Abbreviations (inside front cover and backcover)

PART 1

Basic Concepts and Core Knowledge inMechanical Ventilation -- -- -- --

1 Oxygenation and Acid-Base Evaluation, 1

Review 01Arterial Blood Gases, 2

Evaluating Oxygenation, 2

Evaluating the Trans1er and Uptake 01 Oxygen 1rom theAlveoli-P(A-a)02' Pa02/ PA02, and PaCO/F102, 4

Changes in Alveolar Ventilation Associated with Changes inPA02 and PAC02, 6

Alveolar Ventilation, PaC02, and VC02, 7

Changes in pH, PaC02, and Sodium Bicarbonate, 7

Changes in pH caused by Changes in PaC02, 8

Changes in Plasma Bicarbonate Caused by Changes inPaC02, 8

Metabolic Changes in Bicarbonate and pH, 11

2 Basic Terms and Concepts of MechanicalVentilation, 15

SECTION 1: Physiological Terms and ConceptsRelated to Mechanical Ventilation, 16

Normal Mechanics 01Spontaneous Ventilation, 16Lung Characteristics, 18Time Constants, 21

SECTION 11:Types of Ventilators and TermsApplied to Mechanical Ventilation, 23

Types 01Mechanical Ventilation, 23

De1inition01Pressures in Positive PressureVentilation, 26

3 How Ventilators Work, 31

Historical Perspective on Ventilator Classi1ication, 32

Internal Function, 32

Power Source or Input Power, 32

Control Systems and Circuits, 35

Power Transmission and Conversíon System, 39

4 How a Breath Is Delivered, 45

Basic Model 01Ventilation in the Lung during Inspiratíon, 46

Factors Controlled and Measured by the Ventilator duringInspiration, 47

Overview 01 Inspiratory Wave10rm Control, 48

Four Phases 01 a Breath and Phase Variables, 49

Beginning 01 Inspiration: The Trigger Variable, 50

Inspiratory Factors: The Limit Variable, 51

Termination 01 the Inspiratory Phase: The Cycling Mechanism(Cycle Variable), 54

Types01 Breaths, 56

Expiratory Phase: The Baseline Variable, 57

PART 2Initiating Ventilation

5 Establishing the Need for MechanicalVentilation, 63

Acute Respiratory Failure, 64

Patient History and Diagnosis, 65

Physiological Measurements in Acute Respiratory Failure, 69

Overview 01 Criteria 10r Mechanical Ventilation, 72

Possible Alternatives to Invasive Ventilation, 72

Patient Cases, 75

6 Selecting the Ventilator and the Mode, 81

Invasive or Noninvasive Ventilation: Selecting the PatientInterface, 82

Methods 01 Noninvasive Support and Appropriate PatientInterfaces, 82

Full and Partial Ventilatory Support, 84

Mode 01 Ventilation and Breath Delivery, 84

Type 01 Breath Delivery, 84

Targeting Volume as the Control Variable, 84

Targeting Pressure as the Control Variable, 85

Breath Delivery and Modes 01 Ventilation, 87

Bilevel Positive Airway Pressure, 96

Closed Loop Ventilation, 96

Less Frequently Used Closed Loop Modes 01 Ventilation, 97

7 Initial Ventilator Settings, ~05

Determining Initial Ventilator Setting during VolumeVentilation, 106

SECTION 1: Initial Settings during VolumeVentilation, 106

Setting Minute Ventilation, 106Tidal Volume and Rate, 108

Relationship 01Tidal Volume, Flow, Total Cycle Time, andInspiratory to Expiratory Ratio, 111

Inspiratory Flow and Flow Patterns, 113

Setting the Minute Ventilation: Special Considerations, 116

Inspiratory Pause during Volume Ventilation, 116

Actual Clinical Examples 01Ventilator Adjustment, 117

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xvi Contents

SECTION 11:Determining Initial Ventilator Settingsduring Pressure Ventilation, 117

Setting Baseline Pressure-Physiological PEEp, 118

Determining Tidal Volume Delivery in Pressure Ventilation, 118

Initial Settings for Pressure Support Ventilation, 118

Initial Settings for Pressure Control Ventilation, 120

Initial Settings for Bilevel Positive Airway PressureVentilation, 120

Initial Settings for Dual Control Pressure Ventilation Modeswith Volume Targeting, 121

8 Final Considerations in VentilatorSetup, 127

SECTION 1: Selection ot Additional Parametersand Final Ventilator Setup, 128

Selection of Fractionallnspired O2, 128

Sensitivity Setting, 128

Humidification, 129

Alarms, 132

Action during Ventilator Alarm Situations, 133

Periodic Hyperinflation or Sighing, 133

Final Considerations in Ventilator Equipment Setup, 135

Selecting the Appropriate Ventilator, 135

Evaluation of Ventilator Performance, 136

SECTION 11:Initial Ventilator Settings tor SpeciticPatient Situations, 136

Chronic Obstructive Pulmonary Disease, 136

Neuromuscular Disorders, 139

Asthma, 140

Closed Head Injury, 141

Adult Respiratory Distress Syndrome,143

Acute Cardiogenic Pulmonary Edema and Congestive HeartFailure, 145

PART 3Monitoring in Mechanical Ventilation

9 Initial Assessment of the MechanicallyVentilated Patient, 151

Documentation of the Patient-Ventilator System, 152

The First 30 Minutes, 153

Monitoring Airway Pressures, 158

Vital Signs, Blood Pressure, and Physical Examinationof the Chest, 161

Management of Endotracheal and TracheostomyTube Cuffs, 164

Monitoring Compliance and Airway Resistance, 168

Comment Section of the Ventilator Flow Sheet, 172

10 Ventilator Graphics, 177

Relationship of Pressure, Volume, Flow, and Time, 178

SECTION 1: Volume Ventilation with Constant

Flow, 179

Producing Ventilator Graphics, 179

Calculations, 180

A Closer Look at the Flow- Time Scalar in VC-CMV, 181

Changes in the Pressure- Time Curve, 184

Volume Scalar, 185

Key Points of Volume Ventilation Graphics, 187

SECTION 11:Pressure Ventilation, 187

Pressure Ventilation with a Constant Pressure

Waveform, 187

Key Points of Pressure Ventilation Graphics, 190

SECTION 11I:Pressure Support Ventilation, 191

Details of the Pressure- Time Waveform in PSV, 191

Flow Cycling during PSV, 194

Automatic Adjustment of the Flow-Cycle Criterion, 194

Use of PSV with SIMV, 195

SECTION IV: Pressure-Volume Loops, 194

Components of the P-V Loop, 195

P-V Loop and WOB, 198

Troubleshooting a P-V Loop, 199

SECTION V: Flow-Volume Loops duringMechanical Ventilation, 199

Components of an F-V Loop with Mandatory Breaths, 199

Troubleshooting with F-V Loops during MechanicalVentilation, 201

11 Noninvasive Assessment of RespiratoryFunction, 205

SECTION 1: Noninvasive Measurement of BloodGases, 206

Pulse Oximetry, 206

Capnography and Capnometry, 210Transcutaneous Monitoring, 218

SECTION 11:Indirect Calorimetry and MetabolicMeasurements, 219

Overview of Indirect Calorimetry, 219

Technical Aspects, 219

SECTION 11I:Assessment ot Respiratory SystemMechanics, 222

Airway Pressure Measurements, 222Flow Measurements, 223

Clinical Applications, 223

12 Hemodynamic Monitoring, 231

Review of Cardiovascular Principies, 232

Obtaining Hemodynamic Measurements, 235

Interpretation of Hemodynamic Profiles, 240

Clinical Applications, 249

PART 4Therapeutic Interventions-MakingAppropriate Changes

13 Methods to Improve Ventilation and OtherTechniques in Patient-VentilatorManagement, 257

SECTION 1: Correcting PaC02 Abnormalities, 258

Common Methods of Changing Ventilation Based on PaC02and pH, 258

Metabolic Acidosis and Alkalosis, 261

Mixed Acid-Base Oisturbances, 262

Increased Physiological Oead Space, 263

Increased Metabolism and Increased CO2 Production, 264

Intentionallatrogenic Hyperventilation, 264

Permissive Hypercapnia, 264

SECTION 11: Airway Clearance during MechanicalVentilation, 266

Secretion Clearance from an Artificial Airway, 266

Administering Aerosols to Ventilated Patients, 272

Chest Physiotherapy in Mechanically Ventilated Patients, 277

Flexible Fiberoptic Bronchoscopy during MechanicalVentilation, 278

SECTION 11I: Additional Patient ManagementTechniques and Therapies in VentilatedPatients, 279

Importance of Body Position and Positive PressureVentilation, 279

Ventilator Circuit Changes, 283

Sputum and Upper Airway Infections, 285

Fluid Balance, 285

Psychological and Sleep Status, 286

Patient Comfort and Safety, 287

Transport of Mechanically Ventilated Patients within an AcuteCare Facility, 288

14 Improving Oxygenation and Managementof ARDS, 295

SECTION 1: Basics of Oxygenation Using F102,PEEP studies, and Pressure-Volume Curves forEstablishing Optimum PEEP, 297

Basics of Oxygen Oelivery to the Tissues, 297

Introduction to Positive End-Expiratory PressureandContinuous Positive Airway Pressure, 299

PEEP Ranges, 301

Indications for PEEP/CPAP,301

Initiating PEEPTherapy, 302

Selecting the Appropriate PEEP/CPAPLevel (OptimumPEEP),303

Use of PulmonaryVascularPressureMonitoring with PEEP,307Pressure-Volume Loops in Setting PEEP,308

Contento.SECTION 11:Contraindications and PhysiologicalEffects of PEEP, 312

Contraindications for PEEP, 312

Pulmonary Effects of PEEP, 313

Transmission of Airway Pressure to Pleural Space, 313

Uses of PEEP for Problems Other than Acute Lung Injury, 314

Weaning from PEEP, 315

SECTION 11I:Acute Respiratory DistressSyndrome, 316

Oefinition and Epidemiology, 316

Pathophysiology, 317

Changes in Computed Tomogram with AROS, 317

AROS as an Inflammatory Process, 318

PEEP and the Vertical Gradient in AROS, 320

Lung Protective Strategies: Setting Tidal Volume andPressures in AROS, 320

Long-Term Follow-Up on AROS, 321

SECTION IV: Recruitment Maneuvers in ARDS, 321

IlIustration of a Recruitment Maneuver, 322

The Function of Lung Recruitment, 322

Hazards of Recruitment Maneuvers, 324

Variability among Patients, 324

Effects of Chest Wall Compliance on Lung Recruitment, 324

Patient Evaluation for Lung Recruitment, 325

Types of Recruitment Maneuvers, 325

Summary of Recruitment Maneuvers in AROS, 326

SECTION V: Patient Cases, 327

Case Study: Adult Respiratory Oistress Syndrome, 327

Case Study: Congestive Heart Failure, 328

15 Frequently Used Pharmacological Agentsin Ventilated Patients: Sedatives,Analgesics, and Paralytics, 335

Sedatives and Analgesics, 336

Paralytics, 341

PART 5Effects and Complications of MechanicalVentilation

16 Effects of Positive Pressure Ventilation onthe Cardiovascular, Cerebral, Renal, andOther Organ Systems, 345

SECTION 1: Effects of Positive PressureVentilation on the Heart and ThoracicVessels, 346

Adverse Cardiovascular Effects of PPV,346

Factors Influencing Cardiovascular Effects of PPV,347Beneficial Effects of PPV on Heart Function in Patients with

Left Ventricular Oysfunction, 348

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Minimizing the Physiological Effects and Complications ofMechanical Ventilation, 349

SECTION 11: Effects of Mechanical Ventilation on

Intracranial Pressure, Renal Function, LiverFunction, and Gastrointestinal Function, 351

Effects of Mechanical Ventilation on Intracranial Pressure andCerebral Perfusion, 351

Renal Effects of Mechanical Ventilation, 352Effects of Mechanical Ventilation on Liver and

Gastrointestinal Function, 353

Nutritional Complications during Mechanical Ventilation, 354

17 Effects of Positive Pressure Ventilation onthe Pulmonary System, 357

Lung Injury with Mechanical Ventilation, 358

Effects of Mechanical Ventilation on Gas Distribution and

Pulmonary Blood Flow, 364

Nosocomiallnfections and Ventilator-Associated

Pneumonia, 365

Respiratory and Metabolic Acid-Base Status in MechanicalVentilation, 371

Air Trapping (Auto-PEEP), 373

Hazards of Oxygen Therapy with Mechanical Ventilation, 376

Increased Work of Breathing, 376

Ventilator Mechanical and Operational Hazards, 383

Complications of the Artificial Airway, 384

18 Troubleshooting and Problem Solving, 391

Definition of the Term Problem, 392

Solving Ventilation Problems, 392

Protecting the Patient, 393

Identifying the Patient in Sudden Distress, 393

Patient-Related Problems, 393

Ventilator-Related Problems, 397

Common Alarm Situations, 399

Use of Graphics to Identify Ventilator Problems, 402

Unexpected Ventilator Responses, 406

PART 6Noninvasive Positive Pressure Ventilation

19 Basic Concepts of Noninvasive PositivePressure Ventilation, 417

Noninvasive Ventilation Techniques, 418

Goals and Indications for NPPV, 419

Patient Selection Criteria, 423

Equipment Selection for NPPV, 424

Setup and Preparation for NPPV, 432

Monitoring and Adjustment of NPPV, 433

Complications of NPPV, 435

Patient Weaning and Discontinuation of NPPV, 436

Patient Care Team Concerns, 436

PART 7Discontinuation from Ventilation andLong- Term Ventilation

2 O Discontinuation of and Weaning fromMechanical Ventilation, 443

SECTION 1: Weaning Techniques, 444

Methods of Titrating Ventilator Support during Weaning, 445

Closed Loop Modes for Ventilator Discontinuation, 448

SECTION 11:Evidence-Based Weaning, 451

Evaluation of Clinical Criteria for Weaning, 451

Recommendation 1: Pathology of VentilatorDependence, 452

Recommendation 2: Assessment of Readiness for WeaningUsing Evaluation Criteria, 456

Recommendation 3: Assessment during a SpontaneousBreathing Trial, 457

Recommendation 4: Removal of the Artificial Airway, 457

SECTION 11I: Factors in Weaning Failure, 460

Recommendation 5: SBT Failure, 460

Nonrespiratory Factors That May Complicate Weaning, 460

Recommendation 6: Maintaining Ventilation in Patients withSBT Failure, 464

SECTION IV: Final Recommendations, 464

Recommendation 7: Anesthesia and Sedation Strategies andProtocols, 464

Recommendation 8: Weaning Protocols, 464

Recommendation 9: Role of Tracheostomy in Weaning, 465

Recommendation 10: Long-Term Care Facilities for PatientsRequiring Prolonged Ventilation, 466

Recommendation 11: Clinician Familiarity with Long- TermCare Facilities, 466

Recommendation 12: Weaning in Long-Term VentilationUnits, 466

Ethical Dilemma: Withholding and Withdrawing VentilatorySupport,467

21 Long-Term Ventilation, 473

Goals of LTMV, 474

Sites for Ventilator-Dependent Patients, 475

Patient Selection, 477

Preparation for Discharge to the Home, 478

Follow-Up and Evaluation, 479

Equipment Selection for Patients to Be Ventilatedat Home, 481

Complications of Long-Term Positive PressureVentilation, 487

Alternatives to Invasive Mechanical Ventilation at Home, 488

Expiratory Muscle Aids and Secretion Clearance, 494

TTs, Speaking Valves, and Tracheal Buttons, 495

Ancillary Equipment and Equipment Cleaning for HomeMechanical Ventilation, 501

PART BSpecial Applications of MechanicalVentilation

22 .Neonatal and Pediatric MechanicalVentilation,509

Recognizing the Need tor Mechanical Ventilatory Support, 510

Continuous Positive Airway Pressure, 511

Conventional Mechanical Ventilation, 515

Weaning and Extubation, 535

High-Frequency Ventilation, 535

23 Special Techniques in VentilatorySupport,549

SECTION 1: Airway Pressure-ReleaseVentilation, 550

Other Names, 550

Advantages ot APRV Compared with ConventionalVentilation, 551

Disadvantages, 552

Initial Settings tor APRV,553

Adjusting Ventilation and Oxygenation, 554

Discontinuing APRV,554

SECTION 11:High-Frequency OscillatoryVentilation in the Adult, 555

Technical Aspects, 555

Initial Control Settings tor HFOV in the Adult, 556Indication and Exclusion Criteria tor HFOV in the Adult, 558

Monitoring, Assessment, and Adjustment ot HFO, 558

Adjusting Settings to Maintain ABG Goals, 559Returning to Conventional Ventilation, 561

Contents xix

SECTION 11I: Heliox Therapy and MechanicalVentilation, 561

Gas Flow through the Airways, 562

Heliox in Avoiding Intubation and during MechanicalVentilation, 563

Posfextubation Stridor, 563

Devices tor Delivering Heliox in Spontaneously BreathingPatients, 563

Manutactured Heliox Delivery System, 565

Heliox and Aerosol Delivery during MechanicalVentilation, 566

Heliox with a Mechanical Ventilator, 566

Heliox and NPPV, 568

SECTION IV: Independent Lung Ventilation, 569

Ventilator Procedure tor ILV, 569

Thoracoabdominal Aortic Aneurism Repair, 570

Establishing Sate PEEP and Ventilation with a Slow FlowIntlection Maneuver tor Assessment ot LungCharacteristics, 571

Establishing Mechanical Ventilation after TAAA, 571

Recruitment Maneuvers in Postoperative Patients, 572

SECTION V: Intrapulmonary PercussiveVentilation, 573

Equipment, 573

Administration by Mouthpiece, 573

Administration through a Ventilator, 574

Appendix A, 581

Appendix S, 601

Appendix e, 607

Glossary, 613