classes of, availability of, 299 withdrawal, prolonged paralysis (reasons), 404 Neuromuscular disorders, 45b, 46-47, 109-110 clinical scenario, 110b drugs and, 46 long-term mechanical ventilation and, 416b myasthenia gravis, initial ventilator settings, 110 patient guidelines, 110 ventilation in (case study), 47b Newborn assessment and treatment of, case study on, 451b CPAP in, indications for, 446b pediatric ventilatory support goals for, 445 physical examination of, abnormalities on, 446 transient tachypnea of, 446 Nitric oxide exhaled levels, factors, 172b monitoring, 172 Nitric oxide (Continued) therapy, determining appropriateness of, case study on, 479b NIV see Noninvasive ventilation (NIV) NMBAs see Neuromuscular blocking agents (NMBAs) Nocturnal hypoventilation, 368, 368b Nonbronchoscopic techniques, description of, 285 Nondependent lung, ventilation to, 321-322, 322f Nondepolarizing agents, 299-301 Nonexistent cuff pressure, 132-133 Noninvasive devices, 427-429 Noninvasive nasal continuous positive airway pressure, in neonates, 446-449 Noninvasive positive-pressure ventilation, 52-53, 426 adjustment of, 378-380 case study, 379b advantages and disadvantages of, 60b aerosol delivery in, 380 factors affecting, 380b after extubation, 401 basic concepts of, 364-386 bilevel PAP and, 93 change from, to invasive ventilation, 53b clinical benefits of, 366b complications of, 380-381 case study, 380b contraindications for, 52b discontinuation of, 381-382 disorder management with, 60b equipment selection for, 370-377 exclusion criteria for, 369b expiratory positive airway pressure levels for, 487-488 goals of, 366-368 heliox and, 503 humidification issues during, 373-374 importance of, 43 indications for, 52b, 366-368 in acute respiratory failure, 369t in chronic disorders, 371t initiation of, steps for, 378b instituting, criteria for, 401b interfaces in, advantages and disadvantages of, 374t monitoring of, 378-380 case study, 379b nasal mask for, meeting criteria for, 416 nebulizers, usage, 226 in neonates, 449-451 patient selection for, case study on, 379b preparation for, 378 selecting patient interface for, 59 selection criteria for, list of, 369t, 371t setup for, 378 success predictors of, 378b symptoms for, list of, 369t, 371t termination of, criteria for, 379b therapy, complications associated with, 382t, 430t weaning from, 381-382 Noninvasive respiratory support, 445-452 Noninvasive ventilation (NIV), 287 clinical benefits of, 366b definition of, 364 face or nasal mask, fitting, 105 techniques of, 365-366 Nosocomial pneumonia pathogenic organisms from, 281b risk, reduction methods of, 287b NPV see Negative-pressure ventilation (NPV) Numeric intensity scale, 232f Nurse-driven protocols, 405 Nutrition, adequacy of, 420 Nutritional status, 404 assessment of, 312b O Obstructed expiratory valve, 357 Obstructive sleep apnea (OSA), 365-366 continuous positive airway pressure for, 429-430 therapy for, 368 Occlusion pressure measurements, 183 Occult PEEP, 325 Oliguria, 311 Open-heart surgery, hemodynamic monitoring (case study), 202b Open-loop systems, 18, 19b, 20f Open reservoir, use of, 391f Open suctioning technique, 216 Operational verification procedure (OVP), 119 Operator settings, incompatible with machine parameters, 351 Opioids, 298 pharmacologic action of, 298 side effects of, 298, 298b reversal of, 298 usage, in mechanically ventilated patients, 299b Optical shunting, 163 Optimal lung volume reaching, 474 strategy flow chart for, 476f Optimum PEEP, 245 establishment of, 241-255 selection of, 246-252 case study, 252b study of, 246-252 performing of, 249 Oral cavity, examination of, 344 Oral interfaces, 377 complications associated with, 381 Oral mouthseal, 378f Oronasal mask, 377f Oropharyngeal decontamination, 290 Oropharynx, damage to, 335b-336b OSA see Obstructive sleep apnea (OSA) Oscillator, sinusoidal waveform generation by, 492f Overdistention, 254b, 316, 318 lung injury from, 318 pressure-volume curve for, 319f pressure-volume loop and, 251f, 457f protection from, chest-wall compliance and, 318b Overinflation, 91, 354 OVP see Operational verification procedure (OVP) Oxygen administration equipment for, 422b analyzers, 122 calculation of, 199-200 concentration of, inspired, 461-462 delivery, 200, 200b open reservoir to enhance, 391f to tissues, basics of, 241-243 desaturation of, 368 flow rates of, higher, 372 toxicity of, 327 pulmonary changes associated with, 327b INDEX Oxygenation, 109 adequacy of, 398 adjustment of, 490-491 basics of, 241-255 calculation of, equations for, 241b continuous monitoring of, 46 data, 249f determination of, 445 evaluation of, measures and values used in, 241t failure of, 50 goal for, 496 during HFOV, 496 improvement, 239-279 inadequate, 347 in prone positioning, potential mechanisms of, 271 Oxygen saturation measured by pulse oximetry (SpO2), 107 range of, 119 in ventilator patients, evaluation of, 241-242 Oxygen saturation of arterial blood (SaO2), 199-200 Oxygen therapy, hazards of, mechanical ventilation and, 327-328 Oxyhemoglobin (O2Hb), 163 dissociation curve for arterial blood, 164f right shift, acidosis and, 323 example of, 162, 162f percentage of, 162 P PaCO2 see Arterial partial pressure of carbon dioxide (PaCO2) Palv see Alveolar pressure (Palv) Pancuronium (Pavulon), 300-301 PaO2 see Arterial partial pressure of oxygen (PaO2) PAOP see Pulmonary artery occlusion pressure (PAOP) Paradoxical breathing, 47, 130 Paralytic disorders, 45b Paralytic drugs, 45b Paralytics, 294-303, 299b usage of, 300b Parenchymal lung disease, 70-72 Partial pressure of oxygen in arterial blood (PaO2) mPaw and, 492 Partial ventilatory support (PVS), 60 Passive humidifiers, placement of, 102b Passy-Muir speaking valves (PMVs), 434f Passy-Muir valve, 434 patient’s experience with, clinical scenario on, 435b Patent airway, maintenance of, 46 Patent ductus arteriosus, 447 Patient care team, concerns of, 382 Patient-centered mechanical ventilation, 232-233 Patient circuit, 20 additional components of, 23f adjuncts used with, 23b basic elements of, 22b, 23f Patient-circuit leaks, during PSV, 357 Patient effort, 62b control of, 32 Patient-triggered modes, problems with, 65-66 Patient-triggered ventilation, 455 Patient triggering, 32-33, 32f case study for, 33b control of, 33 inadequate sensitivity setting for, 353 Patient-ventilator asynchrony, 61-62, 343-344, 344b, 355 assessment of, 152, 154f detection of, using Edi catheter, 506-507 examples of, 347-348 Patient-ventilator synchrony, 329-333 improvement of, 455 Patient-ventilator system, documentation of, 119-122 Patients agitation, case study, 299b appearance of, PEEP and, 250 assessment, case study, 130b breath sounds, 107 changing position, 272b chest radiograph, 107-108 circuit, accidental disconnections, 334b clinical stability of, 415-416 closed head injury guidelines, 111 comfort, 232 indication of, 379b confusion and delirium, 232 cough, 107 evaluation of, clinical factors in, 396b history and diagnosis of, 46-47 information of, 119 initial assessment, 107 initial ventilator settings for, 106 interfaces, 374 selection of, 59-60 locking out, 65 lung characteristics of, 62b management techniques, 230-234 mental status, 107 neuromuscular disorder guidelines, 110 physical appearance, 107 preparation of, 105 problems related to, 344-346 protection for, 342-343 respiratory distress in, recognition of, 44, 44f safety, 231-232 selection, 415-417 criteria for, 369-370 sensitivity of, 123 size, suction levels, 217b sudden distress causes of, 343b identification of, 343-344, 343b temperature, 128-129 variability among, 267 ventilated, therapies in, 230-234 ventilator disconnection and, 127b ventilatory performance of, 394-397 vital signs, 107 PC-CMV see Pressure-control continuous mandatory ventilation (PC-CMV) PC-IMV see Pressure-controlled intermittent mandatory ventilation (PC-IMV) PC-IRV see Pressure control inverse ratio ventilation (PC-IRV) Peak expiratory flow, 49, 49f rate (PEFR) defining, 146 increase in, 226 Peak inspiratory pressure (PIP), 11, 12f, 125 adjustments in, 450 changes, examples of, 135t 563 Peak inspiratory pressure (PIP) (Continued) concerns about, 88 elevation, 349-350 evaluation of, case study for, 350b increase in, 62b from increased airway resistance, 309-310, 309f measurements, 178, 180b reduction and, 226 total force, 179 Peak pressure, 11 alarm activating, case study for, 317b pneumothorax and, 317 Pediatric infant ventilators, features of, 455b Pediatric patients, 444 acute lung injury in, 469 bilevel positive airway pressure in, 451-452 continuous positive airway pressure in, 451-452 mechanical ventilation in, indications for, 453b pressure-support ventilation in, use of, 462 prone positioning of, 479 respiratory distress in, 444 ventilatory support for, indications for, 452-453 Pediatric ventilator, 453-456 advancement in, 455 features of, 454b-455b support, goals of, 445 PEEP see Positive end-expiratory pressure (PEEP) Pendelluft, 473 Percent leak, 460 Periodic hyperinflation, 104-105 Permissive hypercapnia (PHY), 109, 215-216, 215b-216b cardiovascular system response of, 216 circulatory effects of, 215-216 clinical scenario, 216b contraindications of, 215-216 implementation, protocol, 215b procedures for managing, 215 technique, 215 Phase variables breath phases and, 30-40, 31b, 41b determination of, 41f Phrenic nerve, severing, 505 Physical appearance, assessment, 107 Physiological dead space, increased, 213-214 Physiological shunt, determination of, 201 Piezoelectric electromechanical transducers, 177 Pilot tube cut in, 133-134 repair, 134f repair kit, 134f PIP see Peak inspiratory pressure (PIP) Piston-driven ventilator, internal pneumatic circuit, example of, 34f Pitt speaking tracheostomy tube, 432-433, 433f Plasma renin activity (PRA), increased sympathetic tone and, 311, 311b Plateau pressure (Pplateau), 3-6, 11-12, 13f, 125, 125b, 178 changes, examples of, 135t evaluation of, case study, 350b 564 INDEX Plateau pressure (Pplateau) (Continued) maintenance of, 84b measurement of, 11-12, 124f accurate, 90b subtraction of, 126b Pleura-occupying lesions, 45b Pleural pressure, graphing, 14f Pleural space, airway pressure to, transmission of, 254 pMDIs see Pressurized metered dose inhalers (pMDIs) Pneumatic circuit, 20-22 external, 22 internal, 20 Pneumatic flow control valve, digital on/off valve, 25f Pneumatically powered ventilators, 17-18, 18b Bird Mark 7, 17, 18f Pneumobelt, 428-429 with positive-pressure generator, 428f Pneumomediastinum, 317 Pneumoperitoneum, 317 Pneumotachometer, 49 Pneumothorax, 317, 345 detection of, 345 tension, 317 Polymicrobial infections, 281 Portable homecare ventilators, 372-373 Portable pressure-targeted ventilators, 373 limitations of, 372 Portex speaking tracheostomy tube, 432, 432f Posey Cuffalator device, usage, 130f Positive end-expiratory pressure (PEEP), 11, 12f, 62b, 80, 309, 457 airway suctioning with, 255 amount, estimation of, 101 application, 244-246, 246b physiological factors for, 252f applied or inadvertent, 197 ARDS vertical gradient and, 261 asynchrony, 332 baseline pressure level and, 38 beneficial effects of, 254 congestive heart failure and, 254-255 continuous positive airway pressure (CPAP) and, 39-40, 39f contraindications of, 253-255 controlled ventilation during, 40f definitions of, 99b devices, technical aspects of, 244 effects of, 114b establishment, pressure-volume curves, 241-255 excessive, 332, 357 flowsheet of, example, 249f goals of, 244 increase in, effects of, 252t-253t, 458f indications for, 245-246, 246b initiating, 246 with intermittent mandatory breaths, 40f introduction to, 243-245 levels high, 250f selection of, 246-252 lung protection and, 321 minimum/low PEEP, 245 optimum, 245 PEEPTOT, subtraction of, 126b physiological effects of, 253-255 positive-pressure ventilation and, 305 Positive end-expiratory pressure (PEEP) (Continued) pulmonary effects of, 254 ranges of, 245 setting, pressure-volume loops in, 263-265 simplified graphic of, 309f study of in experimental model involving oleic acid injury, 251t measurement and monitoring, parameters, 247b terminology of, 244 therapeutic PEEP, 245 titration of, 154, 154f uses of, 254-255 varying levels of, 199f weaning from, 255 examples of, 256t procedures for, 257b withdrawal, 256b, 256f Positive-pressure breath alveolar pressure, graphing, 14f pleural pressure, graphing, 14f pressure-volume loop of, 457 upper airway pressure graph, 12f volume, 113f Positive pressures duration and magnitude of, 307 effect on pulmonary vascular resistance, 322-323, 322f Positive-pressure ventilation (PPV), 4, 10, 122b, 365-366 atelectasis, occurrence of, 489 beneficial effects of, 307, 307b body position during, 269-272 cardiovascular effects of adverse, 304-306 factors influencing, 306-307 coronary blood flow with, 306 definition of pressures in, 11-12 effects on pulmonary system, 315-340 endocrine effects of, on renal function, 311 with expiratory retard, 39f importance, 230 inflation hold with, 38f and lungs, intrapleural pressures and, 305, 305f mechanics and pressure waves associated with, 11f positive end-expiratory pressure (PEEP) and, 305 selection of, 109 thoracic pump mechanism during, 305 usage, 366 Positive pressure ventilators, 18, 20f Postextubation difficulties in, 400-401 laryngospasm, occurrence of, 400 stridor, 499 Postoperative pulmonary complications, 45b Postpolio syndrome, 430 Postural drainage, 226-227 Power input alarm, 351 Power transmission, 22-25 Pplateau see Plateau pressure (Pplateau) PPV see Positive-pressure ventilation (PPV) Premature breath cycling, case study for, 35b Premature pressure support termination (PPST), 463 Pressure amount of, 143b baseline, 11 calculation of, 5b damping, 474f definition of, 2-4, 3t in positive-pressure ventilation, 11-12 determining, 81b at end of exhalation, 12, 13f equivalents of, 2b examples of, 143f flow, volume, and time, relationship of, 143 gradients, 2, 3f, 62b limit, 80, 126-127 overshoot of, PSV graphs with, 71f peak pressure, 11 scalars, 144f, 146f-148f, 150f, 153f flow asynchrony, 153f support, Servo-i ventilator during, main screen, 508f targeting, as control variable, 62-63 triggering sensitivity level for, 32f types of, 329 units of, waves negative-pressure ventilation and, 10f positive-pressure ventilation, impact of, 11f Pressure augmentation (PAug), 72 ventilation, 72 Pressure-control continuous mandatory ventilation (PC-CMV), 66, 67f, 107 advantage of, 93 case study, 91b descending ramp waveform and, 93 high PEEP level, impact of, 268 maximum pressure limit, 66 with PEEP, increased, 268 Pressure control inverse ratio ventilation (PC-IRV), 67 pressure-time curves for, 487f Pressure-controlled breathing, 28 Pressure-controlled breaths, with changing lung characteristics, 63b Pressure-controlled continuous mandatory ventilation, 146f, 456, 456f with volume guarantee, 466f Pressure-controlled inspiration, 30b Pressure-controlled intermittent mandatory ventilation (PC-IMV), pressure, flow, and volume scalars, 147f Pressure-controlled ventilation, 28b, 31f, 34, 36 with airflow limitation, 459f assessing overdistension during, 155-156, 156f factors affecting volume delivery during, 62b using flow-cycle feature, 459f volume, decrease (clinical scenario), 211b volume-controlled ventilation, comparison of, 145 Pressure-control mode, 456-462 Pressure control ventilation, 64f, 66, 81b case study on, 63b comparison, 62 initial settings for, 93 PIP and volume evaluation in, case study, 350b INDEX Pressure-cycled breath, 69-70 Pressure-cycled inspiration, 71b Pressure-cycled pressure support ventilation breath, 93f Pressure-cycled ventilation, 36-37 Pressure cycling, pressure limiting and, 35 Pressure limiting, 34, 34f pressure cycling and, 35 Pressure manometer, 48, 48f Pressure-regulated volume control (PRVC), 72-73, 122, 464, 464f case study on, 95b dual-control mode, evaluation of, case study, 467b effects of leaks in, 464f initial settings of, 94 names for, 94t screen capture of, 73f Pressure setting, 62b Pressure support COPD and, 332f flow synchrony and, 463f Pressure-support breath graph of, 71f waveforms from, 37f Pressure-supported breath, triggering of, nebulizer impairment of, 357-358 Pressure-supported ventilation patient-circuit leaks during, 357 PEEP application during, 366 receiving, 104 Pressure support ventilation (PSV), 34, 69-72, 81b, 390, 462-463 flow cycling during, 156, 156b, 157f initial settings for, 91-93 inspiratory flow and, 69-70 level of, adjustment of, 91 with pressure overshoot, graphs of, 71f rise time adjustment during, 72f settings in, 69-72 spontaneous mode of, 462 time-cycled and pressure-cycled inspiration with, 71b use of, 462 Pressure-targeted breaths, setting pressure in, 91 Pressure-targeted continuous mandatory ventilation, 66-67 Pressure-targeted ventilation, 91 clinical scenario, 211b graphs for, 63f Pressure-targeted ventilators (PTV), 370-372, 371b flow delivery of, 371-372 Pressure-time curve, fluctuations in, 358f Pressure-time product, 182-183, 182f-183f Pressure-time waveforms, 34, 35f with continuous positive airway pressure (CPAP) and, 39f mean airway pressure illustration, 243f Pressure tracing, evaluation of, 198b, 198f Pressure ventilation, 81 changes, 209-210, 210f initial ventilator settings for determining, 91-95 establishment of, 81b inspiratory time, inadequacy of, 354 method to initiate, 91 Pressure ventilation (Continued) modes, with volume targeting, initial settings for, 94-95 required setting selection and variables during, 91t tidal volume delivery in, determining, 91 Pressure-volume (P-V) curves, 250f bedside measurement of, 136-138 data, correlation of, 137t example of, 138f measurement, super syringe technique, usage of, 138f obtaining, technique, 136b plotting of, 136 usage, 241-255 Pressure-volume (P-V) loop, 153f, 266f, 356f components of, 146, 149f overdistention in, 457f PEEP, 154f slope, PEEP increase, effect on, 458f spontaneous breaths and, 146 Pressure waveforms, 93f, 143f, 466f differences in, 68f Pressurized metered dose inhalers (pMDIs), 222 ET, abrupt angle creation (impact), 223b during mechanical ventilation, 224 Preterm infants, transcutaneous carbon dioxide in, 468-469 Problem, definition of, 342 Prone positioning, 262, 270-272, 271f, 479 contraindications to, 271b oxygenation in, mechanisms, 271 protocol for, 272b technical aspects of, 271-272 Prophylactic antibiotics, 290 Prophylactic therapy, 478 Propofol (Diprivan), 297, 297b hemodynamic effects of, 297 onset and duration of, 297 Proportional assist, determining, 75b Proportional assist ventilation, 74-75 Proportional solenoid valve, type of flow control valve, 25, 25f Proximal airway pressure, Proximal pressure lines, 125b PRVC see Pressure-regulated volume control (PRVC) Pseudomonas aeruginosa, 281 Pseudooscillators, 471 PSV see Pressure support ventilation (PSV) Psychological factors in respiratory failure, 396b in weaning, 404-405 Psychological status, 231 Pulmonary angiogram, 346 Pulmonary artery (PA) bedside catheterization of, 192 catheterization, 192-195, 192f pressure, 129, 196-198 response to ventilation, 197f tracing, baseline of, 197 waveform, systemic arterial waveform (resemblance), 197 Pulmonary artery (PA) catheter complications associated with, 194t position, West’s zone relationship, 194f 565 Pulmonary artery occlusion pressure (PAOP), 188 increase on, effects of, 253t role, importance, 196-197 Pulmonary blood flow detection, capnography in, 168 effects of mechanical ventilation on, 321-323 redistribution of, 322 Pulmonary condition, clinical findings of, 137t Pulmonary disorders initial ventilator settings, 116t physical and radiologic findings in, 129t Pulmonary edema, 345 causes of, 345 Pulmonary embolism, 346 as emergency, 346 Pulmonary infiltrates, presence of, 284 Pulmonary injury sequence, 469 Pulmonary interstitial emphysema (PIE), 457 clinical scenario on, 473b Pulmonary mechanics, using graphic in monitoring of, 147-151, 150f-152f Pulmonary overdistention, from CPAP, 449 Pulmonary specialty wards, 415 Pulmonary trauma, alleviation of, 467 Pulmonary vascular pressure monitoring, with PEEP, 252-253 Pulmonary vascular problems, 45b Pulmonary vascular resistance (PVR), 188 positive pressure and, effects on, 322-323, 322f positive pressure ventilation and, 305-306, 306f Pulmonetics LTV 1000 ventilator, 373f flow on, 88b Pulse oximeter, 162f ambient light, impact on, 164 capability, description, 163 case study, 115b low perfusion states, 163 nail polish, impact on, 163 pulsatile and nonpulsatile components, 163f skin pigmentation, impact on, 164 Pulse oximetry, 46, 161-164 clinical practice guideline for, 165b physiologic and technical concerns, 162-164 usefulness of, 164 Pulse rate, determination, 162 Puritan Bennett 840 ventilator, 89t Puritan Bennett 7200 ventilator, fixed flow, 331 Pursed-lip breathing, 39, 92b PVR see Pulmonary vascular resistance (PVR) R Radford’s nomogram, 84f Rales (crackles), occurrence of, 129 Ramp, 372 Ramsay Sedation Scale, 295t Random access memory (RAM), usage, 17-18 Rapid shallow breathing index (RSBI) calculation of, case study on, 397b for weaning status, 396-397 Rat lungs, macroscopic aspect of, 320f Rate control, 32 566 INDEX Read-only memory (ROM), 17-18 Readiness, assessment of, 395b Recruitment, 316 decremental PEEP and, 268 Recruitment maneuver (RM), 265-268, 265b, 269b hazards of, 266-267 illustration of, 265, 265b recommendation of, 494 in setting PEEP, in ARDS, 262-269 summary of, 269 theoretical model of, 267f types of, 268 usage of, 494b Rehabilitation hospital, admission to, 415 Reintubation, 399, 399b Relative humidity changes, concept, 102b decrease, 101 Renal effects impaired, implications of, 311 of mechanical ventilation, 311 Renal failure/malfunction, 231 Renal function, positive-pressure ventilation and, 311 Renal insufficiency, fentanyl (usage), 298, 298b Rescue therapy, 478 Residual volume, 49 Resistance, 6-7 increased, 8f values for, 7b Respiration, Respiratory acidosis adjusting PC-CMV in patient with (clinical scenario), 210b clinical and ECG changes and, 323b decreasing rate (clinical scenario), 211b increasing rate (clinical scenario), 210b volume and pressure ventilation changes, 209-210, 210f Respiratory alkalosis clinical and ECG changes associated with, 323b spontaneous efforts (clinical scenario), 211b-212b VC-CMV and PC-CMV changes, 211 ventilator-induced, 404t Respiratory alternans, 390 Respiratory capabilities, and demands, balance between, 388f Respiratory care plan, equipment checklist for, 422b Respiratory disorders, long-term mechanical ventilation and, 416b Respiratory distress causes of, 343b hemodynamic changes in, 204t management of, in mechanically ventilated patient, 344b physical signs of, 44f recognition of, 44 severe, evaluation of, in a ventilated patient, case study for, 346b signs of, 343f sudden, clinical scenario for, 345b Respiratory drive abnormalities in, 346 decreased, CNS disorders and, 46 Respiratory factors, in respiratory failure, 396b Respiratory failure acute, 43-46 cause of, treatment, 105 clinical indications for, 444 definition of, 44-45, 444 disorders and agents associated with, 45b etiology of, determining, 396b neonates with, management of, 452 Respiratory frequency, basis of, 489 Respiratory frequency, determining, 81b Respiratory function, assessment of, 161-186 Respiratory monitoring, growth of, 456 Respiratory muscles inactivity of, 28 strengthening of, 404 weakness, 109 Respiratory quotient (RQ), variations in, 175b Respiratory rate calculation of, 86 case study, 83b and minute ventilation, 49-50 tidal volume and, interrelation of, 86b Respiratory special care units, 415 Respiratory status, in mechanical ventilation, 323-324 Respiratory support, adjunctive forms of, 478-479 Respiratory system mechanics assessment of, 177-183 clinical applications, 179-183 derived variables, 180-183 measured variables, 179-180 pressure gradients, 3f Respiratory therapy device for, 52f equipment of, 282 Respiratory zone, of comfort, 393 Respirometer, 49 Respironics NICO capnometer, rebreathing circuit, 200f Respite care, 416 Resting energy expenditure (REE), assessment of, 312 Restrictive thoracic disorders, 368, 368b Resuscitation bag, 343 Reticular pattern, 260b Retrograde pressures, 188 Reverse Trendelenburg position, 427-428 Reynold’s number, 498b Right atrial pressure (RAP), 192, 196-198 continuous monitoring of, 196 Right atrium catheter advancement, waveforms, 193f indwelling venous catheter placement, 129 Right heart artery, bedside catheterization, 192 Right ventricular (RV) afterload, increase in, 305 Right ventricular (RV) dilation, 305-306 Right ventricular end-diastolic pressure (RVEDP), 188 Right ventricular (RV) function, altered, 305-306 Right ventricular pressure (RVP), 192 Right ventricular stroke work, calculation, 201-202 Right ventricular stroke work index (RVSWI), 201-202 Rise time definition of, 70 effect of adjustment of, 72f Rise-time control, 372 Rocking bed, 427, 428f caution with, 428b Rotary drive piston, 24b, 24f S Saline instillation, normal, 220 Scalars, 143-145, 144f-145f normal, 146-147 term, usage, 142-143 SCCM see Society of Critical Care Medicine (SCCM) Second-generation portable ventilators, 423b Second-generation ventilators, ventilator setting flexibility of, 424-425 Secretions, 345, 345b clearance, 430-431 removal, 218 Sedation levels of, 295b Joint Commission definitions of, 295 monitoring of, 295, 295b practices, 295-298 strategies and protocols for, 395b, 405 Sedatives, 295-298, 295b usage for critically ill patients, 296t for mechanically ventilated patients, 299b Selective digestive tract decontamination, 290 Self-triggering, occurrence of, 65b Semirecumbent patient positioning, 287 Sensor Medics 3100A, 471-473 breathing circuit of, 472f drive mechanism for, 472f SensorMedics 3100B high-frequency oscillatory ventilation and, 492 control panel of, 493f indications and precautionary use of, 495b patient circuit, schematic of, 493f Servo-i VS of, 333 ICU ventilators, 85 operator control, 38 time-cycled machines, 88 ventilator, main screen in, 507f-509f Set pressure, 125 Set volume, actual delivered volume and, 35-36 Severe acute respiratory distress syndrome, spontaneous breathing in, 467f Severe asthma, clinical scenario of, 498b-499b Severe inspiratory airflow limitation, pressure-controlled ventilation with, 459f Severe respiratory distress causes of, 343b evaluation of, case study, 346b management of, 344b signs of, 343, 343f INDEX Shadow triggering, 329-330, 330f Shallow breathing, 47 Shape signal, 329-330, 330f Shear stress, 319, 319b, 319f Shell ventilator, 365 Shikani, 433-434 Short binasal prongs, use of, 450 Shunt clinical shunt calculation, 247b fraction, 200-201 pulmonary, 242b Sidestream sampling devices, 166-167 schematic, 166f Sigh, 83b, 104-105, 105b appropriateness, 105 deep breath, occurrence of, 104 history of, 104b necessary, 105b techniques, 268 Silent aspiration, occurrence, 219 Silverman-Anderson respiratory scoring system, 444, 445f Simethicone agents, 381 SIMV see Synchronized intermittent mandatory ventilation (SIMV) Sine flow, 88 Sine wave pressure curve, 35f Single-breath CO2 (SBCO2) curve, description of, 170-171, 171f Single-circuit ventilator, 20, 21f Skeletal disorders, long-term mechanical ventilation and, 416b Skilled nursing facilities, 415 Skin pigmentation, pulse oximeter, impact on, 164 Sleep metabolic rate reduction, associated with, 176-177 status, 231 Sleep apnea, 255 syndrome, 45b Small airways, laminar flow in, 498 Small-volume nebulizers (SVNs), 222, 290 position of, 381f Small-volume ultrasonic nebulizer, design, 225f Smoke exposure (carboxyhemoglobin), 163b Society of Critical Care Medicine (SCCM) NMBA administration recommendation, 300 recommendations from, 395b Speaking tracheostomy tubes, 432-433 concerns with, 435 Speaking valves, 431-436 concerns with, 435 Specialized continuous suction endotracheal tubes, 289f Specific dynamic action, 176 Speech loss of, 432 tracheostomy tube and, 431 Splanchnic resistance, increase in, positive-pressure ventilation and, 312 Splanchnic venous outflow, decrease in, positive-pressure ventilation and, 312 SpO2 see Oxygen saturation measured by pulse oximetry (SpO2) Spontaneous baseline pressure, 68 Spontaneous breathing, 2, 69, 467 airway pressures during, 489 prolonged, 329 in severe ARDS, 467f thoracic pump mechanism during, 305 Spontaneous breathing trial (SBT), 69, 394, 394b assessment during, 398-399, 398b failure, 395b recommendation in, 402, 402b problems during, clinical signs and symptoms indicating, 399b ventilation maintenance in, 405 Spontaneous breaths, 40-41, 61 and pressure-volume loops, 146, 149f-150f Spontaneous CPAP, circuitry for, 245 Spontaneous inspiration, intrapleural pressure and, 305f Spontaneous modes, 69-72 of ventilation, 65 Spontaneous ventilation alveolar pressure, graphing, 14f mechanics of, 2-4 example of, 4f pleural pressure, graphing, 14f preservation of, 488-489 Spontaneously breathing patients, heliox delivery devices for, 499-500, 499b Spring-loaded bellows, 24b Sputum color, 230t evaluation, 230 upper airway infections and, 230 Stable chronic lung diseases, 415-416 Static compliance (CS), 5-6, 134, 180 calculation of, 6b case study, 7b measurement of, auto PEEP and, 327 PEEP indicator and, 250-251 serial measurements of, 180 Static pressure, 178 head, 191 Static pressure-volume curves, value, 138 loop, features of, 264-265 Status asthmaticus, acute, case study, 459b Stiff lungs, 249f Stoma, maintenance of, 435-436 Strain gauge pressure transducer, 177-178 electrical circuit, 190-191 Wheatstone bridge, incorporation, 190f Straw-sipping problem, 100 Streaming, 473-474 effect of, 474f Stress ulcer prophylaxis, 290, 290b Stroke index (SI) calculation, 198 case study, 199b Stroke victim (case study), 46b Stroke volume (SV), 198 Stroke work, 202b Subacute care units, 415 Subatmospheric pressure, decrease in, 430-431 Subglottic secretions, continuous aspiration of, 219-220 Substrate utilization monitoring of, 177 pattern, 177 Succinylcholine, 300 inactivation of, 300 intravenous administration of, 300 side effects of, 300 usage of, 300 567 Suction catheters, 216 flexible, 217f reuse of, procedure in, 437b size (estimation), endotracheal size (basis), 217b Suctioning assessment, 218b, 220-221 duration of, 217 hazards and complications of, 218 irritation, 218 Sudden distress, identification of patient in, 343-344, 343b Sudden respiratory distress causes of, 343b clinical scenario, 345b management of, 344b Super-syringe technique, 263-264 usage of, 138f use of, 263f Superior vena cava, indwelling venous catheter placement, 129 Supplemental oxygen therapy, use of, 46 Surfactant administration procedure for, 478 alteration of, 319 deficiency syndromes, 457 replacement therapy, 478-479 complications of, 478 Survanta, 478 Sustained inflation, 268 Swan-Ganz catheter, 192 Synchronized intermittent mandatory ventilation (SIMV), 69b, 389 advantages, risks, and disadvantages of, 70t flow, volume, airway pressure and esophageal pressure measurements in, 390f mode, 422b System-imposed work of breathing, 328 System leaks, 36 System resistance, overcoming, 81b Systemic arterial blood pressure, 129 Systemic arterial pressure, 195-196 direct measurement of, 191 Systemic artery catheterization, 191-192 Systemic vascular resistance (SVR), 188 T Tachycardia, 45b, 195 hypoxemia and, 218 Tachypnea, 45b “Talking” tracheostomy tube, 433f Tank ventilators, 426-427 Taylor-type dispersion, 474 Temperature, 128-129 Tension pneumothorax, 317 Termination asynchrony, 331-332 Therapeutic PEEP, 245 Therapist-driven protocols (TDPs), 405 Thermodilution catheters, lumen (incorporation), 192-193 Thoracic pressure-volume relations, patterns of alteration in, 349t Thoracic pump mechanism, 305 Thorax computed tomographs, drawings of, 259f positive-pressure ventilation and, 304-305, 305b 568 INDEX Threshold resistor, 245, 245b Thrombolytic therapy, 346 Tidal flow-volume loops, mechanical breaths basis, 227f Tidal volume (VT), 460 calculation of, alternative method for, 83 case study on, 83b delivery, 210f capability of, 106 changes, examples of, 135t determining, 91 determining, 81b, 83 display of, 123 flow, total cycle time and inspiratory-toexpiratory ratio and, relationship of, 85-87 flow delivery, dependence, 489-490 flow rate, inspiratory time, expiratory time, total cycle time and respiratory rate with, interrelation of, 86b in HFJV, 473 increasing (clinical scenario), 210b measurement of, 123f respirometer technique for, 123b PEEP effect on, 458f during pressure-control continuous mandatory ventilation (PC-CMV), case study on, 91b range, moderation of, 114 and rate, 83-85 recommended, 83-84 setting, 83b, 261-262 target, volume guarantee on, 464-465 usage, 105b Time, flow, pressure, volume (relationship), 143 Time constants, 7-9, 8b, 460f calculation of, 8b, 458b concept of, 460 passive exhalation and inhalation and, 9f Time-controlled breathing, 29-30 Time controller, 28 Time-cycled, pressure-limited, intermittent mandatory ventilation (TCPL/IMV) breaths, 453-454 Time-cycled breath, pressure-limited, 34 Time-cycled inspiration, 71b Time-cycled ventilation, 36 Time-cycled ventilator effects of changing flow pattern in, 88-89 examples of, 36, 88t inspiratory flow in, 87b Time-triggered, pressure-limited, timecycled ventilation (TPTV), 454f Time-triggered ventilation, 65 Time triggering, 31-32 Tissues oxygen delivery, basics of, 241-243 resistance of, 136 Titrating ventilator, methods of, 388-391 Total cycle time (TCT), 31-32, 81 calculation of, 86 tidal volume and interrelation of, 86b relationship, 85-87 Total face mask, 375-377, 377f Total oxygen consumption ( VO2 ), 81 Total resistance, 136 Total respiratory cycle, pressure readings in, 308f Total shunt fraction, 201 T-piece connection of, 499 weaning, 390-391 Trachea, damage to, 335b-336b Tracheal buttons, 431-436 decannulation and, 435-436 Tracheal dilation, 132f Tracheal injury, from long-term ventilation, 425b Tracheal intubation (verification), capnography (value), 170b Tracheal necrosis, risk (minimization), 131-132 Tracheal pressure curve, using inspiratory pressure support, 392f Tracheoesophageal fistula, 447 Tracheomalacia, 451 Tracheostomy button, 436f consideration for, 407 role of, in weaning, 395b, 407 Tracheostomy speaking valves, 433-435 Tracheostomy tubes, 245, 421, 431-436 care of, 289-290 complications, 335b-336b connector, 434 cuffs, management of, 130-134 early placement of, 431b patients with, 175 removal of, 407 selection and benefits of, 431 speaking, 432-433 Train-of-four (TOF) monitoring of, 300 response, assessment of, 300b Transairway pressure (PTA), 3, 125, 146 airway resistance measurement and, reduced, 226 Transcutaneous electrodes, 173f Transcutaneous monitoring, 172-174, 173b technical considerations, 174 Transcutaneous monitors, pulse oximeters and, 461 Transcutaneous partial pressure of oxygen (PtcO2) monitoring, 172-173 range of, 119 Transcutaneous PO2, 172-174 Transdiaphragmatic pressure, 182 Transmural pressure, 3-4 Transport ventilators, 423b example of, 421-425 Transpulmonary pressure ( PL or PTP), 3-4, 261b changes in, 5t chest-wall and, 318b Transrespiratory pressure (PTR), breathing and, 28 components of, Transthoracic pressure (PW), Trigger asynchrony, 152, 152f-153f, 329-331, 330f Trigger sensitivity, 347 Trigger variable, 31-33, 31b Triggering, case study, 101b Tris-hydroxymethyl-aminomethane (THAM), administration of, 109 Tubing compliance (CT), 84-85 calculating volume lost to, 85b correction of, 124 gas compression and, 84-85 Tubing compressibility, 35-36 Turbine flow meters, 178-179 U Ultrasonic flow transducers, within Servo-i expiratory cassette, 179f Ultrasonic nebulizers (USNs), 222 Unilateral lung disease, patient position in, 272 Unintubated patient, resistance values for, 7b Unseated expiratory valve, 357 Upper airway infections and sputum, 230 pressure, graph of, 12f topical anesthesia to, 228 User interface (control panel), 17, 19, 21f V VAIs see Ventilator-assisted individuals (VAIs) VALI see Ventilator-associated lung injury (VALI) VAP see Ventilator-associated pneumonia (VAP) Vapotherm 2000i, respiratory therapy device, 52f Variable capacitance, 177 Variable orifice pneumotachometers, 178 Variable pressure support/control, 392-393 Vascular endothelial injury, 320-321 Vascular reflexes, blocked, 306 Vascular resistance, 201 Vascular tone, changes in, 196 VC-CMV see Volume-controlled continuous mandatory ventilation (VC-CMV) VC-IMV see Volume-controlled intermittent mandatory ventilation (VC-IMV) VDR-4, 471 Vecuronium, 301 effectiveness of, data on, 301 Vecuronium bromide (Norcuron), 301 Venous return changes in, 89-90 reduction, positive pressure ventilation and, 122b Ventilated patients aerosols, administration, 221-226, 223b severe respiratory distress, evaluation of, case study for, 346b therapies in, 230-234 tidal volume for, 83 transport, patient support equipment/ monitoring equipment, 233b Ventilation, abnormalities, 209-216 absence, 200 adequacy, indicator of, 50b adjustment of, 490-491 autotrigger, 32 backup mode of, 350 basic model of, 27-28 change, methods, PaCO2/pH basis, 209-211 conventional, lung-protective strategies in, 467-469 dead-space, 171b depression of, 328 INDEX Ventilation (Continued) determination of, 445, 490 failure of, 50 flow-cycled, 36, 37f gas flow during, history of, 104b improvement, strategy of, 490-491 intubation without, 53 maintenance of, 496 manual ventilation, 105 methods to improve, in patient-ventilator management, 208-238 mode of, 60-63, 65-72, 122 additional, 72-75 determination of, 145, 146b, 148f-149f selection of, 114 neural control, review of, 504 in neuromuscular disorders (case study), 47b to nondependent lung, 321-322, 322f parameters, case study of, 136b perfusion without, 242b pressure-cycled, 36-37 pressure gradients during, prolongation of, in long-term care facilities, 395b, 407 solving problems in, 342 time-cycled, 36 tracheostomy tubes during, speaking with, 432 volume-cycled, 35 Ventilation/perfusion ( V/Q ) mismatching, 44-45 reduction in, 457 Ventilation-perfusion relationships, 167f Ventilation-to-lung periphery, 322 Ventilation-to-perfusion (V/Q) matching, 89-90 Ventilation-to-perfusion ( V/Q) mismatch, 246 Ventilator alarms, 102-103 inoperative, technical error message and, 351 situations, action, 104 Ventilator-assisted individuals (VAIs), 414 cuff deflation of, 432 discharge of, preparation for, 417-420 psychological problems in, 422b Ventilator-associated lung injury (VALI), ventilator-induced lung injury versus, 316, 316b Ventilator-associated pneumonia (VAP), 280-293, 280b algorithm of, 285, 288f bacteriologic (quantitative) diagnosis of, 284-285 causes and risk factors of, 281-282, 281b-282b CDC surveillance paradigm for, 283t clinical diagnosis of, 284 diagnosis of, 283-285 clinical criteria used in, 284t endotracheal tube and, 289 epidemiology of, 281-282 handwashing and, 286, 286b incidence of, 281 management of antibiotic regimens used for, 288f antibiotics for, 286t noninvasive ventilation and, 287 nonpharmacologic interventions for, 286-290 Ventilator-associated pneumonia (VAP) (Continued) pathogens of, 282-283 association, 286t patient case of, 284b pharmacologic interventions for, 290 positioning and enteral feeding and, 287 prevention of, strategies for, 285-290 treatment of, 285 Ventilator circuit disinfection of, 436-437 leakage, checking of, 127-128 management strategies for, 290, 290b Ventilator control panel, 65 user interface, 19 systems and circuits, 18-22 Ventilator CPAP, 448 Ventilator-dependent patients at home site, respiratory care plan equipment checklist for, 422b sites for, 415 tracheostomy tube placement in, advantages of early, 431b Ventilator graphics, 142-160, 457 problem solving using, case study, 353b troubleshooting for, 342b usage of, 142 Ventilator-induced diaphragm dysfunction (VIDD), 506 Ventilator-induced lung injury (VILI) avoidance of, 467 ventilator-associated lung injury versus, 316, 316b Ventilator-induced respiratory alkalosis, 404t Ventilator-induced respiratory muscle weakness, 321 Ventilator management protocol (VMP), 406f Ventilator patients, evaluation of, 241-242 Ventilator-related problems, 346-348 Ventilators asynchrony, resolution for, 348b breath, triggering, 100f changes in, case study, 306b, 324b classification, historical perspective on, 16-17 components of, 17b compressors (blowers), 22 control systems and circuits of, 18-22 conversion system and, 22-25 cost of purchasing of, 106 dependence, pathology of, 394-398 discontinuation of, closed-loop control modes for, 391-394 double-circuit, 20, 22f drive mechanisms in, 22 electrically powered, 17, 17b equipment setup, considerations in, 105 flow sheet comment section of, 138 example of, 120f-121f fluid logic (fluidic) pneumatic mechanisms, components, 19f function of, 488b auto-PEEP, effect on, 326-327 with heliox, 502b worksheet for, 76f-77f 569 Ventilators (Continued) initial settings for, 80-97 COPD patient, 108 determining, during pressure ventilation, 91-95 input power of, 17 inspiratory waveform maintenance, 30f internal function of, 17 lower- and higher-PEEP groups, 248t mechanical and operational hazards of, 333-334 microprocessor-controlled, 30 minute ventilation determining, 81b display of, 123 mode of selection of, 28 switching from, 510 worksheet for review of, 76f-77f needs, 105 operation, verification of, 119b parameters, PEEP and, 250 patient performance with, 394-397 patient sensitivity in, 123 performance bench test, 106 evaluation, 106 pneumatic circuit, 20-22 pneumatically powered, 17-18, 18b power source of, 17 power transmission and, 22-25 pressure for, determining, 81b problems in, 346-348, 359 evaluation of, 353b, 353f identification of, use of graphics in, 351-355, 351b procedures of, 247t PRVC names on, 94t rate, display of, 123 requirement of, clinical scenario on, 90b respiratory frequency for, determining, 81b response time of, improvement of, 66 scalars, 143 selection of, 58-79, 106-115, 421-425 case study, 18b sensitivity setting, 99-102 settings of, changes in, case study on, 463b setup final considerations in, 98-117 parameters of, 99-105 single-circuit, 20, 21f support, methods of titrating, 388-391 synchrony (interpretation), using Edi waveform, 507 technical error message and, 351 tidal volume for determining, 81b display of, 123 troubleshooting, 352b types of, 9-12, 370-373 unexpected responses to, 355-359 user interface (control panel), 17, 19, 21f valve, effect of, 503 variables, initiation or manipulation of, 119 volume displacement designs, 22 570 INDEX Ventilators (Continued) volume flow-control valves, 25 volume support names on, 94t Ventilatory management, and discontinuation, components of, 388b Ventilatory mechanics adult and critical range values of, 48t bedside measurement of, 48-50 Ventilatory muscle function, 396b Ventilatory support discontinuation of, 388 establishment of, 369 inadequate, 347 indications for, 452 newborn and pediatric, goals of, 445 for postmyocardial infarction, clinical scenario on, 90b special techniques in, 486-515 withholding and withdrawing, ethical dilemma on, 408 Venturi, sliding, high-frequency percussive generator, 471f Very low birth weight (VLBW) neonates, 452 Vest Airway Clearance System, 227f Vibrating mesh nebulizers (VMNs), 222 VIDD see Ventilator-induced diaphragm dysfunction (VIDD) VILI see Ventilator-induced lung injury (VILI) Viscous resistance, Visual alarms, activation of, 126 Visual analog scale, 232f Vital capacity, 49 bedside measurement of, 49b use of, 46 Vital signs, 128-130 assessment, 107 Voice tracheostomy tube (VTT), 432 Volume control mode, 462 delivery delay in, 458f factors affecting, 62b graphs of, 89f device (bellows), usage, 6f evaluation of, case study for, 350b examples of, 143f expiratory portion of, 342f flow, pressure, time, relationship, 143 guarantee, 464-465, 465f lost of, calculation of, to tubing compliance, 85b monitoring of, 460 scalars, 147f-148f, 150f targeting as control variable, 61-62 pressure ventilation modes with, 94-95 waveforms, 466f Volume-assured pressure support (VAPS), 72, 107 Volume-control continuous mandatory ventilation (VC-CMV), Servo-i and, 507f Volume-controlled breathing, 28-29 Volume-controlled breaths, with changing lung characteristics, 62b Volume-controlled continuous mandatory ventilation (VC-CMV), 66 COPD patient settings, 108 goal of, 81 Volume-controlled continuous mandatory ventilation (VC-CMV) (Continued) graphs of, 66f inspiratory pause, setting of, 126f modes of, 453 scalars, 143, 150f volume-time waveform during, 127f Volume-controlled inspiration, 30b Volume-controlled intermittent mandatory ventilation (VC-IMV) scalars, 148f Volume-controlled ventilation, 28b, 31f comparison, 62, 63b with constant flow, 145b factors affecting pressures during, 62b initial settings during, 81-90 peak inspiratory pressure (PIP) and plateau pressure (Pplateau), evaluation of, 350b pressure-controlled ventilation, comparison and, 145 ventilator settings during, determination of, 80-81 Volume-control ventilation, 81b airway pressure waveform during, 124f flow constancy and, 331 Volume-cycled breath, inspiratory phase, 35 Volume-cycled ventilation, 35 Volume-cycled ventilators, 35 effects of changing flow pattern in, 88-89 example of, 89t flow and volume delivery in, graphs of, 89f Volume displacement designs, 22 linear drive piston, 24b, 24f rotary drive piston, 24b, 24f spring-loaded bellows, 24b Volume displacement devices, example of, 24b Volume flow-control valves, 25 Volume limiting, 34 Volume support initial settings of, 94-95 names for, 94t Servo-i, pressure ventilation provision, 107 test breath, 74f time-cycled and pressure-cycled inspiration with, 71b Volume-support ventilation (VSV), 73, 467 Volume-targeted continuous mandatory ventilation, 66 Volume-targeted pressure support ventilation, 392 Volume-targeted ventilation advantage of, 91 VT and, 462 Volume-time curve, 342f below baseline, expiratory portion of, 355 problem, 357f Volume-time waveforms, 34, 35f, 127f Volume triggering, 33 Volume ventilation, 501 initial ventilator settings for, establishing, 81b inspiratory pause during, 90 Volumetric capnometry, 170-172 Volutrauma, 467, 478-479 barotrauma and, 316-318 Vortex ultrasonic flow meters, 178 W Wall attachment phenomenon, 19f Water traps, emptying, 101-102 Waveforms (curves), 143b abnormal, ventilator response to, 352b display, creation of, 143 examples of, 143f ringing, 354-355, 358f Weaning, 475-478 acid-base factors in, 402 anesthesia strategies and protocols for, 405 APRV settings, example of, 491t artificial intelligence system for, 391 attempt evaluation of, case study on, 389b failed, case study, 402b cardiac factors in, 402 clinical criteria for, evaluation of, 394 clinical scenario, 404b complication of, nonrespiratory factors in, 402-405 criteria for, 394 difficulty, case study, 417b evidence-based, 394-401 exercise and, 404 goals for, 407 hyperventilation and, 324 index, requirements of, 396b metabolic factors in, 402 methods of, comparison of, 391 nonrespiratory factors in, 403t nutritional status and, 404 from optimum lung volume HFOV, strategy flow chart for, 477f parameters of, complex, 398b patient’s ability for, 399 pharmacologic agents on, effect of, 404 physiological parameters for, 397t practice of, 389 protocols for, 395b, 405-407, 407b efficiency and effectiveness of, 406b example of, 406f psychological factors in, 404-405 disease-related issues and, 405 manifestations of, 405 psychological fears on, 405 readiness assessment for, evaluation criteria for, 398 sedation strategies and protocols for, 405 T-piece, 390-391 techniques, 388-394 term, use of, 388, 388b titrating ventilator support during, 388-391 tracheostomy in, role of, 395b, 407 work of breathing during, 328, 328b Weaning failure clinical scenario on, 405b criteria for, 401b factors in, 402-405 Webb and Tierney study, 321 Wiggers diagram, 188 illustration of, 189f WOB see Work of breathing (WOB) Women, ideal body weight for, calculating, 83b INDEX Work of breathing (WOB), 45b, 397-398 during continuous positive airway pressure (CPAP), 182f definition, 181 graphic representation of, 181, 181f-182f imposition, 181 increased, 47, 328-333 Work of breathing (WOB) (Continued) physical signs and measurements of, 398b machine sensitivity, setting of, 329 measurement of, 181, 328 reduction of, steps for, 328-333 ventilator, performed by, 328b during weaning, 328, 328b 571 Y Y-connector, 434 Z ZEEP see Zero end-expiratory pressure (ZEEP) Zero end-expiratory pressure (ZEEP), 38 This page intentionally left blank ... of respiratory therapists To be successful, students and instructors must have access to clear and well-designed learning resources to acquire and apply the necessary knowledge and skills associated... pressure support static transpulmonary pressure at a specified lung volume pressure support ventilation transairway pressure transcutaneous PCO2 transcutaneous PO2 transmural pressure transrespiratory... Characteristics Compliance Resistance Time Constants TYPES OF VENTILATORS AND TERMS USED IN MECHANICAL VENTILATION Types of Mechanical Ventilation Negative Pressure Ventilation Positive Pressure Ventilation