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CHAPTER 15 CHAPTER 15 Sedatives, Analgesics, and Paralytics Sedatives, Analgesics, and Paralytics OUTLINE Sedatives and Analgesics Monitoring the Need for Sedation and Analgesia Benzodiazepines Neuroleptics Anesthetic Agents Opioids Paralytics Monitoring Neuromuscular Blockade Depolarizing Agents Nondepolarizing Agents Summary KEY TERMS • Analgesics • Anesthetic • Anterograde amnesic • Depolarizing agents • Miosis • Nondepolarizing agents • Paralytics • Pruritus • Ramsay Sedation Scale • Sedatives • Train-of-four monitoring LEARNING OBJECTIVES On completion of this chapter, the reader will be able to the following: List the most common sedatives and analgesics used in the treatment of critically ill patients Discuss the indications, contraindications, and potential side effects associated with each of the sedatives and analgesic agents reviewed Describe the most common method for assessing the need for and level of sedation Describe the Ramsay scale Discuss the advantages and disadvantages of using benzodiazepines, neuroleptics, anesthetic agents, and opioids in the management of mechanically ventilated patients S edatives, analgesics, and paralytics are often required for the treatment of mechanically ventilated patients in the intensive care unit (ICU) The importance of these drugs in the management of critically ill patients requires critical care therapists to have a working knowledge of the indications and contraindications, mode of action, potential adverse effects, and the most appropriate methods to monitor the effects of these drugs Sedatives are used to reduce anxiety and agitation and to promote sleep and anterograde amnesia; analgesics are used to lessen pain; paralytics are used to facilitate invasive procedures (e.g., surgery, endotracheal intubation), and to prevent movement and ensure the stability of artificial airways Paralysis may also be used to facilitate less conventional mechanical ventilation strategies.1-3 A variety of pharmacologic agents are available for achieving sedation and paralysis of mechanically ventilated patients The most 294 Discuss the mode of action of depolarizing and nondepolarizing paralytics Explain how the train-of-four method is used to assess the level of paralysis in critically ill patients Contrast the indications, contraindications, and potential side effects associated with using various types of neuromuscular blocking agents Recommend a medication for a mechanically ventilated patient with severe anxiety and agitation common sedative drugs used in the ICU include the following: (1) benzodiazepines (e.g., diazepam, midazolam, and lorazepam), (2) neuroleptics (e.g., haloperidol), (3) anesthetic agents (e.g., propofol), and (4) opioids (e.g., morphine, fentanyl) Paralysis can be achieved with neuromuscular blocking agents (NMBA) that are classified as depolarizing and nondepolarizing, depending on their mode of action Succinylcholine is the only example of a depolarizing NMBA in widespread use; the most commonly used nondepolarizing NMBAs include pancuronium, vecuronium, and atracurium Maintaining an optimal level of comfort and safety for the patient should be a primary goal when administering sedatives, analgesics, and NMBAs It is important, therefore, to recognize that although these agents can dramatically improve patient outcomes in mechanically ventilated patients, they can also precipitate significant hemodynamic, autonomic, and respiratory consequences in these patients (Key Point 15-1) Sedatives, Analgesics, and Paralytics Key Point 15-1 Sedatives are used to reduce anxiety and agitation and to promote sleep; analgesics are used to lessen pain SEDATIVES AND ANALGESICS Sedation practices vary considerably because of institutional bias and because the requirements for sedation can vary greatly among patients.4 As mentioned, sedation is generally prescribed for critically ill patients to treat anxiety and agitation and to prevent or at least minimize sleep deprivation Agitation and sleep deprivation can result from a variety of factors, including extreme anxiety, delirium, pain, and adverse drug effects Sedation is also often required for mechanically ventilated patients who are being treated with less conventional modes of ventilation, such as high-frequency ventilation, inverse inspiratory-to-expiratory ratio ventilation, and permissive hypercapnia.5 The Joint Commission has defined four levels of sedation: minimal, moderate, deep, and anesthesia (Box 15-1) It is important to recognize that sedation needs may vary considerably during the course of a patient’s stay in the ICU For example, deeper levels of sedation and analgesia may be required during the initial phases of mechanical ventilation, especially in cases in which the patient is asynchronous or “fighting” the mechanical ventilatory mode being used Conversely, minimal levels of sedation and analgesia are usually required during the recovery phase of an illness Indeed, weaning a patient from mechanical ventilation can be severely hindered if the patient is oversedated.6 It should be apparent, therefore, that reliable and accurate methods for assessing the need and level of sedation and analgesia are essential for the successful management of critically ill patients.7 BOX 15-1 Levels of Sedation Minimal Sedation Patients can respond to verbal commands, although cognitive function may be impaired Ventilatory and cardiovascular functions are unaffected Moderate Sedation (Conscious Sedation) The patient can perform purposeful response following repeated or painful stimulation (NOTE: Reflex withdrawal from painful stimulus is not considered a purposeful response.) Spontaneous ventilation is adequate, and cardiovascular function is usually maintained Deep Sedation The patient is not easily aroused but can respond to painful stimulation Spontaneous ventilation and maintenance of patent airway may be inadequate Cardiovascular function is usually maintained Anesthesia CHAPTER 15 295 Monitoring the Need for Sedation and Analgesia Several techniques have been proposed to assess the level of sedation in adults and children Examples of scoring systems that have been validated for use in critically ill patients include the Ramsay Sedation Scale (RSS), the Motor Activity Assessment Scale (MAAS), the Sedation-Agitation Scale (SAS), and the Comfort Scale Although considerable debate exists over the best technique, it is generally agreed that patients should be assessed regularly to ensure that they are relaxed and are not complaining of pain (Key Point 15-2) Key Point 15-2 Pain assessment and response to therapy should be performed regularly and systematically documented.7 The RSS is shown in Table 15-1.8 Notice that it is a graduated single-category scale The grade assigned by the observer depends on the patient’s response to stimuli The advantages of using this type of single category scale are that it is relatively easy to perform and provides a numerical value that can be used as a target for achieving adequate sedation For example, a score of to on the RSS indicates adequate sedation There are several disadvantages associated with using this type of graded scale Most notably it does not provide any guidance on selection of the most appropriate sedative, and it is a subjective, nonlinear scale that does not allow for consideration of changing physiological and psychological needs of a patient during the course of his or her illness.1 Benzodiazepines Benzodiazepines have been the drugs of choice for the treatment of anxiety in critical care.1 Preferential use of these drugs by critical care physicians is probably related to their relatively low cost and to the ability of these drugs to produce anxiolytic, hypnotic, muscle relaxation, anticonvulsant, and anterograde amnesic effects Anterograde amnesia relates to preventing the acquisition and encoding of new information that can potentially lead to memories of unpleasant experiences and posttraumatic stress disorder (PTSD) Benzodiazepines exert their effects through a nonspecific depression of the central nervous system (CNS) This is accomplished when these drugs bind to benzodiazepine sites on the γ-aminobutyric acid (GABA) receptor complex on neurons in the TABLE 15-1 The Ramsay Sedation Scale Score Description Patient is awake but anxious, agitated, and restless Patient is awake, cooperative, oriented, and tranquil Patient is semi-asleep but responds to verbal commands Patient is asleep and has a brisk response to a light glabellar tap or loud auditory stimulus Patient is asleep and has a sluggish response to a light glabellar tap or loud auditory stimulus Patient is asleep and has no response to a light glabellar tap or loud auditory stimulus This level involves general anesthesia, spinal, or major regional anesthesia; local anesthesia is not included Patient cannot be aroused, even by painful stimulation Ventilatory assistance is typically required (i.e., artificial airway and positive pressure ventilation) Cardiovascular function may be impaired (Modified from the American Society of Anesthesiologists: ASA Standards, Guidelines and Statements, October 2007.) 296 CHAPTER 15 TABLE 15-2 Sedatives, Analgesics, and Paralytics Selected Sedatives Used for Critically Ill Adult Patients Onset After IV Dose (min) Half-Life of Parent Compound (hr) Intermittent IV Dose Infusion Dose Range (Usual) Diazepam 2-5 20-120 — Midazolam 2-5 3-11 Lorazepam 5-20 8-15 Propofol Haloperidol 1-2 3-20 26-32 18-54 0.03-0.1 mg/kg q 0.5-6 hr 0.02-0.08 mg/kg q 0.5-2 hr 0.02-0.06 mg/kg q 2-6 hr — 0.03-0.15 mg/kg q 0.5-6 hr Agent 0.04-0.2 mg/kg/hr 0.01-0.1 mg/kg/hr 5-80 µg/kg/min 0.04-0.15 mg/kg/hr Modified from Jacobi J, Fraser GL, Coursin DB, et al: Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult, Crit Care Med 30:119-141, 2002 IV, Intravenous brain Binding of benzodiazepines to the GABA receptor complex increases the chloride permeability of the neuron, which in turn hyperpolarizes the neuron, making depolarization less likely.9 Benzodiazepines vary in potency, onset of action, uptake, distribution, and elimination half-life (see Table 15-2 for a comparison of the pharmacologic properties of diazepam, midazolam, and lorazepam) It is worth noting that the intensity and duration of action for the various benzodiazepines can be affected by a number of patient-specific factors, including age, underlying pathology, and concurrent drug therapy Prolonged recovery from benzodiazepines typically occurs in patients with renal and hepatic insufficiency.7 Benzodiazepines generally produce only minimal effects on cardiovascular function; however, they can cause a significant drop in blood pressure when initially administered to hemodynamically unstable patients (e.g., patients with hypovolemic shock) Similarly benzodiazepines normally not adversely affect the respiratory system; however, they can produce hypoventilation or apnea by causing a reduction in ventilatory drive in patients with chronic obstructive pulmonary disease (COPD) when combined with opioids Reversal of the effects of benzodiazepines can be accomplished with flumazenil (Romazicon), which prevents the sedative effects of these drugs by competitively binding to benzodiazepine receptors It is a short-acting drug that is administered intravenously at doses of 0.2 to 1.0 mg; subsequent doses may be repeated every 20 minutes up to a maximum dose of 3 mg/h Administration of flumazenil is generally reserved for patients admitted to the emergency department for suspected benzodiazepine overdose The most common side effects of flumazenil include dizziness, panic attacks, and cardiac ischemia, and it may lead to seizures in patients receiving long-term benzodiazepine or tricyclic antidepressant therapy Diazepam Diazepam (Valium) has a rapid onset of action because of its high lipid solubility and ability to traverse the blood–brain barrier relatively quickly The average onset of action for diazepam when it is administered intravenously is to minutes.9 It is metabolized in the liver to active metabolites that have relatively long half-lives (40 to 100 hours) These active metabolites are ultimately eliminated by the kidney As such, diazepam elimination can be decreased in older patients, neonates, and patients with compromised hepatic and renal function, resulting in prolonged clinical effects and delayed recovery from sedation.10 Intravenous (IV) administration of diazepam is the most reliable method to maintain sedation in critically ill patients because absorption through the oral and intramuscular routes can vary considerably Continuous infusion of diazepam is not recommended Instead, a bolus dose of the drug is administered at the start of an infusion, followed by a series of smaller boluses with close titration to produce the desired plasma concentration of the drug.11 Midazolam Midazolam (Versed) has a rapid onset of action and short half-life, making it an ideal sedative for the treatment of acutely agitated patients (Key Point 15-3) Note that although it does have a short half-life, prolonged sedation can occur as a result of the accumulation of the drug and its metabolites in the peripheral tissues when it is administered for longer than 48 hours.1 Key Point 15-3 Midazolam and diazepam should be used for rapid sedation of acutely agitated patients.7 Midazolam causes a reduction in cerebral perfusion pressure, but it does not protect against increases in intracranial pressure for patients receiving ketamine.1 Although midazolam does not cause respiratory depression in most patients, it depresses the sensitivity of upper respiratory reflexes, and it can reduce the ventilatory response in patients with COPD and in patients receiving narcotics.12 Midazolam typically causes only minimal hemodynamic effects (e.g., lower blood pressure, reduction in heart rate) in euvolemic subjects, and is usually well tolerated in patients with left ventricular dysfunction It can produce significant reductions in systemic vascular resistance and blood pressure in patients who are dependent on increased sympathetic tone to maintain venous return.1 Lorazepam Lorazepam (Ativan) is the drug of choice for sedating mechanically ventilated patients in the ICU for longer than 24 hours It has a Sedatives, Analgesics, and Paralytics slower onset of action compared with diazepam and midazolam due to its lower lipid solubility and longer time required to cross the blood–brain barrier Its lower lipid solubility coupled with decreased distribution in peripheral tissues may account for its longer duration of action in some patients when compared with diazepam and midazolam.13 Potential adverse drug interactions are less likely with lorazepam than with other benzodiazepines because it is metabolized in the liver to inactive metabolites Continual use of lorazepam, however, has been associated with several side effects including lactic acidosis, hyperosmolar coma, and a reversible nephrotoxicity These latter side effects have been attributed to the use of the solvents propylene glycol and polyethylene glycol in the manufacture of lorazepam.9 It is also worth noting that lorazepam acts synergistically with other central CNS depressants and should be administered with caution in patients receiving these drugs.13 Case Study 15-1 provides more information about several potential harmful effects associated with long-term use of lorazepam CHAPTER 15 297 have also been reported to occur particularly in patients receiving high-dose bolus administration of haloperidol.16 Case Study 15-1 Patient Case—Discontinuing Lorazepam A 50-year-old man with moderately severe pulmonary fibrosis is admitted to the emergency department with an irregular heart rate and signs of agitation He reports that he is exhausted and unable to get a good night’s sleep He has been treated with lorazepam (Ativan) for anxiety and insomnia for months He explains to the attending physician that he stopped taking his medication because “it makes me feel too tired to get anything done.” What are some common side effects associated with abruptly discontinuing taking the lorazepam? Dexmedetomidine Dexmedetomidine is an α2-adrenoreceptor agonist that is used for short-term sedation and analgesia in the ICU It has been shown to reduce sympathetic tone (i.e., sympatholytic activity), with attenuation of the neuroendocrine and hemodynamic response to anesthesia and surgery.14,15 It has been shown to reduce the need for anesthetic and opioid requirements.14 In a randomized controlled study designed to determine the efficacy of dexmedetomidine versus midazolam and propofol in ICU patients, Jakob and colleagues found that dexmedetomidine had similar effects to midazolam and propofol to maintain light to moderate sedation They also showed that dexmedetomidine appeared to reduce the duration of mechanical ventilation compared to midazolam When compared to midazolam and propofol, dexmedetomidine reduced the time to extubation Another interesting finding was that it reduced delirium in patients compared to propofol, and improved patients’ ability to communicate pain compared with midazolam and propofol The study did find, however, that more adverse effects were associated with dexmedetomidine when compared with midazolam and propofol.15 Neuroleptics Neuroleptics are routinely used to treat patients demonstrating evidence of extreme agitation and delirium Disorganized thinking and unnecessary motor activity characterize delirium; it is often seen in patients who have been treated in the ICU for prolonged periods (i.e., ICU syndrome) (Key Point 15-4) Key Point 15-4 The presence of delirium can delay liberation of patients from mechanical ventilation Haloperidol is a butyrophenone that causes CNS depression Although it is the drug of choice for the treatment of delirium in ICU patients, it can cause some potentially serious side effects It possesses antidopaminergic and anticholinergic effects It can induce α-blockade, lower the seizure threshold, and evoke Parkinson-like symptoms (i.e., extrapyramidal effects, like muscle rigidity, drowsiness, and lethargy) Dose-dependent cardiac dysrhythmias, including QT prolongation and torsades de pointes, The onset of action of haloperidol is to 20 minutes after an initial 5-mg dose is administered intravenously Additional doses of the drug can be administered if the patient continues to be agitated (additional IV doses of 5 mg can usually be administered safely up to a maximum dose of 200 mg) Despite the potential side effects noted above, haloperidol has been demonstrated to be a safe drug for the treatment of delirium in ICU patients.17 Anesthetic Agents Propofol (Diprivan) is an IV, general anesthetic agent that possesses sedative, amnesic, and hypnotic properties at low doses, although it has no analgesic properties It is typically administered as an initial bolus of to 2 mg/kg followed by a continuous infusion at a rate of to 6 mg/kg/hour Propofol produces significant hemodynamic effects Most notably, it causes reductions in systemic vascular resistance with a concomitant fall in blood pressure and bradycardia during the initial induction phase Propofol reduces cerebral blood flow and intracranial pressure (ICP), making it a useful sedative for neurosurgical patients In fact, propofol has been shown to be more effective than fentanyl in reducing ICP in patients with traumatic brain injury Additionally, propofol and morphine administered simultaneously allow greater control of ICP than does morphine alone.9 Propofol has a rapid onset and short duration of sedation once it is discontinued The rapid awakening from propofol allows interruption of the infusion for neurologic assessment Slightly longer recovery times can occur with prolonged infusion Clearance appears to be unaffected by renal and hepatic dysfunction (Key Point 15-5) Key Point 15-5 Propofol is an ideal sedative when rapid awakening is important, such as when neurologic assessment is required, or for extubation.7 Adverse effects associated with propofol administration include hypotension, dysrhythmias, and bradycardia It has also been shown to cause elevation of pancreatic enzymes Propofol infusion syndrome in ICU sedation is characterized by severe 298 CHAPTER 15 Sedatives, Analgesics, and Paralytics metabolic acidosis, hyperkalemia, rhabdomyolysis, hepatomegaly, and cardiac and renal failure Propofol is available as an emulsion in a phospholipid vehicle, which provides 1.1 kcal/mL This fact is important to keep in mind because propofol is a source of triglycerides and supplemental calories in patients receiving parenteral nutrition.1 Prolonged use (>48 hours) has also been associated with lactic acidosis and lipidemia in pediatric patients Opioids Opioids (or opiates) are endogenous and exogenous substances that can bind to a group of receptors located in the CNS and peripheral tissues Opioids are generally classified as naturally occurring, synthetic, and semisynthetic, or as discussed below, may be classified on the basis of their activity at opioid receptors.1 Morphine sulfate is a naturally occurring opioid agonist; fentanyl citrate is a synthetic analog of morphine Although the primary pharmacologic action of opioids is to relieve pain, these drugs can also provide significant secondary sedative and anxiolytic effects, which are mediated through two types of opioid receptors: mu (µ) and kappa (κ) receptors The µ-receptors are responsible for analgesia, and the κ-receptors mediate the sedative effects of these drugs It is well recognized that opioids can cause a number of serious side effects (Box 15-2) The severity of these side effects depends on the dosage administered, as well as the extent of the patient’s illness and the integrity of his or her organ function (i.e., renal, hepatic, and hemodynamic function) Reversal of the aforementioned side effects can be accomplished with the opioid antagonist, naloxone hydrochloride (Narcan) Naloxone has a short onset of action (~30 seconds) and usually lasts about 30 minutes When used to facilitate opioid withdrawal, a continuous IV infusion is required It is important to understand that administering smaller doses of naloxone will reverse the respiratory depressant effects of opioids, while not interfering with the analgesic effects of these drugs Using larger doses will not only reverse respiratory depression, but it will also reduce the analgesic effects Morphine Morphine is a potent opioid analgesic agent that is the preferred agent for intermittent therapy because of its longer duration of action It can produce significant effects on the CNS and alter the control of breathing even in normal healthy individuals Some of the potential side effects of morphine include reductions in minute ventilation ( VE ), periodic breathing, and even apnea by altering respiratory activity of the pontine and medullary respiratory centers in the brainstem.1 Morphine’s effects on the CNS also include reductions of cerebral blood flow, ICP, and cerebral metabolic activity, drowsiness and lethargy, miosis, and suppression of the cough reflex.18 BOX 15-2 Side Effects of Opioids Nausea, vomiting, constipation Respiratory depression Bradycardia and hypotension Myoclonus (muscle twitching), convulsions Histamine release, immunosuppression Physical dependence The effects of morphine on the gastrointestinal (GI) tract include reduction of lower esophageal sphincter tone and propulsive peristaltic activity of the intestine, which in turn leads to constipation Morphine can also increase the tone of the pyloric sphincter and ultimately lead to nausea and vomiting by delaying the passage of contents through the GI tract.1 Morphine can alter vascular resistance by causing decreases in sympathetic tone and increases in vagal tone Reduction in vascular tone can lead to significant hypotension in patients who rely on increased sympathetic tone to maintain blood pressure Increases in serum histamine levels can also occur with the injection of morphine and ultimately add to the peripheral vasodilation and hypotension Increased serum histamine levels are associated with pruritus and bronchospasm in asthmatics and individuals with hypersensitive airways In the ICU, the IV route of delivery is the most effective method of administering morphine for sedation It can be delivered as a bolus or as a continuous infusion when prolonged sedation and analgesia are required The onset of action of morphine is slower than other opioids because of its lower lipid solubility and slower transit time across the blood–brain barrier It is metabolized to active metabolites, including morphine-6 glucuronide, which can result in prolonged clinical effects The presence of renal or hepatic diseases can further impair the clearance of morphine and its metabolites Fentanyl Fentanyl citrate (Sublimaze) is a synthetic opioid that is approximately 100 to 150 times more potent than morphine.19 Its high lipid solubility and short transit time across the blood–brain barrier produce a rapid onset of action Fentanyl has a longer half-life than morphine and can accumulate in the peripheral tissues after prolonged infusion In cases of prolonged infusion, clearance can be delayed, resulting in long-lasting effects (e.g., respiratory depression), particularly in patients with renal failure Fentanyl is normally administered as a loading dose followed by a continuous infusion to maintain its analgesic effect because of its short duration of action Fentanyl transdermal patches are available for patients who require long-term analgesia Although these patches can provide consistent drug delivery in hemodynamically stable patients, the extent of absorption varies depending on the permeability, temperature, perfusion, and thickness of the patient’s skin.9 Different sites should be used when reapplying patches It should also be mentioned that fentanyl patches are not indicated for the treatment of acute analgesia because it takes approximately 12 to 24 hours to reach peak effect Once the patch is removed, a similar lag period occurs before the effects completely disappear Fentanyl has minimal effects on the cardiovascular system and does not cause histamine release as does morphine It also has minimal effects on the renal system compared with other opioids Therefore fentanyl is the opioid of choice for patients with unstable hemodynamic status and renal insufficiency (Key Point 15-6) It can cause respiratory depression in some patients because of a biphasic elimination response that occurs when the drug is mobilized from peripheral tissues Box 15-3 summarizes the agents discussed in this section (Case Study 15-2) Key Point 15-6 Fentanyl is preferred for patients with hemodynamic instability and renal insufficiency.7 Sedatives, Analgesics, and Paralytics BOX 15-3 CHAPTER 15 299 Sedatives, Neuroleptics, Anesthetic Agents, and Opioids Used in Mechanically Ventilated Patients Sedatives (Benzodiazepines) Diazepam (Valium) Anesthetic Propofol (Diprivan) Rapid onset of action Relatively low cost Half-life of 36 hours (or to days); multiple doses result in prolonged effect, especially in older patients and in patients with hepatic dysfunction Onset of action in minute Very high cost Half-life from 2 mg/kg) or repeated doses of diACh can produce a desensitization neuromuscular block resulting in a prolonged paralysis The most common side effects associated with diACh include transient hyperkalemia; cardiac dysrhythmias; anaphylactic reactions; prolonged apnea; postoperative myalgias; increased intragastric, intracranial, and intraocular pressures; myoglobinuria; and sustained skeletal muscle contraction (Hyperkalemia induced by the injection of diACh can be particularly problematic in patients with congestive heart failure who are also receiving diuretics and digitalis.) Succinylcholine can also precipitate malignant hyperthermia in susceptible individuals Malignant hyperthermia is a rare but potentially fatal disorder that that is characterized by sustained skeletal muscle depolarization It occurs at a rate of 1 : 50,000 in adults and 1 : 15,000 in the pediatric population.20-23 Succinylcholine is inactivated by the action of pseudocholinesterase Therefore prolonged action of diACh can occur if the serum pseudocholinesterase concentration is low or inhibited Low concentrations of the enzyme occur during pregnancy, chronic renal failure, severe liver damage, and following starvation The enzyme can be inhibited by anticholinesterases, organophosphates, azathioprine, cyclophosphamide, and monoamine oxidase inhibitors.13 Nondepolarizing Agents Pancuronium Pancuronium (Pavulon) was one of the first nondepolarizing NMBAs used for prolonged paralysis of mechanically ventilated Sedatives, Analgesics, and Paralytics patients in the ICU Paralysis is achieved by administering a loading dose of 0.08 to 0.1 mg/kg Sustained muscle paralysis is accomplished by administering a maintenance dose of 0.05 to 0.1 mg/kg/hour Pancuronium is a quaternary ammonium compound; more specifically, an aminosteroid muscle relaxant that has a slow onset and prolonged duration of action It is metabolized by the liver by acetylation and eliminated through the kidney The most serious side effect attributed to pancuronium includes prolonged paralysis after discontinuation of the drug, particularly in patients with renal and hepatic failure The prolonged duration of action may be partially explained by the fact that it is metabolized in the liver to an active 3-hydroxy metabolite that retains up to 50% of the activity of the parent compound.23 Other significant side effects associated with pancuronium, which result from its vagolytic effect, include tachycardia, increased cardiac output, and elevated mean arterial pressure Its sympathomimetic activity can also lead to alterations in ventilation-perfusion relationship as a result of pulmonary vasoconstriction.23 CHAPTER 15 301 increases Additionally, muscle weakness can occur with prolonged use of these types of agents13 (Case Study 15-4) Case Study 15-4 Patient Case—Neuromuscular Blocking Agent A 45-year-old man is admitted to the emergency department for injuries sustained from a fall that occurred while he was working to repair the chimney on his house His admit diagnosis includes a fractured right radius and contusion to his right upper thorax There is no evidence of head trauma The patient’s respiratory rate is 30 breaths per minute, his blood pressure is 140/85, and his pulse rate is 110 beats per minute The resident on-call physician requests that a neuromuscular blocking agent (NMBA) is administered to accomplish intubation of this patient Which NMBA would be appropriate for this patient? Vecuronium Vecuronium bromide (Norcuron) is an intermediate-duration, nondepolarizing aminosteroid NMBA that does not possess the vagolytic properties of pancuronium.24 The intermediate duration of action for vecuronium may be explained by its metabolism to minimally active metabolites Sustained paralysis can be achieved following the administration of a loading dose of 0.1 mg/kg by delivering a maintenance dose of 0.05 to 0.1 mg/kg/hour.19 Initial data suggested that vecuronium was an effective means of producing prolonged paralysis in patients with renal insufficiency because of its hepatic and biliary elimination Subsequent reports, however, suggested that prolonged paralysis may occur in patients with renal and hepatic insufficiency due to accumulation of vecuronium and its 3-desacetyl metabolite.25 Atracurium/Cisatracurium Like vecuronium, atracurium besylate (Tracrium) and its stereoisomer cisatracurium besylate (Nimbex) are intermediate-duration, nondepolarizing muscle relaxants that not have the hemodynamic side effects of pancuronium Atracurium has been shown to cause mast cell degranulation and histamine release at higher doses, which in turn can lead to peripheral vasodilation and hypotension Cisatracurium has been shown to cause only minimal mast cell degranulation and subsequent histamine release.22 The lack of cardiovascular side effects may be explained on the basis that atracurium and cisatracurium are benzylquinolones that are metabolized to hemodynamically inactive metabolites in the plasma by ester hydrolysis and the Hofmann elimination One of the breakdown products of the Hofmann elimination of atracurium, laudanosine, has been associated with central nervous system stimulation and can precipitate seizures when it accumulates in the plasma The pharmacokinetic profiles of atracurium and cisatracurium make these drugs ideal NMBAs for patients with renal and hepatic insufficiency Recovery from neuromuscular blockade typically occurs in to hours after continuous infusions are stopped However, long-term use of these drugs can lead to the development of tolerance, which in turn may necessitate significant dosage SUMMARY • Selection of the most appropriate drug for sedating or paralyzing a patient should be based on several criteria, including the patient’s condition, the drug’s efficacy and safety profile, as well as the cost of administering the drug over a prolonged period • Although historically the selection of sedatives, analgesics, and NMBAs has been based on personal preference, recent clinical practice guidelines have helped to define more clearly the most appropriate drugs and strategies for clinicians treating ICU patients with these drugs • Sedation is generally prescribed for the treatment of anxiety and agitation and to prevent or at least minimize sleep deprivation • The ideal sedative should have a rapid onset, have a relatively short active effect, and be easily titrated Its effects should be reversible and have minimal, if any, effects on vital organ function • A common reason for using NMBAs is to alleviate patientventilator asynchrony that cannot be resolved with ventilator adjustment • Two classes of NMBAs are available for paralyzing mechanically ventilated patients: depolarizing muscle relaxants and nondepolarizing muscle relaxants • Choosing the most appropriate NMBA depends on the patient’s physical condition, as well as the selected drug’s onset of action and how fast the patient can recover from its effects once it is discontinued NMBAs not possess sedative or analgesic properties and therefore should be used in conjunction with adequate amounts of sedatives and analgesics to ensure patient comfort • Maintaining an optimal level of comfort and safety for the patient should be a primary goal when administering sedatives, analgesics, and NMBAs 302 CHAPTER 15 Sedatives, Analgesics, and Paralytics REVIEW QESTIONS (See Appendix A for answers.) Which of the following is an appropriate short-acting, depolarizing agent to use for intubation of a patient? A Pancuronium B Succinylcholine C Vecuronium D Fentanyl A mechanically ventilated patient exhibits severe anxiety and agitation Talking with the patient does not successfully relieve his symptoms The nurse is concerned that the patient is sleep deprived Which of the following would be an appropriate medication to suggest? A Opioid B Paralyzing agent C Sedative D Neuromuscular blocking agent A patient in the ICU has a Ramsay score of Which of the following is a patient indication resulting from this score? A Patient responds to a painful stimulus B Patient has irreversible brain injury C Patient requires an additional dose of paralyzing agent D Patient is heavily sedated While performing an assessment of the level of sedation of a patient, the following is observed: Patient is asleep; patient has a brisk response to a light glabellar tap or loud auditory stimulus These criteria would suggest that the patient would rate a score of _ on the Ramsay scale A B C D A patient with chronic CO2 retention and lung cancer is being treated with morphine for pain She is very anxious and keeps trying to get out of bed, despite the use of restraints The nurse gives midazolam (Versed) and shortly thereafter notes that the patient’s respirations become irregular and periods of apnea occur Which of the following is the most appropriate treatment for this patient? A Flumazenil (Romazicon) B Caffeine C Noninvasive positive pressure ventilation D Reduction of morphine administration A patient is receiving mechanical ventilation as a result of an apparent tetanus infection The patient is having tetanic contractions What medications would be appropriate for this patient? Paralytic agents Analgesics Sedatives Diuretics A and only B and only C 1, 2, and only D 2, 3, and only A patient receiving morphine postoperatively by a selfactuating morphine pump complains of nausea Which of the following is the appropriate response? A Nausea is not a common side effect when administering opioids, so you should ignore the patient’s complaint B Notify housekeeping C The morphine should be stopped D Contact the nurse and the physician Which of the following is a nondepolarizing NMBA? Pancuronium Vecuronium Atracurium Succinylcholine A and only B and only C 1, 2, and only D 1, 2, 3, and Which of the following is not correctly matched? A Diazepam, Valium B Propofol, Diprivan C Midazolam, Versed D Fentanyl, Ativan 10 Describe the technique of TOF monitoring References Acquilera L, Arizaga A, Stewart TE, et al: Sedation and paralysis during mechanical ventilation In Marini JJ, Slutsky AS, editors: Physiological basis of ventilatory support, New York, 1998, Marcel-Dekker, pp 601–612 Hurford WE: Sedation and paralysis during mechanical ventilation Respir Care 47:334–346, 2002 Frazer GL, Prato S, Berthiaume D, et al: Evaluation of agitation in ICU patients: incidence, severity, and treatment in the young versus the elderly Pharmacotherapy 20:75–82, 2000 Kress JP, Pohlman AS, Hall JB: Sedation and analgesia in the intensive care unit Am J Respir Crit Care Med 166:1024–1028, 2002 Szokol JW, Vender JS: Anxiety, delirium, and pain in the intensive care unit Crit Care Clin 17:821–842, 2001 Blanchard AR: Sedation and analgesia in intensive care Medications attenuate stress response in critical illness Postgrad Med 111:59–60, 63–64, 67–70, 2002 Jacobi J, Fraser GL, Coursin DV, et al: Clinical practice guidelines for the sustained use of sedative and analgesics in the critically ill adult Crit Care Med 30:119–131, 2002 Ramsay MAE, Savege TM, Simpson BRJ, et al: Controlled sedation with alpaxalone-alphadolone Br Med J 2:656–659, 1974 Gardenshire DS: Rau’s Respiratory pharmacology, ed 8, St Louis, 2012, Elsevier 10 Young CC, Prielipp RC: Benzodiazepines in the intensive care unit In Vender JS, Szokol JW, Murphy GS, editors: Sedation, analgesia, and neuromuscular blockers in critical care medicine, 2001, p 843 11 Arbour R: Sedation and pain management in critically ill adults Crit Care Nurse 20:39–56, 2000 12 Murphy PJ, Erskine R, Langton JA: The effects of intravenously administered diazepam, midazolam, and flumazenil on the sensitivity of upper airway reflexes Anaesthesia 49:105–110, 1994 13 Devlin JW, Roberts RJ: Pharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids Crit Care Clin 25:431–449, 2009 Sedatives, Analgesics, and Paralytics 14 Gertler R, Creighton H, Mitchell DH, et al: Dexmedetomidine: a novel sedative analgesic agent Proc (Bayl Univ Med Cent) 14:13–21, 2001 15 Jakob SM, Ruokonen E, Grounds RM, et al: Dexmedetomidine vs midazolam or proposal for sedation during prolonged mechanical ventilation JAMA 307:1151–1160, 2012 16 Metzger E, Friedman R: Prolongation of the corrected QT and torsades de pointes associated with intravenous haloperidol in the medically ill J Clin Psychophamacol 13:128–132, 1993 17 McNicoll LL, Pisani MA, Zhang Y, et al: Delirium in the intensive care unit: occurrence and clinical course in older patients J Am Geriatr Soc 51:591–598, 2003 18 Hardman JG, Limbird LE, Gilman AG: The pharmacologic basis of therapeutics, New York, 2001, McGraw-Hill 19 Hill L, Bertaccini E, Barr J, et al: ICU sedation: a review of its pharmacology and assessment J Intensive Care Med 13:174–183, 1998 CHAPTER 15 303 20 Stoelting RK: Neuromuscular blocking drugs In Pharmacology and physiology of anesthetic practice, Philadelphia, 1991, Lippincott 21 Wiklund RA, Rosenbaum SH: Anesthesiology, Part I N Engl J Med 337:1132–1141, 1997 22 Murray MJ, Cowen J, DeBlock H, et al: Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 30:142–156, 2002 23 Miller RD, Agoston S, Booij LH, et al: Comparative potency and pharmacokinetics of pancuronium and its metabolites in anesthetized man J Pharmcol Exp Ther 207:539–543, 1978 24 Wierda JM, Maestrone E, Bencini AF, et al: Hemodynamic effects of vecuronium Br J Anaesth 62:194–198, 1989 25 Smith CL, Hunter JM, Jones JS: Vecuronium infusion in patients with renal failure in an ICU Anaesthesia 42:387–393, 1987 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 ... Diazepam 2- 5 2 0-1 20 — Midazolam 2- 5 3-1 1 Lorazepam 5 -2 0 8-1 5 Propofol Haloperidol 1 -2 3 -2 0 2 6-3 2 1 8-5 4 0.0 3-0 .1 mg/kg q 0. 5-6 hr 0.0 2- 0 .08 mg/kg q 0. 5 -2 hr 0.0 2- 0 .06 mg/kg q 2- 6 hr — 0.0 3-0 .15 mg/kg... Status in Mechanical Ventilation Hypoventilation Hyperventilation Metabolic Acid–Base Imbalances and Mechanical Ventilation Air Trapping (Auto-PEEP) Physiological Factors That Lead to Auto-PEEP Identifying... 51 mm Hg, PaO2 of 58 mm Hg, and HCO3− of 29 mEq/L Current ABGs on volume-controlled intermittent mandatory ventilation (VCIMV) at a mandatory rate of breaths/min, V T of 600 mL, and FIO2 of 0 .25 at