Mechanical Ventilation : Physiological and Clinical Applications

by Pilbeam & Cairo

• ISBN13: 9780323032360
• ISBN10: 0323032362
• Edition: 4th
• Format: Paperback
• Copyright: 2006-02-08
• Publisher: Mosby

Summary

Reorganized to better reflect the order in which mechanical ventilation is typically taught, this text focuses on the management of patients who are receiving mechanical ventilatory support and provides clear discussion of mechanical ventilation and its application. The 4th edition features two-color illustrations, an increased focus on critical thinking, a continued emphasis on ventilator graphics, and several new chapters including non-invasive positive pressure ventilation and long-term ventilation. Excerpts of the most recent CPGs are included to give students important information regarding indications/contraindications, hazards and complications, assessment of need, assessment of outcome, and monitoring. Clinical Rounds boxes contain problems that may be encountered during actual use of equipment and raise questions for the student to answer. Case studies are included as boxes throughout the chapters within boxes and Clinical Rounds. Historical Notes provide educationally or clinically relevant information. Chapters featuring topics such as methods to improve ventilation, frequently used pharmacologic agents in ventilated patients, cardiovascular complications, pulmonary complications, noninvasive positive pressure ventilation, and long-term ventilation have been added. Key Point boxes have been placed sporadically throughout the chapters and highlight key information for the reader. Increased number of NBRC-type questions reflecting the types of questions and amount of coverage on the board exams. Respected educator J.M. Cairo has been added as co-author, bringing in a fresh voice and a wide breadth of experience. A reorganization of chapters creates a text that is more in line with the way the course is typically taught. lAll chapters have been heavily revised and updated, particularly the chapters on ventilator graphics, methods to improve oxygenation, and neonatal and pediatric ventilation. A second color has been added to enhance the overall design and line drawings. Key terms are listed at the beginning of each chapter and highlighted at first mention.

Table of Contents

PART 1 Basic Concepts and Core Knowledge in Mechanical Ventilation
Oxygenation and Acid-Base Evaluation	1	(14)
Review of Arterial Blood Gases	2	(1)
Evaluating Oxygenation	2	(2)
Evaluating the Transfer and Uptake of Oxygen from the Alveoli---P(A-a)O2, PaO2/PAO2, and PaCO2/F1O2	4	(2)
Changes in Alveolar Ventilation Associated with Changes in PAO2 and PACO2	6	(1)
Alveolar Ventilation, PaCO2, and VCO2	7	(1)
Changes in pH, PaCO2, and Sodium Bicarbonate	7	(1)
Changes in pH caused by Changes in PaCO2	8	(1)
Changes in Plasma Bicarbonate Caused by Changes in PaCO2	8	(3)
Metabolic Changes in Bicarbonate and pH	11	(4)
Basic Terms and Concepts of Mechanical Ventilation	15	(16)
Section I: Physiological Terms and Concepts Related to Mechanical Ventilation	16	(7)
Normal Mechanics of Spontaneous Ventilation	16	(2)
Lung Characteristics	18	(3)
Time Constants	21	(2)
Section II: Types of Ventilators and Terms Applied to Mechanical Ventilation	23	(8)
Types of Mechanical Ventilation	23	(3)
Definition of Pressures in Positive Pressure Ventilation	26	(5)
How Ventilators Work	31	(14)
Historical Perspective on Ventilator Classification	32	(1)
Internal Function	32	(1)
Power Source or Input Power	32	(3)
Control Systems and Circuits	35	(4)
Power Transmission and Conversion System	39	(6)
How a Breath Is Delivered	45	(18)
Basic Model of Ventilation in the Lung during Inspiration	46	(1)
Factors Controlled and Measured by the Ventilator during Inspiration	47	(1)
Overview of Inspiratory Waveform Control	48	(1)
Four Phases of a Breath and Phase Variables	49	(1)
Beginning of Inspiration: The Trigger Variable	50	(1)
Inspiratory Factors: The Limit Variable	51	(3)
Termination of the Inspiratory Phase: The Cycling Mechanism (Cycle Variable)	54	(2)
Types of Breaths	56	(1)
Expiratory Phase: The Baseline Variable	57	(6)
PART 2 Initiating Ventilation
Establishing the Need for Mechanical Ventilation	63	(18)
Acute Respiratory Failure	64	(1)
Patient History and Diagnosis	65	(4)
Physiological Measurements in Acute Respiratory Failure	69	(3)
Overview of Criteria for Mechanical Ventilation	72	(1)
Possible Alternatives to Invasive Ventilation	72	(3)
Patient Cases	75	(6)
Selecting the Ventilator and the Mode	81	(24)
Invasive or Noninvasive Ventilation: Selecting the Patient Interface	82	(1)
Methods of Noninvasive Support and Appropriate Patient Interfaces	82	(2)
Full and Partial Ventilatory Support	84	(1)
Mode of Ventilation and Breath Delivery	84	(1)
Type of Breath Delivery	84	(1)
Targeting Volume as the Control Variable	84	(1)
Targeting Pressure as the Control Variable	85	(2)
Breath Delivery and Modes of Ventilation	87	(9)
Bilevel Positive Airway Pressure	96	(1)
Closed Loop Ventilation	96	(1)
Less Frequently Used Closed Loop Modes of Ventilation	97	(8)
Initial Ventilator Settings	105	(22)
Determining Initial Ventilator Setting during Volume Ventilation	106	(1)
Section I: Initial Settings during Volume Ventilation	106	(11)
Setting Minute Ventilation	106	(2)
Tidal Volume and Rate	108	(3)
Relationship of Tidal Volume, Flow, Total Cycle Time, and Inspiratory to Expiratory Ratio	111	(2)
Inspiratory Flow and Flow Patterns	113	(3)
Setting the Minute Ventilation: Special Considerations	116	(1)
Inspiratory Pause during Volume Ventilation	116	(1)
Actual Clinical Examples of Ventilator Adjustment	117	(1)
Section II: Determining Initial Ventilator Settings during Pressure Ventilation	117	(10)
Setting Baseline Pressure-Physiological PEEP	118	(1)
Determining Tidal Volume Delivery in Pressure Ventilation	118	(1)
Initial Settings for Pressure Support Ventilation	118	(2)
Initial Settings for Pressure Control Ventilation	120	(1)
Initial Settings for Bilevel Positive Airway Pressure Ventilation	120	(1)
Initial Settings for Dual Control Pressure Ventilation Modes with Volume Targeting	121	(6)
Final Considerations in Ventilator Setup	127	(24)
Section I: Selection of Additional Parameters and Final Ventilator Setup	128	(8)
Selection of Fractional Inspired O2	128	(1)
Sensitivity Setting	128	(1)
Humidification	129	(3)
Alarms	132	(1)
Action during Ventilator Alarm Situations	133	(1)
Periodic Hyperinflation or Sighing	133	(2)
Final Considerations in Ventilator Equipment Setup	135	(1)
Selecting the Appropriate Ventilator	135	(1)
Evaluation of Ventilator Performance	136	(1)
Section II: Initial Ventilator Settings for Specific Patient Situations	136	(15)
Chronic Obstructive Pulmonary Disease	136	(3)
Neuromuscular Disorders	139	(1)
Asthma	140	(1)
Closed Head Injury	141	(2)
Adult Respiratory Distress Syndrome	143	(2)
Acute Cardiogenic Pulmonary Edema and Congestive Heart Failure	145	(6)
PART 3 Monitoring in Mechanical Ventilation
Initial Assessment of the Mechanically Ventilated Patient	151	(26)
Documentation of the Patient-Ventilator System	152	(1)
The First 30 Minutes	153	(5)
Monitoring Airway Pressures	158	(3)
Vital Signs, Blood Pressure, and Physical Examination of the Chest	161	(3)
Management of Endotracheal and Tracheostomy Tube Cuffs	164	(4)
Monitoring Compliance and Airway Resistance	168	(4)
Comment Section of the Ventilator Flow Sheet	172	(5)
Ventilator Graphics	177	(28)
Relationship of Pressure, Volume, Flow, and Time	178	(1)
Section I: Volume Ventilation with Constant Flow	179	(8)
Producing Ventilator Graphics	179	(1)
Calculations	180	(1)
A Closer Look at the Flow-Time Scalar in VC-CMV	181	(3)
Changes in the Pressure-Time Curve	184	(1)
Volume Scalar	185	(2)
Key Points of Volume Ventilation Graphics	187	(1)
Section II: Pressure Ventilation	187	(4)
Pressure Ventilation with a Constant Pressure Waveform	187	(3)
Key Points of Pressure Ventilation Graphics	190	(1)
Section III: Pressure Support Ventilation	191	(3)
Details of the Pressure-Time Waveform in PSV	191	(3)
Flow Cycling during PSV	194	(1)
Automatic Adjustment of the Flow-Cycle Criterion	194	(1)
Use of PSV with SIMV	195
Section IV: Pressure-Volume Loops	194	(5)
Components of the P-V Loop	195	(3)
P-V Loop and WOB	198	(1)
Troubleshooting a P-V Loop	199	(1)
Section V: Flow-Volume Loops during Mechanical Ventilation	199	(6)
Components of an F-V Loop with Mandatory Breaths	199	(2)
Troubleshooting with F-V Loops during Mechanical Ventilation	201	(4)
Noninvasive Assessment of Respiratory Function	205	(26)
Section I: Noninvasive Measurement of Blood Gases	206	(13)
Pulse Oximetry	206	(4)
Capnography and Capnometry	210	(8)
Transcutaneous Monitoring	218	(1)
Section II: Indirect Calorimetry and Metabolic Measurements	219	(3)
Overview of Indirect Calorimetry	219	(1)
Technical Aspects	219	(3)
Section III: Assessment of Respiratory System Mechanics	222	(9)
Airway Pressure Measurements	222	(1)
Flow Measurements	223	(1)
Clinical Applications	223	(8)
Hemodynamic Monitoring	231	(26)
Review of Cardiovascular Principles	232	(3)
Obtaining Hemodynamic Measurements	235	(5)
Interpretation of Hemodynamic Profiles	240	(9)
Clinical Applications	249	(8)
PART 4 Therapeutic Interventions---Making Appropriate Changes
Methods to Improve Ventilation and Other Techniques in Patient-Ventilator Management	257	(38)
Section I: Correcting PaCO2 Abnormalities	258	(8)
Common Methods of Changing Ventilation Based on PaCO2 and pH	258	(3)
Metabolic Acidosis and Alkalosis	261	(1)
Mixed Acid-Base Disturbances	262	(1)
Increased Physiological Dead Space	263	(1)
Increased Metabolism and Increased CO2 Production	264	(1)
Intentional latrogenic Hyperventilation	264	(1)
Permissive Hypercapnia	264	(2)
Section II: Airway Clearance during Mechanical Ventilation	266	(13)
Secretion Clearance from an Artificial Airway	266	(6)
Administering Aerosols to Ventilated Patients	272	(5)
Chest Physiotherapy in Mechanically Ventilated Patients	277	(1)
Flexible Fiberoptic Bronchoscopy during Mechanical Ventilation	278	(1)
Section III: Additional Patient Management Techniques and Therapies in Ventilated Patients	279	(16)
Importance of Body Position and Positive Pressure Ventilation	279	(4)
Ventilator Circuit Changes	283	(2)
Sputum and Upper Airway Infections	285	(1)
Fluid Balance	285	(1)
Psychological and Sleep Status	286	(1)
Patient Comfort and Safety	287	(1)
Transport of Mechanically Ventilated Patients within an Acute Care Facility	288	(7)
Improving Oxygenation and Management of ARDS	295	(40)
Section I: Basics of Oxygenation Using F1O2, PEEP studies, and Pressure-Volume Curves for Establishing Optimum PEEP	297	(15)
Basics of Oxygen Delivery to the Tissues	297	(2)
Introduction to Positive End-Expiratory Pressure and Continuous Positive Airway Pressure	299	(2)
PEEP Ranges	301	(1)
Indications for PEEP/CPAP	301	(1)
Initiating PEEP Therapy	302	(1)
Selecting the Appropriate PEEP/CPAP Level (Optimum PEEP)	303	(4)
Use of Pulmonary Vascular Pressure Monitoring with PEEP	307	(1)
Pressure-Volume Loops in Setting PEEP	308	(4)
Section II: Contraindications and Physiological Effects of PEEP	312	(4)
Contraindications for PEEP	312	(1)
Pulmonary Effects of PEEP	313	(1)
Transmission of Airway Pressure to Pleural Space	313	(1)
Uses of PEEP for Problems Other than Acute Lung Injury	314	(1)
Weaning from PEEP	315	(1)
Section III: Acute Respiratory Distress Syndrome	316	(5)
Definition and Epidemiology	316	(1)
Pathophysiology	317	(1)
Changes in Computed Tomogram with ARDS	317	(1)
ARDS as an Inflammatory Process	318	(2)
PEEP and the Vertical Gradient in ARDS	320	(1)
Lung Protective Strategies: Setting Tidal Volume and Pressures in ARDS	320	(1)
Long-Term Follow-Up on ARDS	321	(1)
Section IV: Recruitment Maneuvers in ARDS	321	(6)
Illustration of a Recruitment Maneuver	322	(1)
The Function of Lung Recruitment	322	(2)
Hazards of Recruitment Maneuvers	324	(1)
Variability among Patients	324	(1)
Effects of Chest Wall Compliance on Lung Recruitment	324	(1)
Patient Evaluation for Lung Recruitment	325	(1)
Types of Recruitment Maneuvers	325	(1)
Summary of Recruitment Maneuvers in ARDS	326	(1)
Section V: Patient Cases	327	(8)
Case Study: Adult Respiratory Distress Syndrome	327	(1)
Case Study: Congestive Heart Failure	328	(7)
Frequently Used Pharmacological Agents in Ventilated Patients: Sedatives, Analgesics, and Paralytics	335	(10)
Sedatives and Analgesics	336	(5)
Paralytics	341	(4)
PART 5 Effects and Complications of Mechanical Ventilation
Effects of Positive Pressure Ventilation on the Cardiovascular, Cerebral, Renal, and Other Organ Systems	345	(12)
Section I: Effects of Positive Pressure Ventilation on the Heart and Thoracic Vessels	346	(5)
Adverse Cardiovascular Effects of PPV	346	(1)
Factors Influencing Cardiovascular Effects of PPV	347	(1)
Beneficial Effects of PPV on Heart Function in Patients with Left Ventricular Dysfunction	348	(1)
Minimizing the Physiological Effects and Complications of Mechanical Ventilation	349	(2)
Section II: Effects of Mechanical Ventilation on Intracranial Pressure, Renal Function, Liver Function, and Gastrointestinal Function	351	(6)
Effects of Mechanical Ventilation on Intracranial Pressure and Cerebral Perfusion	351	(1)
Renal Effects of Mechanical Ventilation	352	(1)
Effects of Mechanical Ventilation on Liver and Gastrointestinal Function	353	(1)
Nutritional Complications during Mechanical Ventilation	354	(3)
Effects of Positive Pressure Ventilation on the Pulmonary System	357	(34)
Lung Injury with Mechanical Ventilation	358	(6)
Effects of Mechanical Ventilation on Gas Distribution and Pulmonary Blood Flow	364	(1)
Nosocomial Infections and Ventilator-Associated Pneumonia	365	(6)
Respiratory and Metabolic Acid-Base Status in Mechanical Ventilation	371	(2)
Air Trapping (Auto-PEEP)	373	(3)
Hazards of Oxygen Therapy with Mechanical Ventilation	376	(1)
Increased Work of Breathing	376	(7)
Ventilator Mechanical and Operational Hazards	383	(1)
Complications of the Artificial Airway	384	(7)
Troubleshooting and Problem Solving	391	(26)
Definition of the Term Problem	392	(1)
Solving Ventilation Problems	392	(1)
Protecting the Patient	393	(1)
Identifying the Patient in Sudden Distress	393	(1)
Patient-Related Problems	393	(4)
Ventilator-Related Problems	397	(2)
Common Alarm Situations	399	(3)
Use of Graphics to Identify Ventilator Problems	402	(4)
Unexpected Ventilator Responses	406	(11)
PART 6 Noninvasive Positive Pressure Ventilation
Basic Concepts of Noninvasive Positive Pressure Ventilation	417	(26)
Noninvasive Ventilation Techniques	418	(1)
Goals and Indications for NPPV	419	(4)
Patient Selection Criteria	423	(1)
Equipment Selection for NPPV	424	(8)
Setup and Preparation for NPPV	432	(1)
Monitoring and Adjustment of NPPV	433	(2)
Complications of NPPV	435	(1)
Patient Weaning and Discontinuation of NPPV	436	(1)
Patient Care Team Concerns	436	(7)
PART 7 Discontinuation from Ventilation and Long-Term Ventilation
Discontinuation of and Weaning from Mechanical Ventilation	443	(30)
Section I: Weaning Techniques	444	(7)
Methods of Titrating Ventilator Support during Weaning	445	(3)
Closed Loop Modes for Ventilator Discontinuation	448	(3)
Section II: Evidence-Based Weaning	451	(9)
Evaluation of Clinical Criteria for Weaning	451	(1)
Recommendation 1: Pathology of Ventilator Dependence	452	(4)
Recommendation 2: Assessment of Readiness for Weaning Using Evaluation Criteria	456	(1)
Recommendation 3: Assessment during a Spontaneous Breathing Trial	457	(1)
Recommendation 4: Removal of the Artificial Airway	457	(3)
Section III: Factors in Weaning Failure	460	(4)
Recommendation 5: SBT Failure	460	(1)
Nonrespiratory Factors That May Complicate Weaning	460	(4)
Recommendation 6: Maintaining Ventilation in Patients with SBT Failure	464	(1)
Section IV: Final Recommendations	464	(9)
Recommendation 7: Anesthesia and Sedation Strategies and Protocols	464	(1)
Recommendation 8: Weaning Protocols	464	(1)
Recommendation 9: Role of Tracheostomy in Weaning	465	(1)
Recommendation 10: Long-Term Care Facilities for Patients Requiring Prolonged Ventilation	466	(1)
Recommendation 11: Clinician Familiarity with Long-Term Care Facilities	466	(1)
Recommendation 12: Weaning in Long-Term Ventilation Units	466	(1)
Ethical Dilemma: Withholding and Withdrawing Ventilatory Support	467	(6)
Long-Term Ventilation	473	(36)
Goals of LTMV	474	(1)
Sites for Ventilator-Dependent Patients	475	(2)
Patient Selection	477	(1)
Preparation for Discharge to the Home	478	(1)
Follow-Up and Evaluation	479	(2)
Equipment Selection for Patients to Be Ventilated at Home	481	(6)
Complications of Long-Term Positive Pressure Ventilation	487	(1)
Alternatives to Invasive Mechanical Ventilation at Home	488	(6)
Expiratory Muscle Aids and Secretion Clearance	494	(1)
TTs, Speaking Valves, and Tracheal Buttons	495	(6)
Ancillary Equipment and Equipment Cleaning for Home Mechanical Ventilation	501	(8)
PART 8 Special Applications of Mechanical Ventilation
Neonatal and Pediatric Mechanical Ventilation	509	(40)
Recognizing the Need for Mechanical Ventilatory Support	510	(1)
Continuous Positive Airway Pressure	511	(4)
Conventional Mechanical Ventilation	515	(20)
Weaning and Extubation	535	(1)
High-Frequency Ventilation	535	(14)
Special Techniques in Ventilatory Support	549	(32)
Section I: Airway Pressure-Release Ventilation	550	(5)
Other Names	550	(1)
Advantages of APRV Compared with Conventional Ventilation	551	(1)
Disadvantages	552	(1)
Initial Settings for APRV	553	(1)
Adjusting Ventilation and Oxygenation	554	(1)
Discontinuing APRV	554	(1)
Section II: High-Frequency Oscillatory Ventilation in the Adult	555	(6)
Technical Aspects	555	(1)
Initial Control Settings for HFOV in the Adult	556	(2)
Indication and Exclusion Criteria for HFOV in the Adult	558	(1)
Monitoring, Assessment, and Adjustment of HFO	558	(1)
Adjusting Settings to Maintain ABG Goals	559	(2)
Returning to Conventional Ventilation	561	(1)
Section III: Heliox Therapy and Mechanical Ventilation	561	(8)
Gas Flow through the Airways	562	(1)
Heliox in Avoiding Intubation and during Mechanical Ventilation	563	(1)
Postextubation Stridor	563	(1)
Devices for Delivering Heliox in Spontaneously Breathing Patients	563	(2)
Manufactured Heliox Delivery System	565	(1)
Heliox and Aerosol Delivery during Mechanical Ventilation	566	(1)
Heliox with a Mechanical Ventilator	566	(2)
Heliox and NPPV	568	(1)
Section IV: Independent Lung Ventilation	569	(4)
Ventilator Procedure for ILV	569	(1)
Thoracoabdominal Aortic Aneurism Repair	570	(1)
Establishing Safe PEEP and Ventilation with a Slow Flow Inflection Maneuver for Assessment of Lung Characteristics	571	(1)
Establishing Mechanical Ventilation after TAAA	571	(1)
Recruitment Maneuvers in Postoperative Patients	572	(1)
Section V: Intrapulmonary Percussive Ventilation	573	(8)
Equipment	573	(1)
Administration by Mouthpiece	573	(1)
Administration through a Ventilator	574	(7)
Appendix A	581	(20)
Appendix B	601	(6)
Appendix C	607	(6)
Glossary	613