Clinical Application Of Mechanical Ventilation

by Chang, David W.

• ISBN13: 9781401884857
• ISBN10: 1401884857
• Edition: 3rd
• Format: Paperback
• Copyright: 2005-09-06
• Publisher: CENGAGE Delmar Learning

Summary

With a concise and easy-to-read approach, the new edition of this book integrates the essential concepts of respiratory physiology with the clinical application of mechanical ventilation. Extensive coverage of airway management and weaning criteria, and a concise view of pharmacotherapy for mechanical ventilation are included. Each chapter features visual examples illustrating concepts, key points summarized in margin references, and assessment questions written in NRBC format, to help prepare learners to sit for the exam. Fifteen case studies enable learners to apply theoretical knowledge to real-world critical thinking situations they may face in the field.

Table of Contents

Foreword	xxv
George G. Burton
Preface	xxvii
Acknowledgments	xxix
Contributors	xxxi
Principles of Mechanical Ventilation	1	(27)
Key Terms	2	(1)
Introduction	2	(1)
Airway Resistance	2	(3)
Factors Affecting Airway Resistance	3	(1)
Airway Resistance and the Work of Breathing (ΔP)	4	(1)
Effects on Ventilation and Oxygenation	4	(1)
Airflow Resistance	5	(1)
Lung Compliance	5	(5)
Compliance Measurement	6	(1)
Static and Dynamic Compliance	7	(3)
Compliance and the Work of Breathing	10	(1)
Effects on Ventilation and Oxygenation	10	(1)
Deadspace Ventilation	10	(2)
Anatomic Deadspace	11	(1)
Alveolar Deadspace	11	(1)
Physiologic Deadspace	12	(1)
Ventilatory Failure	12	(5)
Hypoventilation	13	(1)
Ventilation/Perfusion (V/Q) Mismatch	14	(1)
Intrapulmonary Shunting	14	(2)
Diffusion Defect	16	(1)
Oxygenation Failure	17	(1)
Hypoxemia and Hypoxia	17	(1)
Clinical Conditions Leading to Mechanical Ventilation	18	(3)
Depressed Respiratory Drive	19	(2)
Excessive Ventilatory Workload	21	(1)
Failure of Ventilatory Pump	21	(1)
Summary	21	(1)
Self-Assessment Questions	22	(2)
Answers to Self-Assessment Questions	24	(1)
References	25	(2)
Suggested Reading	27	(1)
Effects of Positive Pressure Ventilation	28	(26)
Key Terms	29	(1)
Introduction	29	(1)
Pulmonary Considerations	29	(3)
Spontaneous Breathing	29	(1)
Positive Pressure Ventilation	30	(1)
Airway Pressures	31	(1)
Compliance	31	(1)
Cardiovascular Considerations	32	(4)
Mean Airway Pressure and Cardiac Output	32	(1)
Decrease in Cardiac Output and O2 Delivery	33	(1)
Blood Pressure Changes	34	(1)
Pulmonary Blood Flow and Thoracic Pump Mechanism	34	(2)
Hemodynamic Considerations	36	(2)
Positive Pressure Ventilation	36	(1)
Positive End-Expiratory Pressure	36	(2)
Renal Considerations	38	(2)
Renal Perfusion	38	(1)
Indicators of Renal Failure	38	(1)
Effects of Renal Failure on Drug Clearance	38	(2)
Hepatic Considerations	40	(1)
PEEP and Hepatic Perfusion	40	(1)
Indicators of Liver Dysfunction	40	(1)
Effects of Decreased Hepatic Perfusion on Drug Clearance	41	(1)
Abdominal Considerations	41	(1)
Effects of PEEP and Increased Intra-Abdominal Pressure	41	(1)
Gastrointestinal Considerations	42	(1)
Nutritional Considerations	43	(2)
Muscle Fatigue	43	(1)
Nutritional Support	43	(1)
Nutrition and the Work of Breathing	44	(1)
Neurologic Considerations	45	(2)
Hyperventilation	45	(1)
Ventilatory and Oxygenation Failure	45	(1)
Indicators of Neurologic Impairment	46	(1)
Summary	47	(1)
Self-Assessment Questions	47	(3)
Answers to Self-Assessment Questions	50	(2)
References	52	(2)
Classification of Mechanical Ventilators	54	(26)
Key Terms	55	(1)
Introduction	55	(1)
Ventilator Classification	55	(1)
Ventilatory Work	56	(1)
Input Power	57	(1)
Drive Mechanism	57	(3)
Piston Drive Mechanism	58	(1)
Bellows Drive Mechanism	59	(1)
Reducing Valve Drive Mechanism	59	(1)
Microprocessor-Controlled Pneumatic Drive Mechanism	59	(1)
Control Circuit	60	(2)
Mechanical	60	(1)
Pneumatic	60	(1)
Fluidics	60	(1)
Electric	61	(1)
Electronic	62	(1)
Control Variables	62	(2)
Pressure Controller	62	(2)
Volume Controller	64	(1)
Flow Controller	64	(1)
Time Controller	64	(1)
Phase Variables	64	(5)
Trigger Variable	65	(2)
Limit Variable	67	(1)
Cycle Variable	67	(1)
Baseline Variable	68	(1)
Conditional Variable	69	(1)
Output Waveforms	69	(6)
Pressure Waveforms	72	(2)
Volume Waveforms	74	(1)
Flow Waveforms	74	(1)
Alarm Systems	75	(3)
Input Power Alarms	75	(2)
Control Circuit Alarms	77	(1)
Output Alarms	77	(1)
Summary	78	(1)
Self-Assessment Questions	78	(1)
Answers to Self-Assessment Questions	79	(1)
Suggested Reading	79	(1)
Operating Modes of Mechanical Ventilation	80	(43)
Key Terms	81	(1)
Introduction	81	(1)
Negative and Positive Pressure Ventilation	82	(2)
Negative Pressure Ventilation	82	(1)
Positive Pressure Ventilation	83	(1)
Operating Modes of Mechanical Ventilation	84	(1)
Spontaneous	84	(1)
Apnea Ventilation	85	(1)
Positive End-Expiratory Pressure (PEEP)	85	(4)
Indications for PEEP	86	(1)
Physiology of PEEP Therapy	86	(1)
Complications Associated with PEEP	87	(2)
Continuous Positive Airway Pressure (CPAP)	89	(1)
Bilevel Positive Airway Pressure (BiPAP)	90	(1)
Indications for BiPAP	90	(1)
Initial Settings	90	(1)
Adjustments of IPAP and EPAP	90	(1)
Controlled Mandatory Ventilation (CMV)	91	(2)
Indications for the Control Mode	92	(1)
Complications Associated with the Control Mode	92	(1)
Assist Control (AC)	93	(2)
Assist Control Triggering Mechanism	93	(1)
Assist Control Cycling Mechanism	94	(1)
Indications for the AC Mode	94	(1)
Advantages of the AC Mode	94	(1)
Complications Associated with the AC Mode	94	(1)
Intermittent Mandatory Ventilation (IMV)	95	(1)
Synchronized Intermittent Mandatory Ventilation (SIMV)	96	(4)
SIMV Mandatory Breath-Triggering Mechanism	97	(1)
SIMV Spontaneous Breath-Triggering Mechanism	98	(1)
Indications for the SIMV Mode	98	(1)
Advantages of the SIMV Mode	98	(1)
Complications Associated with the SIMV Mode	99	(1)
Mandatory Minute Ventilation (MMV)	100	(2)
Pressure Support Ventilation (PSV)	102	(2)
Indications for the PSV Mode	103	(1)
Adaptive Support Ventilation (ASV)	104	(1)
Proportional Assist Ventilation (PAV)	105	(1)
Volume-Assured Pressure Support (VAPS)	106	(1)
Pressure-Regulated Volume Control (PRVC)	106	(1)
Automode	107	(1)
Volume Ventilation Plus (VV+)	107	(1)
Volume Control Plus (VC+)	107	(1)
Volume Support (VS)	108	(1)
Pressure Control Ventilation (PCV)	108	(2)
Airway Pressure Release Ventilation (APRV)	110	(2)
Indications for the APRV Mode	111	(1)
Inverse Ratio Ventilation (IRV)	112	(1)
Physiology of IRV	112	(1)
Adverse Effects of IRV	112	(1)
Pressure Control-IRV (PC-IRV)	113	(1)
Automatic Tube Compensation	113	(1)
Summary	114	(1)
Self-Assessment Questions	114	(2)
Answers to Self-Assessment Questions	116	(1)
References	117	(4)
Suggested Reading	121	(2)
Special Airways for Ventilation	123	(25)
Key Terms	124	(1)
Introduction	124	(1)
Oropharyngeal Airway	124	(3)
Types of Oropharyngeal Airways	124	(1)
Selection of Oropharyngeal Airway	125	(1)
Insertion of Oropharyngeal Airway	126	(1)
Esophageal Obturator Airway (EOA)	127	(1)
Insertion of EOA	127	(1)
Esophageal Gastric Tube Airway (EGTA)	128	(1)
Laryngeal Mask Airway (LMA)	129	(6)
Use and Application of LMA	130	(1)
Contraindications for LMA	130	(2)
Selection of LMA	132	(1)
Insertion of LMA	132	(1)
Removal of LMA	132	(2)
Limitations of LMA	134	(1)
Pharyngealtracheal Lumen Airway (PTLA)	135	(2)
Insertion and Use of PTLA	136	(1)
Complications with Use of PTLA	137	(1)
Double-Lumen Endobronchial Tube	137	(4)
Indications	137	(1)
Selection of DLT	137	(2)
Insertion of DLT	139	(1)
Risk Factors for Airway Rupture	139	(2)
Summary	141	(1)
Self-Assessment Questions	141	(2)
Answers to Self-Assessment Questions	143	(1)
References	144	(3)
Suggested Reading	147	(1)
Airway Management in Mechanical Ventilation	148	(42)
Key Terms	149	(1)
Introduction	149	(1)
Intubation	149	(2)
Indications	151	(1)
Common Artificial Airways in Mechanical Ventilation	151	(2)
Oral Endotracheal Tube	151	(1)
Nasal Endotracheal Tube	152	(1)
Tracheostomy Tube	152	(1)
Intubation Procedure	153	(11)
Pre-Intubation Assessment	153	(1)
Supplies	153	(5)
Selection of Endotracheal Tube	158	(1)
Ventilation and Oxygenation	158	(1)
Oral Intubation	159	(1)
Nasal Intubation	159	(3)
Common Errors	162	(1)
Signs of Endotracheal Intubation	162	(2)
Signs of Esophageal Intubation	164	(1)
Rapid Sequence Intubation	164	(3)
Indications and Contraindications	165	(1)
Practice Guidelines	165	(2)
Management of Endotracheal and Tracheostomy Tubes	167	(6)
Securing Endotracheal and Tracheostomy Tubes	168	(1)
Cuff Pressure	169	(1)
Minimal Occlusion Volume and Minimal Leak Technique	169	(1)
Irrigation and Suction	170	(3)
Speaking Valves	173	(2)
Contraindications	173	(1)
Safety Requirements	174	(1)
Positive-Pressure Ventilation	175	(1)
Extubation	175	(3)
Predictors of Successful Extubation	175	(1)
Procedure	176	(1)
Unplanned Extubation	177	(1)
Complications of Endotracheal Airway	178	(3)
During Intubation	179	(1)
While Intubated	180	(1)
Immediately after Extubation	180	(1)
Following Extubation	181	(1)
Summary	181	(1)
Self-Assessment Questions	181	(3)
Answers to Self-Assessment Questions	184	(1)
References	185	(4)
Suggested Reading	189	(1)
Noninvasive Positive Pressure Ventilation	190	(21)
Key Terms	191	(1)
Introduction	191	(1)
Terminology	192	(1)
Physiologic Effects of NPPV	192	(1)
Use of Continuous Positive Airway Pressure (CPAP)	193	(2)
Obstructive Sleep Apnea	193	(2)
Use of Bilevel Positive Airway Pressure (BiPAP)	195	(2)
Common Interfaces for CPAP and Bilevel PAP	197	(4)
Nasal Mask	197	(1)
Facial Mask	197	(1)
Nasal Pillows™	198	(3)
Potential Problems with Interfaces	201	(1)
Titration of Continuous Positive Airway Pressure	201	(2)
Autotitration	202	(1)
Ramp	202	(1)
C-Flex™	202	(1)
Titration of Bilevel Positive Airway Pressures	203	(1)
Bi-Flex™	203	(1)
Summary	204	(1)
Self-Assessment Questions	204	(3)
Answers to Self-Assessment Questions	207	(1)
References	207	(3)
Suggested Reading	210	(1)
Initiation of Mechanical Ventilation	211	(27)
Key Terms	212	(1)
Introduction	212	(1)
Indications	212	(4)
Acute Ventilatory Failure	212	(1)
Impending Ventilatory Failure	213	(2)
Severe Hypoxemia	215	(1)
Prophylactic Ventilatory Support	216	(1)
Contraindications	216	(1)
Initial Ventilator Settings	217	(9)
Mode	217	(1)
Dual-Control Mode	218	(1)
Respiratory Rate	218	(1)
Tidal Volume	219	(2)
F1O2	221	(1)
PEEP	221	(1)
I:E Ratio	222	(1)
Flow Pattern	222	(4)
Ventilator Alarm Settings	226	(1)
Low Exhaled Volume Alarm	226	(1)
Low Inspiratory Pressure Alarm	226	(1)
High Inspiratory Pressure Alarm	226	(1)
Apnea Alarm	227	(1)
High Respiratory Rate Alarm	227	(1)
High and Low F1O2 Alarms	227	(1)
Hazards and Complications	227	(4)
Types of Hazards and Complications	228	(1)
Malfunction and Misuse of Alarms	228	(1)
Barotrauma (Volutrauma)	229	(1)
Decrease in Cardiac Output and Blood Pressure	229	(2)
Summary	231	(1)
Self-Assessment Questions	232	(2)
Answers to Self-Assessment Questions	234	(1)
References	235	(2)
Suggested Reading	237	(1)
Monitoring in Mechanical Ventilation	238	(34)
Key Terms	239	(1)
Introduction	239	(1)
Vital Signs	239	(4)
Heart Rate	239	(1)
Blood Pressure	240	(1)
Respiratory Rate	241	(1)
Temperature	242	(1)
Chest Inspection and Auscultation	243	(3)
Chest Movement	243	(1)
Auscultation	243	(3)
Fluid Balance and Anion Gap	246	(2)
Fluid Balance	247	(1)
Anion Gap	247	(1)
Arterial Blood Gases	248	(4)
Assessment of Ventilatory Status	249	(1)
Assessment of Oxygenation Status	250	(2)
Limitations of Blood Gases	252	(1)
Oxygen Saturation Monitoring	252	(4)
Pulse Oximetry	252	(3)
Accuracy and Clinical Use of Pulse Oximetry	255	(1)
Limitations of Pulse Oximetry	255	(1)
Innovations in Pulse Oximetry	256	(1)
End-Tidal Carbon Dioxide Monitoring	256	(5)
Capnography	256	(3)
Capnography Waveforms and Clinical Applications	259	(1)
P(a-et)CO2 Gradient	260	(1)
Limitations of Capnography Monitoring	261	(1)
Transcutaneous Blood Gas Monitoring	261	(2)
Transcutaneous PO2 (PtcO2)	263	(1)
Transcutaneous PCO2 (PtcCO2)	263	(1)
Cerebral Perfusion Pressure	263	(1)
Summary	264	(1)
Self-Assessment Questions	265	(3)
Answers to Self-Assessment Questions	268	(1)
References	268	(3)
Suggested Reading	271	(1)
Hemodynamic Monitoring	272	(31)
Key Terms	273	(1)
Introduction	273	(1)
Hemodynamic Monitoring	273	(2)
Technical Background	273	(1)
Units of Measurement	274	(1)
Types of Catheters	274	(1)
Arterial Catheter	275	(4)
Insertion of Arterial Catheter	275	(1)
Normal Arterial Pressure and Mean Arterial Pressure	276	(1)
Pulse Pressure	277	(1)
Potential Problems with Arterial Catheter	278	(1)
Central Venous Catheter	279	(2)
Insertion of Central Venous Catheter	279	(1)
Components of Central Venous Pressure Waveform	279	(1)
Normal CVP Measurement	280	(1)
Changes in CVP Measurement	281	(1)
Pulmonary Artery Catheter	281	(8)
Insertion of Pulmonary Artery Catheter	282	(1)
Components of Pulmonary Arterial Pressure Waveform	283	(1)
Abnormal Pulmonary Arterial Pressure	283	(3)
Pulmonary Capillary Wedge Pressure	286	(1)
Components of Pulmonary Capillary Wedge Pressure Waveform	287	(1)
Abnormal Pulmonary Capillary Wedge Pressure	288	(1)
Verification of the Wedged Position	288	(1)
Cardiac Output and Cardiac Index	289	(1)
Summary of Preloads and Afterloads	289	(1)
Calculated Hemodynamic Values	290	(1)
Stroke Volume and Stroke Volume Index	290	(1)
Oxygen Consumption and Oxygen Consumption Index	291	(1)
Pulmonary Vascular Resistance	291	(1)
Systemic Vascular Resistance	291	(1)
Monitoring of Mixed Venous Oxygen Saturation	291	(2)
Decrease in Mixed Venous Oxygen Saturation	292	(1)
Increase in Mixed Venous Oxygen Saturation	293	(1)
Impedance Cardiography	293	(4)
Theory of Operation	293	(2)
Thermodilution Method and ICG	295	(1)
Accuracy of ICG	296	(1)
Clinical Applications	296	(1)
Summary	297	(1)
Self-Assessment Questions	297	(2)
Answers to Self-Assessment Questions	299	(1)
References	300	(3)
Ventilator Waveform Analysis	303	(72)
Key Terms	304	(1)
Introduction	304	(2)
Flow Waves Used for Positive Pressure Ventilation	306	(1)
Effects of Constant Flow during Volume-Controlled Ventilation	307	(13)
Flow-Time Waveform	307	(2)
Pressure-Time Waveform	309	(4)
Controlled Mechanical Ventilation	313	(1)
Assist Mandatory Volume-Controlled Ventilation	314	(4)
Mathematical Analysis of Constant Flow Waveform	318	(2)
Spontaneous Ventilation during Mechanical Ventilation	320	(2)
Synchronized Intermittent Mandatory Ventilation	320	(2)
Continuous Positive Airway Pressure	322	(1)
Effects of Flow, Circuit, and Lung Characteristics on Pressure-Time Waveforms	322	(3)
Flow and Transairway Pressure	322	(2)
Compliance and Alveolar Pressure	324	(1)
Effects of Descending Ramp Flow Waveform during Volume-Controlled Ventilation	325	(10)
Time- and Flow-Limited Ventilation	325	(5)
Peak Flow and Tidal Volume Relationship in Time-Limited Ventilation	330	(1)
Effects of End-Flow on Tidal Volume	331	(1)
Distribution of Delivered Tidal Volume	332	(2)
CMV during Descending Ramp Flow Waveform (DRFW) Ventilation	334	(1)
Waveforms Developed during Pressure-Limited Ventilation	335	(3)
Pressure-Controlled Ventilation (PCV)	335	(2)
Inverse Ratio Pressure-Controlled Ventilation (IRPCV)	337	(1)
Pressure Support and Spontaneous Ventilation	338	(4)
Pressure Support Ventilation (PSV)	338	(2)
Adjusting Rise Time During PSV	340	(1)
SIMV (CFW) and PSV	341	(1)
SIMV (DRFW) and PSV	342	(1)
Effects of Lung Characteristics on Pressure-Limited Waveform	342	(2)
Using Waveforms for Patient and Ventilator-System Assessment	344	(8)
Patient-Ventilator Dyssynchrony	345	(1)
Dyssynchrony during Constant Flow Waveform (CFW) Ventilation	346	(3)
Dyssynchrony during Descending Ramp Flow Waveform (DRFW) Ventilation	349	(1)
Changes in Pressure Waveforms during Respiratory Mechanics Measurement	349	(2)
Dyssynchrony during Pressure-Limited Ventilation	351	(1)
Using Expiratory Flow and Pressure Waveforms as Diagnostic Tools	352	(6)
Increased Airway Resistance	352	(2)
Loss of Elastic Recoil	354	(1)
Decreased Lung-Thorax Compliance (CLT)	354	(1)
Gas Trapping and Uncounted Breathing Efforts	355	(3)
Troubleshooting Ventilator Function	358	(2)
Lack of Ventilator Response	358	(1)
Circuit Leaks	358	(2)
Pressure-Volume Loop (PVL) and Flow-Volume Loop (FVL)	360	(5)
Pressure-Volume Loop (PVL)	360	(1)
Effects of Lung-Thorax Compliance on PVL	360	(2)
Effect of Airflow Resistance on PVL	362	(1)
Lower Inflection Point on PVL and Titration of PEEP	362	(2)
Upper Inflection Point on PVL and Adjustment of VT	364	(1)
Effects of Airway Status on Flow-Volume Loop (FVL)	364	(1)
Summary	365	(1)
Self-Assessment Questions	366	(5)
Answers to Self-Assessment Questions	371	(2)
References	373	(1)
Suggested Reading	374	(1)
Management of Mechanical Ventilation	375	(48)
Key Terms	376	(1)
Introduction	376	(1)
Basic Management Strategies	377	(1)
Strategies to Improve Ventilation	377	(5)
Increase Mechanical Rate	378	(1)
Increase Spontaneous Tidal Volume or Rate	379	(1)
Increase Mechanical Tidal Volume	380	(1)
Other Strategies to Improve Ventilation	380	(1)
Permissive Hypercapnia	380	(2)
Strategies to Improve Oxygenation	382	(6)
Increase Inspired Oxygen Fraction (F1O2)	382	(1)
Improve Ventilation and Reduce Mechanical Deadspace	383	(1)
Improve Circulation	384	(1)
Maintain Normal Hemoglobin Level	384	(1)
Initiate Continuous Positive Airway Pressure (CPAP)	384	(1)
Initiate Positive End-Expiratory Pressure (PEEP)	385	(1)
Inverse Ratio Ventilation (IRV)	386	(1)
Extracorporeal Membrane Oxygenation (ECMO)	386	(1)
High Frequency Oscillatory Ventilation for Adults	387	(1)
Acid-Base Balance	388	(2)
Respiratory Acidosis and Compensated Metabolic Alkalosis	388	(1)
Respiratory Alkalosis and Compensated Metabolic Acidosis	389	(1)
Metabolic Acid-Base Abnormalities	390	(1)
Troubleshooting of Common Ventilator Alarms and Events	390	(6)
Low Pressure Alarm	390	(1)
Low Expired Volume Alarm	391	(1)
High Pressure Alarm	392	(1)
High Respiratory Rate Alarm	392	(1)
Apnea/Low Respiratory Rate Alarm	393	(1)
High PEEP Alarm	393	(1)
Low PEEP Alarm	393	(1)
Auto-PEEP	393	(3)
Care of the Ventilator Circuit	396	(3)
Circuit Compliance	396	(1)
Circuit Patency	396	(2)
Humidity and Temperature	398	(1)
Frequency of Circuit Change	398	(1)
Care of the Artificial Airway	399	(3)
Patency of the Endotracheal Tube	399	(1)
Humidification and Removal of Secretions	400	(1)
Ventilator-Associated Pneumonia	400	(2)
Fluid Balance	402	(2)
Distribution of Body Water	402	(1)
Clinical Signs of Extracellular Fluid Deficit or Excess	403	(1)
Treatment of Extracellular Fluid Abnormalities	403	(1)
Electrolyte Balance	404	(3)
Normal Electrolyte Balance	404	(1)
Sodium Abnormalities	405	(1)
Potassium Abnormalities	406	(1)
Nutrition	407	(3)
Undernutrition	407	(1)
Overfeeding	407	(1)
Low-Carbohydrate High-Fat Diet	408	(1)
Total Caloric Requirements	409	(1)
Phosphate Supplement	410	(1)
Adjunctive Management Strategies	410	(3)
Low Tidal Volume	410	(1)
Prone Positioning	411	(1)
Tracheal Gas Insufflation	412	(1)
Summary	413	(1)
Self-Assessment Questions	414	(2)
Answers to Self-Assessment Questions	416	(1)
References	417	(5)
Suggested Reading	422	(1)
Procedures Related to Mechanical Ventilation	423	(32)
Key Terms	424	(1)
Introduction	424	(1)
Chest Tube and Drainage System	424	(9)
Indications for Chest Tube	424	(1)
Chest Tube Selection and Placement	425	(1)
Methods of Placement	426	(3)
Chest Tube Drainage System	429	(3)
Care and Removal of Chest Tube	432	(1)
Transport with Chest Tube	432	(1)
Assisting in Fiberoptic Bronchoscopy	433	(9)
Indications for Fiberoptic Bronchoscopy	433	(2)
Bronchoscope and Medications	435	(2)
Insertion of Bronchoscope	437	(1)
Types of Specimen	437	(3)
Complications	440	(1)
Postbronchoscopy Care	441	(1)
Transport of Mechanically Ventilated Patients	442	(5)
Indications	442	(1)
Contraindications	442	(1)
Equipment and Supplies	442	(1)
Types of Transport	443	(2)
Procedures for Interhospital Transport	445	(1)
Hazards and Complications	446	(1)
Magnetic Resonance Imaging	446	(1)
Summary	447	(1)
Self-Assessment Questions	447	(2)
Answers to Self-Assessment Questions	449	(1)
References	450	(4)
Suggested Reading	454	(1)
Pharmacotherapy for Mechanical Ventilation	455	(42)
Key Terms	456	(1)
Introduction	456	(1)
Drugs for Improving Ventilation	456	(9)
The Autonomic Nervous System	457	(1)
Adrenergic Bronchodilators (Sympathomimetics)	458	(2)
Anticholinergic Bronchodilators (Parasympatholytics)	460	(1)
Xanthine Bronchodilators	461	(2)
Anti-Inflammatory Agents (Corticosteroids)	463	(2)
Delivery of MDI Medications	465	(1)
Neuromuscular Blocking Agents	465	(9)
Mechanism of Action	466	(2)
Characteristics of Neuromuscular Blocking Agents	468	(1)
Factors Affecting Neuromuscular Blockade	468	(3)
Adverse Effects	471	(2)
Evaluation of Neuromuscular Blockade	473	(1)
Sedatives and Antianxiety Agents (Benzodiazepines)	474	(3)
Mechanism of Action	474	(2)
Adverse Effects	476	(1)
Assessment of Sedation	476	(1)
Narcotic Analgesics	477	(5)
Mechanism of Action	478	(1)
Adverse Effects	479	(2)
Clinical Considerations	481	(1)
Assessment of Adequate Pain Control	482	(1)
Agents for Seizures and Elevated Intracranial Pressure (Barbiturates)	482	(2)
Mechanism of Action	483	(1)
Adverse Effects	483	(1)
Drug Interactions	484	(1)
Other Agents Used in Mechanical Ventilation	484	(5)
Propofol	484	(1)
Haloperidol	485	(2)
Nitric Oxide	487	(2)
Summary	489	(1)
Self-Assessment Questions	489	(2)
Answers to Self Assessment Questions	491	(1)
References	492	(3)
Suggested Reading	495	(2)
Weaning from Mechanical Ventilation	497	(30)
Key Terms	498	(1)
Introduction	498	(1)
Definition of Weaning Success and Failure	498	(2)
Weaning Success	499	(1)
Weaning Failure	499	(1)
Patient Condition Prior to Weaning	500	(1)
Weaning Criteria	500	(7)
Ventilatory Criteria	501	(2)
Oxygenation Criteria	503	(1)
Pulmonary Reserve	504	(1)
Pulmonary Measurements	505	(2)
Combined Weaning Indices	507	(2)
Respiratory Frequency to Tidal Volume (f/VT) Ratio	507	(1)
Simplified Weaning Index (SWI)	508	(1)
Compliance Rate Oxygenation and Pressure (CROP) Index	508	(1)
Weaning Procedure	509	(4)
Spontaneous Breathing Trial	509	(1)
SIMV	510	(1)
Pressure Support Ventilation	511	(1)
Others Modes of Partial Ventilatory Support	511	(2)
Weaning Protocol	513	(1)
Signs of Weaning Failure	513	(1)
Causes of Weaning Failure	514	(2)
Increase of Air Flow Resistance	514	(1)
Decrease of Compliance	515	(1)
Respiratory Muscle Fatigue	515	(1)
Terminal Weaning	516	(2)
Prior to Withdrawal	517	(1)
Withdrawal	518	(1)
Summary	518	(1)
Self-Assessment Questions	518	(2)
Answers to Self-Assessment Questions	520	(1)
References	521	(3)
Suggested Reading	524	(3)
Neonatal Mechanical Ventilation	527	(38)
Key Terms	528	(1)
Introduction	528	(1)
Intubation	528	(2)
Indications	528	(1)
Equipment	529	(1)
Surfactant Replacement Therapy	530	(4)
History	531	(1)
Indications	531	(1)
Types of Surfactant and Dosages	532	(2)
Outcomes	534	(1)
Nasal CPAP	534	(1)
Use of Nasal CPAP	534	(1)
Basic Principles of Neonatal Ventilation	535	(3)
Pressure-Limited Ventilation	535	(1)
Volume-Limited Ventilation	536	(1)
Ventilator Circuits and Humidifiers	536	(2)
Initiation of Neonatal Ventilator Support	538	(3)
Indications for Mechanical Ventilation	538	(1)
Initial Ventilator Parameters	539	(2)
High Frequency Ventilation (HFV)	541	(9)
High Frequency Positive Pressure Ventilation (HFPPV)	542	(1)
High Frequency Jet Ventilation (HFJV)	543	(1)
High Frequency Oscillatory Ventilation (HFOV)	544	(3)
Initial HFOV Settings	547	(3)
Other Methods of Ventilation	550	(1)
Liquid Ventilation	550	(1)
Extracorporeal Membrane Oxygenation (ECMO)	550	(5)
History	551	(1)
Patient Selection	551	(1)
ECMO Criteria	551	(1)
Mechanisms of Bypass	552	(1)
Complications	553	(2)
Summary	555	(1)
Self-Assessment Questions	555	(4)
Answers to Self-Assessment Questions	559	(1)
References	560	(3)
Suggested Reading	563	(2)
Home Mechanical Ventilation	565	(16)
Key Terms	566	(1)
Introduction	566	(1)
Goals of Home Mechanical Ventilation	566	(1)
Indications	567	(3)
Diseases that May Justify Home Mechanical Ventilation	567	(3)
Patient Selection	570	(2)
Desires of the Patient	570	(1)
Desires of the Family	571	(1)
Cost	571	(1)
Available Resources	571	(1)
Equipment Selection	572	(3)
Types of Ventilatory Support	572	(3)
Reliability and Safety	575	(1)
Simplicity and Portability	575	(1)
Resources for Home Mechanical Ventilation	575	(1)
Summary	575	(1)
Self-Assessment Questions	576	(2)
Answers to Self-Assessment Questions	578	(1)
References	579	(1)
Suggested Reading	580	(1)
Case Studies	581	(74)
Case 1: COPD	582	(5)
Case 2: Status Asthmaticus	587	(4)
Case 3: Postabdominal Surgery	591	(3)
Case 4: Head Injury	594	(4)
Case 5: Smoke Inhalation	598	(4)
Case 6: Drug Overdose	602	(4)
Case 7: Tension Hemopneumothorax	606	(5)
Case 8: Chest Trauma	611	(6)
Case 9: Adult Respiratory Distress Syndrome	617	(6)
Case 10: Myasthenia Gravis	623	(5)
Case 11: Guillain-Barre	628	(7)
Case 12: Botulism	635	(4)
Case 13: Meconium Aspiration/Patent Ductus Arteriosus	639	(4)
Case 14: Persistent Pulmonary Hypertension of the Newborn	643	(3)
Case 15: Home Care and Disease Management	646	(9)
APPENDIX 1: RESPIRATORY CARE CALCULATIONS	655	(12)
Airway Resistance: Estimated (Raw)	655	(1)
Alveolar-Arterial Oxygen Tension Gradient: P(A-a)O2	655	(2)
Anion Gap	657	(1)
Arterial Oxygen Tension to Inspired Oxygen Concentration (PaO2/F1O2) Index	657	(1)
Compliance: Dynamic (CDYN)	658	(1)
Compliance: Static (CST)	658	(1)
Corrected Tidal Volume (VT)	659	(1)
Deadspace to Tidal Volume Ratio (VD/VT)	660	(1)
Mean Airway Pressure (mPaw)	660	(1)
Minute Ventilation: Expired and Alveolar	661	(1)
Oxygen Index (Ol)	662	(1)
Shunt Equation (QSP/QT): Classic Physiologic	662	(1)
Shunt Equation (QSP/QT): Estimated	663	(1)
Ventilator Rate Neede0d for a Desired PaCO2	664	(1)
Weaning Index: Rapid Shallow Breathing	665	(1)
Weaning Index: Simplified	665	(2)
APPENDIX 2: DUBOIS BODY SURFACE CHART	667	(1)
APPENDIX 3: PRESSURE CONVERSIONS	668	(1)
APPENDIX 4: FRENCH (FR) AND MILLIMETER (MM) CONVERSIONS	669	(1)
APPENDIX 5: NORMAL ELECTROLYTE CONCENTRATIONS IN PLASMA	670	(1)
APPENDIX 6: OXYGEN TRANSPORT NORMAL RANGES	671	(1)
APPENDIX 7: HEMODYNAMIC NORMAL RANGES	672	(3)
APPENDIX 8: GLASGOW COMA SCORE	675	(1)
APPENDIX 9: APACHE II SEVERITY OF DISEASE CLASSIFICATION SYSTEM	676	(2)
Index	678