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SECTION ITECHNICAL ASPECTS OFMECHANICAL VENTILATION, 1
Chapter 1Classification of Mechanical Ventilators, 1RobertL. Chatbum and Richard D. Branson
Basic Concepts, 2Input Power, 2
Electric, 3Pneumatic, 3
Control Scheme, 3Control Variables, 10Phase Variables, 12Conditional Variables,22Modes of Ventilation, 24Control Subsystems,31Output Waveforms, 35
Ventilator Alarm Systems, 42Input Power Alarms, 43Control Circuit Alarms, 43Output Alarms, 43
Chapter 2
Modes of Ventilator Operation, 49RichardD. Branson
Pressure Control Versus V olume
Control, 50
Pressure Target Versus Volume Target, 50Modes, 51
Continuous Mandatory Ventilation, 51Assist-Control Ventilation, 52Assisted Mechanical Ventilation, 55
Intermittent Mandatory Ventilation, 58Synchronized Intermittent Mandatory
Ventilation, 59
Pressure Support Ventilation, 60Continuous Positive Airway Pressure, 64Airway Pressure Release Ventilation, 66Pressure Control Inverse Ratio
Ventilation, 68
Mandatory Minute Ventilation, 69Combining Modes, 71Dual Control Modes, 71
Dual Control Within a Breath, 71Dual Control Breath-to-Breath-
Pressure-Limited, Flow-CycledVentilation, 73
Dual Control Breath-to-Breath-
Pressure-Limited, Time-CycledVentilation, 73
Automode,74
Adaptive Support Ventilation, 76Adaptive Tidal V olume Support, 78Automatic Tube Compensation, 79Proportional Assist Ventilation, 80SMARTCAREPS,82
Chapter 3The Patient-Ventilator Interface:
Ventilator Circuit, Airway Care, andSuctioning, 89Richard D. Branson
The Ventilator Circuit, 90Ventilation, 90Exhalation Valves, 91
Care of the Artificial Airway, 92Tube Placement, 92
Securing the Tube, 96Special Endotracheal Tubes, 97
Silver-Coated or Silver-ImpregnatedEndotracheal Tubes, 97
Subglottic Suction Endotracheal Tubes, 97Oral Care, 98
Management of the Endotracheal TubeCuff, 98
Monitoring Cuff Pressure, 99Suctioning, 100
Bronchial Suctioning, 101Use of Saline Instillation, 102
Complications of Suctioning, 102Patient-Ventilator System Check, 103
xiü
xiv CONTENTS
Chapter 4
Humidification and Aerosol Therapy, 111Richard D. Branson
Physical Properties, 112Physiologic PrincipIes, 114High-Flow Humidifiers, 115
Types of High-Flow Humidifiers, 116Passive Humidifier, 116Characteristics of Artificial Noses, 119
Moisture Output, 119Resistance, 119
Dead Space, 120Additives, 120Cost, 120Choosing the Right Passive Humidifier, 121
Use of Humidification Devices DuringMechanical Ventilation, 121
Active Hygroscopic Heat and MoistureExchangers, 123
Heat and Moisture Exchanger Booster, 124Aerosol Therapy During Mechanical
Ventilation, 124Physical Properties, 124Types of Aerosol Generators, 125Choosing an Aerosol Delivery System, 128Aerosol Delivery During Mechanical
Ventilation, 128
Monitoring Bronchodilator Efficacy, 130Recommendations for Aerosol Therapy in
Mechanically Ventilated Patients, 132Aerosolized Pharmacologic Agents, 132
Bronchodilators, 132
Anticholinergics, 135Anti-Inflammatory Agents, 136Aerosolized Antibiotics, 137
Chapter 5Ventilator Monitors and Displays, 146Neíl R. MacIntyre
Pressure and Flow Sensors, 147Pressure Sensors, 147Flow and Volume Sensors, 148
Output from Pressure/Flow IV olumeSensors, 149
Monitoring Maneuvers, 149Gas Analyzers and Gas Exchange
Monitors, 151Display Screens, 151Future Sensors and Monitors, 151
Ventilator Alarm Systems, 153Levels ofEvents and Alann Requirements, 153Alarm Cost Effectiveness, 155
SECTION 11
PHYSIOLOGY, 159
Chapter 6Respiratory System Mechanics, 159Neíl R. MacIntyre
Measurements, 159
Lung Inflation and Respiratory SystemMechanics: Equation of Motion, 162
Compliance (Elastance), 162Resistance, 164
Mechanical Loads, 165
Interaction of Respiratory System Mechanicswith Ventilator Settings, 167
Mechanical Determinants of Delivered
Ventilation, 167
Chapter 7Alveolar-Capi/lary Gas Transport, 171Neil R. MacIntyre
Steady-State Alveolar-Capillary PressureGradients, 171
Ventilation-Perfusion Matching, 173Positive Pressure Ventilation Effects on
Ventilation-Perfusion Matching, 174Inspiratory and Expiratory Positive
Pressure, 174
Inspiratory Flow Pattern and Inspiratory-Expiratory Time Relationship, 177
Intrathoracic Pressures and Perfusion, 178
Alveolar-Capillary Gas Transport inthe Context of Overall OxygenDelivery, 178
Chapter 8Patient-Ventilator Interactions, 182Lawrence R. Tom and Catheríne S. H. Sassoon
Determinants of SpontaneousVentilation, 183
Respiratory Control System, 183Equation of Motion, 184
Patient- V entilator Interactions, 185Patient-Related Factors, 185Ventilator-Related Factors, 186
The Future, 193
Chapter 9Cardiopulmonary Interactions, 198David N. Hager and Henry E. Pessler
Mechanical Forces During Ventilation, 199Venous Return, 199Ventricular Interdependence, 199Pulmonary VascularResistance, 200
CONTENTS xv
Pulmonary Vascular Capacitance, 200Ventricular Afterload, 200Stress on Abdominal Vessels, 200
Clinical Applications: Transient Effects, 200Valsalva Maneuver, 200
Respiratory Changes in Pulse Pressure, 201Clinical Applications: Steady-State
Effects, 201PEEP, 201
Weaning, 203
Chapter 10Ventilator-Induced Lung Injury, 206
Renee D. Stapleton and Kenneth P. Steinbert
Alveolar Rupture and Extra-AlveolarAir, 207
Stretch-Induced Lung Injury, 208Experimental and Mechanistic Evidence for
VIL!, 208
Clinical Studies Providing Evidencefor VIL!, 211
Summary, 212
SECTION 111
AD..JUNCTIVE THERAPY, 217
Chapter 11Nutrition,217
Richard D. Branson and jay A. johannigman
Malnutrition in the MechanicallyVentilated Patient, 218
Effect of Underfeeding, 218Effect of Overfeeding, 219Nutritional Assessment, 220
Nutritional Requirements, 221Performance of Indirect Calorimetry, 222Design of the Nutrition Support
Regimen, 225Monitoring Response and Patient
Tolerance, 229Conclusions, 230
Chapter 12Sedation, Analgesia, and NeuromuscularBlockade, 235BryanA. Pisk and Lisa K. Moores
Pain, 237Rationale for Pain Management, 237Recognition of Pain, 237Management of Pain, 238
Delirium, 240Recognition of Delirium, 240Treatment of Delirium, 240
Sedation, 241
Rationale for Sedation Management, 241Titration and End Points, 241Drugs Used for Sedation, 242Approach to Management, 243
Neuromuscular Blockade, 245
Drugs Used for NeuromuscularBlockade, 245
Monitoring Use of NMBAs, 247Summary, 248
Chapter 13
Patient Positioning, 252joseph A. Govert
Effects of Posture and Position on HealthyPatients, 253
Lung Volumes, 253Regional Pleural Pressures, 253Regional Lung Inflation, 254Pulmonary Mechanics, 255Distribution of Ventilation, 256Distribution of Perfusion, 256Ventilation-Perfusion (V/Q)
Relationships, 256Effects of Posture and Position
on Patients with RespiratoryDisease, 256
Neuromuscular Disease, 256Obstructive Airway Disease, 257Unilateral Lung Injury, 258Acute Respiratory Distress Syndrome, 258
Chapter 14Ventilator-Associated Pneumonia, 266Mohammed Hijazi and Mariam AI-Ansari
Incidence and Risk Factors, 266Morbidity, Mortality, and Cost, 267Pathogenesis, 268
Colonization, 269
Respiratory Therapy Equipment, 269Host Defenses, 270
Microbiology, 270Diagnosis, 272
Clinical Features and Chest X-Ray, 272Qualitative Culture Techniques, 273Quantitative Culture Techniques, 273
Therapy, 274Empiric Therapy, 274Pharinacologic Consideration, 275De-Escalation and Specific Therapy, 276Duration of Therapy, 276Response to Therapy, 277
Prevention, 277
xvi CONTENTS
SECTION IV
CLlNICAL APPLlCATIONS, 287
Chapter 15
Management of Parenchymal LungInjury, 287
Neil R. MacIntyre
Pathophysiology of Parenchymal LungInjury, 288
Goals of Ventilatory Support, 288Mechanical Ventilation Strategies, 289
Modes Selection, 289
Frequency- Tidal Volume Settings, 290Positive End-Expiratory Pressure and lnspired
Oxygen Concentration, 291Novel Approaches to Lung Protection in
Parenchymal Lung Injury, 292Airway Pressure Release Ventilation,
293
High-Frequency Ventilation, 293Other Considerations in Managing
Parenchymal Lung Injury, 293Outcome of Parenchymal Lung Injury, 293
Chapter 16
Management of Obstructive AirwayDisease, 297
Neil R. MacIntyre
Pathophysiology of Obstructive AirwayDiseases, 297
Goals of Ventilatory Support, 298Mechanical Ventilation Strategies, 298
Mode Selection, 298
Tidal Volume/Frequency /InspiratoryTime, 300
Positive End-Expiratory Pressure/lnspiredOxygen Concentration, 301
Other Considerations in VentilatoryManagement, 302
Outcomes of Respiratory Failure inObstructed Airway Disease, 303
Chapter 17
Unique Patient Populations, 306John H. Shemer and Lisa K. Moores
Traumatic Brain Injury, 307Pathophysiology and Unique Features, 307Management, 307
Neuromuscular Disease, 309Pathophysiology and Unique Features, 309Management, 309
Lung Transplantation, 310Donor Care, 310
Perioperative Care of TransplantRecipients, 311
Buro Injuries, 313Pathophysiology and Unique Features, 313Assessment, 313
Management, 313Perioperative Respiratory Failure, 313
Pathophysiology and Unique Features, 313Management, 313
Conclusions, 314
Chapter 18
Discontinuing Mechanical Ventilation, 317Neíl R. MacIntyre
Considering Ventilator Discontinuation, 318Assessing the Potential for
Discontinuation, 318Next Steps for Patients With Successful
Spontaneous Breathing Trial, 319Managing the Not-Yet-Ready-to-Be
Discontinued Patient, 320The Impact of Newer Feedback
Controllers on Discontinuation, 321Approaches for the Difficult-to- W ean
Patient, 322
Chapter 19Prolonged Mechanical Ventilation, 325Christopher E. Cox and Shannon S. Carson
Prolonged Mechanical Ventilation, 326Epidemiology of PMV, 326
Economics of PMV, 326PMV Patients, 327
Ventilator-Dependent Patients, 327Predicting the Need for PMV, 328
Reducing the Likelihood of PMV, 328Timing for Tracheostomy Placement, 329
Placing a Tracheostomy, 331Outcome of PMV Patients, 331
Disposition, 331Weaning Success, 331Survival, 331
Quality of Life and Functional Status, 331Cost-Effectiveness, 332
Most Effective Way to Wean PMVPatients, 332
Predicting Weaning Success, 333Interventions to Improve PMV
Outcomes, 333
Post-Acute Care Facilities and RespiratoryCare Units in PMV Care, 335
Palliative Care in the PMV Population, 335Summary,336
CONTENTS xvii
Chapter 20Mechanical Ventilation DuringTransport and CardiopulmonaryResuscitation, 339Richard D. Branson and Jay A. Johannigman
Ventilation During CardiopulmonaryResuscitation, 340
Standards for Ventilation and Devices, 340Lung Compliance After Cardiac Arrest, 340
Techniques of EmergencyVentilation, 341
Expired Air Resuscitation, 341Cricoid Pressure, 342Disease Transmission, 342Barrier Devices, 343Mouth-to-Mask, 344
Bag-Valve Devices, 346Description, 346Bag-Valve Device Performance, 347Ventilation Efficacy, 347Delivered Oxygen Concentration, 348Nonrebreathing Valve Performance, 348
Oxygen-Powered Breathing Devices, 349Description, 349Assessment, 350Ventilator-to-Mask Ventilation, 350
Impedence Threshold Device, 352
Transport of the Mechanically VentilatedPatient, 352
Rationale for Transport, 352Preparation, 352Equipment, 353Characteristics of a Ventilator for lntrahospital
Transport, 354Physiologic Effects and Risks of
Transport, 357
Chapter 21Noninvasive MechanicalVentilation,366Nicholas S. Hill
Rationale for the Use of Noninvasive
Ventilation, 367Indications for Noninvasive Ventilation:
Acute Applications, 367Best Established lndications, 367
Indications Supported by WeakerEvidence, 369
Other Obstructive Diseases, 369Extubation Failure, 369
Postoperative Respiratory Failure/lnsufficiency, 370
Do Not Intubate Status, 370
Other Acute Applications of NoninvasiveVentilation, 370
Selection Guidelines for Noninvasive
Ventilation in Acute RespiratoryFailure, 370
Determinants of Success/Failure, 370Selection Process, 371
Long- Term Applications of NoninvasiveVentilation, 372
Restrictive Thoracic Disease, 372
Chronic Obstructive Pulmonary Disease, 372Obesity Hypoventilation, 373Selection Guidelines, 373
Contraindication to Long- TermNoninvasive Ventilation, 373
Techniques and Equipment forNoninvasive Ventilation, 374
N oninvasive Positive- Pressure
Ventilation, 374Interfaces, 375Ventilators for Positive-Pressure Noninvasive
Ventilation, 378Application of Noninvasive Positive-
Pressure Ventilation, 381Initiation, 381General Considerations, 382
Adaptation and Monitoring, 383Long- Term Applications, 383Common Problems and Possible
Remedies, 384
Summary and Conclusions, 386
Chapter 22Modifications on ConventionalVentilation Techniques,392
John D. Davies
Airway Pressure Release Ventilation, 393Description and Rationale, 393Clinical Data, 394Recommendations, 394
Independent Lung Ventilation, 394Description and Rationale, 394Clinical Data, 397Recommendations, 397
Proportional Assist Ventilation, 397Description and Rationale, 397Clinical Data, 398Recommendations, 400
Tracheal Gas Insufilation, 400
Description and Rationale, 400Clinical Data, 401Recommendations, 401
xviii CONTENTS
Modifications for Nuclear MagneticScanners and HyperbaricCharnbers, 402
MRI-Compatible Equipment, 402Hyperbaric Chamber-Compatible
Equipment, 402
Chapter 23
High-Frequency Ventilatian, 407
Michael A. Gentile and Neil R. MacIntyre
Devices, 408Jets, 408Oscillators, 410
Mechanisrn of Gas Transport, 411Applications, 412Cornplications, 414Surnrnary, 414
Chapter 24Extracarpareal Techniques far
Cardiapulmanary Suppart, 418Michael A. Gentile and Ira M. Cheifetz
History of Extracorporeal Life Support,418
Patient Selection and Criteria for
Extracorporeal Life Support, 419Types of Extracorporeal Life Support, 421
Venoarterial Extracorporeal Life Support, 421Venovenous Extracorporeal Life Support, 422
Cornplications Associated WithExtracorporeal Life Support, 423
Patient Managernent DuringExtracorporeal Life Support, 423
Ventilator and Respiratory Care, 423
Anticoagulation, 424Sedation and Analgesia, 424Nutrition, 424
Current Status of ExtracorporealLife Support and Outcorne inPediatrics, 424
Extracorporeal Life Support Technologyfor Adult Respiratory Failure, 424
Surnrnary, 426
Chapter 25Heliax and Inhaled Nitric Oxide, 429Dean R. Hess
Heliox, 429
Physics and Physiology, 429Clinical Applications, 431Oelivery Systems for Heliox, 435
Inhaled Nitric Oxide, 437
Biology of Nitric Oxide, 437Selective Pulmonary Vasodilation, 438Clinical Applications, 439Toxicity and Complications of Inhaled Nitric
Oxide, 439
Oelivery Systems for lnhaled NitricOxide, 440
Appendix 1Mechanical Ventilatian Case Studies, 451Neil R. MacIntyre
Appendix 2Assessment Questian Answers, 467
Glossary, 473