Use practical exercises to learn the essentials of mechanical ventilation! Workbook for Pilbeams Mechanical Ventilation, 5th Edition ISBN: 978-0-323-07208-3 This workbook simplifies complex information, helping you answer three basic questions: What I need to know? Why I need to know it? How will I use it? makes learning easy by using real-life examples It ma and a wide range of activities including: s-A s-ATCHINGEXERCISES s&ILL IN THE BLANK s&ILL s#ROSSWORDPUZZLES s#RO s#A s#ASESTUDIES s."2# STYLEMULTIPLE CHOICEQUESTIONS s." Get your copy today! – On Online at www.elsevierhealth.com n#ALL    n#A Visit your local bookstore – Vis YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK ACTIVATE THE COMPLETE LEARNING EXPERIENCE THAT COMES WITH YOUR BOOK BY REGISTERING AT http://evolve.elsevier.com/Cairo/pilbeams/ventilation Once you register, you will have access to your FREE STUDY TOOLS: • Workbook Answer Key • Student Lecture Notes • Lab values • Special Techniques REGISTER TODAY! PILBEAM’S Mechanical Ventilation Physiological and Clinical Applications FIFTH EDITION J.M Cairo, PhD, RRT, FAARC Dean of the School of Allied Health Professions Professor of Cardiopulmonary Science, Physiology, and Anesthesiology Louisiana State University Health Sciences Center New Orleans, Louisiana 3251 Riverport Lane St Louis, Missouri 63043 PILBEAM’S MECHANICAL VENTILATION: PHYSIOLOGICAL AND CLINICAL APPLICATIONS 978-0-323-07207-6 Copyright © 2012, 2006 by Mosby, Inc., an affiliate of Elsevier Inc No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the Authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Previous editions copyrighted 1986, 1992, 1998 ISBN: 978-0-323-07207-6 Managing Editor: Billie Sharp Developmental Editor: Kathleen Sartori Editorial Assistant: Andrea Hunot Publishing Services Manager: Julie Eddy Senior Project Manager: Andrea Campbell Design Direction: Karen Pauls Working together to grow libraries in developing countries Printed in the United States of America  Last digit is the print number:  9  8  7  6  5  4  3  www.elsevier.com | www.bookaid.org | www.sabre.org To David and Allyson “Courage is the first of human qualities because it is the quality which guarantees all others.” —Aristotle Contributors Paul Barraza, RCP, RRT Education Coordinator Respiratory Care Services Santa Clara Valley Medical Center San Jose, California Georgine Bills, MBA/HSA, RRT Program Director Respiratory Therapy Dixie State College of Utah St George, Utah Robert M DiBlasi, RRT-NPS, FAARC Respiratory Research Coordinator Respiratory Therapy Department, Center for Developmental Therapeutics Seattle Children’s Hospital and Research Institute Seattle, Washington Craig Black, PhD, RRT-NPS, FAARC Director, Respiratory Care Program The University of Toledo Toledo, Ohio Theresa A Gramlich, MS, RRT Assistant Professor of Respiratory Care University of Arkansas for Medical Sciences Central Arkansas Veterans Health System Department of Respiratory and Surgical Technologies Little Rock, Arkansas Susan P Pilbeam, MS, RRT, FAARC Editor Emeritus Respiratory Care Educational Consultant St Augustine, Florida ANCILLARY CONTRIBUTORS Sandra Hinski, MS, RRT-NPS Faculty, Respiratory Care Division Gateway Community College Phoenix, Arizona Sindee K Karpel, MPA, RRT Clinical Coordinator Respiratory Care Program Edison State College Fort Myers, Florida James R Sills, MEd, CPFT, RRT Professor Emeritus Former Director, Respiratory Care Program Rock Valley College Rockford, Illinois REVIEWERS Allen W Barbaro, MS, RRT Department Chairman, Respiratory Care Education St Lukes College Sioux City, Iowa vi Margaret-Ann Carno, PhD, MBA, CPNP, D, ABSM, FNAP Assistant Professor of Clinical Nursing and Pediatrics School of Nursing University of Rochester Rochester, New York Laurie A Freshwater, MA, RCP, RRT, RPFT Division Director, Health Sciences Carteret Community College Morehead City, North Carolina Charlie Harrison, BS, RRT Instructor of Respiratory Therapy School of Nursing and Allied Health Dixie State College St George, Utah J Kenneth Le Jeune MS, RRT, CPFT Program Director Respiratory Education University of Arkansas Community College at Hope Hope, Arkansas Ronald P Mlcak, PhD, RRT, FAARC Director of Respiratory Care Services Shriners Hospitals for Children Galveston, Texas Suezette R Musick-Hicks, BAAS Ed, RRT-CPFT Director Respiratory Care Program Black River Technical College Pocahontas, Arkansas Joshua J Neumiller, Pharm D, CDE, CGP, FASCP Assistant Professor of Pharmacotherapy Washington State University College of Pharmacy Spokane, Washington CONTRIBUTORS Bernie R Olin, PharmD Associate Clinical Professor Director of Drug Information Harrison School of Pharmacy Auburn University Auburn, Alabama Tim Op’t Holt, EdD, RRT, AE-C, FAARC Professor University of South Alabama Mobile, Alabama Robin L Ross, MS, RRT, RCP Instructional Coordinator Director of Clinical Education CVCC School of Health Services Catawba Valley Community College Respiratory Therapy Program Hickory, North Carolina Paula Denise Silver, MS Bio., MEd, Pharm D Medical Instructor Medical Careers Institute School of Health Science of ECPI University Newport News, Virginia Shawna L Strickland, PhD, RRT-NPS, AE-C Clinical Assistant Professor University of Missouri Columbia, Missouri Robert J Tralongo, MBA, RT, RRT-NPS, AE-C Respiratory Care Program Director Molloy College Rockville Centre, New York Stephen F Wehrman, RRT, RPFT, AE-C Professor, University of Hawaii; Program Director Kapi’olani Community College Honolulu, Hawaii Richard Wettstein, MMEd, RRT Director of Clinical Education University of Texas Health Science Center at San Antonio San Antonio, Texas Mary-Rose Wiesner, BS, RCP, RRT Program Director Department Chair Mt San Antonio College Walnut, California Kenneth A Wyka, MS, RRT, AE-C, FAARC Center Manager and Respiratory Care Patient Coordinator Anthem Health Services Queensbury, New York vii Foreword T he management of the mechanically ventilated patient represents one of the most challenging responsibilities for practitioners in the intensive care unit In this fifth edition of Pilbeam’s Mechanical Ventilation: Physiological and Clinical Application, J.M Cairo., PhD, RRT, FAARC, continues a long tradition of providing a compendium of information about mechanical ventilation, going from basic principles to the most advanced concepts As was the original intention of the text, the presentation and organization continue to reflect the needs of the learner, as well as feedback from those who have read and learned from earlier editions The content of the fifth edition includes the most recent medical evidence and accepted practices related to mechanical ventilation, including the indications, contraindications, and complications related to its use Pilbeam’s Mechanical Ventilation has a history dating back to the 1980s when the first chapter, “The History of Mechanical Ventilation,” was produced on a typewriter The first edition took five years to complete, due not only to the unavailability of personal computers, but also to the fact that medical journals were only available on the stacks of the medical library because there was no Internet After three decades, the textbook has stood the test of time and viii continues to be a primary source for students learning the science and art of mechanical ventilation Although I have retired from being the first author, I have continued to work with Jim, who took on the task of updating, editing, and reorganizing the text My input has been to assist with editing and provide a sounding board in discussing the pros and cons that exist in certain areas of current clinical practice of mechanical ventilation I have also contributed to a few chapters Dr Cairo and I believe that readers of the fifth edition will undoubtedly experience the trials and triumphs that earlier generations of students encountered when they were introduced to mechanical ventilation Becoming an effective clinician, particularly in critical care medicine, requires a personal commitment to becoming a life-long learner As with previous editions of Mechanical Ventilation, I believe that this text will provide essential resources for those who care for mechanically ventilated patients SUSAN P PILBEAM, MS, RRT, FAARC Editor Emeritus Acknowledgments A number of individuals should be recognized for their contributions to this project I wish to offer my sincere gratitude to Sue Pilbeam for her continued support throughout this project and for her many years of service to the Respiratory Care profession Her contributions to the science and art of mechanical ventilation span four decades I feel fortunate to have worked with her on a number of projects and have always been impressed with her insight and dedication to our profession I also wish to thank Theresa Gramlich, MS, RRT, who authored the chapters on Noninvasive Positive Pressure Ventilation and Long-Term Ventilation; Rob Diblasi, BS, RRT, who authored the chapter on Neonatal and Pediatric Ventilation; and Sindee Karpel, BS, RRT, Sandra Hinski, MS, RRT-NPS, and Jim Sills, PhD, RRT, for authoring the ancillaries that accompany this text I wish to thank all of the Respiratory Care educators and students who provided valuable suggestions and comments throughout the course of editing and writing the fifth edition of Pilbeam’s Mechanical Ventilation I particularly want to acknowledge all of the reviewers and my colleagues at LSU Health Sciences Center at New Orleans and Our Lady of the Lake College in Baton Rouge: Michael Levitzky, PhD, John Zamjahn, PhD, RRT, Tim Cordes, MHS, RRT, Terry Forrette, MHS, RRT, Sue Davis, MEd, RRT, Shantelle Graves, BS, RRT, and Martha Baul I would like to offer special thanks for the guidance provided by the staff of Elsevier throughout this project, particularly Kathleen Sartori, Senior Development Editor; Billie Sharp, Managing Editor; Andrea Campbell, Senior Project Manager; Julie Eddy, Publishing Services Manager; and Andrea Hunolt, Editorial Assistant Their dedication to this project has been immensely helpful and I feel fortunate to have had the opportunity to work with such a professional group This edition of Pilbeam’s Mechanical Ventilation certainly would not have come to fruition without the love and support of my wife, Rhonda ix 580 INDEX Mechanical ventilation (Continued) physiological effects, minimization, 319-322 physiological objectives, 49 physiological terms/concepts, 3-9 pMDIs, usage, 236-238 pressure, 525f pressure-volume curves, 143f rate, display, 129 receiving, 553 sudden respiratory distress, causes, 355b renal effects, 323-324 respiratory status, 335-336 SVNs, usage, 238, 239b terms, usage, 9-14 tidal volume, display, 129 types, 10-11 weaning, nonrespiratory factors, 418t WOB reduction, steps, 341-345 Mechanical ventilators connection, 338f equipment, 436 flow patterns, 157f usage, 263, 519 Mechanical ventilatory support, necessity, 52t recognition, 461-462 Meconium aspiration syndrome (MAS), 474 Medically stable, term (usage), 384 Medication administration protocol, nebulizers (usage), 240b Men, ideal body weight (IBW), calculation, 88b Mental status, assessment, 112 Metabolic acid-base imbalances, mechanical ventilation (relationship), 336 Metabolic acid-base status, 335-336 Metabolic acidosis, 226-227 blood chemistry, 337t respiratory alkalosis, combination (clinical scenario), 227b-228b Metabolic alkalosis, 226-227 acid loss, association, 336 blood chemistry, 337t respiratory acidosis, combination (clinical scenario), 228b Metabolic carts/monitors, 188-189 Metabolic disturbances, clinical scenario, 227b Metabolic factors, 411 Metabolic measurements, 187-190 clinical applications, 189-190 Metabolic monitoring system, components, 188f Metabolic rate factors, 189 reduction, sleep (association), 190 Metabolism, increase, 228 clinical scenario, 228b Meter dose inhaler (MDI), usage, 107 Metered dose inhaler, ventilator circuit adaptation, 238f Metered-dose inhaler (MDI), usage, 518 Methemoglobin (MetHb), 177 example, 176f Methemoglobinemia, 495 Methicillin-resistant S aureus (MRSA), case study, 300b Microprocessor random access memory, usage, 20 read-only memory (ROM), updating, 20 Microprocessor-controlled ventilators, 129-130 theoretical waveforms, 161f waveform display capability, 32-33 Midazolam, 309 Minimal sedation, 308 Minimum leak technique, 134, 134b Minimum occlusion technique, 134b Minimum PEEP, 263 Minute ventilation (VE) calculation, 86 case study, 88b constancy, 79t demands, reduction, 345 determination, 86b display, 129 estimation, 86 improvement, 509 increase, 365f-368f measurement, respirometer technique, 130b needs, case study, 87b product, 55 reduction, 51, 311 respiratory rate, 55 setting, 86-94 considerations, 94-95 Mixed acid-base disturbances, 227-228 Mixed respiratory disturbances, clinical scenario, 227b Mixed venous oxygen saturation (SvO2), 212, 270 Mixed venous oxygen tension, 270 Mode, review (worksheet), 81f-82f Mode asynchrony, 344 Moderate sedation (conscious sedation), 308 Monitoring equipment, 250b Moraxella catarrhalis, 295-296 Morphine, 311 effects, 311 Motion, equation, 30b model, 31f Motion, production (energy requirement), 30 Motor nerve damage, 52 Mouth care, 140 Mouthpieces headgear/straps, requirement (absence), 392 interface, 382 Mouth pressure (PM), sum, 150 Multidrug-resistant (MDR) infections, risk factors, 296b Multidrug-resistant (MDR) microorganisms, 295 Multidrug-resistant (MDR) pathogens, development (risks), 300t Multiple organ dysfunction syndrome, 276-277, 332 Multisystem organ failure, 276-277 Muscle dysfunction, 52 Muscle function, impairment, 50 Muscle strength, 409-412 Myasthenia gravis initial ventilator settings, 114 patient care, case study, 258b Myocardial function, 135 Myocardial ischemia, impact, 110-111 N Nail polish, pulse oximeter impact, 177-178 Naloxone hydrochloride (Narcan), 59b Narcotic analgesics, usage, 312 Nasal CPAP, 262, 462-463 application, 464-466 neonates, 463-466 usage, 517 Nasal headgear, 390f Nasal high-frequency ventilation (nasal HFV), usage, 467-468 Nasal IMV, triggering, 467 Nasal interfaces, 389-392 Nasal mask disadvantages, 389 fitting, 389f problems, 394 usage, 431 Nasal mini-mask/headgear, 390f Nasal passages, damage, 347 Nasal pillows, 390f usage, 395 Nasal prongs CPAP delivery system, diagram, 466f fitting, 464 usage, 463b Nasal seals, usage, 395 Nasal “sigh” positive airway pressure, 467 Nasopharyngeal injury, 440 Nasopharyngeal tubes, usage, 463b Nebulization, ventilator (usage), 239-240 Nebulizers impairment, 371 usage, 240 protocol, 240b Negative end-expiratory pressure (NEEP), 40 advocacy, 40-41 expiration occurrence, 41f subambient pressure, 40-41 technique, 40 Negative inspiratory force (NIF), 53, 412 Negative intrapleural pressures, transmission, 317f Negative-pressure ventilation (NPV), 10, 379, 441-442 airtight garments, usage, 443f cuirass shell, usage, 443f impact, 6t example, 11f usage, 10, 379 rarity, 113 Negative-pressure ventilators, 20 usage, 10 Neonatal lung disorders, lung-protective ventilation strategies, 484t Neonatal ventilator advance, 472 circuit, schematic, 471f features, 472b Neonates, 461 chest radiographic evaluation, 462 cuffless ETs, usage, 477 data, interpretation/response (case study), 484b extubation, 464, 491-493 graphical waveform, 473f heart rate, 207 high-frequency ventilation, 485-491 INO therapy, 494-495 invasive mechanical ventilation, clinical indications, 469b management, respiratory failure (usage), 469 nasal CPAP, 462-466 application, 464-466 INDEX Neonates (Continued) indications/contraindications, 463-464 nasal “sigh” positive airway pressure, 467 NIV, usage, 466-468 noninvasive nasal high-frequency ventilation, 467-468 noninvasive nasal intermittent mandatory ventilation, 467 oxygenation/ventilation, determination, 462 patients, transcutaneous blood gas monitoring (AARC clinical practice guideline), 187b patient-triggered PC-IMV, receiving, 473f PEEP, 474 prone positioning, 494 prophylactic therapy, 494 respiratory distress, 461 magnitude (assessment), Silverman Score (usage), 462f respiratory support, adjunctive forms, 493-495 TCPL/IMV asynchrony, display, 471 ventilators, features, 470b ventilatory support, indications, 469-470 weaning, 491-493 Neural control, review, 522 Neurally adjusted ventilator assist (NAVA), 483, 505, 527-528 alarms, 528 breath, inspiration, 528 development, motivation, 527 electrical activity, monitoring, 522-529 evaluation, 528 level, accidental setting, 527-528 monitoring, 522-529 safety features, 528 ventilation initiation, results, 528 Servo ventilator, main screen, 526f usage, 527-528 weaning, 528 Neuroleptics, 310 usage, 312 Neurologic factors, 411 Neuromuscular blockade, monitoring, 313 accomplishment, 313 Neuromuscular blocking agents (NMBAs), 307 administration, SCCM recommendation, 313 case study, 314b classes, availability, 312 usage, 312 withdrawal, prolonged paralysis (reason), 419 Neuromuscular disorders, 50, 52, 113-114 clinical scenario, 114b drugs, impact, 52 myasthenia gravis, initial ventilator settings, 114 patient guidelines, 114 ventilation, usage (case study), 52b Newborns assessment/treatment, case study, 468b CPAP, indications, 463b pediatric ventilatory support goals, 462 physical examination, abnormalities, 463 transient tachypnea, 463 NICO2 capnometer, 185f Nitric oxide (NO) therapy (appropriateness), determination (case study), 495b Nitric oxide (NO), exhalation levels, factors, 186b monitoring, 186 Nocturnal hypoventilation, 382 Nonbronchoscopic techniques, description, 298 Noncardiogenic pulmonary edema, cause, 357 Nondependent lung, ventilation, 333-334 Nondepolarizing agents, 312-314 Nonexistent cuff pressure, 138 Nonhomogeneous lung, ventilation-toperfusion (V/Q) matching, 95 Noninvasive devices, 442-444 Noninvasive nasal intermittent mandatory ventilation, 467 Noninvasive positive-pressure ventilation (NIV), 58, 64-65, 441 adjustment, 393-394 case study, 393b advantages/disadvantages, 65b aerosol delivery, 394 factors, 394b alternative, importance, 48-49 BiPAP usage, 98-99 change, 58b clinical benefits, 380b complications, 394-396 case study, 394b consideration, 384 contraindications, 58b discontinuation, 396 disorder management, 65b equipment selection, 384-392 exclusion criteria, 383b expiratory PAP levels, 505 extubation, relationship, 416-417 goals, 380-382 heliox, relationship, 521-522 humidification issues, 388 indications, 58b, 380-383 list, 383t, 385t initiation, 392b instituting, criteria, 416b interfaces, advantages/disadvantages, 388t monitoring, 393-394 case study, 393b nasal mask, usage, 431 nebulizers, usage, 240 neonates, impact, 466-468 patient interface, selection, 64-65 patient selection, case study, 393b preparation, 392-393 selection, list, 383t, 385t setup, 392-393 success, predictors, 393b symptoms, list, 383t, 385t termination, criteria, 394b therapy, complications, 396t, 445t usage, 302, 380 weaning, 396 Noninvasive ventilation, 302 techniques, 379-380 Noninvasive ventilation face/nasal mask, fitting, 110 Noninvasive ventilatory support, 462-469 Normal pressure limit, 37 581 Nosocomial pneumonias isolated pathogenic organisms, impact, 295b risk, reduction methods, 302b Numeric intensity scale, 250f Nurse-driven protocols, 420 Nutrition, adequacy, 435 Nutritional depletion, impact, 324 Nutritional status, 419 assessment, 325b O Obstructed expiratory valve, 371 Obstructive sleep apnea (OSA), 379-380 CPAP, usage, 444-445 treatment, 382 Occlusion pressure measurements, 195 Occult PEEP, 336-337 One-way valve connection, 54f Open-heart surgery, hemodynamic monitoring (case study), 214b Open-loop systems, 21 choice, 21b example, 21f unintelligent systems, 21 Open reservoir, usage, 406f Open suctioning technique, 231 Operational verification procedure (OVP), 125 Opioids, 310-311 pharmacologic action, 310-311 side effects, 311b reversal, 311 usage, 312 Optical shunting, 177-178 Optimum lung volume HFOV strategy flow chart, 492f weaning strategy flow chart, 93f Optimum PEEP, 263-270 establishment, 258-273 selection, case study, 270b study, 266-270 performing, 267 Oral cavity, examination, 356 Oral interfaces, 391-392 Oral mouthseal, 392f Oronasal mask, 391f Oropharynx, damage, 347 Oscillator, sinusoidal waveform generation, 510f Overdistention display, pressure-volume loop (usage), 474f protection, 330b Overinflation, 368 Oxygen administration equipment, 436 amount, representation, 211 analyzers, usage, 126 concentration calculation, 211 inspired level, 478-479 consumption, increase, 419 delivery (enhancement), open reservoir (usage), 406f desaturation, 382 estimates, clinical shunt equation (usage), 556 flow rates, increase, 386 toxicity, 339 pulmonary changes, 340b usage, 339 582 INDEX Oxygenation adequacy, 413 adjustment, 508-509 basics, 258-273 calculation, equations, 259b continuous monitoring, 50 data, 268f determination, 462 evaluation, P(A-a)O2 (usage), 56 failure, 55-56 goal, 514 improvement, 42 inadequacy, 359 maintenance, 115, 258 usage, 514 Oxygenation, mechanisms, 245 Oxygen delivery (DO2), 212 basics, 258-260 Oxygen saturation of arterial blood (SaO2), 211 PaO2, relationship, 178 Oxygen therapy hazards, mechanical ventilation (usage), 339-340 Oxyhemoglobin (O2Hb), 177 dissociation curve, 178f right shift, acidosis (impact), 335 example, 176f percenteage, presence, 176 P Pancuronium (nondepolarizing agent) (Pavulon), 313 quaternary ammonium compound, 313 Paradoxical breathing, 53 indication, 136 Paralytic disorders, 50 Paralytic drugs, 50 Paralytics, 312-314 usage, 307, 312b Parenchymal lung disease, 75-76 Partial pressure of arterial carbon dioxide (PaCO2) elevation, 223 factors, 223f increase, 335 occurrence, 515 reduction, steps, 515b Partial pressure of carbon dioxide in arterial blood (PaCO2), 50 alterations, 229 decrease, 116 elevation, 55 maintenance, 90b range, 125 Partial pressure of oxygen (PO2), PCO2 (relationship), 557f Partial pressure of oxygen in arterial blood (PaO2), 50 increase, PEEP (usage), 270 maintenance, 90b mean airway pressure, relationship, 320 mPaw, impact, 510-511 PaO2/FIO2 ratio, usage, 56 PaO2/PAO2, ratio, 56 PaO2/PAO2 ratio, usage, 260 range, 125 SaO2, relationship, 178 Partial ventilatory support (PVS), 65 Passive expiration, zero baseline, 41f Passive filling/emptying (representation), time constants (usage), Passive humidifiers, placement, 107 Passive spontaneous ventilation, impact, 6t Passy-Muir, 448 valve, patient experience (clinical scenario), 450b Passy-Muir speaking valves (PMVs), examples, 450f Patent airway, maintenance, 50 Patient breathing, endotracheal tube (usage), 195f Patient care team concerns, 396-397 Patient-centered mechanical ventilation, 249-250 Patient circuit, 21 adjuncts, usage, 24b components, 24f addition, 24f elements, 23b gas flow, 22f Patient-circuit leaks, occurrence, 371 Patient effort, 68 control, 34-35 Patient-related problems, 356-358 Patients agitation, case study, 311b appearance, 267 assessment, 144 case study, 136b breath sounds, 112 chest radiograph, 113 circuit, accidental disconnections (reasons), 346b clinical stability, 430-431 closed head injury guidelines, 116-117 comfort, 249-250 confusion/delirium, 249 cough, 112 CPAP, weaning (example), 274t distress, recognition, 49 evaluation, clinical factors, 411b feeding, transpyloric enteral route (usage), 246 history/diagnosis, 51-53 information, 126 initial assessment, 112-113 clinical laboratory tests, 126b initial ventilator settings, 111-121 interfaces, 388 selection, 64-65 lockout, 70 lung characteristics, 66, 68 management techniques, 244-251 mental status, 112 muscle strength, 409-412 neuromuscular disorder guidelines, 114 PEEP, weaning (examples), 274t physical appearance, 112 position, change (case study), 246b preparation, 110 prone positioning, 244-246 contraindications, 240b protocol, 246b protection, 354-355 safety, 249-250 selection, 430-432 criteria, 383-384 sensitivity, 129 size, suction levels, 231b sudden distress, identification, 355-356 temperature, 135 triggering, sensitivity setting (inadequacy), 368 variability, 284 ventilator disconnection, 134 ventilatory performance, 409-412 vital signs, 112 Patient-triggered (assisted) breath, 155 airway P-V loop, 168f pressure, negative deflection, 36f sensitivity, 156f Patient-triggered mandatory breath, P-V loop, 167-168 Patient-triggered modes, problems, 71 Patient-triggered ventilation, 472 Patient triggering, 34-36 case study, 35b control, 34-35 enabling, 34-35 Patient-ventilator asynchrony, 370 examples, 359-360 identification, 356 improvement, 472f Patient-ventilator asynchrony detection, Edi catheter (usage), 524 impact, 524 Patient-ventilator interaction, sleep (relation), 248 Patient-ventilator synchrony, 341-345 Patient-ventilator system, documentation, 125-126 Peak airway pressure, 12 Peak expiratory flow rate (PEFR), 54-55 defining, 151-152 increase, 240 reduction, 170 Peak flow control, absence, 94 Peak inspiratory pressure (PIP), 12, 131 adjustments, 467 applied/auto-PEEP, impact, 192 changes, examples, 141t concerns, 93 defining, 153 elevation, 361 evaluation, case studies, 362b impact, 166f increase, 68, 320-321 measurement, 191 Pplateau, pressure differences, 322f pressure plateau, subtraction, 132 reduction, 240 total force, 192 Peak pressure, 12 alarm activation, case study, 329b Pediatric infant ventilators, features, 472b Pediatric patients acute lung injury, 483-484 BiPAP, usage, 468-469 CPAP, usage, 468-469 mechanical ventilation, usage (indications), 470b mechanical ventilatory support, goals, 462 pressure-support ventilation, usefulness, 479 respiratory distress, 461 transcutaneous blood gas monitoring, AARC clinical practice guideline, 187b ventilatory support indications, 470 recognition, 470 Pediatric ventilator, 470-473 advance, 472 features, 470b support, goals, 462 Pendelluft, 489 Perfusion, ventilation (absence), 212 Periodic hyperinflation, 109-110 INDEX Permissive hypercapnia (PHY), 115, 229-230 cardiovascular system response, 230 circulatory effects, 230 clinical scenario, 230b contraindications, 230 implementation, protocol, 230b management, procedures, 229 technique, 229 Phase variables, 33-43 breath phases, 34b determination, criteria, 44f list, 43b types, 43 Phrenic nerve, severing, 524 Physical appearance, assessment, 112 Physiological dead space (VD) (VDphys), 553 clinical monitoring, 553-554 definition, 553 increase, 228 monitoring, 553 Physiological shunt, determination, 212 Piezoelectric transducer, usage, 190 Pilot tube cut, 138-140 repair, 140f repair kit, 140f Piston-driven ventilator, internal pneumatic circuit (example), 36f Pittsburgh speaking tracheostomy tube, 449f Pittsburgh Talking TT, 448 Plasma renin activity (PRA), sympathetic tone (relationship), 323 Plateau pressure (Pplateau), 4, 12-13, 191 evaluation, case study, 362b level, control, 131 maintenance, 88 measurement, 12-13, 130f measurement accuracy, 95 requirement, 39 usage, 13 Pleural pressure graphing, 15f increase, 278 Pleural space, airway pressure (transmission), 272-273 Pleura-occupying lesions, 50 Plunger, position, 26 Pneumatically powered ventilators, 18 Bird Mark 7, 19f classification, 18 Pneumatic circuit, 21-23 external pneumatic circuit, 21, 23 internal pneumatic circuit, 21-23 Pneumatic flow control valve, digital on/off valve, 27f Pneumobelt positive-pressure generator, inclusion, 444f usage, 444 Pneumomediastinum, 329 Pneumoperitoneum, 329 Pneumotachograph, fixed/variable orifices, 192f Pneumotachometer, usage, 54 Pneumothorax, 329, 357 detection, 329, 357 development, 329 impact, 329 Poiseuille’s law, Polyneuritis, severity, 318 Portable homecare ventilators, 386-387 Portable pressure-targeted ventilators, 387 limitations, 386 Porta-lung, 442 negative pressure ventilator, example, 442f Portex Speaking TT, 448 example, 448f Posey Cuffalator device, usage, 137f Positive end-expiratory pressure (PEEP), 12, 42-43, 66, 321 administration, 246 amount, estimation, 106 application, 264-270 application, physiological factors (change), 270f applied/inadvertent usage, 209 ARDS vertical gradient, 278 asynchrony, 344 baseline pressure level, 40 benefits, 272 congestive heart failure, relationship, 273 contraindications, 271-273 controlled ventilation, 42f decremental PEEP, 285 definitions, 104b devices, application, 262-263 effects, 119b, 474 establishment, pressure-volume curves (usage), 258-273 excess, 344, 371 frequency, 478 goals, 262 increase, 285 effects, 271t-272t, 475f indications, 263-264 intermittent mandatory breaths, 42f introduction, 261-263 minimum/low PEEP, 263 neonates, 474 PEEPTOT, subtraction, 132 physiological effects, 271-273 pulmonary effects, 272 ranges, 263 role, 333 setting, pressure-volume loops (usage), 280-282 simplification, 321f study flowsheet, example, 268f measurement/monitoring, parameters, 266b technical aspects, 262 term, definition, 42 terminology, 262 therapeutic PEEP, 263 titration, 279 usage, 85-86, 258-273 weaning, 273 examples, 274t procedures, 275b withdrawal, 274b Positive end-expiratory pressure (PEEP) levels impact, 211f, 268f increase, 474 selection, 264-270 Positive end-expiratory pressure (PEEP) therapy indications, 263b initiation, 264 usage, 88 variation, 43 583 Positive pressure breath alveolar pressures, graphing, 15f pleural pressures, graphing, 15f pressure-volume curve, 166f pressure-volume loop, impact, 474 upper-airway pressure graph, 13f Positive-pressure breath, volume distribution, 331f impact, 118f Positive pressures, duration/magnitude, 319 Positive-pressure ventilation (PPV), 10-11, 379-380 adverse cardiovascular effects, 317-318 alteration, 316 atelectasis, occurrence, 507 benefits, 319 cardiovascular effects, factors, 318-319 effects, evaluation, 119 endocrine effects, 323 expiratory retard, 41f impact, 6t, 126 inflation hold, usage, 40f lung/intrapleural pressure impact, 317f mechanics, association, 12f occurrence, 10-11 physiological effects, 317 pressures, definition, 11-13 pressure waves, association, 12f receiving, 248 selection, 113 thoracic pump mechanism, 317 usage, 318, 380 Positive pressure ventilation, importance, 244-246 Positive-pressure ventilators, 20 gas flow, 20 Postextubation difficulties, 415-416 laryngospasm, occurrence, 415 stridor, 517 Postoperative atelectasis, mask CPAP treatment, 273 Postoperative pulmonary complications, 50 Posttraumatic stress disorder (PTSD), 308 Postural drainage, 241 Power alarms, loss, 365f-368f Powered ventilators, examples, 18b Power input alarm, 363-364 Power transmission, 23-26 Premature breath cycling, case study, 38b Premature infants, intraventricular hemorrhage, 486 Premature neonates, management, 463 Premature pressure support termination (PPST), 480 Prematurity, apnea, 463 Pressure baseline pressure, 12 calculation, 6b change, time (relationship), 477f controller, 31 damping, 490f definition, 4-5, 11-13 determination, 86b equivalents, 4b examples, 4f, 149f gradients, 3, 68 examples, 4f list, 3t importance, 330 limit, 37, 85-86, 133 584 INDEX Pressure (Continued) negative deflection, display, 36f overshoot, provision, 77f peak pressure, 12 scalars, 153f, 156f, 162f, 164f setting, 68 support inadequacy, flow asynchrony (impact), 480f Servo ventilator main screen, 526f targeting, control variable, 67-68 tracing, evaluation (case study), 210b trigger, types, 342 triggering, sensitivity level, 35 variations, 152-155 volume/flow/time, relationship, 149-150 waves negative-pressure ventilation, impact, 11f result, 5f Pressure augmentation (PAug), 76-77 usage, 77 ventilation, 76-77 Pressure control, 37 ventilation, 38-39 initial settings, 98 Pressure-control continuous mandatory ventilation (PC-CMV), 71-72 adjustment, clinical scenario, 224b advantage, 98 case study, 96b changes, 225-226 descending ramp waveform, 98 flow/pressure/volume scalars, examples, 162f flow-volume (F-V), 170f graph, example, 101f high PEEP level, impact, 285 maximum pressure limit, 72 mode, 72f PEEP, impact, 285 problem solving, case study, 160b scalars, 159f Pressure-control inverse ratio ventilation (PCIRV), 72-73 Pressure control-inverse ratio ventilation (PC-IRV), pressure-time curves, 505f Pressure-controlled breathing, 30 Pressure-controlled breaths, lung characteristics (change), 67b Pressure-controlled continuous mechanical ventilation, compliance (changes), 159 Pressure-controlled inspiration, 33 Pressure-controlled synchronized intermittent mandatory ventilation (PC-SIMV), 128-129 CPAP, inclusion, 160 pressure/flow/volume scalars, example, 164f Pressure-controlled ventilation, 158-161 constant pressure waveform, 158-160 graphics, 160-161 volume, decrease (clinical scenario), 225b-226b volume-controlled ventilation, comparison, 159 volume delivery, factors, 68b waveforms, 33f Pressure-control mode, 473-479 pressure ventilation, 161f Pressure-control ventilation (PCV), 71-72 PIP/volume, evaluation (case study), 362b usage, 476f Pressure-control ventilation (PC-CMV), 86 case study, 70b comparison, 68 Pressure-cycled breath, 75 Pressure-cycled inspiration, 76b Pressure-cycled pressur support ventilation breath, depiction, 98f Pressure-cycled ventilation, 39 inspiration, cessation, 39 Pressure-cycled ventilators, disadvantage, 39 Pressure cycling occurrence, 39 pressure limiting, contrast, 37 Pressure limiting, 36-37 modes, 37 pressure cycling, contrast, 37 Pressure plateau (Pplateau) changes, examples, 141t pressure, 12-13 subtraction, 132 Pressure-regulated volume control (PRVC), 77-78, 129, 481 case study, 99b change, 408 initial settings, 99 mode, usage, 481f names, 99t screen capture, 78f Pressure-release valve, example, 36f Pressure-support breath graph, 76f triggering, nebulizer impairment (impact), 371 waveforms, 39f Pressure-supported ventilation (PSV), PEEP (application), 380 Pressure-support ventilation (PSV), 74-76, 86, 161-165, 405 COPD, impact, 342f flow cycling, 162-163 graphs, pressure overshoot (provision), 77f initial settings, 96-98 inspiratory flow, 75-76 termination, case study, 98b level, adjustment, 97 pressure-time curve, 101f pressure-time waveform, details, 161-162 receiving, 109 rise time adjustment, effect, 77f settings, 75-76 spontaneous breathing, preservation, 334 spontaneous mode, 479-482 termination flow, changes (impact), 164f usage, 76b SIMV, impact, 165-169 usefulness, 479 Pressure-targeted breaths, pressure setting, 96 Pressure-targeted CMV, 71-73 Pressure-targeted ventilation (constant pressure), graphs, 68f Pressure-targeted ventilators, 384-386 flow delivery, 386 operational characteristics, 385t Pressure time, graph (example), 101f Pressure-time curve changes, 155 fluctuations, 371f Pressure-time product, 195 measurement apparatus, 196f Pressure-time scalars, 153 Pressure-time waveform, 36-37 characteristics, 164f details, 161-162 mean airway pressure illustration, 261f simplification, 42f Pressure units, Pressure ventilation, 86 changes, 223-225 clinical scenario, 225b impact, 166f initial ventilator settings determination, 96-100 establishment, 86b initiation methods, 96 inspiratory time, inadequacy, 368-369 modes (initial settings), volume targeting (usage), 99-100 provision, 112 selection/variables, requirement, 96t tidal volume delivery, determination, 96 usage, 31 Pressure/volume changes, occurrence, 194f Pressure-volume (P-V) curves, 269f bedside measurement, 142-144 data, correlation, 143t example, 144f, 166f measurement equipment, usage, 280f super syringe technique, usage, 144f obtaining, technique, 142b plotting, 142 usage, 258-273 Pressure-volume loop, 369f slope, PEEP increase (effects), 475f Pressure-volume (P-V) loops, 165-169 abnormal finding, 169f airway resistance, increase, 167 changes, 165 volume-targeted ventilation, 167f compliance changes, 166-167 components, 165-168 conditions, 195f creation, super syringe technique (usage), 281f flow, changes, 165 flow set, 166f illustration, 283f peak inspiratory pressure (PIP), 166f pressure ventilation demonstration, 167f impact, 166f spontaneous breaths, 167-168 troubleshooting, 169 usage, 279-286 work of breathing, 168-169 Pressure waveform, 98f differences, 73f shape, 149f variation, 159 Pressurized metered dose inhalers (pMDIs), 235 ET, abrupt angle creation (impact), 238 usage, 236-238 Pre-term infants, transcutaneous carbon dioxide (presence), 483 Primary ARDS, 277 Problem, term (definirtion), 354 INDEX Prone positioning, 244-246, 494 absolute contraindication, 245 contraindications, 245b oxygenation, mechanisms, 245 protocol, 246b relative contraindications, 245 technical aspects, 245-246 Prophylactic antibiotics, 304 Prophylactic therapy, 494 Propofol (Diprivan), 310 administration, adverse effects, 310 hemodynamic effects, 310 onset/duration, 310 Proportional assist, determination, 80b Proportional assist ventilation (PAV), 80 Proportional solenoid valve, 26f design, 26 Proximal airway pressure, Proximal pressure lines, usage, 131 Pseudomonas aeruginosa, 295 Pseudooscillators, 487 Psychological status, 248-249 Pulmonary artery (PA) bedside catheterization, 204 catheterization, 204-207 complications, 206t pressure, 135, 209-210 tracing, baseline, 209 waveform, systemic arterial waveform (resemblance), 209 ventilation response, 209f Pulmonary artery (PA) catheter, 204 features, 204f insertion sites/problems, 205t position, West’s zone relationship, 206f wedging, 206 Pulmonary artery occlusion pressure (PAOP), 200 increase, effects, 272t low level, 248 role, importance, 208 values/patterns, causes, 209b Pulmonary blood flow detection, capnography (usage), 182 mechanical ventilation, effects, 333-335 Pulmonary circulation, 206t Pulmonary condition (evaluation), clinical findings (usage), 143t Pulmonary disorder initial ventilator settings, 120t physical/radiologic findings, 136t Pulmonary edema, 357 cause, 357 Pulmonary embolism (PE), 358 emergency, 358 Pulmonary infiltates, presence, 297 Pulmonary injury sequence (PIS), 485 Pulmonary interstitial emphysema (PIE), clinical scenario, 487b-488b Pulmonary microvasculature, low lung volume/high lung volume (drawing), 277f Pulmonary overdistention, CPAP (impact), 466 Pulmonary perfusion unevenness, 554f Pulmonary perfusion, ventilation (mismatching), 553 Pulmonary shunt perfusion, ventilation (absence), 260b Pulmonary specialty wards, 430 Pulmonary trauma, alleviation, 483 Pulmonary vascular pressure monitoring (usage), PEEP (usage), 270-271 Pulmonary vascular problems, 50 Pulmonary vascular resistance (PVR), 200 increase, 213, 317-318 positive pressure, effects, 334-335 Pulmonetics LTV ventilator, receiving, 439f Pulmonetics LTV-1000 ventilator, 387f components, 439f flow, 93b Pulse oximeter ambient light, impact, 178 capability, description, 177 case study, 120b example, 176f low perfusion states, impact, 177 nail polish, impact, 177-178 output signal, 177f physiological/technical concerns, 176-178 pulsatile/nonpulsatile components, 177f skin pigmentation, impact, 178 Pulse oximetry, 50, 74, 175-179 AARC clinical practice guideline, 179b usage, 178 usefulness, 178 Pulse pressure readings, 133b Pulse rate, determination, 176 Puritan Bennett 840 ventilators, 26, 35 circuit compliance/compressibility calculation, 38 fixed flow, 343 operator control, 40 user interface, 22f volume-(flow-time) cycled ventilator, example, 94t Pursed-lip breathing, 41-42 maneuver, effectiveness, 97b R Radford’s nomogram (breathing nomogram), 89f Radiation pneumonitis, 297 Rales (crackles), occurrence, 135 Ramsay Sedation Scale, 308t Random access memory (RAM), usage, 20 Rapid shallow breathing index (RSBI) calculation, case study, 412b study, 412 Rate of rise of left ventricular pressure (dP/dT), 200 Rat lungs, macroscopic aspect, 333f Raw (value), increase, 160f Readiness, assessment, 410 Read-only memory (ROM), 20 Rebreathing circuit, Respironics NICO Capnometer (usage), 212f Recruitment decremental PEEP, 285 occurrence, 282 Recruitment maneuver (RM), 282-286 hazards, 283-284 illustration, 282 maintenance, 286 performing, 282 recommendation, 512 summary, 286 theoretical model, 284f types, 285-286 usage, 513b Reduced hemoglobin, 176f Rehabilitation hospital, admission, 430 Reintubation, 414 585 Relative humidity changes, concept, 107b decrease, 106 Renal effects, impairment (implications), 324 Renal failure/malfunction, 248 Renal function mechanical ventilation, effects, 322-324 positive pressure ventilation, endocrine effects, 323 Renal insufficiency, fentanyl (usage), 311 Renin-angiotensin-aldosterone changes, humoral response, 323 Residual volume (RV), 54 Resistance, 7-8 increase, 9f values, 8b Respiration, involvement, Respiratory acidosis clinical/ECG changes, 335b impact, clinical scenario, 224b kidney compensation, 335 metabolic alkalosis, combination (clinical scenario), 228b PC-CMV adjustment, clinical scenario, 224b rate increase, clinical scenario, 225b volume/pressure ventilation changes, 223-225 Respiratory alkalosis, 336 clinical/ECG changes, 335b metabolic acidosis, combination (clinical scenario), 227b-228b pressure-controlled ventilation, volume decrease (clinical scenario), 225b-226b rate decrease, clinical scenario, 225b spontaneous efforts, clinical scenario, 226b VC-CMV/PC-CMV changes, 225-226 Respiratory capabilities/demands, balance (schematic), 403f Respiratory care plan equipment, checklist, 436b Respiratory diseases, hemodynamic changes, 216t Respiratory distress initial assessment, 49 physical signs, 49f, 355f Respiratory distress syndrome (RDS), 463 Respiratory drive abnormalities, 358 decrease, CNS disorders (impact), 51 Respiratory factors, 411 Respiratory failure acute respiratory failure, 49-50 cause, treatment, 111 clinical indications, 461-462 definition, 50, 461 disorders/agents, association, 50b usage, 469 Respiratory frequency, 86 basis, 507 determination, 86b Respiratory monitoring, growth, 473 Respiratory muscles inactivity, 30 strength, assessment, 52 strengthening, 419 weakness, 113 Respiratory quotient (RQ) reduction, 190 variations, 188b 586 INDEX Respiratory rate calculation, 91 case study, 88b minute ventilation, 55 tidal volume, interrelation, 91b Respiratory special care units, 430 Respiratory status, 335-336 Respiratory support, adjunctive forms, 493-495 Respiratory syncytial virus (RSV) bronchiolitis, 463 Respiratory system pressure gradients, 3t examples, 4f static inspiratory pressure-volume curve, example, 281f terms/abbreviations, 3t Respiratory system mechanics assessment, 190-195 clinical applications, 192-195 derived variables, 193-195 measured variables, 192-193 Respiratory therapy device, example, 57f equipment, 296-297 Respiratory zone of comfort, 408-409 Respirometer, usage, 54 Respironics NICO capnometer, rebreathing circuit, 212f Restrictive disease, patient guidelines, 117-118 Restrictive thoracic disorders, 382 Reticular pattern, 277 Retrograde pressures, 200 Reverse Trendelenburg position, 444 Reynold’s number, 516b Right atrial pressure (RAP), 200 continuous monitoring, 208 Right atrium catheter advancement, waveforms (display), 205f indwelling venous catheter placement, 135 pressure, 201f Right heart artery, bedside catheterization, 204 Right-to-left shunts, 555 Right ventricular (RV) afterload, increase, 317-318 Right ventricular (RV) dilation, 318 Right ventricular end-diastolic pressure (RVEDP), 200 Right ventricular (RV) function, alteration, 317-318 Right ventricular pressure (RVP), 204 Right ventricular stroke work (RVSW), calculation, 213 Right ventricular stroke work index (RVSWI), 213 Rise time adjustment effect, 77f limitation, 160 Rise-time control, usage, 386 Rocking bed example, 443f motorization, 443-444 obsolescence, 443 usage, caution, 444b Rotary drive piston, 26 S Safety pressure, maximum, 37 Saline instillation, 234-235 practice, evidence, 235 Saturation of peripheral oxygen (SPO2), 112 range, 125 usage, 259 Scalars display, 150 term, usage, 149 Secondary ARDS, 277 Second-generation portable ventilators, 438-440 advancement, 438-439 Second-generation portable volume ventilators, list, 437 Second-generation ventilators, ventilator setting flexibility, 440 Secretions, 357 clearance, 445-447 removal, importance, 232 thickness, assessment, 107t Sedation levels Joint Commission definitions, 308 list, 308b necessity, monitoring, 308 practices, variation, 308 strategies/protocols, 410, 420 Sedatives, 308-311 usage, 312 list, 309t Selective digestive tract decontamination, 304 Self-contained closed-system suction catheter, parts, 233f Self-triggering, occurrence, 70 Semirecumbent patient positioning, 300-302 Sensitivity setting, inappropriateness, 161 SensorMedics 3100A, 487 high-frequency oscillator, breathing circuit, 488f oscillator, drive mechanism, 488f SensorMedics 3100B high-frequency oscillatory ventilation, indications/precautions, 513b high-frequency oscillatory ventilator, 510 control panel, 511f patient circuit, schematic, 511f Servo active inspiration, flow-time scalar, 155f expiratory cassette, ultrasonic flow transducers, 192f ICU ventilator, 89 operator control, 40 time-cycled ventilator, 38, 93 ventilator, main screen (display), 525f-526f Servo 300 flow derivation device, 521 VS, usage, 344-345 Servo 900C, flow derivation device, 521 Set pressure, 132 Set volume, actual delivered volume (contrast), 38 Severe ARDS, spontaneous breathing, 483f Severe asthma, case study, 517b Severe inspiratory airflow limitation, pressure-control ventilation (usage), 476f Severe respiratory distress evaluation, case study, 358b physical signs, 49f, 355f Shadow trigger, 342 comparison, 342f Shallow breathing, WOB (impact), 53 Shape signal, comparison, 342f Shear stress, 331 occurrence, 331 Shell ventilator, 379 Shikani, 448 Short binasal prongs, usage, 467 Shunt, 555-556 calculation, 556 clinical shunt calculation, 266b effect, 555-556 fraction, 212-213 increase, 267f Sidestream capnographs sampling/reporting, delay, 180-181 schematic, 180f Sighing, 109-110 Sighs, 110b appropriateness, 110 deep breath, occurrence, 109 history, 109b necessity, 110 techniques, 285-286 Signal Extraction Technology (SET) pulse oximeter, usage, 177 Silent aspiration, occurrence, 234 Simethicone agents, 395 Sine flow, 92-93 Sine wave pressure curve, 37f Single breath CO2 (SBCO2) curve description, 184-185 recordation, 185f Single-circuit ventilator, 21 example, 22f Skeletal disorders, 431 Skilled nursing facilities, 430 Skin pigmentation, pulse oximeter impact, 178 Sleep metabolic rate reduction, association, 190 status, 248-249 Sleep apnea, 273 syndrome, 50 Slow PV loop, performing (purpose), 280 Small airways, laminar flow, 516 Small-volume nebulizers (SVNs), 235 position, 395f usage, 238 Small-volume ultrasonic nebulizer, design, 240f Smoke exposure (carboxyhemoglobin), 177 Society for Critical Care Medicine (SCCM) NMBA administration recommendation, 313 recommendations, 410b Solid line, representation, 154-155 Speaking tracheostomy tubes, 448 concerns, 451 Speaking valves, 447-452 Specialized continuous suction endotracheal tubes, 303f Specific dynamic action, 189 Speech loss, 447 tracheostomy tubes, usage, 447-448 Splanchnic resistance (increase), positive-pressure ventilation (impact), 324 Splanchnic venous outflow (decrease), positive-pressure ventilation (impact), 324 INDEX Spontaneous baseline pressure, control, 73 Spontaneous breathing, 3, 74 prolongation, 341 severe ARDS, 483f thoracic pump mechanism, 317 Spontaneous breathing, airway pressures, 507 Spontaneous breathing trial (SBT), 409 assessment, 413-414 failure, 410 recommendation, 417 ventilation, maintenance, 420 problems, clinical signs/symptoms, 414b Spontaneous breaths, 43, 66, 195f airway pressure graph, 13f occurrence, 74 pressure requirements, 195f pressure-volume loops, 167-168 taking, 42f Spontaneous CPAP, circuitry, 263 Spontaneous inspiration, negative intrapleural pressures (transmission), 317f Spontaneously breathing patients heliox delivery devices, 517-518 Spontaneously breathing patients, compliance, Spontaneous modes, 70, 74-76 Spontaneous respiratory cycle, example, 42f Spontaneous unsupported breath, P-V loop, 168f Spontaneous ventilation, alveolar pressures, graphing, 15f differences, 73f mechanics, 3-5 example, 5f pleural pressures, graphing, 15f preservation, 506-507 Spring-loaded bellows, 25 Sputum color, 247t evaluation, 247 upper airway infections, 247 Stable chronic lung diseases, 431 Static compliance, 6, 140, 193 determination, case study, measurement, auto-PEEP (usage), 339 PEEP indicator, 267-268 serial measurements, 193 Static compliance calculation equation, 7b plateau pressure measurement, accuracy requirement, 39 Static effective compliance, Static inspiratory pressure-volume curve, example, 281f Static pressure, 191 head, 202-203 Static pressure-volume (SPV) curve, 281f value, 144 loop features, 281-282 performing, purpose, 280 Status asthmaticus, 59b acuteness, case study, 476b impact, 229 Stiff lungs, 267f Stoma, maintenance, 451 Strain gauge, 190 pressure transducer electrical circuit, usage, 202 Wheatstone bridge, incorporation, 203f Straw-sipping problem, solution, 105 Streaming (asymmetric velocity profiles), 489 effect, 490f Stress ulcer prophylaxis, 303 Stroke index (SI) calculation, 210 case study, 210b Stroke victim, case study, 52b Stroke volume (SV), 210 Stroke work, case study, 213b Subacute care units, location, 430 Subambient pressure, 40-41 Subatmospheric pressure application, 20f decrease, 446 Subcutaneous emphysema, 328-329 Subglottic secretions, continuous aspiration, 234 Substrate utilization influence, 190 pattern, 190 Succinylcholine (depolarizing agent) (diACh), 312-313 inactivation, 313 intravenous administration, 313 side effects, 313 usage, 313 Suction catheters material, 231 reuse, procedure, 452b size (estimation), endotracheal tube size (basis), 232b usage, 231f Suctioning assessment, 235 duration, 232 hazards/complications, 232 irritation, 232 Suction levels, 231b Sudden distress, identification, 355-356 Sudden respiratory distress airway problems, causes, 356b causes, 355b clinical scenario, 357b Sudden severe respiratory distress management, 356b Superior vena cava, indwelling venous catheter placement, 135 Super syringe technique, 280 usage, 144f Supine patient, recruitment maneuver (theoretical model), 284f Supplemental oxygen therapy, usage, 50 Surfactant administration procedure, 494 alteration, 331 replacement therapy, 493-494 complications, 494 Sustained inflation, 285 Swan-Ganz catheter, 204 Sympathetic tone, increase, 323 Synchronized intermittent mechanical ventilation (SIMV), 70, 73-74, 321-322 advantages/disadvantages/risks, 75t differences, 73f flow/volume/airway pressure/esophageal pressure measurements, 405f mode, 438 popularity, 340 587 Systemic arterial blood pressure, 135 Systemic arterial pressure, 207-208 direct measurement, 203 Systemic arterial waveform, PA pressure waveform (resemblance), 209 Systemic artery catheterization, 203-204 Systemic hypotension, occurrence (rarity), 318 Systemic vascular resistance (SVR), 200 calculation, 213 System-imposed work of breathing, 340 System leaks, 38 System resistance, overcoming, 86 T Tachycardia, 50, 207 hypoxemia, impact, 232 Tachypnea, 50 Talking tracheostomy tube, 449f Tank ventilators (iron lungs), 441-442 disadvantages, 442 Taylor-time dispersion, 489 Temperature, 135 Tension pneumothorax threat, 329 treatment, 329 Termination asynchrony, 343-344 Termination flow, changes (impact), 164f Theoretical waveforms, 161f Therapeutic PEEP, 263 Therapist-driven protocols (TDPs), 420 usage, 421 Thermodilution catheters, lumen (incorporation), 204 Thoracic pressure-volume relationships, alterations (patterns), 362t Thoracic pump mechanism, 317 Thoracic vessels, PPV (effects), 316-322 Thorax computed tomographs, drawings, 276f vascular pressures, 317 Threshold resistors, 262-263 device, 263 Thrombotic mediators, 276-277 Tidal flow-volume loops, mechanical breath basis, 241f Tidal volume (VT), 86, 92, 477-478 analysis, 93b calculation, method (alternative), 88 case study, 88b concept, analysis, 88b delivery, 371 capability, 111 changes, examples, 141t determination, 96 impact, 224f determination, 86b, 88, 91-92 display, 129 flow delivery, dependence, 507-508 flow rate/inspiratory time/expiratory time/ total cycle time/respiratory rate, interrelation, 91b flow/total cycle time/inspiratory-toexpiratory ratio, relationship, 90-92 increase, 88, 365f-368f respiratory acidosis, impact (clinical scenario), 224b measurement, 129f respirometer technique, 130b minimum, guarantee, 481 PEEP, increase (effects), 475f prediction, 89f 588 INDEX Tidal volume (VT) (Continued) pressure-control continuous mandatory ventilation (PC-CMV), case study, 96b range, moderation, 119 rate, 87-90 recommendation, 88 setting, 88, 90b, 278-279 usage, 21f, 110 Time, volume/flow/pressure (relationship), 149-150 Time constants, 8-9 calculation, 9, 475b concept, relationship, 477 measure, 10f Time-controlled breathing, 32 Time controller, 31 Time-cycled breath, 37 Time-cycled inspiration, 76b Time-cycled pressure-limited intermittent mandatory ventilation (TCPL/IMV) breaths, usage, 471 display, 471 Time-cycled pressure ventilation, 38-39 Time-cycled ventilation, 38 Time-cycled ventilators examples, 38, 93t flow pattern change, effects, 93-94 inspiratory flow, 92b Time-cycled volume ventilation, 38 Time-triggered constant-flow volumetargeted ventilation (VC-CMV), 152f Time-triggered descending-flow volumetargeted ventilation (VC-CMV), 152f Time-triggered pressure-limited timecycled ventilation (TPTV), 471f Time triggering, 34 Tissues oxygen delivery, basics, 258-260 resistance, 142 Titrating ventilator, methods, 403-406 Total cardiac output, 556 Total cycle time (TCT) calculation, 91 control, 86 inspiratory time, equivalence, 91 tidal volume interrelation, 91b relationship, 90-92 usefulness, 91 Total facemask, 391f Total face mask/helmet, 390-391 Total lung capacity (TLC), 278, 282 Total mechanical WOB, sum, 169 Total oxygen consumption (VO2), 86 monitoring, 86 Total resistance, 142 Total respiratory cycle, pressure readings, 320f Total shunt fraction, 212 T-piece connection, 517 weaning, 405-406 Trachea, damage, 347 Tracheal buttons, 447-452 decannulation, relationship, 451-452 Tracheal dilation, 139f Tracheal injury, 440 Tracheal-innominate artery fistula, occurrence, 234 Tracheal intubation (verification), capnography (value), 182 Tracheal necrosis, risk (minimization), 137 Tracheal pressure (Ptrach) curves, inspiratory pressure support (usage), 407f Tracheostomy button, parts/positioning, 451f complications, 348 consideration, 422 role, 410, 422 Tracheostomy speaking valves, 448-450 Tracheostomy tubes (TTs), 437, 447-452 care, 302 complications, 347b-348b connector, 448 cuffs, management, 136-140 placement, 447 removal, 422 selection/benefits, 447 speaking, 447-448 usage, 189, 262 Train-of-four (TOF) monitoring, 313 response, assessment, 313b Transairway pressure (Pta), 4, 132 calculation, case study, 153b reduction, 240 sum, 150 transrespiratory pressure component, Transcutaneous blood gas, monitoring, AARC clinical practice guideline, 187b Transcutaneous carbon dioxide partial pressure (PtcCO2), 186-187 PaO2, correlation, 186 range, 125 Transcutaneous electrodes, 188f Transcutaneous monitoring, 186-187 technical considerations, 187 Transcutaneous monitors (replacement), pulse oximeters (usage), 478 Transcutaneous partial pressure of carbon dioxide (PtcCO2), 188f Transcutaneous partial pressure of oxygen (PtcO2), 188f Transcutaneous PO2, 186 Transdiaphragmatic pressure, 195 measurement apparatus, 196f Transport ventilators, 437b examples, 437-440 Transpulmonary pressure (PL) (Ptp), 4-5, 330b changes, 6t definition, 278 Transpyloric enteral route, patient feeding, 246 Transrespiratory pressure (Ptr), components, Transthoracic pressure (Pw), transrespiratory pressure component, Trapped air, volume, 337f Trending CO2 production, 185-186 Trigger asynchrony, 342-343 Triggering case study, 106b difficulty, 371 Trigger threshold, operator control, 70 Trigger variable, 33-36 flow triggering, features (schematic drawing), 35f impact, 33 inspiratory flow initiation, 34 Tris-hydroxymethylaminomethane (THAM), administration, 115 Tubing compliance (CT), 88-90 correction, 129-130 gas compression, 88 impact, 90b volume loss, 130b Tubing compressibility, 38 Turbine flowmeters, rotating vane (usage), 191 Twinkle factor, 419-420 U Ultrasonic flow transducers, 192f Ultrasonic nebulizers (USNs), 235 usage, increase, 239 Uncomplicated metabolic alkalosis, alveolar hypoventilation (association), 227 Unexplained acute respiratory failure, case study, 52b Unilateral lung disease pathological findings, 246 patient position, 246 PEEP, administration, 246 Unintubated patient, resistance values, Unseated expiratory valve, 371 Untreated hypoxemia, 50 Upper airway infections, sputum (relationship), 247 pressure, graph, 13f topical anesthesia, 242 Upper inflection point, 278 Upper inflection point on the deflation portion of the curve (UIPd), 281 Upper inflection point on the inspiratory limb (UIPi), 281 Upper-pressure limit, 37 User interface (control panel), 18, 21 V Vapotherm 2000i, respiratory therapy device, 57f Variable capacitance, 190 Variable orifice pneumotachometers resistive elements, usage, 191 usage, 191 Variable pressure support/control, 407-408 Vascular endothelial injury, 332 Vascular reflexes, blockade, 318 Vascular resistance, 213 alteration, morphine (usage), 311 Vascular tone, changes, 208 VDR-4, high-frequency percussive generator, 486-487 Vecuronium, 313-314 effectiveness, data, 313-314 Vecuronium bromide (Norcuron), 313 Venous admixture, 555-556 Venous return effects, 317 reduction, PPV (impact), 126 Venous return, changes, 95 Ventilated-associated lung injury (VALI), 328 Ventilated patients aerosols, administration, 235-240 Edi catheters, usage, 527 hypercapnia tolerance, 485 positions, 241 severe respiratory distress, evaluation (case study), 358b therapies, 244-251 INDEX Ventilated patients (Continued) tidal volumes determination, 88 recommendation, 88 transport, patient support equipment/ monitoring equipment, 250b Ventilation, abnormalities, correction, 223-230 absence, 58, 212 adequacy, indicator, 55 adjustment, 508-509 autotrigger, 35 backup mode, provision, 363 case study, 52b change, methods, PaCO2/pH basis, 223-226 depression, 340 determination, 462, 508 failure, 55 flow-cycled ventilation, 39 flow limitation, 37 gas flow, history, 109b improvement, strategy, 508-509 lung-protective strategies, 483-485 machine, settings (incompatibility), 363 maintenance, 410, 514 manual ventilation, 110 mode, 65-68, 128-129 addition, 76-80 selection, 29-30, 119 model, 30 neural control, review, 522 parameters, case study, 142b pressure-cycled ventilation, 39 pressure gradients, problems, solution, 354 prolongation, long-term care facilities, 410, 422 pulmonary artery response, 209f time-cycled ventilation, 38-39 tracheostomy tubes, speaking, 447-448 transport option, 250 unevenness, 554f volume-cycled ventilation, 38 Ventilation/perfusion (V/Q) abnormalities, 556-557 mismatching, 55 reduction, 474 Ventilation-perfusion relationships, 181f Ventilation-to-lung periphery, 334 Ventilation-to-perfusion (V/Q) matching, 95 Ventilation-to-perfusion (V/Q) mismatch, 266 Ventilator alarms, 108-109 operation problem/technical error message, 363 problem, 364 situations, action, 109 Ventilator-assisted individuals (VAIs) cuff deflation, 447 discharge, 429 psychological problems, 441 Ventilator-associated pneumonia (VAP), 294 algorithm, 298 bacteriologic (quantitative) diagnosis, 298 case study, 298b causes/risk factors, 295-297 clinical diagnosis, 297-298 conditions/risk factors, 296b diagnosis, 297-298 clinical criteria, 297t epidemiology, 295-297 Ventilator-associated pneumonia (VAP) (Continued) handwashing, 300 incidence, 295 management antibiotic regimens, usage, 301f antibiotics, usage, 299t noninvasive ventilation, 302 nonpharmacologic interventions, 300-303 pathogenesis, 297 pathogens, 299t association, 300t pharmacologic interventions, 303-304 prevention, strategies, 299-304 risk, increase, 296 treatment, 298 Ventilator circuit disinfection, 452 leakage, checking, 133-134 metered dose inhaler adaptation, 238f SVNs, usage, 303 Ventilator control functions, 31b mode, selection, 34 panel, 70 user interface, 21 systems/circuits, 21-23 Ventilator-dependent patients early tracheostomy tube placement, advantages, 447b sites, 430 respiratory care plan equipment checklist, 436b Ventilator function control, open-loop/closed-loop systems (usage), 21 effects, 339 worksheet, 81f-82f Ventilator graphics clinical scenario, 150b problem, troubleshooting, 354b production, 150 screen, absence, 153-154 usage, 149 usage, case study, 369b Ventilator-induced diaphragm dysfunction (VIDD), 524 Ventilator-induced lung injury (VILI), 278, 328 acinus level occurrence, 328 ARDS, resemblance, 328 avoidance, 483 Ventilator-induced respiratory alkalosis, effect, 419t Ventilator-induced respiratory muscle weakness, 333 Ventilator management protocol (VMP), example, 421f Ventilator patients disconnection, 134 evaluation, 259 preparation, 110 Ventilator-related problems, 358-360 Ventilators APRV provision, 79 asynchrony, resolution, 360b breath, triggering, 105f changes, case study, 336b classification, historical perspective, 17-18 combined-power ventilators, 18-20 components, 18b compressors (blowers), 23-25 589 Ventilators (Continued) computer monitors, usage, 149 conversion system, 23-26 dependence, pathology, 409-413 discontinuation closed-loop control modes, 406-409 indicator, 414 double-circuit ventilator, 23 example, 23f drive mechanism, 23 electrically powered ventilators, 18 electrical power source, 18 equipment setup, considerations, 110-111 flow-control valves, 26 flow cycle, names/settings, 163t flow sheet comment section, 144 example, 127f-128f fluid logic (fluidic) pneumatic mechanisms, components, 19f function, heliox (usage), 520b gas flow, basis, 20 initial settings COPD patient, 113 determination, 85-86 pressure ventilation, 96-100 input power, 18-20 inspiratory rise time, names/settings, 163t inspiratory waveform maintenance, 32f internal function, 18 internal maximum safety pressure, 37 internal pneumatic circuit, 21-23 mechanical/operational hazards, 345-347 microprocessor-controlled models, 18-20 microprocessors, usage, minute ventilation, determination, 86b mode switch, 528 worksheet, 81f-82f needs, 111 operation, verification, 125b parameters, 267 measurement, 149 performance, 409-412 bench test, 111 evaluation, 111 pneumatically powered ventilators, 18 pneumatic circuit, 21-23 power source, 18-20 power transmission, 23-26 pressure/tidal volume, determination, 86b primary variable, 30 problems, 358-360, 372 evaluation, case study, 369b identification, graphics (usage), 363-370 procedures, 264t lower-PEEP/higher-PEEP groups, 265t PRVC, names, 99t purchase cost, 111 Puritan Bennett 840, user interface, 22f requirement, clinical scenario, 95b-96b respiratory frequency, determination, 86b responses, problems, 370-372 response times, improvement, 71 scalars, display, 150 selection, 63-64, 111, 437-440 factors, 437 590 INDEX Ventilators (Continued) selection, case study, 20b sensitivity setting, 104-108 settings changes, case study, 480b observation, 527 setup, parameters (selection), 104-111 single-circuit ventilator, 21 example, 22f support, titration (methods), 403-406 synchrony (interpretation), Edi waveform (usage), 524-527 technical error message, 364 troubleshooting, 364b types, 9-14, 384-388 user interface (control panel), 21 value, calculations, 150-151 valve, effect, 521 variables adjustment, 30 initiation/manipulation, 125 volume-displacement designs, 25 volume support, names, 99t Ventilatory management/discontinuation, components, 403b Ventilatory mechanics adult/critical range values, 53t bedside measurements, 53-55 Ventilatory muscle function, 411 Ventilatory support discontinuation, 403 establishment, 383 inadequacy, 359 indications, 469-470 post-myocardial infarction, clinical scenario, 95b withholding/withdrawal, ethical dilemma, 423 Very low-birth-weight (VLBW), 463 Vest Airway Clearance System, 241f Vibrating mesh nebulizers (VMNs), 235 usage, increase, 239 Viscous resistance, occurrence, Visual alarms, activation, 133 Visual analog scale, 250f Vital capacity (VC), 54 bedside measurement, 54 usage, 52 Vital signs, 134-136 assessment, 112 Voice tracheostomy tube (VTT), 448 Volume air injection, 280 bracketing, usage, 481 controller, 31 control mode, 479 delivery delay, 475f factors, 68b graphs, 94f device (bellows), usage, 7f evaluation, case study, 362b examples, 149f expiratory portion, 354f flow/pressure/time, relationship, 149-150 guarantee, 482 increase, 151f loss calculation, tubing compliance (usage), 90b tubing compliance, impact, 130b monitors, usage, 477-478 scalars, 155-157 examples, 153f, 162f, 164f Volume (Continued) setting, 66 targeting control variable, 66-67 usage, 99-100 triggering, occurrence, 35 variations, 152-155 ventilator, waveforms, 37f Volume-assured pressure support (VAPS), 76, 481-482 evaluation, case study, 482b pressure ventilation provision, 112 Volume-control continuous mandatory ventilation, graphs, 71f Volume-controlled breathing, 32 Volume-controlled breaths, lung characteristics (change), 66b Volume-controlled continuous mandatory ventilation (VC-CMV), 71 changes, 225-226 COPD patient settings, 113 display (Servo ventilator), 525f flow-time scalar, examination, 151-155 goal, 86 inspiratory pause, setting, 132f modes, 470-471 scalars, 156f volume-time waveform, usage, 133f Volume-controlled inspiration, 33 Volume-controlled spontaneous intermittent mechanical ventilation, 157 Volume-controlled synchronized intermittent mandatory ventilation (VC-SIMV), 128-129 example, 158f Volume-controlled ventilation constant flow, inclusion, 150-158 gas flow waveforms, variation, 157 graphics, 157-158 PIP/Pplateau evaluation, case study, 362b pressure-controlled ventilation, comparison, 159 pressures, factors, 66b ventilator settings, determination, 85-96 waveforms, 33f Volume-control ventilation (VC-CMV), 86 airway pressure waveform, 130f case study, 70b comparison, 68 flow, constancy, 343 Volume-cycled breath, inspiratory phase, 38 Volume-cycled ventilation, 38 Volume-cycled ventilators classification, 38 flow delivery, graphs, 94f flow pattern change, effects, 93-94 flow-time cycled ventilator, example, 94t volume delivery, graphs, 94f Volume displacement devices, examples, 25b-26b mechanisms, avoidance, 38 Volume-displacement designs, 25 linear drive piston, 25 rotary drive piston, 26 spring-loaded bellows, 25 Volume guarantee dual-control mode, evaluation (case study), 482b Volume-limited breath, control, 37 Volume limiting, 37 example, 37 Volume support (VS) initial settings, 99-100 names, 99t pressure ventilation provision, 112 test breath, 79f usage, 76b Volume-supported ventilation (VSV), 78 Volume-support ventilation (VSV), 482 Volume-targeted breaths, F-V loops, 170f Volume-targeted CMV, 71 Volume-targeted pressure-support ventilation, 407 Volume-targeted ventilation advantage, 96 P-V loop, changes, 167f VT permission, 479 Volume-time curve, 354f problem, 369f sub-baseline expiratory portion, 370 Volume-time scalar, 155-156 Volume-time waveform, 36-37 usage, 133f Volumetric capnography, 184-186 Volume ventilation, 519 changes, 223-225 flow variation, flow-volume loops (usage), 169-170 flow-volume loop, 169f, 171f production, 171f initial ventilator settings, establishment, 86b inspiratory pause, 95-96 pressure/flow scalars, 156f usage, 31 Volutrauma, 483, 494 barotrauma, contrast, 329-330 Vortex ultrasonic flowmeters, 191 W Wall attachment phenomenon (Coanda effect), 19f Water traps, emptying, 106-107 Waveforms (curves), 149b abnormality, ventilator response, 364b display, 205f creation, 149-150 examples, 149f ringing, 369-370 Weaning, 491-493 anesthesia protocols, 420 APRV settings, example, 509t artificial intelligence system, inclusion, 406 attempt evaluation, case study, 404b failure, case study, 417b cardiac factors, 417 clinical criteria, evaluation, 409 clinical scenario, 419b complication, nonrespiratory factors, 417-420 criteria, 409 difficulty, case study, 432b evidence-based weaning, 409-417 exercise, 419 goals, 422 index, requirements, 411b metabolic factors, 417 methods, comparison, 406 nonrespiratory factors, 418t nutritional status, 419 optimum lung volume HFOV strategy flow chart, 493f parameters, complexity, 413 INDEX Weaning (Continued) patient ability, 414 pharmacologic agents, effect, 419 physiological parameters, 412t practice, 404-405 protocols, 410, 420-422 efficiency/effectiveness, 421 example, 421f psychological factors, 419-420 disease-related issues, 420 manifestation, 420 psychological fears, 420 readiness assessment, evaluation criteria (usage), 413 sedation strategies/protocols, 420 TDP usage, 421 techniques, 403-409 MMV, usage, 408 term, usage, 403 titrating ventilator support methods, 403-406 Weaning (Continued) T-piece weaning, 405-406 tracheostomy, role, 410, 422 Weaning failure clinical scenario, 420b criteria, 416b factors, 417-420 Webb/Tierney study, 332-333 West’s zones, 206t Wheatstone bridge, 202 Wiggins diagram, 200 example, 201f Women, ideal body weight (IBW), calculation, 88b Work of breathing (WOB), 50, 413 chest trauma, impact, 53 CPAP, occurrence, 194f definition, 194 graphic representation, 194-195 imposition, 162 occurrence, 195f 591 Work of breathing (WOB) (Continued) increase, 53, 78, 328, 340-345 physical signs/measurements, 413b machine sensitivity, setting, 341 measurement, 193-195, 340 overcoming, 76 pressure-volume loop, 168-169 reduction, 76, 160, 355 steps, 341-345 ventilator, usage, 340b weaning, 340 Work of breathing imposed (WOBi), 162, 193-194 Work reduction, artificial airway (impact), 341 Y Y-connector, 448 Z Zero end-expiratory pressure (ZEEP), 40 This page intentionally left blank ABBREVIATIONS Δ µ µg µm µV AARC ABG(s) A/C ACBT ADH P(a-et)CO2 Ag AgCl AI AIDS ALI ALV anat ANP AOP APRV ARDS ARF ASV ATC ATM ATPD ATPDS ATS auto PEEP AV AVP BAC BE bilevel PAP BiPAP BP BPD BSA BTPS BUN C C °C CaO2 C ( a - v )O2 CC cc Cc’O2 CD CDC CDH CHF CI CL cm cm H2O CMV CNS CO CO2 COHb COLD COPD CPAP CPG CPP CPPB CPPV CPR CPT CPU CRT Cs CSF CSV CT CT CV CvO2 CvO2 CVP change in micromicrogram micrometer microvolt American Association for Respiratory Care arterial blood gas(es) assist/control active cycle of breathing technique antidiuretic hormone arterial-to-end tidal partial pressure of carbon dioxide silver silver chloride airborne infection isolation acquired immunodeficiency syndrome acute lung injury adaptive lung ventilation anatomic atrial natriuretic peptide apnea of prematurity airway pressure release ventilation acute respiratory distress syndrome acute respiratory failure adaptive support ventilation automatic tube compensation atmospheric pressure ambient temperature and pressure, dry ambient temperature and pressure saturated with water vapor American Thoracic Society unintended positive end-expiratory pressure arteriovenous arginine vasopressin blood alcohol content base excess bilevel positive airway pressure registered trade name for a bilevel PAP device blood pressure bronchopulmonary dysplagia body surface area body temperature and pressure, saturated with water vapor blood urea nitrogen compliance Pulmonary-end capillary degrees of Celsius arterial content of oxygen arterial-to-mixed venous oxygen content difference closing capacity cubic centimeter content of oxygen of the alveolar capillary dynamic characteristic or dynamic compliance Centers for Disease Control and Prevention congenital diaphragmatic hernia congestive heart failure cardiac index lung compliance (also CLung) centimeters centimeters of water pressure controlled (continuous) mandatory mechanical ventilation central nervous system carbon monoxide carbon dioxide carboxyhemoglobin chronic obstructive lung disease chronic obstructive pulmonary disease continuous positive airway pressure Clinical Practice Guideline cerebral perfusion pressure continuous positive pressure breathing continuous positive pressure ventilation cardiopulmonary resuscitation chest physical therapy central processing unit cathode ray tube static compliance cerebral spinal fluid continuous spontaneous ventilation computerized tomogram tubing compliance (also Ctubing) closing volume venous oxygen content mixed venous oxygen content central venous pressure DL DC DC-CMV DC-CSV DIC DO2 DPAP DPPC Dm DVT E ECG ECCO2R ECLS ECMO Edi EDV EE EEP EIB EPAP ERV est ET EtCO2 F °F f FDA FEF FEFmax FEFX FETX FEVt FEV1 FEV1/VC FICO2 FIF FIO2 FIVC FRC ft f/VT FVC FVS Gaw g/dL [H+] HAP Hb HCAP HCH HCO3− H2CO3 He He/O2 HFFI HFJV HFO HFOV HFPV HFPPV HFV HHb HMD HME HMEF H2O HR ht Hz IBW I IC ICP ICU ID IDSA diffusing capacity discharges, discontinue Dual controlled – continuous mandatory ventilation Dual controlled – continuous spontaneous ventilation disseminated intravascular coagulation (DIV no longer used) oxygen delivery demand positive airway pressure dipalmitoyl phosphatidycholine diffusing capacity of the alveolar-capillary membrane deep venous thrombosis elastance electrocardiogram extracorporeal carbon dioxide removal extracorporeal life support extracorporeal membrane oxygenation electrical activity of the diaphragm end-diastolic volume energy expenditure end-expiratory pressure exercise-induced bronchospasm (end-)expiratory positive airway pressure expiratory reserve volume estimated endotracheal tube end-tidal CO2 fractional concentration of a gas degrees Fahrenheit respiratory frequency, respiratory rate Food and Drug Administration forced expiratory flow maximal forced expiratory flow achieved during an FVC forced expiratory flow, related to some portion of the FVC curve forced expiratory time for a specified portion of the FVC forced expiratory volume (timed) forced expiratory volume at second Or FEV1/SVC – Forced expiratory volume in second over slow vital capacity fractional inspired carbon dioxide forced inspiratory flow fractional inspired oxygen forced inspiratory vital capacity functional residual capacity foot rapid shallow breathing index (frequency divided by tidal volume) forced vital capacity full ventilatory support airway conductance grams per deciliter hydrogen ion concentration hospital- acquired pneumonia hemoglobin health care-associated pneumonia hygroscopic condenser humidifier bicarbonate carbonic acid helium helium/oxygen mixture, heliox high-frequency flow interrupter high-frequency jet ventilation high-frequency oscillation high-frequency oscillatory ventilation high-frequency percussive ventilation high-frequency positive pressure ventilation high-frequency ventilation reduced or deoxygenated hemoglobin hyaline membrane disease heat moisture exchanger heat moisture exchange filter water heart rate height hertz ideal body weight inspired inspiratory capacity intracranial pressure intensive care unit internal diameter Infectious Diseases Society of America I : E ILD IMV iNO IPAP IPPB IPPV IR IRDS IRV IRV ISO IV IVC IVH IVOX kcal kg kg-m kPa L LAP lb LBW LED LFPPVECCO2R LV LVEDP LVEDV LVSW m2 MABP MalvP MAP MAS max mcg MDI MDR mEq/L MEP metHb mg mg% mg/dL MI-E MIF MIP mL MLT mm MMAD mm Hg mmol MMV MOV mPaw - Paw MRI ms MV MVV NaBr NaCl NAVA NBRC NEEP nHFOV NICU NIF NIH NIV nM nm NMBA nM/L NO NO2 NP NPO NPV NSAIDS nSIMV inspiratory-to-expiratory ratio interstitial lung disease intermittent mandatory ventilation inhaled nitric oxide inspiratory positive airway pressure intermittent positive-pressure breathing intermittent positive-pressure ventilation infrared infant respiratory distress syndrome inverse ratio ventilation inspiratory reserve volume International Standards Organization intravenous inspiratory vital capacity intraventricular hemorrhage intravascular oxygenator kilocalorie kilogram kilogram-meters kilopascal liter left atrial pressure pound low birth weight light emitting diode low frequency positive pressure ventilation with extracorporeal carbon dioxide removal left ventricle left ventricular end-diastolic pressure left ventricular end-diastolic volume left ventricular stroke work meters squared mean arterial blood pressure mean alveolar pressure mean arterial pressure meconium aspiration syndrome maximal microgram metered-dose inhaler multidrug-resistant milliequivalents/liter maximum expiratory pressure methemoglobin milligram milligram percent milligrams per deciliter mechanical insufflation-exsufflation maximum inspiratory force minute maximum inspiratory pressure milliliter minimal leak technique millimeter median mass aerodynamic diameter millimeters of mercury millimole mandatory minute ventilation minimal occluding volume mean airway pressure magnetic resonance imaging millisecond mechanical ventilation maximum voluntary ventilation sodium bromide sodium chloride neurally adjusted ventilatory assist National Board of Respiratory Care negative end-expiratory pressure nasal high-frequency oscillatory ventilation neonatal intensive care unit negative inspiratory force (also see MIP and MIF) National Institutes of Health noninvasive positive pressure ventilation (also NPPV) nanomole nanometer neuromuscular blocking agent nanomole/liter nitric oxide nitrous oxide nasopharyngeal nothing by mouth negative pressure ventilation non-steroidal anti-inflammatory drugs nasal synchronized intermittent mandatory ventilation Continued ABBREVIATIONS, cont’d N-SiPAP O2 O2Hb OH− OHDC OSA P ΔP P50 P100 Pa PA P(A-a)O2 P(A-awo) PACO2 PaCO2 Palv PAO2 PaO2 PaO2/FIO2 PaO2/PAO2 PAOP PAP PAP P(a-et)CO2 PAGE Paug PAV Paw Paw Pawo PAWP PB Pbs PC-CMV PCEF PCIRV PCO2 PC-IMV PC-SIMV PCV PCWP PCWPtm PDA PE PEmax PE CO2 PEEP PEEPE PEEPI PEEPtotal PEFR Pes PetCO2 PFT Pflex Pga Phigh pH PHY PIE PImax Pintrapleural PIO2 PIP PL Plow Nasal positive airway pressure with periodic (sigh) bilevel positive airway pressure breaths or bilevel nasal continuous positive airway pressure oxygen oxygenated hemoglobin hydroxide ions oxyhemoglobin dissociation curve obstructive sleep apnea pressure change in pressure PO2 at which 50% saturation of hemoglobin occurs pressure on inspiration measured at 100 milliseconds arterial pressure pulmonary artery alveolar-to-arterial partial pressure of oxygen pressure gradient from alveolus to airway opening partial pressure of carbon dioxide in the alveoli partial pressure of carbon dioxide in the arteries alveolar pressure partial pressure of oxygen in the alveoli partial pressure of oxygen in the arteries ratio of arterial PO2 to FIO2 ratio of arterial PO2 to alveolar PO2 pulmonary artery occlusion pressure pulmonary artery pressure mean pulmonary artery pressure arterial-to-end-tidal partial pressure of carbon dioxide (also a-et PCO2) perfluorocarbon associated gas exchange pressure augmentation proportional assist ventilation airway pressure mean airway pressure airway opening pressure pulmonary artery wedge pressure barometric pressure pressure at the body’s surface pressure-controlled continuous mandatory ventilation peak cough expiratory flow pressure control inverse ratio ventilation partial pressure of carbon dioxide pressure-controlled intermittent mandatory ventilation pressure controlled-synchronized intermittent mandatory ventilation pressure control ventilation pulmonary capillary wedge pressure transmural pulmonary capillary wedge pressure patent ductus arteriosus pulmonary embolism maximal expiratory pressure partial pressure of mixed expired carbon dioxide positive end-expiratory pressure extrinsic PEEP(set-PEEP, applied PEEP) intrinsic PEEP (auto-PEEP) total PEEP (the sum of intrinsic and extrinsic PEEP) peak expiratory flow rate esophageal pressure partial pressure of end-tidal carbon dioxide pulmonary function test(ing) pressure at the inflection point of a pressure/ volume curve gastric pressure high pressure during APRV relative acidity or alkalinity of a solution permissive hypercapnia pulmonary interstitial edema maximum inspiratory pressure (also MIP, MIF, NIF) intrapleural pressure (also Ppl) partial pressure of inspired oxygen peak inspiratory pressure (also Ppeak) transpulmonary pressure low pressure during APRV PLV PM pMDI Pmus PO2 Ppeak PPHN Ppl Pplateau ppm PPST PPV PRA PRVC PS PSB psi psig Pset PSmax Pst PSV Pta PtcCO2 PtcO2 Ptm Ptr PTSD Ptt P-V PV PVC(s) PvO2 PVR PVS Pw q2h Q Q Qc′ QT Qs /Q t Qs R RAM RAP Raw RCP RDS Re REE RI RICU ROM RM RQ RSV RT Rti RV RV/TLC% RVP RVEDP RVEDV RVSW SA SaO2 SBCO2 SCCM S.I SI SIDS SIMV Sine SiPAP SpO2 partial liquid ventilation mouth pressure pressurized metered-dose inhaler muscle pressure partial pressure of oxygen peak inspiratory pressure (also PIP) primary pulmonary hypertension of the neonate intrapleural pressure plateau pressure parts per million premature pressure-support termination positive pressure ventilation plasma renin activity pressure regulated volume control pressure support protected specimen brush pounds per square inch pounds per square inch gauge set pressure maximum pressure support static transpulmonary pressure at a specified lung volume pressure support ventilation transairway pressure transcutaneous PCO2 transcutaneous PO2 transmural pressure transrespiratory pressure posttraumatic stress disorder transthoracic pressure (also Pw) pressure-volume pressure ventilation premature ventricular contraction(s) partial pressure of oxygen in mixed venous blood pulmonary vascular resistance partial ventilatory support transthoracic pressure (also Ptt) every two hours blood volume blood flow pulmonary capillary blood volume cardiac output shunt physiologic shunt flow (total venous admixture) resistance (ie, pressure per unit flow) random access memory right atrial pressure airway resistance respiratory care practitioner respiratory distress syndrome Reynold’s number resting energy expenditure total inspiratory resistance respiratory intensive care unit read-only memory lung recruitment maneuver respiratory quotient respiratory syncytial virus respiratory therapist tissue resistance residual volume residual volume to total lung capacity ratio right ventricular pressure right ventricular end-diastolic pressure right ventricular end-diastolic volume right ventricular stroke work sinoatrial arterial oxygen saturation single breath carbon dioxide curve Society for Critical Care Medicine Système International d’Unités stroke index sudden infant death syndrome synchronized intermittent mandatory ventilation sinusoidal positive airway pressure with periodic (sigh), bilevel positive airway pressure breaths, or bilevel continous positive airway pressure oxygen saturation measured by pulse oximeter STPD SV SVC SvO2 SVN SVR t T TAAA Tc tcCO2 TCT TE TGI TGV TI T1% TID TI/TCT Thigh Tlow TJC TLC TLV TOF torr TTN U UN USN V v v V VE VA VA VAI VALI VAP VAPS VC VCT VC-CMV VC-IMV VCIRV VCO2 VD VD VDanat VDAN VDalv VDmech VD/VT VE VEDV VI VILI VL VLBW VO2 VS VT VTalv VTexp VTinsp vol% V/Q VSV W WOB WOBi wye X X Y yr ZEEP standard temperature, pressure saturated; zero degrees Celsius, 760 mm Hg, dry stroke volume slow vital capacity mixed venous oxygen saturation small volume nebulizer systemic vascular resistance time temperature thoraco-abdominal aortic aneurysm time constant transcutaneous CO2 total cycle time expiratory time tracheal gas insufflation thoracic gas volume inspiratory time inspiratory time percent three times per day duty cycle time for high pressure delivery in APRV time for low pressure delivery in APRV The Joint Commission total lung capacity total liquid ventilation tetralogy of Fallot measurement of pressure equivalent to mm Hg transient tachypnea of the neonate unit urinary nitrogen ultrasonic nebulizer gas volume venous mixed venous flow expired minute ventilation alveolar ventilation per minute alveolar gas volume ventilator-assisted individuals ventilator-associated lung injury ventilator-associated pneumonia volume-assured pressure support vital capacity volume lost to tubing compressibility volume-controlled continuous mandatory ventilation volume-controlled intermittent mandatory ventilation volume controlled inverse ratio ventilation carbon dioxide production per minute volume of dead space physiologic dead space ventilation per minute anatomic dead space ventilation per minute volume of anatomic dead space alveolar dead space mechanical dead space dead space-to-tidal volume ratio expired volume ventricular end-diastolic volume inspired volume per minute ventilator-induced lung injury actual lung volume (including conducting airways) very low birth weight oxygen consumption per minute volume support tidal volume alveolar tidal volume expired tidal volume inspired tidal volume volume per 100 mL of blood ventilation/perfusion ratio volume-support ventilation work work of breathing imposed work of breathing wye or Y-connector any variable mean value connects patient ET to patient circuit year zero end-expiratory pressure ... airways and the tissue viscous resistance offered by the lungs and adjacent tissues and organs As the lungs and thorax move during ventilation, the movement and displacement of structures such as... pressure is used to describe the pressure required to inflate the lungs and airways during positive-pressure ventilation In this situation, the body surface pressure (Pbs) is atmospheric and usually... Four basic pressure gradients are used to describe normal ventilation: transairway pressure, transthoracic pressure, transpulmonary pressure, and transrespiratory pressure • Two types of forces oppose