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Table of Contents


PART 1	BASIC CONCEPTS AND CORE KNOWLEDGE IN MEHANICAL VENTILATION
1	Basic Terms and Concepts of Mechanical Ventilation	2
	Physiological Terms and Concepts Related to Mechanical Ventilation	3
	Normal Mechanics of Spontaneous Ventilation	3
	Lung Characteristics	5
	Time Constants	8
	Types of Ventilators and Terms Used in Mechanical Ventilation	9
	Types of Mechanical Ventilation	10
	Definition of Pressures in Positive-Pressure Ventilation	11
2	How Ventilators Work	17
	Historical Perspective on Ventilator Classification	17
	Internal Function	18
	Power Source or Input Power	18
	Control Systems and Circuits	21
	Power Transmission and Conversion System	23
3	How a Breath is Delivered	29
	Basic Model of Ventilation in the Lung During Inspiration	30
	Factors Controlled and Measured During Inspiration	30
	Overview of Inspiratory Waveform Control	32
	Four Phases of a Breath and Phase Variables	33
	Types of Breaths	43
PART 2	INITIATING VENTILATION
4	Establishing the Need for Mechanical Ventilation	48
	Acute Respiratory Failure	49
	Patient History and Diagnosis	51
	Physiological Measurements in Acute Respiratory Failure	53
	Overview of Criteria for Mechanical Ventilation	56
	Possible Alternatives to Invasive Ventilation	56
5	Selecting the Ventilator and the Mode	63
	Noninvasive and Invasive Positive-Pressure Ventilation: Selecting the Patient Interface	64
	Full and Partial Ventilatory Support	65
	Mode of Ventilation and 8reath Delivery	65
	Breath Delivery and Modes of Ventilation	70
	Bilevel Positive Airway Pressure	76
	Additional Modes of Ventilation	76
6	Initial Ventilator Settings	85
	Determining Initial Ventilator Setting During Volume-Controlled Ventilation	85
	Initial Settings during Volume-Controlled Ventilation	86
	Setting Minute Ventilation	86
	Setting the Minute Ventilation: Special Considerations	94
	Inspiratory Pause During Volume Ventilation	95
	Determining Initial Ventilator Settings During Pressure Ventilation	96
	Setting Baseline Pressure�Physiological PEEP	96
	Initial Settings for Pressure Ventilation Modes with Volume Targeting	99
7	Final Considerations in Ventilator Setup	103
	Selection of Additional Parameters and Final Ventilator Setup	104
	Selection of Fractional Concentration of Inspired Oxygen F₁O₂	104
	Sensitivity Setting	104
	Alarms	108
	Periodic Hyperinflation or Sighing	109
	Final Considerations in Ventilator Equipment Setup	110
	Selecting the Appropriate Ventilator	111
	Evaluation of Ventilator Performance	111
	Initial Ventilator Settings for Specific Patient Situations	111
	Chronic Obstructive Pulmonary Disease	111
	Neuromuscular Disorders	113
	Asthma	114
	Closed Head Injury	115
	Acute Respiratory Distress Syndrome	117
	Acute Cardiogenic Pulmonary Edema and Congestive Heart Failure	118
PART 3	MONITORING IN MECHANICAL VENTILATION
8	Initial Patient Assessment	124
	Documentation of the Patient-Ventilator System	125
	The First 30 Minutes	126
	Monitoring Airway Pressures	131
	Vital Signs, Blood Pressure, and Physical Examination of the Chest	134
	Management of Endotracheal and Tracheostomy Tube Cuffs	136
	Monitoring Compliance and Airway Resistance	140
	Comment Section of the Ventilator Flow Sheet	144
9	Ventilator Graphics	148
	Relationship of Volume, Flow, Pressure and Time	149
	Volume-Controlled Ventilation with Constant Flow	150
	Producing Ventilator Graphics	150
	Calculations	150
	A Closer Look at the Flow-Time Scalar in Volume-Controlled Continuous Mandatory Ventilation	151
	Changes in the Pressure-Time Curve	155
	Volume Scalar	155
	Key Points of Volume-Controlled Ventilation Graphics	157
	Pressure-Controlled Ventilation	158
	Pressure-Controlled Ventilation with a Constant Pressure Waveform	158
	Key Points of Pressure-Controlled Ventilation Graphics	160
	Pressure Support Ventilation	161
	Details of the Pressure-Time Waveform in Pressure-Support Ventilation	161
	Flow Cycling During Pressure-Support Ventilation	162
	Automatic Adjustment of the Flow-Cycle Criterion	163
	Use of Pressure-Support Ventilation with SIMV	165
	Pressure-Volume Loops	165
	Pressure-Volume Loop and Work of Breathing	168
	Troubleshooting a Pressure-Volume Loop	169
	Flow-Volume Loops During Mechanical Ventilation	169
	Components of an Flow-Volume Loop with Mandatory Breaths	169
	Troubleshooting with Flow-Volume Loops During Mechanical Ventilation	171
10	Assessment of Respiratory Function	175
	Noninvasive Measurements of Blood Gases	175
	Pulse Oximetry	175
	Capnography (Capnometry)	179
	Exhaled Nitric Oxide Monitoring	186
	Transcutaneous Monitoring	186
	Indirect Calorimetry and Metabolic Measurements	187
	Overview of Indirect Calorimetry	187
	Assessment of Respiratory System Mechanics	190
	Measurements	190
11	Hemodynamic Monitoring	199
	Review of Cardiovascular Principles	200
	Obtaining Hemodynamic Measurements	202
	Interpretation of Hemodynamic Profiles	207
	Clinical Applications	214
PART 4	THERAPEUTIC INTERVENTIONS�MAKING APPROPRIATE CHANGES
12	Methods to Improve Ventilation in Patient- Ventilator Management	222
	Correcting Ventilation Abnormalities	223
	Common Methods of Changing Ventilation Based on PaCO₂ and pH	223
	Metabolic Acidosis and Alkalosis	226
	Mixed Acid-Base Disturbances	227
	Increased Physiological Dead Space	228
	Increased Metabolism and Increased Carbon Dioxide Production	228
	Intentional latrogenic Hyperventilation	229
	Permissive Hypsrcapnia	229
	Airway Clearance during Mechanical Ventilation	230
	Secretion Clearance from an Artificial Airway	230
	Administering Aerosols to Ventilated Patients	235
	Postural Drainage and Chest Percussion	241
	Flexible Fiberoptic Bronchoscopy	241
	Additional Patient Management Techniques and Therapies in Ventilated Patients	244
	Importance of Body Position and Positive-Pressure Ventilation	244
	Sputum and Upper Airway Infections	247
	Fluid Balance	247
	Psychological and Sleep Status	248
	Patient Safety and Comfort	249
	Transport of Mechanically Ventilated Patients within an Acute Care Facility	250
13	Improving Oxygenation and Management of Acute Respiratory Distress Syndrome Susan P. Pilbeam and J.M. Cairo	257
	Basics of Oxygenation Using F₁O₂, PEEP Studies, and Pressure-Volume Curves for Establishing Optimum PEEP	258
	Basics of Oxygen Delivery to the Tissues	258
	Introduction to Positive End-Expiratory Pressure and Continuous Positive Airway Pressure	261
	PEEP Ranges	263
	Indications for PEEP and CPAP	263
	Initiating PEEP Therapy	264
	Selecting the Appropriate PEEP/CPAP Level (Optimum PEEP)	264
	Use of Pulmonary Vascular Pressure Monitoring with PEEP	270
	Contraindications and Physiological Effects of PEEP	271
	Weaning from PEEP	273
	Acute Respiratory Distress Syndrome	275
	Pathophysiology	275
	Changes in Computed Tomogram with ARDS	275
	ARDS as an Inflammatory Process	276
	PEEP and the Vertical Gradient in ARDS	278
	Lung Protective Strategies: Setting Tidal Volume and Pressures in ARDS	278
	Long-Term Follow-Up on ARDS	279
	Pressure-Volume Loops and Recruitment Maneuvers in Setting PEEP in ARDS	279
PART 5	EFFECTS AND COMPLICATIONS OF MECHANIC VENTILATION
14	Ventilator-Associated Pneumonia	294
	Epidemiology	295
	Pathogenesis of Ventilator-Associated Pneumonia	296
	Diagnosis of Ventilator-Associated Pneumonia	297
	Treatment of Ventilator-Associated Pneumonia	298
	Strategies to Prevent Ventilator-Associated E- Pneumonia	299
15	Sedatives, Analgesics, and Paralytics	307
	Sedatives and Analgesics	308
	Paralytics	312
16	Extra pulmonary Effects of Mechanical , Ventilation	316
	Effects of Positive-Pressure Ventilation on the Heart and Thoracic Vessels	316
	Adverse Cardiovascular Effects of Positive-Pressure Ventilation	317
	Factors Influencing Adverse Cardiovascular Effects of Positive-Pressure Ventilation	318
	Beneficial Effects of Positive-Pressure Ventilation on Heart Function in Patients with Left Ventricular Dysfunction	319
	Minimizing the Physiological Effects and Complications of Mechanical Ventilation	319
	Effects of Mechanical Ventilation on l Intracranial Pressure, Renal Function, :, Liver Function, and Gastrointestinal Function	322
	Effects of Mechanical Ventilation on Intracranial Pressure and Cerebral Perfusion	322
	Renal Effects of Mechanical Ventilation	323
	Effects of Mechanical Ventilation on Liver and Gastrointestinal Function	324
	Nutritional Complications During Mechanical Ventilation	324
17	Effects of Positive-Pressure Ventilation on the Pulmonary System	327
	Lung Injury with Mechanical Ventilation	328
	Effects of Mechanical Ventilation on Gas Distribution and Pulmonary Blood Flow	333
	Respiratory and Metabolic Acid-Base Status in Mechanical Ventilation	335
	Air Trapping (Auto-PEEP)	336
	Hazards of Oxygen Therapy with Mechanical Ventilation,	339
	Increased Work of Breathing	340
	Ventilator Mechanical and Operational Hazards	345
	Complications of the Artificial Airway	347
18	Troubleshooting and Problem Solving Theresa A. Gramlich	353
	Definition of the Term Problem	354
	Protecting the Patient	354
	Identifying the Patient in Sudden Distress	355
	Patient-Related Problems	356
	Ventilator-Related Problems	358
	Common Alarm Situations	360
	Use of Graphics to Identify Ventilator Problems	363
	Unexpected Ventilator Responses	370
PART 6	NONINVASIVE POSITIVE PRESSURE VENTILATION
19	Basic Concepts of Noninvasive Positive- Pressure Ventilation Theresa A. Gramlich	378
	Types of Noninvasive Ventilation Techniques	379
	Goals and Indications for Noninvasive Positive-Pressure Ventilation	380
	Other Indications for NIV	382
	Patient Selection Criteria	383
	Equipment Selection for NIV	384
	Setup and Preparation for NIV	392
	Monitoring and Adjusting NIV	393
	Aerosol Delivery in NIV	394
	Complications of NIV	394
	Weaning from and Discontinuing NIV	396
	Patient Care Team Concerns	396
PART 7	DISCONTINUATION FROM VENTILATION AND LONG- TERM VENTILATION
20	Weaning and Discontinuation from Mechanical Ventilation	402
	Weaning Techniques	402
	Methods of Titrating Ventilator Support During Weaning	403
	Closed-Loop Control Modes for Ventilator Discontinuation	406
	Evidence-Based Weaning	409
	Evaluation of Clinical Criteria for Weaning	409
	Recommendation 1: Pathology of Ventilator Dependence,	409
	Recommendation 2: Assessment of Readiness for Weaning Using Evaluation Criteria	413
	Recommendation 3: Assessment During a Spontaneous Breathing Trial	413
	Recommendation 4: Removal of the Artificial Airway	414
	Factors in Weaning Failure	417
	Recommendation 5: Spontaneous Breathing Trial Failure	417
	Nonrespiratory Factors That May Complicate Weaning	417
	Recommendation 6: Maintaining Ventilation in Patients with Spontaneous Breathing Trial Failure	420
	Final Recommendations	420
	Recommendation 7: Anesthesia and Sedation Strategies and Protocols	420
	Recommendation 8: Weaning Protocols	420
	Recommendation 9: Role of Tracheostomy in Weaning	422
	Recommendation 10: Long-Term Care Facilities for Patients Requiring Prolonged Ventilation	422
	Recommendation 11: Clinician Familiarity with Long-Term Care Facilities	422
	Recommendation 12: Weaning in Long-Term Ventilation Units	422
	Ethical Dilemma: Withholding and Withdrawing Ventilatory Support	423
21	Long-Term Ventilation Theresa A. Gramlich	428
	Goals of Long-Term Mechanical Ventilation	429
	Sites for Ventilator-Dependent Patients	430
	Patient Selection	430
	Preparation for Discharge to the Home	432
	Follow-Up and Evaluation	435
	Equipment Selection for Home Ventilation	436
	Complications of Long-Term Positive-Pressure Ventilation	440
	Alternatives to Invasive Mechanical Ventilation at Home	441
	Expiratory Muscle Aids and Secretion Clearance	445
	Tracheostomy Tubes, Speaking Valves, and Tracheal Buttons	447
	Ancillary Equipment and Equipment Cleaning for Home Mechanical Ventilation	452
PART 8	NEONATAL AND PEDIATRIC RESPIRATORY SUPPORT
22	Neonatal and Pediatric Mechanical Ventilation Robert M. DiBlasi	460
	Recognizing the Need for Mechanical Ventilatory Support	461
	Goals of Newborn and Pediatric Ventilatory Support	462
	Noninvasive Respiratory Support	462
	Conventional Mechanical Ventilation	469
	High-Frequency Ventilation	485
	Weaning and Extubation	491
	Adjunctive Forms of Respiratory Support	493
PART 9	SPECIAL APPLICATIONS IN VENTILATORY SUPPORT
23	Special Techniques in Ventilatory Support Sue Pilbeam, J.M. Cairo, Paul Barraza	504
	Airway Pressure-Release Ventilation	505
	Other Names	505
	Advantages of APRV Compared with Conventional Ventilation	506
	Disadvantages	507
	Initial Settings	507
	Adjusting Ventilation and Oxygenation	508
	Discontinuation	509
	High-Frequency Oscillatory Ventilation in the Adult	509
	Technical Aspects	510
	Initial Control Settings	510
	Indication and Exclusion Criteria	512
	Monitoring, Assessment, and Adjustment	513
	Adjusting Settings to Maintain Arterial Blood Gas Goals	514
	Returning to Conventional Ventilation	515
	Heliox Therapy and Mechanical Ventilation	515
	Gas Flow Through the Airways	516
	Heliox in Avoiding Intubation and During Mechanical Ventilation	516
	Postextubation Stridor	517
	Devices for Delivering Heliox in Spontaneously Breathing Patients	517
	Manufactured Heliox Delivery System	518
	Heliox and Aerosol Delivery during Mechanical Ventilation	519
	Monitoring the Electrical Activity of the Diaphragm and Neurally Adjusted Ventilatory Assist	522
	Review of Neural Control of Ventilation	522
	Diaphragm Electrical Activity Monitoring	522
	Neurally Adjusted Ventilatory Assist	527
Appendix A	Answer Key	534
Appendix B	Review of Abnormal Physiological Processes	553
Appendix C	Graphic Exercises	558
	Glossary	563
	Index	569