Egan's Fundamentals of Respiratory Care

Front Cover
Inside Front Cover
Egan's Fundamentals of Respiratory Care
Copyright Page
Dedication
Contributors
Reviewers
Preface
Organization
Features
New to This Edition
Learning Aids
Workbook and Evolve Resources
For the Instructor
Evolve Resources
Table Of Contents
I Foundations of Respiratory Care
1 Early History of Respiratory Care
Chapter Outline
Chapter Objectives
Key Terms
Definitions
History of Respiratory Medicine and Science
Ancient Times
The Middle Ages, Renaissance, and Enlightenment Period
Nineteenth and Early Twentieth Centuries
Development of the Respiratory Care Profession
Clinical Advances in Respiratory Care
Oxygen Therapy
Aerosol Medications
Mechanical Ventilation
Airway Management
Cardiopulmonary Diagnostics and Pulmonary Function Testing
Professional Organizations and Events
American Association for Respiratory Care
Respiratory Care Week
Board of Medical Advisors
American Respiratory Care Foundation
International Council for Respiratory Care
National Board for Respiratory Care
Committee on Accreditation for Respiratory Care
Respiratory Care Education
Summary Checklist
References
2 The Profession of Respiratory Therapy
Chapter Outline
Chapter Objectives
Key Terms
Introduction
Scope of Respiratory Care Practice Today
Practice Settings
Respiratory Therapy Department Composition
Department Director
Educational Coordinator
Quality Assurance Coordinator
Supervisors/Lead Therapists
Respiratory Therapists
Medical Director
Designations and Credentials of Respiratory Therapists
Researcher
Professional Respiratory Care Organizations Today
American Association for Respiratory Care
Board of Directors
House of Delegates
Board of Medical Advisors
President’s Council
National Board for Respiratory Care
National Board for Respiratory Care Examinations
Commission on Accreditation for Respiratory Care
American Respiratory Care Foundation
Coalition for Baccalaureate and Graduate Respiratory Therapy Education
International Council for Respiratory Care
Other Organizations Affecting Respiratory Care
National Educator Certification Board
Joint Commission
Centers for Medicare and Medicaid Services
Association for the Advancement of Medical Instrumentation
Respiratory Therapy Education
Degree Advancement Programs
State Licensure
Professionalism
The Future of Respiratory Care
Pulmonary Disease Manager
Advance Practice Respiratory Therapist
Summary Checklist
References
3 Quality, Patient Safety, and Communication
Chapter Outline
Chapter Objectives
Key Terms
Quality Considerations
What Is Quality of Medical Care?
Methods of Quality Improvement
Plan-Do-Study-Act Cycle
Plan Phase
Do Phase
Study (or Check) Phase
Act Phase
The Plan-Do-Study-Act Cycle Starts Over
Six Sigma
Origin of the Term Six Sigma
Lean Management
The Evolution of Quality in Healthcare in the United States
Disease Management
Monitoring Quality in Respiratory Care
Peer Review Organizations
Safety Considerations
Patient Movement and Ambulation
Basic Body Mechanics
Moving the Patient in Bed
Ambulation
Electrical Safety
Fundamentals of Electricity
Preventing Shock Hazards
Ground Electrical Equipment Near the Patient
Fire Hazards
General Safety Concerns
Direct Patient Environment
Magnetic Resonance Imaging Safety
Medical Gas Cylinders
Communication
Communication in Healthcare
Factors Affecting Communication
Improving Communication Skills
Practitioner as Sender
Practitioner as Receiver and Listener
Providing Feedback
Minimizing Barriers to Communication
Conflict and Conflict Resolution
Sources of Conflict
Ineffective Communication
Structural Problems
Personal Behavior
Role Conflict
Conflict Resolution
Competing
Accommodating
Avoiding
Collaborating
Compromising
Summary Checklist
References
4 Principles of Infection Prevention and Control
Chapter Outline
Chapter Objectives
Key Terms
Spread of Infection
Sources of Infectious Agents
Susceptible Hosts
Modes of Transmission
Contact Transmission
Droplet Transmission
Airborne Transmission
Miscellaneous Types of Aerosol Transmission
Other Sources of Infection Not Involving Person-to-Person Transmission
Strategies for the Prevention of Infection
Creating a Safe Culture
Maintaining a Healthy Workforce
Eliminating the Source of Pathogens
Interrupting Transmission
Standard Precautions
Hand Hygiene
Gloves
Mouth, Nose, Eye, and Face Protection
Respiratory Protection
Gowns, Aprons, and Protective Apparel
Cough Etiquette
Transmission-Based Precautions
Protective Environment
Cystic Fibrosis Patients
Transport of Infected Patients
Medical Devices and Bundles
Disinfection and Sterilization
The Spaulding Approach to Disinfection and Sterilization of Patient Care Equipment
Cleaning
Disinfection
Chemical Disinfection
Sterilization
Steam Sterilization
Immediate-Use Sterilization
Low-Temperature Sterilization Technologies
Equipment-Handling Procedures
Maintenance of In-Use Equipment
Nebulizers
Ventilators and Ventilator Circuits
Bag-Mask Devices
Suction Systems
Oxygen Therapy Apparatus
Pulmonary Function Equipment
Other Respiratory Care Devices
Reprocessing Reusable Equipment
Respiratory Care Equipment
Bronchoscope reprocessing.
Disposable Equipment
Fluid and Medication Precautions
Handling Contaminated Articles and Equipment
Handling Laboratory Specimens
Surveillance for Hospital- Acquired Infections
Summary Checklist
References
5 Ethical and Legal Implications of Practice
Chapter Outline
Chapter Objectives
Key Terms
Philosophical Foundations of Ethics
Ethical Dilemmas of Practice
Codes of Ethics
Ethical Theories and Principles
Autonomy
Veracity
Nonmaleficence
Beneficence
Confidentiality
Justice
Role Duty
Ethical Viewpoints and Decision-Making
Formalism
Consequentialism
Mixed Approaches
Virtue Ethics
Intuitionism
Comprehensive Decision-Making Models
Legal Issues Affecting Respiratory Care
Systems of Law
Public (Criminal and Administrative) Law
Civil Law
Tort law.
Professional negligence.
Malpractice.
Intentional torts.
Strict liability.
Breach of contract.
Civil suits.
Helping Avoid Lawsuits
Health Insurance Portability and Accountability Act of 1996
Medical Supervision
Scope of Practice
Basic elements of a practice act.
Licensure laws and regulations.
Providing emergency care without physician direction.
Interaction of Ethics and the Law
Professional Licensure Issues
Licensure Statute
Understanding the Causes of Discipline
Engaging Counsel
Respiratory Therapists Who Speak Out About Wrongdoing
Patient Protection and Affordable Care Act
National Labor Relations Act
False Claims Act
Healthcare and Change
Healthcare Advance Directives
Summary Checklist
References
6 Physical Principles of Respiratory Care
Chapter Outline
Chapter Objectives
Key Terms
States of Matter
Internal Energy of Matter
Laws of Thermodynamics
Heat Transfer
Conduction
Convection
Radiation
Evaporation and Condensation
Temperature
Absolute Zero
Temperature Scales
Change of State
Liquid-Solid Phase Changes (Melting and Freezing)
Melting
Freezing
Properties of Liquids
Pressure in Liquids
Buoyancy (Archimedes Principle)
Viscosity
Cohesion and Adhesion
Surface Tension
Capillary Action
Liquid-Vapor Phase Changes
Boiling
Evaporation, Vapor Pressure, and Humidity
Influence of temperature.
Humidity.
Influence of pressure.
Influence of surface area.
Properties of Gases
Kinetic Activity of Gases
Molar Volume and Gas Density
Molar volume.
Density.
Gaseous Diffusion
Gas Pressure
Measuring atmospheric pressure.
Clinical pressure measurements.
Partial Pressures (the Dalton’s Law)
Solubility of Gases in Liquids (the Henry’s Law)
Gas Behavior Under Changing Conditions
Gas Laws
Effect of Water Vapor
Corrected Pressure Computations
Correction Factors
Properties of Gases at Extremes of Temperature and Pressure
Critical Temperature and Pressure
Fluid Dynamics
Pressures in Flowing Fluids
Patterns of Flow
Laminar Flow
Turbulent Flow
Transitional Flow
Flow, Velocity, and Cross-Sectional Area
Bernoulli Principle
Fluid Entrainment
Fluidics and the Coanda Effect
Summary Checklist
References
7 E-Medicine in Respiratory Care
Chapter Outline
Chapter Objectives
Key Terms
The Electronic Health Record and the Electronic Medical Record
Computerized Physician Order Entry
Enterprise Software Packages
Applications for Patient Care
Applications in Diagnostics
Hemodynamic Monitoring
Blood Gas Laboratories and Point-of-Care Applications
Medical Imaging and Picture Archiving and Communication Systems
Pulmonary Function Testing and Interpretation
Interpretation of Pulmonary Function Tests
Applications in Treatment
Applications in the Acute Care Setting
Mechanical ventilators.
Closed-loop ventilation.
Therapist-driven protocols.
Applications in Nonacute Care Settings and Chronic Diseases
Asthma.
Chronic obstructive pulmonary disease.
Applications in Disease and Infection Prevention
Treatment of Tobacco Use and Dependence
Education of the Public and Healthcare Consumer
Informatics and Clinical Decision Support
Business Intelligence
Clinical Decision Support
Evidence Supporting Clinical Decision Support
Mobile Applications (m-Health)
Administrative Decision Support
American Association for Respiratory Care Benchmarking System
Research
Telehealth and Telemonitoring
Sources of Health Information
Health Information Sources for Respiratory Therapists and Other Clinicians
Health Information Sources for Consumers
Applications in Healthcare Administration
Documentation, Workload, Staffing, and Scheduling
Financial Management
Quality Assurance
Regulatory Compliance
Web Analytics
Human Resources
Privacy and Confidentiality
Applications in Training and Education
Clinical Simulations
Full-Scale Physiologic Clinical Simulators
Clinical Education Applications
National Board for Respiratory Care Credentialing
Learning Management Systems
American Association for Respiratory Care
Future of E-Medicine
Summary Checklist
References
8 Fundamentals of Respiratory Care Research
Chapter Outline
Chapter Objectives
Key Terms
Overview of Respiratory Care Research
The Importance of Research in Healthcare
How to Review and Evaluate the Literature
Bibliographic Databases
Synthesized Databases
Portals
Electronic Journals and Books
General Internet Resources
Suggestions for Conducting Searches
Evaluating the Quality of Research
Evidence-Based Medicine
How to Begin Doing Research
How to Develop a Study Idea
Key Roles in Research
How to Write a Study Protocol
How to Analyze the Data
How to Submit a Paper for Publication
How to Write the Abstract
How to Make a Poster
How to Write a Paper
How to Respond to Reviews
Summary
Summary Checklist
References
II Applied Anatomy and Physiology
9 The Respiratory System
Chapter Outline
Chapter Objectives
Key Terms
Development of the Respiratory System
Transition From Uterine to Extrauterine Life
Placental Structure and Function
Fetal Circulation
Cardiopulmonary Events at Birth
Postnatal Lung Development
Upper Airway
Lower Airway and Alveoli
Development of Vascular, Lymphatic, and Nervous Systems
Chest Wall Development, Diaphragm, and Lung Volume
Respiratory System in the Adult
Surface Features of the Thorax
Components of the Thoracic Wall
Rib Movement
Respiratory Muscles
Pleural Membranes, Space, and Fluid
Mediastinum
Lungs
Pulmonary Vascular, Lymphatic, and Nervous Systems
Pulmonary Circulation
Respiratory Function of Pulmonary Circulation
Non-respiratory Function of the Pulmonary Circulation
Bronchial Circulation
Lymphatics
Neural Control of the Lungs
Efferent Pathways
Afferent Pathways
Anatomy of the Respiratory Tract
Upper Respiratory Tract
Nasal Cavity and Sinuses
Oral Cavity
Pharynx
Larynx
Speech.
Breath hold, effort closure, and cough.
Patent Upper Airway
Lower Respiratory Tract
Trachea and Bronchi
Lobar and Segmental Pulmonary Anatomy
Histology of the Airway Wall
Respiratory Zone Airways
Alveoli
Blood-Gas Barrier
Summary Checklist
References
10 The Cardiovascular System
Chapter Outline
Chapter Objectives
Key Terms
Functional Anatomy
Heart
Anatomy of the Heart
Properties of the Heart Muscle
Microanatomy of the Heart Muscle
Vascular System
Systemic Circulation
Vascular Resistance
Determinants of Blood Pressure
Control of the Cardiovascular System
Regulation of Peripheral Vasculature
Local Control
Central Control
Regulation of Cardiac Output
Changes in Stroke Volume
Changes in Heart Rate
Cardiovascular Control Mechanisms
Cardiovascular Control Centers
Peripheral Receptors
Blood Volume Regulation
Events of the Cardiac Cycle
Summary Checklist
References
Bibliography
11 Ventilation
Chapter Outline
Chapter Objectives
Key Terms
Mechanics of Ventilation
Pressure Differences During Breathing
Forces Opposing Inflation of the Lung
Surface Tension Forces
Elastic Forces Opposing Lung Inflation
Compliance
Combined Compliances
Resistive Forces Opposing Lung Inflation
Tissue viscous resistance.
Airway resistance.
Combined Resistances
Factors affecting resistance.
Distribution of resistance.
Static Versus Dynamic Mechanics
Mechanics of Exhalation
Work of Breathing
Mechanical Work
Metabolic Work
Distribution of Ventilation
Regional Factors Affecting Distribution
Differences in Thoracic Expansion
Transpulmonary Pressure Gradients
Local Factors Affecting Distribution
Time Constants
Frequency Dependence of Compliance
Efficiency and Effectiveness of Ventilation
Efficiency
Minute Ventilation
Alveolar Ventilation
Anatomic Dead Space
Alveolar Dead Space
Physiologic Dead Space
Ratio of Dead Space to Tidal Volume
Effectiveness of Ventilation
Summary Checklist
References
12 Gas Exchange and Transport
Chapter Outline
Chapter Objectives
Key Terms
Diffusion
Whole-Body Diffusion Gradients
Determinants of Alveolar Gas Tensions
Alveolar Carbon Dioxide
Alveolar Oxygen Tensions
Changes in Alveolar Gas Partial Tensions
Mechanism of Diffusion
Barriers to Gaseous Diffusion
The Fick First Law of Diffusion
Pulmonary Diffusion Gradients
Time Limits to Diffusion
Systemic Diffusion Gradients
Variations From Ideal Gas Exchange
Anatomic Shunts
Inequalities in Ventilation and Perfusion
Ventilation/Perfusion Ratio
Effect of Alterations in Ventilation/Perfusion Ratio
Dead Space
Regional Differences in Ventilation/Perfusion Ratio
Oxygen Transport
Chemically Combined Oxygen (Oxyhemoglobin)
Hemoglobin and Oxygen Transport
Hemoglobin Saturation
Total Oxygen Content of the Blood
Oxyhemoglobin Dissociation Curve
Normal Loading and Unloading of Oxygen (Arteriovenous Differences)
Fick Equation
Factors Affecting Oxygen Loading and Unloading
pH (Bohr Effect)
Body Temperature
Organic Phosphates (2,3-Diphosphoglycerate)
Abnormal Hemoglobin
Carbon Dioxide Transport
Transport Mechanisms
Dissolved in Physical Solution
Chemically Combined With Protein
Ionized as Bicarbonate
Carbon Dioxide Dissociation Curve
Abnormalities of Gas Exchange and Transport
Impaired Oxygen Delivery
Causes of Hypoxemia
Hemoglobin deficiencies.
Reduction in Blood Flow (Shock or Ischemia)
Circulatory failure (shock).
Local reductions in perfusion (ischemia).
Dysoxia
Impaired Carbon Dioxide Removal
Inadequate Minute Ventilation
Increased Dead Space Ventilation
Ventilation/Perfusion Imbalances
Summary Checklist
References
13 Solutions, Body Fluids, and Electrolytes
Chapter Outline
Chapter Objectives
Key Terms
Solutions, Colloids, and Suspensions
Definition of a Solution
Concentration of Solutions
Starling Forces
Osmotic Pressure of Solutions
Quantifying Solute Content and Activity
Equivalent Weights
Gram equivalent weight values.
Gram equivalent weight of an acid.
Gram equivalent weight of a base.
Conversion of gram weight to equivalent weight.
Milligram equivalent weights.
Solute Content by Weight
Calculating Solute Content
Quantitative Classification of Solutions
Dilution Calculations
Electrolytic Activity and Acid-Base Balance
Characteristics of Acids, Bases, and Salts
Acids
Acids with single ionizable hydrogen.
Acids with multiple ionizable hydrogens.
Bases
Hydroxide bases.
Nonhydroxide bases.
Ammonia.
Carbonates.
Protein bases.
Designation of Acidity and Alkalinity
Nanomolar Concentrations
pH Scale
Body Fluids and Electrolytes
Body Water
Distribution
Composition
Regulation
Water losses.
Water replacement.
Ingestion.
Metabolism.
Transport Between Compartments
Electrolytes
Sodium (Na+)
Chloride (Cl−)
Bicarbonate
Potassium (K+)
Calcium (Ca2+)
Magnesium (Mg2+)
Phosphorus
Summary Checklist
References
14 Acid–Base Balance
Chapter Outline
Chapter Objectives
Key Terms
Hydrogen Ion Regulation in Body Fluids
Strong and Weak Acids and Bases: Equilibrium Constants
Buffer Solution Characteristics
Bicarbonate and Nonbicarbonate Buffer Systems
pH of a Buffer System: Henderson-Hasselbalch Equation
Clinical Use of Henderson-Hasselbalch Equation
Physiologic Roles of Bicarbonate and Nonbicarbonate Buffer Systems
Bicarbonate Buffer System
Nonbicarbonate Buffer System
Acid Excretion
Lungs
Kidneys
Basic Kidney Function
Reabsorption of Bicarbonate Ion
Excess Hydrogen Ion Excretion and Role of Urinary Buffers
Acid-Base Disturbances
Normal Acid-Base Balance
Primary Respiratory Disturbances
Primary Metabolic (Nonrespiratory) Disturbances
Compensation: Restoring pH to Normal
Effect of the Carbon Dioxide Hydration Reaction on [HCO3−]
Clinical Acid-Base States
Systematic Acid-Base Classification
Step 1: Categorize pH
Step 2: Determine Respiratory Involvement
Step 3: Determine Metabolic (Nonrespiratory) Involvement
Step 4: Assess for Compensation
Respiratory Acidosis
Causes
Compensation
Correction
Respiratory Alkalosis
Causes
Clinical Signs
Compensation
Correction
Alveolar Hyperventilation Superimposed on Compensated Respiratory Acidosis
Metabolic (Nonrespiratory) Acidosis
Causes
Anion Gap
Compensation
Symptoms
Correction
Metabolic Alkalosis
Causes
Compensation
Correction
Metabolic Acid-Base Indicators
Standard Bicarbonate
Base Excess
Mixed Acid-Base States
Summary Checklist
References
15 Regulation of Breathing
Chapter Outline
Chapter Objectives
Key Terms
Medullary Respiratory Center
Dorsal Respiratory Groups
Ventral Respiratory Groups
Inspiratory Ramp Signal
Pontine Respiratory Centers
Apneustic Center
Pneumotaxic Center
Reflex Control of Breathing
Hering-Breuer Inflation Reflex
Deflation Reflex
Head Paradoxical Reflex
Irritant Receptors
J-Receptors
Peripheral Proprioceptors
Muscle Spindles
Chemical Control of Breathing
Central Chemoreceptors
Peripheral Chemoreceptors
Response to Decreased Arterial Oxygen
Response to Increased PaCO2 and Hydrogen Ions
Control of Breathing in Chronic Hypercapnia
Oxygen-Associated Hypercapnia
Central Chemoreceptor Response to Acute Carbon Dioxide Increase in Chronic Hypercapnia
Ventilatory Response to Exercise
Carbon Dioxide and Cerebral Blood Flow
Summary Checklist
References
III Assessment of Respiratory Disorders
16 Bedside Assessment of the Patient
Chapter Outline
Chapter Objectives
Key Terms
Interviewing the Patient and Taking a Medical History
Principles of Interviewing
Structure and Technique for Interviewing
Common Cardiopulmonary Symptoms
Dyspnea
Breathlessness.
Positional dyspnea.
Language of dyspnea.
Assessing dyspnea in the interview.
Psychogenic dyspnea: panic disorders and hyperventilation.
Cough
Sputum Production
Hemoptysis
Chest Pain
Fever
Pedal Edema
The Medical Record and Medical History
Physical Examination
General Appearance
Level of Consciousness
Vital Signs
Body Temperature
Pulse Rate
Respiratory Rate
Arterial Blood Pressure
Examination of the Head and Neck
Head
Neck
Examination of the Thorax and Lungs
Inspection
Thoracic configuration.
Thoracic expansion.
Breathing pattern and effort.
Assessing the diaphragm.
Palpation
Vocal and tactile fremitus.
Skin and subcutaneous tissues.
Percussion of the Chest
Percussion over lung fields.
Clinical implications.
Auscultation of the Lungs
Stethoscope.
Technique.
Normal lung sound terminology.
Lung Sounds in Pulmonary Disease
Mechanisms and significance of lung sounds.
Diminished breath sounds.
Wheezes and stridor.
Crackles.
Pleural friction rub.
Voice sounds.
Cardiac Examination
Inspection and Palpation
Auscultation of Heart Sounds
Abnormal Heart Sounds
Abdominal Examination
Examination of the Extremities
Clubbing
Cyanosis
Pedal Edema
Capillary Refill
Peripheral Skin Temperature
Summary Checklist
References
Bibliography
17 Interpreting Clinical and Laboratory Data
Chapter Outline
Chapter Objectives
Key Terms
Interpreting Clinical Laboratory Tests
Introduction to Laboratory Medicine
Reference Range
Critical Test Value
Complete Blood Count
White Blood Cell Count
Red Blood Cell Count
Electrolyte Tests
Basic Concepts for Understanding Electrolyte Balance
Basic Chemistry Panel
Glucose
Anion Gap
Lactate
Enzyme Tests
Liver Function Tests
Pancreatic and Muscle Enzyme Tests
Cardiac Enzyme and Protein Tests
Coagulation Studies
Infection Monitoring
Microbiology Tests
Sputum Gram Stain
Sputum Culture
Sputum Testing for Mycobacterium Tuberculosis
Sweat Chloride
Clinical Application of Laboratory Data
Coagulation Disorders
Electrolyte Disorders and Conclusion
Summary Checklist
References
18 Interpreting the Electrocardiogram
Chapter Outline
Chapter Objectives
Key Terms
Basic Principles of Electrophysiology
Impulse-Conducting System
Electrocardiogram Procedural Summary
Basic Electrocardiographic Waves
Electrocardiographic Paper and Measurements
Interpreting the Electrocardiogram
Steps to Follow
Axis Evaluation
Recognizing Arrhythmias
Normal sinus rhythm.
Sinus tachycardia.
Sinus bradycardia.
Sinus arrhythmia.
First-degree heart block.
Second-degree heart block.
Third-degree heart block.
Atrial flutter.
Atrial fibrillation.
Premature ventricular contractions.
Ventricular tachycardia.
Ventricular fibrillation.
Pulseless Electrical Activity
Summary Checklist
References
19 Analysis and Monitoring of Gas Exchange
Chapter Outline
Chapter Objectives
Key Terms
Invasive Versus Noninvasive Procedures
Monitoring Fractional Inspired Oxygen
Instrumentation
Procedure
Problem Solving and Troubleshooting
Sampling and Analyzing Blood Gases
Sampling
Arterial Puncture and Interpretation
Equipment.
Procedure.
Indications for blood gas sampling.
Problem solving and troubleshooting.
Getting a good sample.
Pre-analytic error.
Interpretation of arterial blood gases.
Indwelling Catheters (Arterial Pressure, Central Venous Pressure, and Pulmonary Artery Lines)
Equipment.
Procedure.
Problem solving and troubleshooting.
Capillary Blood Gases
Equipment.
Procedure.
Problem solving and troubleshooting.
Analyzing
Instrumentation
Procedure
Quality Assurance
Recordkeeping.
Performance validation.
Preventive maintenance and function checks.
Automated calibration.
Internal statistical quality control.
External quality control (proficiency testing).
Remedial action.
Point-of-Care Testing
Instrumentation.
Clinical performance.
Blood Gas Monitoring
Transcutaneous Blood Gas Monitoring
Instrumentation
Procedure
Problem Solving and Troubleshooting
Tissue Oxygen
Instrumentation
Oximetry
Methemoglobin
Carboxyhemoglobin
Hemoximetry
Instrumentation
Procedure and Quality Assurance
Problem Solving and Troubleshooting
Pulse Oximetry
Instrumentation
Procedure.
Problem Solving and Troubleshooting
Venous Oximetry
Instrumentation
Clinical Usefulness
Tissue Oximetry
Instrumentation
Capnometry and Capnography
Instrumentation
Interpretation
Normal Capnogram
Abnormal Capnogram
Procedure
Problem Solving and Troubleshooting
Summary Checklist
References
20 Pulmonary Function Testing
Chapter Outline
Chapter Objectives
Key Terms
Pulmonary Function Testing
Purposes
Pathophysiologic Patterns
Infection Control
Equipment
Grading of Quality
Reference Values and Interpretation of Results
Principles of Measurement and Significance
Individual Tests and Measurements
Spirometry
Forced Vital Capacity
Forced Expiratory Volume in 1 Second
Peak Expiratory Flow
Maximal Voluntary Ventilation
Other values obtained during spirometry.
Interpretation
Reversibility of Airway Obstruction
Bronchoprovocation
Lung Volumes and Capacities
Values Measured During Spirometry
Values Not Measured During Spirometry
Helium Dilution
Nitrogen Washout
Plethysmography
Interpretation
Normal values for lung volumes.
Diffusing Capacity
Single-Breath Technique
Interpretation
Interpretation of the Pulmonary Function Report
Sample Pulmonary Function Test Reports and Interpretation
Solution 2
Solution Report 3
Solution Report 4
Summary Checklist
References
21 Review of Thoracic Imaging
Chapter Outline
Chapter Objectives
Key Terms
Overview of the Chest X-Ray
Approach to Reading a Plain Chest X-Ray
Chest X-Ray Technique and Quality
Anatomic Structures Seen on a Chest X-Ray
Advanced Chest Imaging Techniques
Computed Tomography of the Chest
Computed Tomography Angiography
Three-Dimensional Reconstruction
Magnetic Resonance Imaging of the Chest
Ultrasound
Nuclear Medicine
Pleura
Pleural Effusion
Ultrasound for Evaluating Pleural Fluid
Computed Tomography
Pneumothorax
Lung Parenchyma
Alveolar Disease
Pulmonary Edema
Interstitial Disease
Assessing Lung Volume
Solitary Pulmonary Nodule
Mediastinum
Pneumomediastinum
Catheters, Lines, and Tubes
Endotracheal Tube
Tracheostomy Tube
Central Line
Peripherally Inserted Central Venous Catheter
Pulmonary Artery (Swan-Ganz) Catheter
Chest Tube
Intra-Aortic Balloon Pump
Summary Checklist
References
22 Flexible Bronchoscopy and the Respiratory Therapist
Chapter Outline
Chapter Objectives
Key Terms
Flexible Bronchoscopy
Procedure, Sedation, and Monitoring
Diagnostic Bronchoscopy
Bronchoalveolar Lavage
Bronchoalveolar Lavage Technique
Bronchial Washings
Bronchial Brushings
Endobronchial Biopsy
Transbronchial Biopsy
Transbronchial Needle Aspiration: Conventional and Ultrasound-Guided Procedures
Electromagnetic Navigational Bronchoscopy
Ultrathin Bronchoscopy
Narrow Band Imaging
Therapeutic Bronchoscopy
Thermal Ablation of an Endobronchial Lesion
Cryotherapy
Brachytherapy
Endobronchial Stents
Bronchial Thermoplasty
Bronchoscopy in Difficult Intubation
The Role of the Respiratory Therapist in Bronchoscopy
Special Considerations for Bronchoscopy During Mechanical Ventilation
Physiologic and Mechanical Alterations Associated With Flexible Bronchoscopy in Intubated Patients
Emerging Bronchoscopic Interventions
Conclusion
Summary Checklist
References
23 Nutrition Assessment
Chapter Outline
Chapter Objectives
Key Terms
Nutrition Assessment
Food-Related and Nutrition-Related History
Evaluation of Nutrition History
Anthropometrics
Height and Weight
Body mass index.
Overweight and obesity.
Kwashiorkor and marasmus.
Body Composition
Skin fold.
Arm muscle area.
Waist circumference.
Biochemical Indicators
Albumin
Transthyretin and Retinol-Binding Protein
Biomarkers of Inflammation
Other Tests and Procedures
Creatinine-Height Index
Nitrogen Balance (Protein Catabolism)
Immune Status
Pulmonary Function
Nutrition-Focused Physical Findings
Outcomes of Nutrition Assessment
Macronutrients and Energy Requirements
Estimating Energy Requirements
Indirect Calorimetry
Equipment and Technique
Problems and Limitations
Interpretation and Use of Results
Alternative Resting Energy Expenditure Measures
General Aspects of Nutrition Support
Meeting Overall Energy Needs
Insufficient Energy Consumed
Protein-Energy Malnutrition
Micronutrient Malnutrition
Respiratory Consequences of Malnutrition
Providing the Appropriate Combination of Substrates
Protein
Carbohydrate
Fat
Routes of Administration
Enteral Feeding
Enteral Tube Routes
Tube Feeding Administration
Enteral Formula Selection
Complications of Enteral Therapy
Parenteral Nutrition Support
Nutrition Support in Specific Circumstances
General Guidelines for Critically Ill Patients
Systemic Inflammatory Response Syndrome
Mechanical Ventilation
Chronic Obstructive Pulmonary Disease
Asthma
Cystic Fibrosis
Summary Checklist
References
IV Review of Cardiopulmonary Disease
24 Pulmonary Infections
Chapter Outline
Chapter Objectives
Key Terms
Classification
Pathogenesis
Microbiology
Clinical Manifestations
Chest X-Ray
Risk Factors for Mortality and Assessing the Need for Hospitalization
Diagnostic Studies
Community-Acquired Pneumonia
Hospital-Acquired Pneumonia, Ventilator-Associated Pneumonia, and Ventilator-Associated Events
Antimicrobial Therapy
Community-Acquired Pneumonia
Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia
Inhaled Antibiotics
Prevention
Community-Acquired Pneumonia
Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia
Tuberculosis
Epidemiology
Pathophysiology and Clinical Manifestations
Primary Tuberculosis
Reactivation Tuberculosis
Endobronchial Tuberculosis and Tuberculomas
Complications
Extrapulmonary Tuberculosis
Diagnosis
Precautions
Treatment
Role of the Respiratory Therapist in Pulmonary Infections
Summary Checklist
References
25 Obstructive Lung Disease
Chapter Outline
Chapter Objectives
Key Terms
Chronic Obstructive Pulmonary Disease
Overview and Definitions
Epidemiology
Risk Factors and Pathophysiology
Clinical Signs and Symptoms
Management
Establishing the Diagnosis
Optimizing Lung Function
Stable Chronic Obstructive Pulmonary Disease
Acute Exacerbation of Chronic Obstructive Pulmonary Disease
Maximizing Functional Status
Preventing Progression of Chronic Obstructive Pulmonary Disease and Acute Exacerbations, and Enhancing Survival
Additional Therapies
Asthma
Definition
Incidence
Etiology and Pathogenesis
Clinical Presentation and Diagnosis
Management
Objective Measurement and Monitoring
Pharmacotherapy
Anti–Immunoglobulin E Therapy
Anti-Interleukin 5 Therapy
Emergency Department and Hospital Management of Asthma
Bronchial Thermoplasty
Immunotherapy
Environmental Control
Patient Education
Special Considerations in Asthma Management
Bronchiectasis
Clinical Presentation
Evaluation
Management
Role of the Respiratory Therapist in Obstructive Lung Disease
Summary Checklist
References
26 Interstitial Lung Disease
Chapter Outline
Chapter Objectives
Key Terms
Characteristics of Interstitial Lung Disease
Clinical Signs and Symptoms
Physical Examination
Radiographic Features
Physiologic Features
Selected Specific Types of Interstitial Lung Disease and Therapies
Exposure-Related Disease
Tobacco-Associated Lung Disease
Drug-Related and Radiation-Related Disease
Hypersensitivity Pneumonitis
Occupational Disease
Interstitial Lung Disease Associated With a Systemic Disease
Connective Tissue Disease
Sarcoidosis
Lymphangioleiomyomatosis
Interstitial Lung Disease of Unknown Cause
Idiopathic Interstitial Pneumonias
Idiopathic pulmonary fibrosis.
Nonspecific interstitial pneumonia.
Organizing pneumonia.
Lymphocytic Interstitial Pneumonia
Nonspecific Therapies
Summary
Role of the Respiratory Therapist in Interstitial Lung Disease
Summary Checklist
References
27 Pleural Diseases
Chapter Outline
Chapter Objectives
Key Terms
The Pleural Space
Pleural Effusions
Transudative Effusions
Congestive Heart Failure
Nephrotic Syndrome
Hypoalbuminemia
Liver Disease
Atelectasis
Lymphatic Obstruction
Rare Causes of Transudative Pleural Effusion
Exudative Effusions
Parapneumonic Effusion
Viral Pleurisy
Tuberculous Pleurisy
Malignant
Postoperative Effusion
Chylothorax
Hemothorax
Connective Tissue Diseases
Uremic Effusion
Miscellaneous Causes
Physiologic Importance
Mechanics of Ventilation
Hypoxemia
Diagnostic Tests
Chest Radiography
Ultrasonography and Computed Tomography
Thoracentesis
Chest Thoracotomy Tubes
Chest Tube Drainage Systems
Thoracoscopy
Pleurodesis
Pleuroperitoneal Shunt and Indwelling Catheter
Pneumothorax
Traumatic
Blunt and Penetrating Chest Trauma
Iatrogenic
Neonatal
Spontaneous
Primary
Secondary
Catamenial Pneumothorax
Complications of Pneumothorax
Tension Pneumothorax
Re-Expansion Pulmonary Edema
Diagnosis
Therapy
Oxygen
Observation
Simple Aspiration
Chest Tubes
Small-bore chest tube.
Large-bore chest tube.
Bronchopleural Fistula
Pleurodesis
Role of the Respiratory Therapist in Pleural Diseases
Summary Checklist
References
28 Pulmonary Vascular Disease
Chapter Outline
Chapter Objectives
Key Terms
Venous Thromboembolic Disease
Pathogenesis
Pathology
Pathophysiology
Clinical Features
Chest X-Ray
Electrocardiogram
Arterial Blood Gases
Diagnostic Modalities
By-Products of Plasmin Activation
Testing for Lower-Extremity Deep Venous Thrombosis
Testing for Pulmonary Embolism
Risk Assessment
Treatment
Prophylaxis
Management of Venous Thromboembolism—Anticoagulation
Management of Deep Venous Thrombosis
Management of Pulmonary Embolism
Prognosis
Pulmonary Embolism Response Teams
Pulmonary Hypertension
Pathogenesis
Epidemiology and Clinical Findings
Diagnosis
Management of Pulmonary Hypertension
General Measures
Calcium Channel Blockers
Prostanoids
Endothelin-Receptor Antagonists
Phosphodiesterase-5 Inhibitors
Soluble Guanylate Cyclase Stimulators
Surgical Therapy
Atrial septostomy.
Lung transplantation.
Pulmonary Hypertension in Chronic Lung Disease
Role of the Respiratory Therapist in Pulmonary Vascular Disease
Key Points
References
29 Acute Respiratory Distress Syndrome
Chapter Outline
Chapter Objectives
Key Terms
Physiology of Pulmonary Edema
Liquid and Solute Transport in the Lungs
Hydrostatic Versus Nonhydrostatic Edema
Hydrostatic Pulmonary Edema
Nonhydrostatic Pulmonary Edema
Gas Exchange and Lung Mechanics in Pulmonary Edema
Definition and Diagnosis
Criteria for Clinical Syndrome
Distinguishing Acute Respiratory Distress Syndrome from Nonhydrostatic Pulmonary Edema in Clinical Practice
Histopathologic Findings
Key Features
Risk Factors (Triggers) and Host Susceptibility
Epidemiology and Outcomes
Therapeutic Approach
Mechanical Ventilation and Other Respiratory Supportive Care
Setting Tidal Volume
Positive End-Expiratory Pressure
Managing Airway Pressures
Selecting the Mode of Mechanical Ventilation
Respiratory Rate and Inspiratory Time
Oxygen Titration
Adjunctive Strategies to Improve Lung Function
Prone Positioning
Neuromuscular Blockade
Inhaled Vasodilators
Corticosteroids
Beta-2 Agonists
Exogenous Surfactant Administration
Alternative and Rescue Ventilation Strategies
Inverse-Ratio Ventilation
Airway Pressure Release Ventilation
High-Frequency Ventilation
Extracorporeal Support
Nonventilatory Supportive Care
Conservative fluid management.
Sedation and Analgesia
Nutrition
Mobility
Role of the Respiratory Therapist in Acute Respiratory Distress Syndrome
Summary Checklist
References
30 Respiratory Management of Trauma, Obesity, Near Drowning, and Burns
Chapter Outline
Chapter Objectives
Key Terms
Life-Threatening Trauma
Epidemiology
Clinical Assessment and Specific Pathophysiologic Concerns
Head, Neck, and Upper Airway Injuries
Lower Respiratory Injuries
Special Considerations in Patients With Chest Trauma
Respiratory Management
Obesity
Epidemiology
Specific Pathophysiologic Concerns
Clinical Assessment
Respiratory Management
Oxygen Therapy
Aerosolized Pharmacology
Noninvasive Ventilation
Invasive Mechanical Ventilation
Intubation.
Tidal volume, minute volume, and respiratory rate.
Lung recruitment and positive end expiratory pressure.
Positioning.
Ventilator discontinuation.
Near Drowning
Epidemiology
Specific Pathophysiologic Concerns
Respiratory Management
Airway Clearance Therapy
Mechanical Ventilation
Positioning
Burns
Epidemiology
Clinical Assessment
Pathophysiology of Burn Patients
Specific Concerns
Respiratory Management
Oxygen Therapy
Early Endotracheal Intubation
Flexible Bronchoscopy
Active Humidification
Mechanical Ventilation
Summary Checklist
References
31 Acute Heart Failure
Chapter Outline
Chapter Objectives
Key Terms
Definition, Epidemiology, and Burden of Care
Pathophysiology of Acute Heart Failure
Medical Management of Acute Heart Failure
Identifying Respiratory Distress and Hemodynamic Instability
Confirming the Diagnosis of Acute Heart Failure
Identifying the Causes of Acute Heart Failure
Assessing Organ Injuries
Monitoring and Assessment of Cardiac Function
Hemodynamics
Blood Tests
Fluid Balance and Weight Change
Electrocardiography
Echocardiography
Coronary Angiography
Cardiac Computed Tomography and Heart Magnetic Resonance Imaging
Lung Imaging
Treatment
Pharmacotherapy
Vasodilators
Diuretics
Vasopressors and Inotropes
Other Drugs and Common Combinations of Drugs
Antiarrhythmic Treatment
Anticoagulation
Alternative Interventions (Other Than Pharmacotherapy)
Mechanical Treatment
Surgical Treatment
Respiratory Support and Monitoring During Acute Heart Failure
Respiratory Pathophysiology of Acute Heart Failure
Ventilatory Support as Part of the Treatment of Right and Left Acute Heart Failure
Titration of Ventilatory Support During Acute Heart Failure
Summary Checklist
References
32 Lung Cancer
Chapter Outline
Chapter Objectives
Key Terms
Epidemiology
New Cases
Deaths
Tobacco-Related Products
Occupational Agents and Other Risks
Classification
Pathophysiology
Clinical Features
Diagnosis
Staging
Preoperative Evaluation for Lung Resection Surgery
Screening
Treatment and Outcomes
Non–Small Cell Lung Cancer (Table 32.3)
Early Stage Non–Small Cell Carcinoma
Locally and Regionally Advanced Non–Small Cell Carcinoma
Metastatic Non–Small Cell Carcinoma
Small Cell Lung Cancer
Future Scenario
Role of the Respiratory Therapist in Managing Patients With Lung Cancer
Summary Checklist
References
33 Neuromuscular and Other Diseases of the Chest Wall
Chapter Outline
Chapter Objectives
Key Terms
Pathophysiology and Pulmonary Function Testing
Clinical Signs and Symptoms
Monitoring and Assessing Patients With Neuromuscular Respiratory Weakness
Management of Respiratory Muscle Weakness
Specific Neuromuscular Diseases
Disorders of the Muscle (Myopathic Disease)
Duchenne Muscular Dystrophy and Becker Muscular Dystrophy
Myotonic Dystrophy
Polymyositis and Dermatomyositis
Ventilator-induced diaphragm dysfunction.
Disorders of the Neuromuscular Junction
Myasthenia Gravis
Lambert-Eaton Syndrome
Disorders of the Nerves
Guillain-Barré Syndrome
Phrenic Nerve Dysfunction and Diaphragm Paralysis
Disorders of the Spinal Cord
Amyotrophic Lateral Sclerosis
Traumatic Spinal Cord Injury
Acute Brain Injury
Disorders of the Thoracic Cage
Kyphoscoliosis
Ankylosing Spondylitis
The Role of the Respiratory Therapist in Caring for Patients With Neuromuscular Weakness and Other Diseases of the Chest Wall
Summary Checklist
References
34 Disorders of Sleep
Chapter Outline
Chapter Objectives
Key Terms
Pathophysiology
Obstructive Sleep Apnea
Central Sleep Apnea
Overlap Syndrome
Hypoventilation Syndromes
Clinical Features
Screening Questionnaires
Laboratory Testing
Treatment
Behavioral Interventions and Risk Counseling
Positional Therapy
Medical Interventions
Positive Pressure Therapy
Continuous positive airway pressure therapy.
Bilevel positive airway pressure therapy.
Autotitrating devices.
Side effects and troubleshooting strategies for positive airway pressure therapy.
Oral Appliance Therapy
Medications
Surgical Interventions
Palatal Surgery
Maxillofacial Surgery
Upper Airway Stimulation
Additional Therapies
Role of the Respiratory Therapist in Disorders of Sleep
Summary Checklist
References
35 Neonatal and Pediatric Respiratory Disorders
Chapter Outline
Chapter Objectives
Key Terms
Neonatal Respiratory Disorders
Lung Parenchymal Disease
Respiratory Distress Syndrome
Background.
Pathophysiology.
Clinical manifestations.
Treatment.
Transient Tachypnea of the Newborn
Background.
Clinical manifestations.
Treatment.
Meconium Aspiration Syndrome
Background.
Pathophysiology.
Clinical manifestations.
Treatment.
Bronchopulmonary Dysplasia
Background.
Pathophysiology.
Clinical manifestations.
Treatment.
Control of Breathing
Apnea of Prematurity
Background.
Cause.
Treatment.
Sudden Infant Death Syndrome
Cause
Prevention
Pulmonary Vascular Disease
Persistent Pulmonary Hypertension of the Newborn
Background.
Pathophysiology.
Clinical manifestations.
Treatment.
Congenital Abnormalities Affecting Respiration
Airway Diseases
Lung Malformations
Congenital Diaphragmatic Hernia
Abdominal Wall Abnormalities
Neuromuscular Control
Congenital Heart Disease
Cyanotic Heart Diseases
Tetralogy of Fallot.
Transposition of the great arteries.
Hypertension of the Newborn
Acyanotic Heart Diseases
Ventricular septal defect.
Atrial septal defect.
Patent ductus arteriosus.
Left ventricular outflow obstructions.
Neonatal Resuscitation
Pediatric Respiratory Disorders
Gastroesophageal Reflux Disease
Bronchiolitis
Clinical Manifestations
Prophylaxis.
Treatment.
Croup
Clinical Manifestations
Treatment
Epiglottitis
Clinical Manifestations
Treatment
Cystic Fibrosis
Clinical Manifestations
Diagnosis
Monitoring
Treatment
Prognosis
Role of the Respiratory Therapist in Neonatal and Pediatric Respiratory Disorders
Summary Checklist
References
V Basic Therapeutics
36 Airway Pharmacology
Chapter Outline
Chapter Objectives
Key Terms
Principles of Pharmacology
Drug Administration Phase
Pharmacokinetic Phase
Pharmacodynamic Phase
Airway Receptors and Neural Control of the Lung
Adrenergic Bronchodilators
Indications for Use
Indication for Short-Acting Agents
Indication for Long-Acting Agents
Indication for Racemic Epinephrine
Mechanism of Action and Effects
Adrenergic Bronchodilator Agents
Ultrashort-Acting Catecholamines
Short-Acting Noncatecholamine Agents
Single-isomer β agonists.
Long-Acting Adrenergic Bronchodilators
Adverse Effects
Assessment of Bronchodilator Therapy
Anticholinergic Bronchodilators
Indications for Use
Indication for Anticholinergic Bronchodilators
Indication for Combined Anticholinergic and β-Agonist Bronchodilators
Mechanism of Action
Adverse Effects
Assessment
Mucus-Controlling Agents
N-Acetyl Cysteine
Indications for Use
Mechanism of Action
Side Effects
Dornase Alfa
Indication for Use
Mechanism of Action
Side Effects
Other Mucoactive Agents
Assessment of Mucoactive Drug Therapy
Before Treatment
During Treatment and in the Short Term
In the Long Term
General Contraindications
Inhaled Corticosteroids
Indications and Purposes
Mechanism of Action
Adverse Effects
Special Considerations
Assessment of Drug Therapy
In the Long Term
Nonsteroidal Antiasthma Drugs
Indication for Use
Mechanism of Action
Adverse Effects
Assessment of Drug Therapy
In the Long Term
Aerosolized AntiInfective Agents
Pentamidine Isethionate
Indication for Use
Adverse Effects
Assessment
In the Long Term
Ribavirin
Adverse Effects
Assessment
Inhaled Tobramycin
Adverse Effects
Assessment
Inhaled Aztreonam
Adverse Effects
Colistimethate Sodium
Adverse Effects
Inhaled Zanamivir
Indication for Use
Mechanism of Action
Adverse Effects
Clinical Efficacy
Assessment
Inhaled Pulmonary Vasodilators
Nitric Oxide
Indications for Use
Iloprost
Indications for Use
Mechanism of Action
Adverse Effects
Treprostinil
Indication for Use
Mechanism of Action
Adverse Effects
Summary Checklist
References
37 Airway Management
Chapter Outline
Chapter Objectives
Key Terms
Suctioning
Endotracheal Suctioning
Equipment and Procedure
Minimizing Complications and Adverse Responses
Nasotracheal Suctioning
Equipment and Procedure
Minimizing Complications and Adverse Responses
Sputum Sampling
Establishing an Artificial Airway
Routes
Pharyngeal Airways
Tracheal Airways
Artificial Airways
Endotracheal Tubes
Specialized endotracheal tubes.
Tracheostomy Tubes
Surgical Emergency Airways
Procedures
Orotracheal Intubation
Nasotracheal Intubation
Direct visualization.
Blind passage.
Tracheotomy
Procedure.
Laryngectomy
Airway Trauma Associated With Tracheal Tubes
Laryngeal Lesions
Tracheal Lesions
Prevention
Airway Maintenance
Securing the Airway and Confirming Placement
Providing for Patient Communication
Ensuring Adequate Humidification
Minimizing Nosocomial Infections
Facilitating Secretion Clearance
Providing Cuff Care
Importance of Cuff Pressure
Cuff Inflation and Measuring and Adjusting Cuff Pressure
Alternative Cuff Designs
Minimizing Likelihood of Aspiration
Care of Tracheostomy and Tube
Tracheostomy Care
Changing a Tracheostomy Tube
Troubleshooting Airway Emergencies
Tube Obstruction
Cuff Leaks
Unplanned Extubation
Extubation or Decannulation
Assessing Patient Readiness for Extubation
Procedures
Orotracheal or Nasotracheal Tubes
Tracheostomy Tube Removal (Decannulation)
Fenestrated Tracheostomy Tubes
Progressively Smaller Tubes
Tracheal Buttons
Assessment After Tracheostomy Decannulation
Summary Checklist
References
38 Emergency Cardiovascular Life Support
Chapter Outline
Chapter Objectives
Key Terms
Causes and Prevention of Sudden Death
Basic Life Support
Determining Unresponsiveness
Restoring Circulation
Determining Pulselessness
Providing Chest Compressions
Adults.
Children.
Infants.
Neonates.
Chest Compressions Under Special Circumstances
Near drowning.
Suspected opioid-related life-threatening emergency.
Restoring the Airway
Restoring Ventilation
Providing Artificial Ventilation
Mouth-to-mouth ventilation.
Adults.
Infants and children.
Mouth-to-nose ventilation.
Mouth-to-stoma ventilation.
One-Rescuer Versus Two-Rescuer Adult Cardiopulmonary Resuscitation
Automated External Defibrillation
Early Defibrillation
Automated External Defibrillators
Evaluating the Effectiveness of Cardiopulmonary Resuscitation
Hazards and Complications
Neck and Spine Injuries
Gastric Inflation
Internal Trauma
Foreign Body Airway Obstruction
Contraindications to Cardiopulmonary Resuscitation
Health Concerns and Cardiopulmonary Resuscitation
Treating Foreign Body Airway Obstruction
Abdominal Thrusts (Heimlich Maneuver)
Vomiting
Internal organ damage.
Back Blows and Chest Thrusts
Evaluating the Effectiveness of Foreign Body Removal
Advanced Cardiovascular Life Support
Support for Oxygenation
Airway Management
Pharyngeal Airways
Nasopharyngeal Airways
Masks
Endotracheal Intubation
Bag-Mask Devices
Design
Use
Hazards and Troubleshooting
Restoring Cardiac Function
Electrocardiogram Monitoring
Supraventricular tachycardia.
Ventricular tachycardia.
Ventricular fibrillation.
Pulseless electrical activity.
Pharmacologic Intervention
Routes of administration.
Electrical Therapy
Unsynchronized countershock (defibrillation).
Synchronized countershock (cardioversion).
Electrical pacing.
Patient Care After Resuscitation
Respiratory Management
Cardiovascular Management
Summary Checklist
References
39 Humidity and Bland Aerosol Therapy
Chapter Outline
Chapter Objectives
Key Terms
Humidity Therapy
Physiologic Control of Heat and Moisture Exchange
Indications for Humidification and the Warming of Inspired Gases
Equipment
Physical Principles Governing Humidifier Function
Temperature.
Surface area.
Contact time.
Thermal mass.
Types of Humidifiers
Active humidifiers
Bubble.
Pass-over.
Vaporizer humidifiers.
Heat and moisture exchangers.
Active heat and moisture exchangers.
Heated Humidifiers
Reservoir and Feed Systems
Manual systems.
Automatic systems.
Setting Humidification Levels
Problem Solving and Troubleshooting
Condensation
Cross Contamination
Proper Conditioning of Inspired Gas
Bland Aerosol Therapy
Equipment
Aerosol Generators
Large-volume jet nebulizers.
Ultrasonic nebulizers.
Airway Appliances
Enclosures (Mist Tents and Hoods)
Problem Solving and Troubleshooting
Cross Contamination
Environmental Exposure
Inadequate Aerosol Output
Overhydration
Bronchospasm
Selecting the Appropriate Therapy
Mechanical Ventilation
Noninvasive Ventilation
High-Flow Nasal Oxygen
Sputum Induction
Summary Checklist
References
40 Aerosol Drug Therapy
Chapter Outline
Chapter Objectives
Key Terms
Characteristics of Therapeutic Aerosols
Aerosol Output
Particle Size
Deposition
Inertial Impaction
Sedimentation
Diffusion
Aging
Quantifying Aerosol Delivery
Hazards of Aerosol Therapy
Infection
Airway Reactivity
Pulmonary and Systemic Effects
Drug Concentration
Eye Irritation
Secondhand Exposure to Aerosol Drugs
Aerosol Drug Delivery Systems
Pressurized Metered Dose Inhalers
Breath-Actuated Pressurized Metered Dose Inhaler
Dose Counters
Factors Affecting Pressurized Metered Dose Inhaler Performance and Drug Delivery
Temperature.
Nozzle size and cleanliness.
Priming.
Timing of actuation intervals.
Aerosol Delivery Characteristics
Technique
Pressurized Metered Dose Inhaler Accessory Devices
Spacers and valved holding chambers.
Types of accessory devices.
Cost
Dry Powder Inhalers
Equipment Design and Function
Factors Affecting Dry Powder Inhaler Performance and Drug Delivery
Intrinsic resistance and inspiratory flow rate.
Exposure to humidity and moisture.
Patient’s inspiratory flow ability.
Technique.
New Dry Powder Inhaler Technologies
Easyhaler.
Ellipta.
Podhaler.
Tudorza pressair.
Spiromax.
Nebulizers
Pneumatic (Jet) Nebulizers
Factors affecting nebulizer performance.
Nebulizer design.
Flow.
Gas source (hospital versus home).
Density.
Humidity and temperature.
Characteristics of drug formulation.
Small Volume Nebulizers
Small volume nebulizer with a reservoir.
Continuous small volume nebulizer with collection bag.
Breath-enhanced nebulizers.
Breath-actuated nebulizers.
Technique.
Infection control issues.
Large Volume Jet Nebulizers
Hand-Bulb Atomizers and Spray Pumps
Ultrasonic Nebulizers
Large volume ultrasonic nebulizers.
Small volume ultrasonic nebulizers.
Vibrating Mesh Nebulizers
Smart Nebulizers
Fox.
Dance 501.
New nebulizer designs for liquid medications.
InnoSpire Go.
Examples of nebulizers with drug device combinations.
Lonhana magnair.
Tyvaso.
Cayston Altera eFlow
Staccato.
Soft Mist Inhalers
Respimat.
Aqueous droplet inhaler liquid inhaler device.
Advantages and Disadvantages of Aerosol Systems
Special Medication Delivery Issues for Infants and Children
Selecting an Aerosol Drug Delivery System
Assessment-Based Bronchodilator Therapy Protocols
Sample Protocol
Assessing Patient Response
Use and Limitations of Peak Flow Monitoring
Other Components of Patient Assessment
Dose-Response Assessment
Frequency of Patient Assessment
Patient Education
Special Considerations
Aerosol Therapy for Treatment of Pulmonary Arterial Hypertension
Acute Care and Off-Label Use
Continuous Nebulization for Refractory Bronchospasm
Transnasal Pulmonary Aerosol Delivery
Aerosol Administration During Ventilator Support
Use of a Small Volume Nebulizer During Mechanical Ventilation
Use of a Vibrating Mesh Nebulizer During Mechanical Ventilation
Use of a Pressurized Metered Dose Inhaler During Mechanical Ventilation
Aerosol Generator Placement
Placement During Noninvasive Ventilation
Placement During Transnasal Pulmonary Delivery of Aerosol With High-Flow and Low-Flow Nasal Cannula
Placement During Intrapulmonary Percussive Ventilation
Placement During High-Frequency Oscillatory Ventilation
Controlling Environmental Contamination
Negative-Pressure Rooms
Booths and Stations
Personal Protective Equipment
Summary Checklist
References
41 Storage and Delivery of Medical Gases
Chapter Outline
Chapter Objectives
Key Terms
Characteristics of Medical Gases
Oxygen
Characteristics
Production
Fractional distillation.
Physical separation.
Air
Carbon Dioxide
Helium
Nitric Oxide
Nitrous Oxide
Storage of Medical Gases
Gas Cylinders
Markings and Identification
Cylinder Sizes and Contents
Cylinder Safety Relief Valves
Filling (Charging) Cylinders
Compressed gases.
Liquefied gases.
Measuring Cylinder Contents
Compressed gas cylinders.
Liquid gas cylinders.
Estimating Duration of Cylinder Gas Flow
Estimating Duration of Liquid Oxygen Cylinder Gas Flow
Gas Cylinder Safety
Cylinder storage.
Cylinder transport.
Cylinder use.
Bulk Oxygen
Gas Supply Systems
Bulk Oxygen Safety Precautions
Distribution and Regulation of Medical Gases
Central Piping Systems
Safety Indexed Connector Systems
American Standard Safety System
Pin-Index Safety System
Diameter-Index Safety System
Quick-Connect Systems
Regulating Gas Pressure and Flow
High-Pressure Reducing Valves
Preset reducing valve.
Adjustable reducing valve.
Multiple-stage reducing valve.
Proper use of high-pressure reducing valves.
Low-Pressure Gas Flow Meters
Flow restrictor.
Bourdon gauge.
Thorpe tube.
Summary Checklist
References
42 Medical Gas Therapy
Chapter Outline
Chapter Objectives
Key Terms
Oxygen Therapy
General Goals and Clinical Objectives
Correcting Hypoxemia
Decreasing Symptoms of Hypoxemia
Minimizing Cardiopulmonary Workload
Assessing the Need for Oxygen Therapy
Precautions and Hazards of Supplemental Oxygen
Oxygen Toxicity/Hyperoxic Acute Lung Injury
Depression of Ventilation
Retinopathy of Prematurity
Absorption Atelectasis
Fire Hazard
Oxygen Delivery Systems: Design and Performance
Low-Flow Systems
Nasal cannula (low flow).
Nasal catheter.
Transtracheal catheter.
Performance Characteristics of Low-Flow Systems
Troubleshooting Low-Flow Systems
Reservoir Systems
Reservoir cannula.
Reservoir masks.
Troubleshooting reservoir systems.
High-Flow Systems
Principles of gas mixing.
Air-entrainment systems.
Air-entrainment (venturi) mask.
Air-entrainment nebulizer.
Troubleshooting air-entrainment systems.
Providing moderate to high FiO2 at high flow.
Problems with downstream flow resistance.
High-flow nasal cannula.
Blending systems.
Mixing gases manually.
Oxygen blenders.
Enclosures.
Other Oxygen Delivery Devices
Bag-mask devices.
Demand-flow and pulse-dose systems.
Selecting a Delivery Approach
Purpose
Patient
Performance
General Goals and Patient Categories
Protocol-Based Oxygen Therapy
Hyperbaric Oxygen Therapy
Physiologic Effects
Methods of Administration
Indications
Air Embolism
Carbon Monoxide Poisoning
Complications and Hazards
Troubleshooting
Other Medical Gas Therapies
Nitric Oxide Therapy
Mode of Action
Indications
Dosing
Toxicity and Adverse Effects
Methods of Administration
Withdrawing Therapy
Helium-Oxygen Therapy
Indications
Guidelines for Use
Troubleshooting and Hazards
Carbon Dioxide–Oxygen (Carbogen) Therapy
Summary Checklist
References
43 Lung Expansion Therapy
Chapter Outline
Chapter Objectives
Key Terms
Causes and Types of Atelectasis
Factors Associated With Causing Atelectasis
Clinical Signs of Atelectasis
Lung Expansion Therapy
Baseline Assessment
Early Mobilization of the Patient
Intensive Care Unit Patient
Non–Intensive Care Unit Patient
Incentive Spirometry
Physiologic Basis
Indications
Contraindications
Hazards and Complications
Equipment
Administration
Preliminary planning.
Implementation.
Follow-up.
Noninvasive Ventilation
Intermittent Positive Airway Pressure Breathing
Physiologic Basis
Indications
Contraindications
Hazards and Complications
Administration
Preliminary planning.
Evaluating alternatives.
Discontinuation and Follow-Up
Posttreatment assessment.
Continuous Positive Airway Pressure
Physiologic Basis
Indications
Contraindications
Hazards and Complications
Monitoring and Troubleshooting
Administration
Equipment.
Procedures.
Preliminary planning.
Evaluating alternatives.
Discontinuing and Follow-Up
Posttreatment assessment.
High-flow nasal cannula.
Physiologic Basis
Other Therapies
Positive Airway Pressure
Physiologic Basis
Indications
Contraindications
Hazards and Complications
Equipment
Procedures.
Monitoring and Troubleshooting
Initiation of Therapy
Preliminary Planning
Evaluating Alternatives
Discontinuing and Follow-Up
Posttreatment Assessment
Selecting an Approach
Summary Checklist
References
44 Airway Clearance Therapy
Chapter Outline
Chapter Objectives
Key Terms
Physiology of Airway Clearance Therapies
Normal Clearance
Abnormal Clearance
Diseases Associated With Abnormal Clearance
General Goals and Indications
Airway Clearance Therapy for Acute Conditions
Airway Clearance Therapy for Chronic Conditions
Airway Clearance Therapy to Prevent Retention of Secretions
Determining the Need for Airway Clearance Therapy
Airway Clearance Methods
Chest Physical Therapy Also Known as Postural Drainage and Percussion
Technique
Percussion and Vibration
Manual percussion.
Mechanical percussion and vibration.
Coughing and Related Expulsion Techniques
Directed Cough
Standard technique.
Modifications to directed cough technique.
Forced Expiratory Technique
Manual Assisted Cough
Active Cycle of Breathing Technique
Autogenic Drainage
Mechanical Insufflation-Exsufflation
Positive Airway Pressure Adjuncts
Positive Expiratory Pressure and Oscillating Positive Expiratory Pressure
High-Frequency Positive Airway Pressure Devices
High-Frequency Chest Wall Compression
Exercise, Mobilization, and Physical Activity
Selecting Airway Clearance Techniques
Selection Factors
Outcome Assessment
Documentation and Follow-Up
Protocol-Based Airway Clearance
Summary Checklist
References
VI Acute and Critical Care
45 Respiratory Failure and the Need for Ventilatory Support
Chapter Outline
Chapter Objectives
Key Terms
Hypoxemic Respiratory Failure (Type I)
Ventilation/Perfusion Mismatch
Clinical Presentation
Shunt
Clinical Presentation
Alveolar Hypoventilation
Diffusion Impairment
Clinical Presentation
Perfusion/Diffusion Impairment
Clinical Presentation
Decreased Inspired Oxygen
Clinical Presentation
Venous Admixture
Clinical Presentation
Differentiating the Causes of Acute Hypoxemic Respiratory Failure
Hypercapnic Respiratory Failure (Type II)
Unexpected Exposure to Breathing Carbon Dioxide
Clinical Presentation
Increased Carbon Dioxide Production
Clinical Presentation
Impairment in Respiratory Control
Clinical Presentation
Impairment in Exhaling Carbon Dioxide
Neurologic Diseases
Clinical presentation.
Increased Work of Breathing
Clinical presentation.
Chronic Respiratory Failure (Type I and Type II)
Acute-on-Chronic Respiratory Failure
Complications of Acute Respiratory Failure
Clinical Presentation
Indications for Ventilatory Support
Parameters Indicating Need for Ventilatory Support
Hypoxemic respiratory failure.
Hypercapnic respiratory failure (ventilatory failure).
Significance of elevated alveolar partial pressure of carbon dioxide.
Assessment of Respiratory Fatigue, Weakness, Failure, and Work of Breathing
Respiratory Muscle Weakness
Respiratory Muscle Fatigue
Respiratory Failure
Work of Breathing
Choosing a Ventilatory Support Strategy for Different Causes of Respiratory Failure
Noninvasive Ventilation
Noninvasive Ventilation in Acute Conditions
Exacerbations of Chronic Obstructive Pulmonary Disease
Cardiogenic Pulmonary Edema
Acute Asthma
Acute Respiratory Distress Syndrome
Noninvasive Ventilation in Chronic Conditions
Obesity-Hypoventilation Syndrome
Stable Chronic Obstructive Pulmonary Disease
Neuromuscular Diseases and Thoracic Cage Abnormalities
Invasive Ventilatory Support
Acute Respiratory Distress Syndrome
Increased Intracranial Pressure
Obstructive Lung Disease
Ventilatory Support in Chronic Hypercapnic Respiratory Failure
Summary Checklist
References
46 Mechanical Ventilators
Chapter Outline
Chapter Objectives
Key Terms
How Ventilators Work
The Operator Interface
Ventilator Displays
Alphanumeric values.
Trends.
Waveforms and loops.
Picture Graphics
Alarm Settings
The Patient Interface
Identifying Modes of Mechanical Ventilation
The 10 Maxims for Understanding Modes
A Breath Is One Cycle of Positive Flow (Inspiration) and Negative Flow (Expiration) Defined in Terms of the Flow-Time Curve
A Breath Is Assisted If the Ventilator Provides Some or All of the Work of Breathing
A Ventilator Assists Breathing Using Either Pressure Control or Volume Control Based on the Equation of Motion for the Respiratory System
Breaths Are Classified According to the Criteria That Trigger (Start) and Cycle (Stop) Inspiration
Trigger Variable and Cycle Events Can Be Initiated by Either the Patient or the Machine
Breaths Are Classified as Spontaneous or Mandatory Based on Both the Trigger and Cycle Events
There Are Three Basic Breath Sequences: Continuous Mandatory Ventilation, Intermittent Mandatory Ventilation, and Continuous Spontaneous Ventilation
There Are Five Basic Ventilatory Patterns: VC-CMV, VC-IMV, PC-CMV, PC-IMV, and PC-CSV
Ventilatory Patterns Vary According to Their Targeting Schemes (Set-Point, Dual, Bio-Variable, Servo, Adaptive, Optimal, and Intelligent)
Targeting schemes.
A Mode of Ventilation Is Classified According to Its Control Variable, Breath Sequence, and Targeting Schemes
A Taxonomy for Mechanical Ventilation
How to Classify Modes
Examples
Comparing Modes of Mechanical Ventilation
Types of Ventilators
Conventional Versus High-Frequency Ventilators
Conventional Ventilators
High-Frequency Ventilators
Classification of Ventilators by Use
Critical Care Ventilators
Subacute Care Ventilators
Home Care Ventilators
Transport Ventilators
Noninvasive Ventilators
Summary Checklist
References
47 Physiology of Ventilatory Support
Chapter Outline
Chapter Objectives
Key Terms
Pressure and Pressure Gradients
Airway, Alveolar, and Intrathoracic Pressure, Volume, and Flow During Spontaneous Ventilation
Airway, Alveolar, and Intrathoracic Pressure, Volume, and Flow During Negative Pressure Mechanical Ventilation
Airway, Alveolar, and Intrathoracic Pressure, Volume, and Flow During Positive Pressure Mechanical Ventilation
Effects of Mechanical Ventilation on Ventilation
Minute Ventilation
Increased Alveolar Ventilation
Ventilation/Perfusion Ratio
Alveolar and Arterial Carbon Dioxide
Acid–Base Balance
Effects of Mechanical Ventilation on Oxygenation
Inspired Oxygen
Alveolar Oxygen and Alveolar Air Equation
Arterial Oxygenation and Oxygen Content
Decreased Shunt
Increased Tissue Oxygen Delivery
Effects of Positive Pressure Mechanical Ventilation on Lung Mechanics
Time Constants
Increased Pressure
Mean Airway Pressure
Effect of Peak Airway Pressure on Lung Recruitment
Increased Lung Volume: Tidal Volume
Increased Functional Residual Capacity
Pressure-Volume Curve and Lung Recruitment in Acute Respiratory Distress Syndrome
Increased Dead Space
Decreased Work of Breathing
Minimizing Adverse Pulmonary Effects of Positive Pressure Mechanical Ventilation
Decreasing Pressure
Positive End-Expiratory Pressure or Continuous Positive Airway Pressure
Effects of Ventilatory Pattern
Trigger Site and Work of Breathing
Physiologic Effects of Ventilatory Modes
Volume-Controlled Ventilation Versus Pressure-Controlled Ventilation
Continuous Mandatory Ventilation
Volume-Controlled Continuous Mandatory Ventilation
Pressure-Controlled Continuous Mandatory Ventilation
Pressure-Controlled Inverse Ratio Ventilation
Intermittent Mandatory Ventilation
Volume-Controlled Intermittent Mandatory Ventilation
Pressure-Controlled Intermittent Mandatory Ventilation
Airway Pressure Release Ventilation
Continuous Spontaneous Ventilation
Continuous Positive Airway Pressure
Pressure Support Ventilation
Example.
Proportional Assist Ventilation
Neurally Adjusted Ventilatory Assist
Automatic Tube Compensation
Adaptive Modes and Dual Control
Example.
Patient Positioning to Optimize Oxygenation and Ventilation
Prone Positioning
Cardiovascular Effects of Positive Pressure Mechanical Ventilation
Thoracic Pump and Venous Return During Spontaneous and Mechanical Ventilation
Compensation in Healthy Persons
Pulmonary Vascular Pressure, Blood Flow, and Pulmonary Vascular Resistance
Right and Left Ventricular Function
Effect on Left Ventricular Dysfunction
Endocardial Blood Flow
Cardiac Output, Cardiac Index, and Systemic Blood Pressure
Minimizing Cardiovascular Effects of Positive Pressure Mechanical Ventilation
Mean Pleural Pressure
Decreasing Mean Airway Pressure
Fluid Management and Cardiac Output
Pharmacologic Maintenance of Cardiac Output and Blood Pressure
Effects of Positive Pressure Mechanical Ventilation on Other Body Systems (Box 47.2)
Increased Intracranial Pressure
Treatment of a Patient With a Closed Head Injury
Effect on Renal Function
Decreased Liver and Splanchnic Perfusion
Decreased Gastrointestinal Function
Effect on Central Nervous System
Sedatives, Hypnotics, and Neuromuscular Blocking Agents
Opioids
Complications of Mechanical Ventilation
Negative Pressure Ventilation
Pulmonary
Cardiovascular
Positive Pressure Ventilation: Artificial Airway Complications
Complications Related to Pressure
Complications Related to Volume
Auto–Positive End-Expiratory Pressure
Oxygen Toxicity
Ventilator-Associated (Nosocomial) Pneumonia
Prevention of Ventilator-Associated Pneumonia
Ventilator Malfunction
Operator Error
Summary Checklist
References
48 Patient–Ventilator Interactions
Chapter Outline
Chapter Objectives
Key Terms
Effects of Poor Patient–Ventilator Interaction on Outcome
Causes of Poor Patient–Ventilator Interactions
Change in Clinical Status
Artificial Airways
Pneumothorax
Airway Emergencies
The Mechanical Ventilator
Variables Controlled During Mechanical Ventilation
Types of Asynchrony
Causes of Asynchrony
Flow Asynchrony
Volume Ventilation
Pressure Ventilation
Trigger Asynchrony
Auto–Positive End-Expiratory Pressure/Missed Triggering
Trigger Delay
Autotriggering
Double Triggering
Reverse Triggering
Cycle Asynchrony
Mode Asynchrony
Patient–Ventilator Assessment
Summary Checklist
References
49 Initiating and Adjusting Invasive Ventilatory Support
Chapter Outline
Chapter Objectives
Key Terms
Goals of Mechanical Ventilation
Lung Protective Ventilatory Strategies
Ventilator Initiation
Establishment of the Airway
Pressure-Controlled Versus Volume-Controlled Ventilation
Full Ventilatory Support Versus Partial Ventilatory Support
Choice of a Ventilator
Initial Ventilator Settings
Choice of Mode
Assist/Control Ventilation (Patient-Triggered or Time-Triggered Continuous Mandatory Ventilation)
Controlled Ventilation (Time-Triggered Continuous Mandatory Ventilation)
Synchronized Intermittent Mandatory Ventilation
Pressure Support Ventilation
Airway Pressure Release Ventilation
High continuous positive airway pressure.
Low continuous positive airway pressure.
High continuous positive airway pressure time.
Low continuous positive airway pressure time.
Concerns with airway pressure release ventilation.
High-Frequency Oscillatory Ventilation
Initial Choice of Mode
Tidal Volume and Rate
Trigger Sensitivity
Inspiratory Flow, Time, and Inspiratory-to-Expiratory Ratio for Volume Ventilation
Flow Waveform
Inspiratory Pause
Oxygen Percentage (Fractional Inspired Oxygen)
Positive End-Expiratory Pressure and Continuous Positive Airway Pressure
Open Lung Strategy, Recruitment Maneuvers, and Positive End-Expiratory Pressure
Pressure Rise Time or Slope
Limits and Alarms
Humidification
Periodic Sighs
Adjusting Ventilatory Support
Patient–Ventilator Interaction
Oxygenation
Oxygen Concentration
Positive End-Expiratory Pressure and Continuous Positive Airway Pressure
Minimum Positive End-Expiratory Pressure
Optimal or Best Positive End-Expiratory Pressure Based on Oxygen Delivery
Compliance-Titrated Positive End-Expiratory Pressure
Positive End-Expiratory Pressure Titrated With Pressure-Volume Curves as Part of a Lung Protective Strategy
Positive End-Expiratory Pressure and Lung Recruitment Maneuvers
Esophageal manometry.
Electrical impedance tomography.
Positive End-Expiratory Pressure Tables
Other Techniques for Improving Oxygenation
Bronchial Hygiene
Prone Positioning
Ventilation
Adjusting Tidal Volume and Rate
Apnea (Controlled Ventilation)
Rate.
Tidal volume.
Mechanical dead space.
Control of PaCO2 in Synchronized Intermittent Mandatory Ventilation Mode
Assist/Control Mode Volume Ventilation and PaCO2
Pressure Support Ventilation and PaCO2
Pressure-Controlled Ventilation and PaCO2
PaCO2 When Using Lung Protective Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome
Open Lung Approach
Other Lung Protective Strategies
Summary Checklist
References
50 Noninvasive Ventilation
Chapter Outline
Chapter Objectives
Key Terms
History and Development of Noninvasive Ventilation
Indications for Noninvasive Ventilation
Goals and Benefits of Using Noninvasive Ventilation
Acute Care Indications
Hypercapnic Respiratory Failure
Chronic obstructive pulmonary disease.
Asthma
Facilitation of Weaning in Chronic Obstructive Pulmonary Disease
Hypoxemic Respiratory Failure
Acute Cardiogenic Pulmonary Edema
Pneumonia
Acute Lung Injury and Acute Respiratory Distress Syndrome
Respiratory Failure in Immunocompromised Patients
Do-Not-Intubate and Comfort-Measures-Only Orders
Postoperative Respiratory Failure
Prevention of Reintubation in High-Risk Patients
Postextubation Respiratory Failure
Long-Term Care Indications
Nocturnal Hypoventilation
Restrictive Thoracic Diseases
Amyotrophic Lateral Sclerosis
Chronic Obstructive Pulmonary Disease With Stable Hypercapnia
Obesity-Hypoventilation Syndrome
Selecting Appropriate Patients for Noninvasive Ventilation
Acute Care Setting
Long-Term Care Setting
Exclusion Criteria for Noninvasive Ventilation in a Long-Term Care Setting
Equipment Used for Noninvasive Ventilation
Patient Interfaces
Nasal and Oronasal Masks
Nasal Pillows
Hybrid Oronasal Mask
Total Face Mask
Helmet
Types of Mechanical Ventilators and Modes of Ventilation
Noninvasive Ventilators
Critical Care Ventilators
Portable Home Care or Transport Ventilators
Heated Humidifiers
Management of Noninvasive Ventilation
Initial Application of Noninvasive Ventilation
Clinical Assessment Criteria to Identify Success or Failure of Noninvasive Ventilation
Adjusting Noninvasive Ventilator Settings
Aerosolized Medication Delivery
Safe Delivery of Noninvasive Ventilation
Monitoring During Noninvasive Ventilation
Patient Location
Weaning from Noninvasive Ventilation
Complications of Noninvasive Ventilation
Time and Costs Associated With Noninvasive Ventilation
Summary Checklist
References
51 Extracorporeal Life Support
Chapter Outline
Chapter Objectives
Key Terms
The Respiratory Therapist as Extracorporeal Membrane Oxygenation Specialist
International Registry
Patients Receiving Extracorporeal Membrane Oxygenation
Newborns
Pediatric and Adult Patients
Physiology
Equipment
Anticoagulation Management
Cannulas
Types of Support
Venoarterial Extracorporeal Membrane Oxygenation
Venovenous Extracorporeal Membrane Oxygenation
Extracorporeal Carbon Dioxide Removal
Hybrid Extracorporeal Membrane Oxygenation
Initiation of Support
Maintenance of an Extracorporeal Membrane Oxygenation Run
Transporting a Patient on Extracorporeal Membrane Oxygenation
Risks and Complications
Blood Products During Extracorporeal Membrane Oxygenation
Weaning and Decannulation
Summary Checklist
References
52 Monitoring the Patient in the Intensive Care Unit
Chapter Outline
Chapter Objectives
Key Terms
Principles of Monitoring
History
Pathophysiology and Monitoring
Monitoring Oxygenation
Arterial Pulse Oximetry
Oxygen Consumption
Alveolar-Arterial Oxygen Tension Difference
PaO2/FiO2 Ratio
Murray Lung Injury Score
Other Oxygenation Measurements
Monitoring Ventilation
Capnography
Dead Space
Monitoring of Inspired and Exhaled Gas Volumes
Inspired Versus Expired Tidal Volume During Mechanical Ventilation
Peak and Plateau Pressures
Mean Airway Pressure
Driving Pressure
Resistance
Monitoring Lung and Chest Wall Mechanics
Respiratory System Compliance
Chest Wall Compliance
Transpulmonary Pressure
Lung Stress and Strain
Monitoring the Patient–Ventilator System
Graphics Monitoring
Monitoring During Lung-Protective Ventilation
Stress Index
Auto–Positive End-Expiratory Pressure (Intrinsic Positive End-Expiratory Pressure)
Methods for Determining Auto–Positive End-Expiratory Pressure
End-Expiratory Hold by the Ventilator
Esophageal Pressure Measurements
Using Positive End-Expiratory Pressure With Auto–Positive End-Expiratory Pressure
Monitoring Breathing Effort and Patterns
Work of Breathing
Pressure-Time Product
Oxygen Cost of Breathing
Assessing Ventilatory Drive
Airway Occlusion Pressure
Diaphragm Ultrasound
Rapid Shallow Breathing Index
Respiratory Inductive Plethysmography
Monitoring Strength and Muscle Endurance
Endurance: Maximal Voluntary Ventilation
Lung Imaging at the Bedside
Lung Ultrasound
Electrical Impedance Tomography
Cardiac and Cardiovascular Monitoring
Electrocardiography
Monitoring of Arterial Blood Pressure
Monitoring of Central Venous Pressure–Right Atrial Pressure
Monitoring of Pulmonary Artery Pressure
Preload
Contractility
Afterload
Cardiac Output
Cardiac Muscle Injury
Monitoring Renal Function
Monitoring Liver Function
Nutritional Monitoring
Assessment of Nutritional Status
Global Monitoring Indices
Acute Physiology and Chronic Health Evaluation (APACHE)
Neurologic Monitoring
Neurologic Status and Examination
Pupillary Response
Eye Movements
Corneal Responses
Gag Reflex
Respiratory Rate and Pattern
Motor Evaluation
Sensory Evaluation
Glasgow Coma Scale
Intracranial Pressure Monitoring
Troubleshooting
Summary Checklist
References
53 Discontinuing Ventilatory Support
Chapter Outline
Chapter Objectives
Key Terms
Reasons for Ventilator Dependence
Ventilatory Workload and Demand
Ventilatory Capacity
Global Criteria for Discontinuing Ventilatory Support
Patient Evaluation
The Most Important Criterion
Weaning Indices
Ventilation
Oxygenation
Acid–Base Balance
Metabolic Factors
Renal Function and Electrolytes
Cardiovascular Function
Psychologic Factors and Central Nervous System Assessment
Integrated Indices
Evaluation of the Airway
Preparing the Patient
Optimizing the Patient’s Medical Condition
Patients’ Psychologic and Communication Needs
Caregiver Preparation
Methods
Rapid Ventilator Discontinuation
Patients Who Need Progressive Weaning of Ventilatory Support
Spontaneous Breathing Trials
Continuous Positive Airway Pressure
Synchronized Intermittent Mandatory Ventilation
Pressure Support Ventilation
Synchronized Intermittent Mandatory Ventilation With Pressure Support Ventilation
Spontaneous Awaking Trials
Newer Techniques for Facilitating Ventilator Discontinuance
Mandatory Minute Volume Ventilation
Adaptive Support Ventilation/Intellivent
Computer-Based Weaning
Automatic Tube Compensation
Volume Support
Proportional Assist Ventilation and Neurally Adjusted Ventilatory Assist
Newer Techniques for Evaluation of Diaphragm Function and Prediction of Successful Discontinuation
Noninvasive Ventilation/Continuous Positive Airway Pressure
High-Flow Nasal Cannula
Role of Mobility
Respiratory Therapist–Driven Protocols
Recent ATS/ACCP Ventilation Liberation Guidelines
Selecting an Approach
The Morbidly Obese Patient
Monitoring the Patient During Weaning
Ventilatory Status
Oxygenation
Cardiovascular Status
Extubation
Artificial Airways and Weaning
Post Extubation Complications
Ventilator Discontinuance Failure
Prolonged Mechanical Ventilation
Chronically Ventilator- Dependent Patients
Terminal Weaning
Summary Checklist
References
54 Neonatal and Pediatric Respiratory Care
Chapter Outline
Chapter Objectives
Key Terms
Assessment of the Newborn
Maternal Factors
Fetal Assessment
Fetal Blood Gas Analysis
Evaluation of the Newborn
Apgar Score
Assessment of Gestational Age
Respiratory Assessment of the Infant
Physical Assessment
Surfactant
Blood Gas and Pulse Oximetry Analysis
Respiratory Assessment of the Pediatric Patient
Respiratory Care
Oxygen Therapy
Goals and Indications
Methods of Administration
Surfactant Administration
Secretion Clearance Techniques
Methods
Monitoring
Humidity and Aerosol Therapy
Humidity Therapy
Aerosol Drug Therapy
Airway Management
Intubation
Suctioning Intubated Pediatric Patients
Suctioning.
Continuous Positive Airway Pressure
Methods of Administration
High-Flow Nasal Cannula
Noninvasive Ventilation
Mechanical Ventilation
Basic Principles
Goals of Mechanical Ventilation
Modes of Ventilation and Breath Delivery Types
Bag-Mask Ventilation
Ventilator Settings and Parameters
Peak Inspiratory Pressure
Positive End-Expiratory Pressure
Tidal Volume
Ventilator Rate
Inspiratory Time
Oxygen Concentration
Mean Airway Pressure
Monitoring Mechanical Ventilation
Physical Examination
Patient–Ventilator Interaction
Additional Monitoring
Patient–Ventilator Periodic Assessment
Weaning From Mechanical Ventilation
High-Frequency Ventilation
Cardiovascular Effects
Weaning From High-Frequency Ventilation
Complications of Mechanical Ventilation
Specialty Gases
Inhaled Nitric Oxide
Heliox
Neonatal and Pediatric Transport
Summary Checklist
References
VII Patient Education and Long-Term Care
55 Patient Education and Health Promotion
Chapter Outline
Chapter Objectives
Key Terms
Patient Education
Cultural Awareness
Health Literacy
Establishing Goals for the Patient Teaching
Performance Objectives
Learning Domains
Cognitive Domain
Psychomotor Domain
Affective Domain
Provide Educational Resources
Teaching Children, Adolescents, Adults, and Older Adults
Teaching Children and Their Parents
Teaching Adolescents and Adults
Teaching Older Adults
Teach Back or Echo Method
Evaluation of Patient Education
Patient Education Teaching Tips
Health Education
Health Promotion and Disease Prevention
Chronic Disease Management and Population Health
Implications for the Respiratory Therapist
Healthcare Institutions
Work Site
Home
Community
Educational Institutions
Summary Checklist
References
56 Cardiopulmonary Rehabilitation
Chapter Outline
Chapter Objectives
Key Terms
Definitions and Goals
Historical Perspective
Physical and Psychosocial Basis
Physical Reconditioning
Psychosocial Support
Structure of a Pulmonary Rehabilitation Program
Program Qualification
Program Goals and Objectives
Patient Evaluation and Selection
Patient Evaluation
Patient Selection
Program Design
Format
Content
Physical Reconditioning
Educational Component
Breathing control methods.
Methods of relaxation and stress management.
Secretion clearance and bronchial hygiene techniques.
Home oxygen and aerosol therapy.
Medications.
Dietary guidelines.
Recreational and vocational counseling.
Psychosocial and Behavioral Components
Program Implementation
Staffing
Facilities
Scheduling
Class Size
Equipment
Web-Based Pulmonary Rehabilitation
Financial Considerations
Costs and Fees
Reimbursement Qualifications
Program Results
Potential Hazards
Cardiac Rehabilitation
Conclusion
Summary Checklist
References
57 Respiratory Care in Alternative Settings
Chapter Outline
Chapter Objectives
Key Terms
More Recent Developments and Trends
Relevant Terms and Goals
Long-Term Subacute Care Hospitals
Subacute Care
Home Care
Standards
Regulations
Private Sector Accreditation
Traditional Acute Care Versus Alternative Setting Care
Discharge Planning
Multidisciplinary Team
Oxygen Therapy in Alternative Settings
Oxygen Therapy Prescription
Oxygen Qualification Criteria
Supply Methods
Compressed Oxygen Cylinders
Liquid Oxygen Systems
Oxygen Concentrators
Problem Solving and Troubleshooting
Delivery Methods
Transtracheal Oxygen Therapy
Demand-Flow Oxygen Systems
Selecting a Long-Term Oxygen Delivery System
Problem Solving and Troubleshooting
Ventilatory Support in Alternative Settings
Patient Selection
Settings and Approaches
Standards and Guidelines
Special Challenges in Providing Home Ventilatory Support
Prerequisites
Planning
Caregiver Education
Invasive Versus Noninvasive Ventilatory Support
Equipment
Selecting the Appropriate Ventilator
Positive Pressure Ventilators
Other Modes of Respiratory Care in Alternative Sites
Bland Aerosol Therapy
Aerosol Drug Administration
Airway Care and Clearance Methods
Nasal Continuous Positive Airway Pressure Therapy
Equipment
Determining Proper Continuous Positive Airway Pressure Level
Sleep Remote Telemonitoring
Use and Maintenance
Problem Solving and Troubleshooting
Apnea Monitoring
Patient Assessment and Documentation
Institutional Long-Term Care
Screening
Treatment Planning and Ongoing Assessment
Discharge Summary
Home-Care Plan
Equipment Disinfection and Maintenance
Summary Checklist
References
58 Ethics and the End of Life
Chapter Outline
Chapter Objectives
Key Terms
Introduction
“Goals of Care” as an Essential Organizing Framework
Medical Prognosis and Rehabilitative Prognosis
Values, Beliefs, and Preferences
Particulars
Context
Relationships
Ethical and Legal Parameters
Refusal of Life-Sustaining Treatment
Summary
Management of Pain and Other Symptoms at the End of Life: Legal and Ethical Considerations
Physician-Assisted Suicide
Euthanasia
Ethically Defensible Comfort-Oriented Care
Doctrine or Rule of Double Effect
Pain and Symptoms at the End of Life: Clarifying the Roles of the Physician and Health Care Agent
Palliative Sedation
Withdrawal of Life-Sustaining Treatment
Special Situations
Status Epilepticus
Patient Receiving Paralytics
Ethical Conflict at the End of Life
Professional Position Statements, Empirical Data, and Hospital Policy Provide Support in Ethical Conflict
The Respiratory Therapist as Ethical Practitioner
Summary Checklist
References
Glossary
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Z
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Abbreviations