Pilbeam's Mechanical Ventilation: Physiological and Clinical Applications

Front Cover
IFC
Title Page
Pilbeam's Mechanical Ventilation, 8th edition
Copyright
Dedication
Contributors
Preface
ORGANIZATION
FEATURES
LEARNING AIDS
Workbook
FOR EDUCATORS
Acknowledgments
Contents
1 - Basic Terms and Concepts of Mechanical Ventilation
PHYSIOLOGICAL TERMS AND CONCEPTS RELATED TO MECHANICAL VENTILATION
NORMAL MECHANICS OF SPONTANEOUS VENTILATION
Ventilation and Respiration
Gas Flow and Pressure Gradients During Ventilation
Units of Pressure
Definitions of Pressures and Gradients in the Lungs
Transairway Pressure
Transthoracic Pressure
Transpulmonary Pressure
Transrespiratory Pressure
LUNG CHARACTERISTICS
Compliance
Resistance
Measuring Airway Resistance
TIME CONSTANTS
TYPES OF VENTILATORS AND TERMS USED IN MECHANICAL VENTILATION
TYPES OF MECHANICAL VENTILATION
Negative Pressure Ventilation
Positive Pressure Ventilation
High-Frequency Ventilation
DEFINITION OF PRESSURES IN POSITIVE PRESSURE VENTILATION
Baseline Pressure
Peak Pressure
Plateau Pressure
Pressure at the End of Exhalation
SUMMARY
References
2 - How Ventilators Work
HISTORICAL PERSPECTIVE ON VENTILATOR CLASSIFICATION
INTERNAL FUNCTION
POWER SOURCE OR INPUT POWER
Electrically Powered Ventilators
Pneumatically Powered Ventilators
Positive and Negative Pressure Ventilators
CONTROL SYSTEMS AND CIRCUITS
Open-Loop and Closed-Loop Systems to Control Ventilator Function
Control Panel (User Interface)
Pneumatic Circuit
Internal Pneumatic Circuit
External Pneumatic Circuit
POWER TRANSMISSION AND CONVERSION SYSTEM
Compressors (Blowers)
Volume Displacement Designs
Volume Flow-Control Valves
SUMMARY
References
3 - How a Breath Is Delivered
BASIC MODEL OF VENTILATION IN THE LUNG DURING INSPIRATION
FACTORS CONTROLLED AND MEASURED DURING INSPIRATION
Pressure-Controlled Breathing
Volume-Controlled Breathing
Flow-Controlled Breathing
Time-Controlled Breathing
OVERVIEW OF INSPIRATORY WAVEFORM CONTROL
PHASES OF A BREATH AND PHASE VARIABLES
Beginning of Inspiration: The Trigger Variable
Time Triggering
Patient Triggering
The Limit Variable During Inspiration
Pressure Limiting
Volume Limiting
Flow Limiting
Maximum Safety Pressure: Pressure Limiting Versus Pressure Cycling
Termination of the Inspiratory Phase: The Cycling Mechanism (Cycle Variable)
Volume-Cycled Ventilation
Set Volume Versus Actual Delivered Volume
Tubing Compressibility
System Leaks
Time-Cycled Ventilation
Flow-Cycled Ventilation
Pressure-Cycled Ventilation
Inflation Hold (Inspiratory Pause)
Expiratory Phase: The Baseline Variable
Definition of Expiration
Baseline Pressure
Time-Limited Expiration
Continuous Gas Flow During Expiration
Expiratory Hold (End-Expiratory Pause)
Expiratory Retard
Continuous Positive Airway Pressure and Positive End-Expiratory Pressure
TYPES OF BREATHS
SUMMARY
References
4 - Establishing the Need for Mechanical Ventilation
ACUTE RESPIRATORY FAILURE
Recognizing the Patient in Respiratory Distress
Definition of Respiratory Failure
Recognizing Hypoxemia and Hypercapnia
PATIENT HISTORY AND DIAGNOSIS
Central Nervous System Disorders
Neuromuscular Disorders
Increased Work of Breathing
PHYSIOLOGICAL MEASUREMENTS IN ACUTE RESPIRATORY FAILURE
Bedside Measurements of Ventilatory Mechanics
Maximum Inspiratory Pressure
Vital Capacity
Peak Expiratory Flow and Forced Expiratory Volume in 1 Second
Respiratory Rate and Minute Ventilation
Failure of Ventilation and Increased Dead Space
Failure of Oxygenation
OVERVIEW OF CRITERIA FOR MECHANICAL VENTILATION
POSSIBLE ALTERNATIVES TO INVASIVE VENTILATION
Noninvasive Positive Pressure Ventilation
Intubation Without Ventilation
Ethical Considerations
SUMMARY
References
5 - Selecting the Ventilator and the Mode
NONINVASIVE AND INVASIVE POSITIVE PRESSURE VENTILATION: SELECTING THE PATIENT INTERFACE
Noninvasive Positive Pressure Ventilation
Continuous Positive Airway Pressure
Noninvasive Positive Pressure Ventilation
Invasive Positive Pressure Ventilation
FULL AND PARTIAL VENTILATORY SUPPORT
BREATH DELIVERY AND MODES OF VENTILATION
Type of Breath Delivery
Mandatory Breaths
Spontaneous Breaths
Assisted Breaths
Targeting Volume as the Control Variable
Targeting Pressure as the Control Variable
Timing of Breath Delivery
MODES OF VENTILATION
History of Intermittent Positive Pressure Breathing and Intermittent Positive Pressure Ventilation: Understanding the Termi ...
Continuous Mandatory Ventilation
Controlled Ventilation
Assisted Ventilation
Volume-Controlled Continuous Mandatory Ventilation
Pressure-Controlled Continuous Mandatory Ventilation
Intermittent Mandatory Ventilation
Spontaneous Modes
Spontaneous Breathing
Continuous Positive Airway Pressure
Pressure Support Ventilation
Additional settings in pressure support ventilation
BILEVEL POSITIVE AIRWAY PRESSURE
ADDITIONAL MODES OF VENTILATION
Pressure Augmentation
Pressure-Regulated Volume Control
Volume Support Ventilation
Mandatory Minute Ventilation
Adaptive Support Ventilation
Airway Pressure Release Ventilation
Proportional Assist Ventilation
Neurally Adjusted Ventilatory Assist
SUMMARY
References
6 - Initial Ventilator Settings
DETERMINING INITIAL VENTILATOR SETTINGS DURING VOLUME-CONTROLLED VENTILATION
INITIAL SETTINGS DURING VOLUME-CONTROLLED VENTILATION
Setting Minute Ventilation
Tidal Volume and Rate
Tubing Compliance
Mechanical Dead Space Considerations
Relationship of Tidal Volume, Flow, Total Cycle Time, and Inspiratory-to-Expiratory Ratio
Calculating Total Cycle Time and Respiratory Rate
Calculating Inspiratory-to-Expiratory Ratio
Inspiratory Time, Tidal Volume, and Flow
Flow, Tidal Volume, and Inspiratory Time
Inspiratory Flow and Flow Patterns
Rate of Gas Flow
Flow Patterns
Constant flow
Descending ramp
Ascending ramp
Sine flow
Comparison of descending ramp and constant flow
Concerns about high peak inspiratory pressure and mean airway pressure
Effects of changing flow pattern in time-cycled versus volume-cycled ventilators
SETTING THE MINUTE VENTILATION: SPECIAL CONSIDERATIONS
INSPIRATORY PAUSE DURING VOLUME VENTILATION
DETERMINING INITIAL VENTILATOR SETTINGS DURING PRESSURE VENTILATION
SETTING BASELINE PRESSURE: PHYSIOLOGICAL POSITIVE END-EXPIRATORY PRESSURE
Determining Tidal Volume Delivery in Pressure Ventilation
Initial Settings for Pressure Support Ventilation
Initial Settings for Pressure Control Ventilation
Initial Settings for Bilevel Positive Airway Pressure Ventilation
Initial Settings for Pressure Ventilation Modes With Volume Targeting
Initial Settings of Pressure-Regulated Volume Control
Initial Settings of Volume Support
SUMMARY
References
7 - Final Considerations in Ventilator Setup
SELECTION OF ADDITIONAL PARAMETERS AND FINAL VENTILATOR SETUP
Selection of Fractional Concentration of Inspired Oxygen
SENSITIVITY SETTING
Humidification
Heated Humidifiers
Heat-Moisture Exchangers
ALARMS
Action During Ventilator Alarm Situations
PERIODIC HYPERINFLATION OR SIGHING
FINAL CONSIDERATIONS IN VENTILATOR EQUIPMENT SETUP
Preparing the Patient
Establishing an Interface
Manual Ventilation
Cardiovascular Stabilization
Ventilator Needs
Treating the Cause of Respiratory Failure
SELECTING THE APPROPRIATE VENTILATOR
EVALUATION OF VENTILATOR PERFORMANCE
Initial Ventilator Settings for Specific Patient Situations
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Guidelines for Patients With Chronic Obstructive Pulmonary Disease
ASTHMA
Guidelines for Patients With Asthma
NEUROMUSCULAR DISORDERS
Guidelines for Patients With Neuromuscular Disorders
CLOSED HEAD INJURY
Guidelines for Patients With a Closed Head Injury
ACUTE RESPIRATORY DISTRESS SYNDROME
Guidelines for Patients With ARDS
ACUTE CARDIOGENIC PULMONARY EDEMA AND CONGESTIVE HEART FAILURE
Guidelines for Patients With Congestive Heart Failure
SUMMARY
References
8 - Initial Patient Assessment
DOCUMENTATION OF THE PATIENT-VENTILATOR SYSTEM
THE FIRST 30 MINUTES
Mode
Sensitivity
Tidal Volume, Rate, and Minute Ventilation
Correcting Tubing Compliance
Alveolar Ventilation
Dead Space
Added Mechanical Dead Space
Final Alveolar Ventilation
MONITORING AIRWAY PRESSURES
Peak Inspiratory Pressure
Plateau Pressure
Set Pressure
Transairway Pressure: PIP Minus Pplat
Mean Airway Pressure
End-Expiratory Pressure
Driving Pressure
Pressure Limit
Low-Pressure Alarm
Checking the Circuit: Checking for Leaks
VITAL SIGNS, BLOOD PRESSURE, AND PHYSICAL EXAMINATION OF THE CHEST
Heart Rate
Temperature
Systemic Arterial Blood Pressure
Central Venous Pressure
Pulmonary Artery Pressure
Physical Examination of the Chest
MANAGEMENT OF ENDOTRACHEAL TUBE AND TRACHEOSTOMY TUBE CUFFS
Cuff Pressure Measurement
High Cuff Pressure
Nonexistent or Low Cuff Pressure
Cut in the Pilot Tube
Tube and Mouth Care
MONITORING COMPLIANCE AND AIRWAY RESISTANCE
Static Compliance
Dynamic Characteristic (Dynamic Compliance)
Airway Resistance
Bedside Measurement of Pressure-Volume Curves
COMMENT SECTION OF THE VENTILATOR FLOW SHEET
SUMMARY
References
9 - Ventilator Graphics
RELATIONSHIP OF FLOW, PRESSURE, VOLUME, AND TIME
A CLOSER LOOK AT SCALARS, CURVES, AND LOOPS
Scalars
Comparison of Pressure-Controlled Ventilation and Volume-Controlled Ventilation
Determining the Mode of Ventilation
Components of the Pressure-Volume Loop
Spontaneous Breaths and Pressure-Volume Loops
Components of the Flow-Volume Loop
Summary: Normal Scalars, Loops, and Curves
USING GRAPHICS TO MONITOR PULMONARY MECHANICS
ASSESSING PATIENT-VENTILATOR ASYNCHRONY
ADVANCED APPLICATIONS
Auto-PEEP and Air Trapping
Titrating PEEP
APRV Settings
Integrated Ventilator and Esophageal Graphics
Assessing Overdistention During Pressure-Controlled Ventilation
Inspiratory Rise Time Control: Sloping or Ramping
Flow Cycling During Pressure Support Ventilation
SUMMARY
Bibliography
10 - Assessment of Respiratory Function
NONINVASIVE MEASUREMENTS OF BLOOD GASES
Pulse Oximetry
Physiological and Technical Concerns
Low Perfusion States
Dysfunctional Hemoglobins and Dyes
Nail Polish
Skin Pigmentation
Ambient Light
Clinical Applications
CAPNOGRAPHY (CAPNOMETRY)
Technical Considerations
Chemical Methods
Infrared Spectroscopy
Physiological Considerations
Clinical Applications
Capnograph Contours
Arterial to Maximum End-Expiratory PCO2 Difference
Volumetric Capnometry
Description of the Single-Breath CO2 Curve
Single-Breath CO2 Loop of Inspiration and Exhalation
Trending CO2 Production and Alveolar Minute Ventilation Over Time
EXHALED NITRIC OXIDE MONITORING
TRANSCUTANEOUS MONITORING
Transcutaneous PO2
Transcutaneous PCO2
Technical Considerations
INDIRECT CALORIMETRY AND METABOLIC MEASUREMENTS
Overview of Indirect Calorimetry
Technical Considerations
Obtaining Indirect Calorimetry Measurements
Clinical Applications of Metabolic Measurements
ASSESSMENT OF RESPIRATORY SYSTEM MECHANICS
MEASUREMENTS
Airway Pressure Measurements
Flow Measurements
Clinical Applications
Measured Variables
Derived Variables
Mean airway pressure
Dynamic and static compliances
Airway resistance
Work of breathing
Work of breathing defined
Graphic representation of WOB
Pressure-time product
Occlusion pressure measurements
SUMMARY
References
11 - Hemodynamic Monitoring
REVIEW OF CARDIOVASCULAR PRINCIPLES
Factors Influencing Cardiac Output
OBTAINING HEMODYNAMIC MEASUREMENTS
Hemodynamic Monitoring Systems
Fluid Pressures
Systemic Artery Catheterization
Central Venous Lines
Pulmonary Artery Catheterization
INTERPRETATION OF HEMODYNAMIC PROFILES
Heart Rate
Systemic Arterial Pressure
Right Atrial and Pulmonary Artery Pressures
Atrial Pressures
Pulmonary Artery Pressure
Cardiac Output
Fick Principle and Cardiac Output Measurements
Indirect Fick Method
Mixed Venous Oxygen Saturation
Oxygen Delivery
Shunt Fraction
Vascular Resistance
Ejection Fraction
Cardiac Work
CLINICAL APPLICATIONS
SUMMARY
References
12 - Methods to Improve Ventilation in Patient-Ventilator Management
CORRECTING VENTILATION ABNORMALITIES
COMMON METHODS OF CHANGING VENTILATION BASED ON PACO2 AND PH
Respiratory Acidosis: Volume and Pressure Ventilation Changes
Respiratory Alkalosis: VC-CMV and PC-CMV Changes
Metabolic Acidosis and Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
Mixed Acid-Base Disturbances
Increased Physiological Dead Space
Increased Metabolism and Increased Carbon Dioxide Production
Intentional Iatrogenic Hyperventilation
Permissive Hypercapnia
Procedures for Managing Permissive Hypercapnia
Contraindications of Permissive Hypercapnia
Airway Clearance During Mechanical Ventilation
SECRETION CLEARANCE FROM AN ARTIFICIAL AIRWAY
Hazards and Complications of Suctioning
Closed-Suction Catheters (Inline Suction Catheters)
Aspiration of Subglottic Secretions
Normal Saline Instillation
Assessment After Suctioning
ADMINISTERING AEROSOLS TO VENTILATED PATIENTS
TYPES OF AEROSOL-GENERATING DEVICES
Ventilator-Related Factors
Patient-Related Factors
Circuit-Related Factors
Use of Pressurized Metered-Dose Inhaler During Mechanical Ventilation
Use of Small-Volume Nebulizers During Mechanical Ventilation
Technical Problems Associated With Continuous Nebulization Using an External Gas Source
Nebulization Provided by the Ventilator
Use of Nebulizers During Noninvasive Positive Pressure Ventilation
Patient Response to Bronchodilator Therapy
POSTURAL DRAINAGE AND CHEST PERCUSSION
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
ADDITIONAL PATIENT MANAGEMENT TECHNIQUES AND THERAPIES IN VENTILATED PATIENTS
Sputum and Upper Airway Infections
FLUID BALANCE
PSYCHOLOGICAL AND SLEEP STATUS
PATIENT SAFETY AND COMFORT
Patient Safety
Patient Comfort
Patient-Centered Mechanical Ventilation
TRANSPORT OF MECHANICALLY VENTILATED PATIENTS WITHIN AN ACUTE CARE FACILITY
SUMMARY
References
13 - Improving Oxygenation and Management of Acute Respiratory Distress Syndrome
BASICS OF OXYGENATION USING FIO2, PEEP STUDIES, AND PRESSURE-VOLUME CURVES FOR ESTABLISHING OPTIMAL PEEP
Basics of Oxygen Delivery to the Tissues
Evaluating PaO2, SpO2, and FIO2 in Ventilator Patients
Adjusting FIO2
Selection of FIO2 or Adjustment of Mean Airway Pressures
INTRODUCTION TO POSITIVE END-EXPIRATORY PRESSURE AND CONTINUOUS POSITIVE AIRWAY PRESSURE
Pathophysiology of Atelectasis
Goals of PEEP and CPAP
Terminology
Technical Aspects of PEEP and CPAP Devices
Application of CPAP and PEEP to the Patient's Airway
Mask CPAP
Nasal CPAP
Endotracheal or Tracheostomy Tubes
Flow and Threshold Resistors
Circuitry for Spontaneous CPAP With Freestanding Systems and Mechanical Ventilators
PEEP RANGES
Minimum or Low PEEP
Therapeutic PEEP
Optimal PEEP
INDICATIONS FOR PEEP AND CPAP
INITIATING PEEP THERAPY
SELECTING THE APPROPRIATE PEEP/CPAP LEVEL (OPTIMAL PEEP)
Application of PEEP Above 5 cm H2O
Optimal PEEP Study
Performing an Optimal PEEP Study
Patient Appearance
Blood Pressure
Breath Sounds
Ventilator Parameters
Static Compliance
Arterial Po2, FIO2, and PaO2/FIO2
Arterial PaCO2 and pH
Alveolar-to-Arterial Oxygen Tension (P(A-a)O2)
Arterial to End-Tidal CO2 Tension Gradient (P(a-et)CO2)
Hemodynamic Data
Arterial-to-Venous Oxygen Content Difference
Mixed Venous Oxygen Tension or Saturation
Cardiac Output
USE OF PULMONARY VASCULAR PRESSURE MONITORING WITH PEEP
CONTRAINDICATIONS AND PHYSIOLOGICAL EFFECTS OF PEEP
Contraindications for PEEP
Pulmonary Effects of PEEP
Transmission of Airway Pressure to Pleural Space
Uses of PEEP for Problems Other Than ARDS
PEEP and Congestive Heart Failure
Mask CPAP as a Treatment for Postoperative Atelectasis and Hypoxemia
Sleep Apnea
Cystic Fibrosis
Airway Suctioning With PEEP
WEANING FROM PEEP
ACUTE RESPIRATORY DISTRESS SYNDROME
PATHOPHYSIOLOGY
CHANGES IN COMPUTED TOMOGRAM WITH ARDS
ARDS AS AN INFLAMMATORY PROCESS
Two Categories of ARDS
ARDS: A Heterogeneous Disorder-Normal Lung versus ARDS
PEEP AND THE VERTICAL GRADIENT IN ARDS
LUNG-PROTECTIVE STRATEGIES: SETTING TIDAL VOLUME AND PRESSURES IN ARDS
LONG-TERM FOLLOW-UP ON ARDS
PRESSURE-VOLUME LOOPS AND RECRUITMENT MANEUVERS IN SETTING PEEP IN ARDS
Patient Evaluation for Lung Recruitment
Pressure-Volume Loops in Setting PEEP
Super-Syringe Technique
Low-Flow (Quasi-Static) Technique
Features of the SPV Loop
Recruitment Maneuvers
Illustration of a Recruitment Maneuver
Function of Lung Recruitment
Hazards of Recruitment Maneuvers
Variability Among Patients
Effects of Chest Wall Compliance on Lung Recruitment
Potential Complications During Lung Recruitment
Types of Recruitment Maneuvers
Sustained inflation
PC-CMV with a high PEEP level
PC-CMV with increased PEEP
Recruitment and decremental PEEP
Sigh techniques
Derecruitment Maneuver
SUMMARY OF RECRUITMENT MANEUVERS IN ARDS
IMPORTANCE OF BODY POSITION DURING POSITIVE PRESSURE VENTILATION
Positioning in a Patient With ARDS: Prone Positioning
Potential Mechanisms of Improved Oxygenation in Prone Positioning
Technical Aspects of Prone Positioning
Patient Position in Unilateral Lung Disease
ADDITIONAL PATIENT CASES
SUMMARY
References
14 - Ventilator-Associated Pneumonia
EPIDEMIOLOGY
Causes and Risk Factors
PATHOGENESIS OF VENTILATOR-ASSOCIATED PNEUMONIA
DIAGNOSIS OF VENTILATOR-ASSOCIATED PNEUMONIA
Clinical Diagnosis
Bacteriological (Quantitative) Diagnosis
TREATMENT OF VENTILATOR-ASSOCIATED PNEUMONIA
STRATEGIES TO PREVENT VENTILATOR-ASSOCIATED PNEUMONIA
Nonpharmacological Interventions
Handwashing
Semirecumbent Patient Positioning and Enteral Feeding
Noninvasive Ventilation
Selection, Changing, and Suctioning of the Endotracheal Tube
Continuous Aspiration of Subglottic Secretions (CASS)
Care of the Tracheostomy Tube
Ventilator Circuit Management Strategies
Kinetic Therapy
Pharmacological Interventions
Oropharyngeal Decontamination
Stress Ulcer Prophylaxis
Selective Digestive Tract Decontamination
Prophylactic Antibiotics
Sedation Interruption and Daily Assessment of Readiness for Endotracheal Extubation
SUMMARY
References
15 - Sedatives, Analgesics, and Paralytics
SEDATIVES AND ANALGESICS
Monitoring the Need for Sedation and Analgesia
Benzodiazepines
Diazepam
Midazolam
Lorazepam
Dexmedetomidine
Neuroleptics
Anesthetic Agents
Opioids
Morphine
Fentanyl
Paralytics
Monitoring Neuromuscular Blockade
Depolarizing Agents
Succinylcholine
Nondepolarizing Agents
Pancuronium
Vecuronium
Atracurium and Cisatracurium
SUMMARY
References
16 - Extrapulmonary Effects of Mechanical Ventilation
EFFECTS OF POSITIVE PRESSURE VENTILATION ON THE HEART AND THORACIC VESSELS
ADVERSE CARDIOVASCULAR EFFECTS OF POSITIVE PRESSURE VENTILATION
The Thoracic Pump Mechanism During Normal Spontaneous Breathing and During Positive Pressure Ventilation
Increased Pulmonary Vascular Resistance and Altered Right and Left Ventricular Function
Coronary Blood Flow With Positive Pressure Ventilation
FACTORS INFLUENCING CARDIOVASCULAR EFFECTS OF POSITIVE PRESSURE VENTILATION
Compensation in Individuals With Normal Cardiovascular Function
Effects of Lung and Chest Wall Compliance and Airway Resistance
Duration and Magnitude of Positive Pressures
BENEFICIAL EFFECTS OF POSITIVE PRESSURE VENTILATION ON HEART FUNCTION IN PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION
MINIMIZING THE PHYSIOLOGICAL EFFECTS AND COMPLICATIONS OF MECHANICAL VENTILATION
Mean Airway Pressure and PaO2
Reduction in Airway Pressure
Inspiratory Flow
Inspiratory-to-Expiratory Ratio
Inflation Hold
Positive End-Expiratory Pressure
High Peak Pressures From Increased Airway Resistance
Intermittent Mandatory Ventilation
EFFECTS OF MECHANICAL VENTILATION ON INTRACRANIAL PRESSURE, RENAL FUNCTION, LIVER FUNCTION, AND GASTROINTESTINAL FUNCTION
Effects of Mechanical Ventilation on Intracranial Pressure and Cerebral Perfusion
RENAL EFFECTS OF MECHANICAL VENTILATION
Renal Response to Hemodynamic Changes
Endocrine Effects of Positive Pressure Ventilation on Renal Function
Arterial Blood Gases and Kidney Function
Implications of Impaired Renal Effects
EFFECTS OF MECHANICAL VENTILATION ON LIVER AND GASTROINTESTINAL FUNCTION
NUTRITIONAL COMPLICATIONS DURING MECHANICAL VENTILATION
SUMMARY
References
17 - Effects of Positive Pressure Ventilation on the Pulmonary System
LUNG INJURY WITH MECHANICAL VENTILATION
Ventilator-Associated Lung Injury Versus Ventilator-Induced Lung Injury
Barotrauma or Extraalveolar Air
Subcutaneous Emphysema
Pneumomediastinum
Pneumothorax
Pneumoperitoneum
Barotrauma or Volutrauma
Atelectrauma
Shear Stress
Surfactant Alteration
Biotrauma
Multiple Organ Dysfunction Syndrome
Vascular Endothelial Injury
Historic Webb and Tierney Study
Role of PEEP in Lung Protection
Ventilator-Induced Respiratory Muscle Weakness
EFFECTS OF MECHANICAL VENTILATION ON GAS DISTRIBUTION AND PULMONARY BLOOD FLOW
Ventilation to Nondependent Lung
Ventilation-to-Lung Periphery
Increase in Dead Space
Redistribution of Pulmonary Blood Flow
Effects of Positive Pressure on Pulmonary Vascular Resistance
RESPIRATORY AND METABOLIC ACID-BASE STATUS IN MECHANICAL VENTILATION
Hypoventilation
Hyperventilation
Metabolic Acid-Base Imbalances and Mechanical Ventilation
AIR TRAPPING (AUTO-PEEP)
How Auto-PEEP Occurs
Physiological Factors That Lead to Auto-PEEP
Identifying and Measuring Auto-PEEP
Effect on Ventilator Function
Measuring Static Compliance With Auto-PEEP
Methods of Reducing Auto-PEEP
HAZARDS OF OXYGEN THERAPY WITH MECHANICAL VENTILATION
Oxygen Toxicity and the Lower Limits of Hypoxemia
Absorption Atelectasis
Depression of Ventilation
INCREASED WORK OF BREATHING
System-Imposed Work of Breathing
Work of Breathing During Weaning
Measuring Work of Breathing
Steps to Reduce Work of Breathing During Mechanical Ventilation86,91
Reducing Work Imposed by the Artificial Airway
Setting Machine Sensitivity and Inspiratory Flow
Patient-Ventilator Synchrony
Trigger asynchrony
Flow asynchrony
Cycle asynchrony
Mode asynchrony
PEEP asynchrony
Closed-loop ventilation asynchrony
Reducing Minute Ventilation Demands
VENTILATOR MECHANICAL AND OPERATIONAL HAZARDS
COMPLICATIONS OF THE ARTIFICIAL AIRWAY
SUMMARY
References
18 - Troubleshooting and Problem Solving
DEFINITION OF THE TERM PROBLEM
Solving Ventilation Problems
PROTECTING THE PATIENT
IDENTIFYING THE PATIENT IN SUDDEN DISTRESS
PATIENT-RELATED PROBLEMS
Airway Problems
Pneumothorax
Bronchospasm
Secretions
Pulmonary Edema
Dynamic Hyperinflation
Abnormalities in Respiratory Drive
Change in Body Position
Drug-Induced Distress
Abdominal Distention
Pulmonary Embolism
VENTILATOR-RELATED PROBLEMS
Leaks
Inadequate Oxygenation
Inadequate Ventilatory Support
Trigger Sensitivity
Inadequate Flow Setting
Other Examples of Patient-Ventilator Asynchrony
COMMON ALARM SITUATIONS
Low-Pressure Alarm
High-Pressure Alarm
Low-PEEP/CPAP Alarms
Apnea Alarm
Low-Source Gas Pressure or Power Input Alarm
Ventilator Inoperative Alarm and Technical Error Message
Operator Settings Incompatible With Machine Parameters
Inspiratory-to-Expiratory Ratio Indicator and Alarm
Other Alarms
USE OF GRAPHICS TO IDENTIFY VENTILATOR PROBLEMS
Leaks
Inadequate Flow
Inadequate Sensitivity Setting for Patient Triggering
Overinflation
Auto-PEEP
Inadequate Inspiratory Time During Pressure Ventilation
Waveform Ringing
Expiratory Portion of Volume-Time Curve Below Baseline
Patient-Ventilator Asynchrony
UNEXPECTED VENTILATOR RESPONSES
Unseated or Obstructed Expiratory Valve
Excessive CPAP/PEEP
Nebulizer Impairment of Patient's Ability to Trigger a Pressure-Supported Breath
High Tidal Volume Delivery
Altered Alarm Function
Electromagnetic Interference
Operator's Manuals
SUMMARY
References
19 - Basic Concepts of Noninvasive Positive Pressure Ventilation
TYPES OF NONINVASIVE VENTILATION TECHNIQUES
Negative Pressure Ventilation
Positive Pressure Ventilation
GOALS OF AND INDICATIONS FOR NONINVASIVE POSITIVE PRESSURE VENTILATION
Acute Care Setting
Acute Exacerbation of Chronic Obstructive Pulmonary Disease
Asthma
Hypoxemic Respiratory Failure
Community-Acquired Pneumonia
Cardiogenic Pulmonary Edema
Chronic Care Setting
Restrictive Thoracic Disorders
Chronic Stable Chronic Obstructive Pulmonary Disease
Cystic Fibrosis
Nocturnal Hypoventilation
OTHER INDICATIONS FOR NONINVASIVE VENTILATION
Facilitation of Weaning From Invasive Ventilation
“Do Not Intubate” Patients
PATIENT SELECTION CRITERIA
Acute Care Setting
Chronic Care Setting
EQUIPMENT SELECTION FOR NONINVASIVE VENTILATION
Types of Ventilators
Pressure-Targeted Ventilators
Portable Homecare Ventilators
Adult Acute Care Ventilators
Humidification During Noninvasive Ventilation
Patient Interfaces
Nasal Interfaces
Full (Oronasal) and Total Face Mask and Helmet
Oral Interfaces
SETUP AND PREPARATION FOR NONINVASIVE VENTILATION
MONITORING AND ADJUSTMENT OF NONINVASIVE VENTILATION
AEROSOL DELIVERY IN NONINVASIVE VENTILATION
COMPLICATIONS OF NONINVASIVE VENTILATION
DISCONTINUING NONINVASIVE VENTILATION
PATIENT CARE TEAM CONCERNS
SUMMARY
References
20 - Weaning From and Discontinuation of Mechanical Ventilation
WEANING TECHNIQUES
METHODS OF TITRATING VENTILATOR SUPPORT DURING WEANING
Intermittent Mandatory Ventilation
Pressure Support Ventilation
T-Piece Weaning
Comparison of Traditional Weaning Methods
CLOSED-LOOP CONTROL MODES FOR VENTILATOR DISCONTINUATION
Automatic Tube Compensation
Arguments Against the Use of Automatic Tube Compensation
Summary of Automatic Tube Compensation
Volume-Targeted Pressure Support Ventilation
Automode and Variable Pressure Support/Variable Pressure Control
Mandatory Minute Ventilation
Adaptive Support Ventilation
Artificial Intelligence Systems
EVIDENCE-BASED WEANING
EVALUATION OF CLINICAL CRITERIA FOR WEANING
Recommendation 1: Pathology of Ventilator Dependence
Weaning Criteria
Patient Ventilatory Performance and Muscle Strength
Measurement of Drive to Breathe
Work of Breathing
Adequacy of Oxygenation
Recommendation 2: Assessment of Readiness for Weaning Using Evaluation Criteria
Recommendation 3: Assessment During a Spontaneous Breathing Trial
Recommendation 4: Removal of the Artificial Airway
Postextubation Difficulties
Noninvasive Positive Pressure Ventilation After Extubation
FACTORS IN WEANING FAILURE
Recommendation 5: Spontaneous Breathing Trial Failure
NONRESPIRATORY FACTORS THAT MAY COMPLICATE WEANING
Cardiac Factors
Acid-Base Factors
Metabolic Factors
Effect of Pharmacological Agents
Nutritional Status and Exercise
Psychological Factors
Recommendation 6: Maintaining Ventilation in Patients With Spontaneous Breathing Trial Failure
FINAL RECOMMENDATIONS
Recommendation 7: Anesthesia and Sedation Strategies and Protocols
Recommendation 8: Weaning Protocols
Recommendation 9: Role of Tracheostomy in Weaning
Recommendation 10: Long-Term Care Facilities for Patients Requiring Prolonged Ventilation
Recommendation 11: Clinician Familiarity With Long-Term Care Facilities
Recommendation 12: Weaning in Long-Term Ventilation Units
AMERICAN THORACIC SOCIETY/AMERICAN COLLEGE OF CHEST PHYSICIANS CLINICAL PRACTICE GUIDELINE: LIBERATION FROM MECHANICAL VENT ...
ETHICAL DILEMMA: WITHHOLDING AND WITHDRAWING VENTILATORY SUPPORT
SUMMARY
References
21 - Long-Term Ventilation
GOALS OF LONG-TERM MECHANICAL VENTILATION
SITES FOR VENTILATOR-DEPENDENT PATIENTS
Acute Care Sites
Intermediate Care Sites
Long-Term Care Sites
PATIENT SELECTION
Disease Process and Clinical Stability
Psychosocial Factors
Financial Considerations
PREPARATION FOR DISCHARGE TO THE HOME
Geographical and Home Assessment
Family Education
Additional Preparation
FOLLOW-UP AND EVALUATION
Adequate Nutrition
Family Issues
EQUIPMENT SELECTION FOR HOME VENTILATION
Tracheostomy Tubes
Ventilator Selection
Examples of Homecare and Transport Ventilators
First-generation portable volume ventilators
Current-generation portable ventilators
COMPLICATIONS OF LONG-TERM POSITIVE PRESSURE VENTILATION
ALTERNATIVES TO INVASIVE MECHANICAL VENTILATION AT HOME
Noninvasive Positive Pressure Ventilation
Negative Pressure Ventilation
Tank Ventilators/Iron Lungs
The Chest Cuirass
The Body Suit
Additional Noninvasive Devices
Diaphragm Pacing
Continuous Positive Airway Pressure for Obstructive Sleep Apnea
CPAP Systems
Potential complications of CPAP
Glossopharyngeal Breathing
EXPIRATORY MUSCLE AIDS AND SECRETION CLEARANCE
Assisted Coughing
Mechanical Oscillation
Mechanical Insufflation-Exsufflation
TRACHEOSTOMY TUBES, SPEAKING VALVES, AND TRACHEAL BUTTONS
Tracheostomy Tube Selection and Benefits
Loss of Speech
Speaking With Tracheostomy Tubes During Ventilation
Electrically Activated Speaking Devices
Speaking Tracheostomy Tubes
Tracheostomy Speaking Valves
Concerns With Speaking Tubes and Valves
Tracheal Buttons and Decannulation
ANCILLARY EQUIPMENT AND EQUIPMENT CLEANING FOR HOME MECHANICAL VENTILATION
Disinfection Procedures
Ventilator Circuit Disinfection
Humidifiers
SUMMARY
References
22 - Neonatal and Pediatric Mechanical Ventilation
RECOGNIZING THE NEED FOR MECHANICAL VENTILATORY SUPPORT
Clinical Indications for Respiratory Failure
Neonate
Pediatric
Determining Effective Oxygenation and Ventilation
GOALS OF NEWBORN AND PEDIATRIC VENTILATORY SUPPORT
NONINVASIVE RESPIRATORY SUPPORT
Noninvasive Nasal Continuous Positive Airway Pressure in Neonates
Indications and Contraindications
Application of N-CPAP
Complications of CPAP
Noninvasive Positive Pressure Ventilation in Neonates
Nasal Intermittent Mandatory Ventilation in Neonates
Nasal “Sigh” Positive Airway Pressure in Neonates
Noninvasive Nasal High-Frequency Ventilation in Neonates
Continuous Positive Airway Pressure and Bilevel Positive Airway Pressure in Pediatric Patients
CONVENTIONAL MECHANICAL VENTILATION
Indications for Ventilatory Support of Neonates
Indications for Ventilatory Support of Pediatric Patients
The Pediatric Ventilator
Pressure Control Mode
Inspiratory Pressure
Positive End-Expiratory Pressure
Inspiratory Time, Expiratory Time, and Inspiratory-to-Expiratory Ratio
Tidal Volume
Frequency
Mean Airway Pressure
Inspired Oxygen Concentration
Volume Control Mode
Pressure Support Ventilation
Dual-Control Mode
Pressure-Regulated Volume Control
Volume Guarantee
Volume Support Ventilation
Airway Pressure Release Ventilation
Neurally Adjusted Ventilatory Assist
Lung-Protective Strategies in Conventional Ventilation
HIGH-FREQUENCY VENTILATION
Indications for High-Frequency Ventilation
Contraindications and Complications of High-Frequency Ventilation
High-Frequency Ventilation Techniques
High-Frequency Positive Pressure Ventilation
High-Frequency Flow Interruption
High-Frequency Percussive Ventilation
High-Frequency Oscillatory Ventilation
High-Frequency Jet Ventilation
Physiology of High-Frequency Ventilation
Management Strategies for High-Frequency Ventilation
Management of High-Frequency Oscillatory Ventilation in Infants
WEANING AND EXTUBATION
ADJUNCTIVE FORMS OF RESPIRATORY SUPPORT
Surfactant Replacement Therapy
Prone Positioning
Inhaled Nitric Oxide Therapy
SUMMARY
References
23 - Special Techniques Used in Ventilatory Support
AIRWAY PRESSURE RELEASE VENTILATION
OTHER NAMES
ADVANTAGES OF AIRWAY PRESSURE RELEASE COMPARED WITH CONVENTIONAL VENTILATION
Preserving Spontaneous Ventilation
APRV and Airway Pressures During Spontaneous Breathing
DISADVANTAGES
INITIAL SETTINGS21,32,33
Setting High Pressure
Setting Low Pressure
Setting High Time
Setting Low Time
ADJUSTING VENTILATION AND OXYGENATION21,32,33
DISCONTINUATION
HIGH-FREQUENCY OSCILLATORY VENTILATION IN THE ADULT
TECHNICAL ASPECTS
INITIAL CONTROL SETTINGS
Mean Airway Pressure
Amplitude
Frequency
Inspiratory Time Percentage
Bias Flow
Additional Settings
INDICATION AND EXCLUSION CRITERIA
MONITORING, ASSESSMENT, AND ADJUSTMENT
ADJUSTING SETTINGS TO MAINTAIN ARTERIAL BLOOD GAS GOALS
RETURNING TO CONVENTIONAL VENTILATION
HELIOX THERAPY AND MECHANICAL VENTILATION
GAS FLOW THROUGH THE AIRWAYS
HELIOX IN AVOIDING INTUBATION AND DURING MECHANICAL VENTILATION
POSTEXTUBATION STRIDOR
DEVICES FOR DELIVERING HELIOX IN SPONTANEOUSLY BREATHING PATIENTS
Mask Heliox
Cost and Gas Consumption During Heliox Therapy
Heliox and Aerosol Delivery
MANUFACTURED HELIOX DELIVERY SYSTEM
HELIOX AND AEROSOL DELIVERY DURING MECHANICAL VENTILATION
Heliox With a Mechanical Ventilator
Technical Considerations in Heliox Delivery
Heliox and NIV
MONITORING THE ELECTRICAL ACTIVITY OF THE DIAPHRAGM AND NEURALLY ADJUSTED VENTILATORY ASSIST
REVIEW OF NEURAL CONTROL OF VENTILATION
DIAPHRAGM ELECTRICAL ACTIVITY MONITORING
History of Diaphragm Electrical Activity Monitoring
The Edi Catheter: Its Characteristics and Placement
Detecting Patient-Ventilator Asynchrony Using the Edi Catheter
Using the Edi Waveform to Interpret Ventilator Synchrony
NEURALLY ADJUSTED VENTILATORY ASSIST
Using NAVA Ventilation
Alarms and Safety Features in NAVA
Results of Initiating NAVA Ventilation
Weaning from NAVA
Evaluating NAVA
SUMMARY
References
A - Answer Key
PART 1: REVIEW QUESTIONS ANSWER KEY
Chapter 1
Basic Terms and Concepts of Mechanical Ventilation
Chapter 2
How Ventilators Work
Chapter 3
How a Breath Is Delivered
Chapter 4
Establishing the Need for Mechanical Ventilation
Chapter 5
Selecting the Ventilator and Mode
Chapter 6
Initial Ventilator Settings
Chapter 7
Final Considerations in Ventilator Setup
Chapter 8
Initial Patient Assessment
Chapter 9
Ventilator Graphics
Chapter 10
Assessment of Respiratory Function
Chapter 11
Hemodynamic Monitoring
Chapter 12
Methods to Improve Ventilation in Patient-Ventilator Management
Chapter 13
Improving Oxygenation and Management of Acute Respiratory Distress Syndrome
Chapter 14
Ventilator-Associated Pneumonia
Chapter 15
Sedatives, Analgesics, and Paralytics
Chapter 16
Extrapulmonary Effects of Mechanical Ventilation
Chapter 17
Effects of Positive Pressure Ventilation on the Pulmonary System
Chapter 18
Troubleshooting and Problem Solving
Chapter 19
Basic Concepts of Noninvasive Positive Pressure Ventilation
Chapter 20
Weaning and Discontinuation From Mechanical Ventilation
Chapter 21
Long-Term Ventilation
Chapter 22
Neonatal and Pediatric Mechanical Ventilation
Chapter 23
Special Techniques Used in Ventilatory Support
PART 2: CASE STUDY ANSWER KEY
Chapter 1: Basic Terms and Concepts of Mechanical Ventilation
Case Study 1.1
Determine Static Compliance (CS) and Airway Resistance (Raw)
Chapter 2: How Ventilators Work
Case Study 2.1
Ventilator Selection
Chapter 3: How a Breath Is Delivered
Case Study 3.1
Patient Triggering
Case Study 3.2
Premature Breath Cycling
Chapter 4: Establishing the Need for Mechanical Ventilation
Case Study 4.1
Stroke Victim
Case Study 4.2
Unexplained Acute Respiratory Failure
Case Study 4.3
Ventilation in Neuromuscular Disorders
Case Study 4.4
Asthma Case
Chapter 5: Selecting the Ventilator and Mode
Case Study 5.1
What type of breath is it?
Case Study 5.2
Pressure Control (PC-CMV) or Volume Control Ventilation (VC-CMV)
Chapter 6: Initial Ventilator Settings
Case Study 6.1
Minute Ventilation (V˙E) Needs
Case Study 6.2
Minute Ventilation (V˙E), Tidal Volume (VT), and Respiratory Rate
Case Study 6.3
Inspiratory/Expiratory Ratio (I/E) and Flow
Case Study 6.4
Tidal Volume (VT) During Pressure Control Continuous Mandatory Ventilation (PC-CMV)
Case Study 6.5
Inspiratory Flow Termination in Pressure Support Ventilation (PSV)
Case Study 6.6
Pressure-Regulated Volume Control (PRVC)
Chapter 7: Final Considerations in Ventilator Setup
Case Study 7.1
Auto-PEEP and Triggering
Case Study 7.2
Key Questions for ARDS Patient
Case Study 7.3
Troubleshooting: The Pulse Oximeter
Chapter 8: Initial Patient Assessment
Case Study 8.1
The Importance of Documentation
Case Study 8.2
Circuit Disconnect
Case Study 8.3
Cuff Inflation Techniques
Case Study 8.4
Patient Assessment Cases
Case Study 8.5
Evaluating CS and Raw During Mechanical Ventilation
Chapter 9: Ventilator Graphics
Case Study 9.1
Case Study 9.2
Chapter 10: Assessment of Respiratory Function
Case Study 10.1
Causes of Cyanosis
Case Study 10.2
Capnography During Intubation
Case Study 10.3
Dead Space Ventilation
Chapter 11: Hemodynamic Monitoring
Case Study 11.1
Evaluation of Pressure Tracing
Case Study 11.2
Cardiac Index and Stroke Index
Case Study 11.3
Application of the Fick Principle
Case Study 11.4
Stroke Work
Case Study 11.5
Hemodynamic Monitoring: After Open-Heart Surgery
Case Study 11.6
Hemodynamic Monitoring: Chest Injury
Case Study 11.7
ICU and Hemodynamic Assessment
Chapter 12: Methods to Improve Ventilation in Patient-Ventilator Management
Case Study 12.1
Hyperventilation
Case Study 12.2
Assessment During Suctioning
Case Study 12.3
Evaluation of Bronchodilator Therapy
Case Study 12.4
Evaluating Fluid Status
Chapter 13: Improving Oxygenation and Management of Acute Respiratory Distress Syndrome
Case Study 13.1
Myasthenia Gravis
Case Study 13.2
Changing FIO2
Case Study 13.3
Problem Solving: Infant CPAP
Case Study 13.4
Selecting Optimum PEEP
Case Study 13.5
Changing Patient Position
Chapter 14: Ventilator-Associated Pneumonia
Case Study 14.1
Patient Case-VAP
Case Study 14.2
Patient Case-Methicillin-Resistant S. aureus
Chapter 15: Sedatives, Analgesics, and Paralytics
Case Study 15.1
Patient Case-Discontinuing Lorazepam
Case Study 15.2
Patient Case-Agitated Patient
Case Study 15.3
Patient Case-Asynchrony
Case Study 15.4
Patient Case-Neuromuscular Blocking Agent
Chapter 16: Extrapulmonary Effects of Mechanical Ventilation
Case Study 16.1
The Effects of Ventilator Changes on Blood Pressure
Chapter 17: Effects of Positive Pressure Ventilation on the Pulmonary System
Case Study 17.1
Peak Pressure Alarm Activating
Case Study 17.2
Patient Case-Acute Pancreatitis
Case Study 17.3
Appropriate Ventilator Changes
Case Study 17.4
Difficulty Triggering in a Patient With COPD
Chapter 18: Troubleshooting and Problem Solving
Case Study 18.1
Evaluating Severe Respiratory Distress in a Ventilated Patient
Case Study 18.2
Evaluating Peak Inspiratory Pressure (PIP) and Plateau Pressure (Pplat) in Volume-Controlled (VC) Ventilation
Case Study 18.3
Evaluating PIP and Volume in Pressure Control Ventilation
Case Study 18.4
Problem Solving Using Ventilator Graphics
Case Study 18.5
Evaluating a Ventilator Problem
Chapter 19: Basic Concepts of Noninvasive Positive Pressure Ventilation
Case Study 19.1
Patient Selection for NIV
Case Study 19.2
Monitoring and Adjusting NIV
Case Study 19.3
Common Complications of NIV
Chapter 20: Weaning and Discontinuation From Mechanical Ventilation
Case Study 20.1
Evaluation of Weaning Attempt
Case Study 20.2
Calculation of Rapid Shallow Breathing Index (RSBI)
Case Study 20.3
Failed Weaning Attempt
Chapter 21: Long-Term Ventilation
Case Study 21.1
Patient Case-Difficulty Weaning
Case Study 21.2
Patient Case-Communication Difficulty
Chapter 22: Neonatal and Pediatric Mechanical Ventilation
Case Study 22.1
Assessment and Treatment of a Newborn
Case Study 22.2
Adjustments to Home Therapy
Case Study 22.3
Patient Case-Acute Status Asthmaticus
Case Study 22.4
Recommending Changes in Ventilator Settings
Case Study 22.5
Evaluation of PRVC Dual-Control Mode
Case Study 22.6
Interpretation and Response to Monitored Data
Case Study 22.7
Patient Case-Acute Respiratory Distress Syndrome Managed With HFO
Case Study 22.8
Determining Appropriateness of Nitric Oxide Therapy
Chapter 23: Special Techniques Used in Ventilatory Support
Case Study 23.1
Patient Assessment During HFOV
Case Study 23.2
Calculating Gas Flows During Heliox Therapy
PART 3: CRITICAL CARE CONCEPTS ANSWER KEY
Chapter 1: Basic Terms and Concepts of Mechanical Ventilation
Critical Care Concept 1.1
Calculate Pressure
Chapter 2: How Ventilators Work
Critical Care Concept 2.1
Open Loop or Closed Loop
Chapter 5: Selecting the Ventilator and the Mode
Critical Care Concept 5.1
Volume-Controlled Breaths With Changing Lung Characteristics
Critical Care Concept 5.2
Pressure-Controlled Breaths With Changing Lung Characteristics
Chapter 6: Initial Ventilator Settings
Critical Care Concept 6.1
Tidal Volume (VT) and Ideal Body Weight (IBW)
Critical Care Concept 6.2
Inspiratory Flow in a Time-Cycled Ventilator
Chapter 7: Final Considerations in Ventilator Setup
Critical Care Concept 7.1
Chapter 11: Hemodynamic Monitoring
Critical Care Concept 11.1
Fick Principle
Chapter 16: Extrapulmonary Effects of Mechanical Ventilation
Critical Care Concept 16.1
Calculating Cardiac Transmural Pressure
B - Review of Abnormal Physiological Processes
MISMATCHING OF PULMONARY PERFUSION AND VENTILATION
PHYSIOLOGICAL DEAD SPACE AND ITS CLINICAL MONITORING
CALCULATION OF MECHANICAL DEAD SPACE VOLUME NEEDED TO INCREASE PACO2
SOME CAUSES OF HYPOXEMIA
Shunt
Calculation of Shunt
Ventilation/Perfusion Abnormalities
Diffusion Defects
References
C - Graphics Exercises
GRAPHING VENTILATOR WAVEFORMS
Problem 1
CHANGES IN WAVEFORMS WITH CHANGES IN LUNG CHARACTERISTICS
Ventilator Working Pressure
Constant-Flow Volume Ventilation With High Working Pressure
Constant-Flow Volume Ventilation With Low Working Pressure
Glossary
A
B
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D
E
F
G
H
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K
L
M
N
O
P
Q
R
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Z
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
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R
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V
W
Y
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