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 Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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 David W. Chang

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 David W. Chang, Ed.D., RRT–NPS
Professor
Department of Cardiorespiratory Care
University of South Alabama
Mobile, Alabama

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 Clinical Application of Mechanical © 2014, 2006, 2001, 1997 Delmar, Cengage Learning
Ventilation, Fourth Edition
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 Dedicated with love
to my wife, Bonnie and our children,
Michelle, Jennifer, and Michael
for their support in my professional endeavors
and personal leisure activities

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 Contents
Preface xxvi
Acknowledgments xxx

Chapter 1: Principles of Mechanical Ventilation

Introduction 2
Airway Resistance 3
Factors Affecting Airway Resistance 3
Airway Resistance and the Work of Breathing (∆P) 4
Effects on Ventilation and Oxygenation 5
Airflow Resistance 5
Lung Compliance 6
Compliance Measurement 6
Static and Dynamic Compliance 7
Compliance and the Work of Breathing 10
Effects on Ventilation and Oxygenation 10
Deadspace Ventilation 10
Anatomic Deadspace 11
Alveolar Deadspace 11
Physiologic Deadspace 11
Ventilatory Failure 12
Hypoventilation 12
Ventilation/Perfusion (V/Q) Mismatch 13
Intrapulmonary Shunting 14
Diffusion Defect 15
Oxygenation Failure 16
Hypoxemia and Hypoxia 17
Clinical Conditions Leading to Mechancial Ventilation 18
Depressed Respiratory Drive 18
Excessive Ventilatory Workload 18
Failure of Ventilatory Pump 19

VII­

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VIII Contents

Summary 21
Self-Assessment Questions 21
Answers to Self-Assessment Questions 24
References 24
Additional Resources 25

Chapter 2: Effects of Positive Pressure Ventilation

Introduction 27
Pulmonary Considerations 28
Spontaneous Breathing 28
Positive Pressure Ventilation 28
Airway Pressures 29
Compliance 30
Cardiovascular Considerations 30
Mean Airway Pressure and Cardiac Output 30
Decrease in Cardiac Output and O2 Delivery 31
Blood Pressure Changes 31
Pulmonary Blood Flow and Thoracic Pump Mechanism 32
Hemodynamic Considerations 34
Positive Pressure Ventilation 34
Positive End-Expiratory Pressure 34
Renal Considerations 35
Renal Perfusion 35
Indicators of Renal Failure 36
Effects of Renal Failure on Drug Clearance 36
Hepatic Considerations 38
PEEP and Hepatic Perfusion 38
Indicators of Liver Dysfunction 38
Effects of Decreased Hepatic Perfusion on Drug Clearance 38
Abdominal Considerations 39
Effects of PEEP and Increased Intra-Abdominal Pressure 39
Gastrointestinal Considerations 40
Nutritional Considerations 40
Muscle Fatigue 41
Diaphragmatic Dysfunction 41
Nutritional Support 41
Nutrition and the Work of Breathing 42
Neurologic Considerations 43
Hyperventilation 43
Ventilatory and Oxygenation Failure 44
Indicators of Neurologic Impairment 44
Summary 45
Self-Assessment Questions 45
Answers to Self-Assessment Questions 48
References 48

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 Contents IX

Chapter 3: Classification of Mechanical Ventilators

Introduction 51
Ventilator Classification 52
Ventilatory Work 52
Input Power 53
Drive Mechanism 53
Piston Drive Mechanism 54
Bellows Drive Mechanism 55
Microprocessor-Controlled Pneumatic Drive Mechanism 55
Control Circuit 56
Mechanical 56
Pneumatic 56
Fluidics 56
Electronic 57
Control Variables 57
Pressure Controller 57
Volume Controller 59
Flow Controller 59
Time Controller 59
Phase Variables 60
Trigger Variable 60
Limit Variable 61
Cycle Variable 62
Baseline Variable 62
Conditional Variable 63
Terminology of Ventilation Modes 66
Volume-Controlled Ventilation 66
Pressure-Controlled Ventilation 66
Intermittent Mandatory Ventilation (IMV) 67
Pressure Support 67
Dual Control within a Breath 68
Dual Control Breath-to-Breath 68
Pressure-Limited Time-Cycled Breaths 68
Pressure-Limited Flow-Cycled Breaths 68
Automode 69
Proportional Assist Ventilation 69
Automatic Tube Compensation 69
Airway Pressure Release Ventilation 70
Output Waveforms 70
Pressure Waveforms 72
Volume Waveforms 73
Flow Waveforms 74
Alarm Systems 75
Input Power Alarms 75

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X Contents

Control Circuit Alarms 75

Output Alarms 76
Summary 76
Self-Assessment Questions 77
Answers to Self-Assessment Questions 78
References 78
Additional Resources 79
Chapter 4: Operating Modes of Mechanical Ventilation

Introduction 82
Negative and Positive Pressure Ventilation 82
Negative Pressure Ventilation 83
Positive Pressure Ventilation 84
Operating Modes of Mechanical Ventilation 84
Closed-Loop System 86
Spontaneous 86
Apnea Ventilation 87
Positive End-Expiratory Pressure (Peep) 87
Indications for PEEP 87
Physiology of PEEP 89
Complications of PEEP 89
Continuous Positive Airway Pressure (Cpap) 91
Bilevel Positive Airway Pressure (Bipap) 91
Indications for BiPAP 91
Initial Settings 92
Adjustments of IPAP and EPAP 92
Controlled Mandatory Ventilation (Cmv) 92
Indications for Control Mode 93
Complications of Control Mode 94
Assist/Control (Ac) 94
Assist Control Triggering Mechanism 94
Assist Control Cycling Mechanism 95
Indications for AC Mode 95
Advantages of AC Mode 96
Complications of AC Mode 96
Intermittent Mandatory Ventilation (Imv) 96
Synchronized Intermittent Mandatory Ventilation (Simv) 97
SIMV Mandatory Breath-Triggering Mechanism 97
SIMV Spontaneous Breath-Triggering Mechanism 98
Indications for SIMV Mode 99
Advantages of SIMV Mode 99
Complications of SIMV Mode 100
Mandatory Minute Ventilation (Mmv) 100
Pressure Support Ventilation (Psv) 102
Indications for PSV Mode 103
Adaptive Support Ventilation (Asv) 104

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 Contents XI

Proportional Assist Ventilation (Pav) 105

Volume-Assured Pressure Support (Vaps) 106
Pressure-Regulated Volume Control (Prvc) 107
Automode 108
Adaptive Pressure Control (Apc) 108
Volume Ventilation Plus (VV1) 108
Volume Control Plus (VC1) 109
Volume Support (VS) 109
Pressure-Controlled Ventilation (PCV) 109
Airway Pressure Release Ventilation (APRV) 111
Indications for APRV 112
Biphasic Positive Airway Pressure (Biphasic PAP) 112
Inverse Ratio Ventilation (IRV) 113
Physiology of IRV 113
Adverse Effects of IRV 114
Pressure Control-IRV (PC-IRV) 114
Automatic Tube Compensation (ATC) 115
Neurally Adjusted Ventilatory Assist (NAVA) 115
High-Frequency Oscillatory Ventilation (HFOV) 115
Summary 116
Self-Assessment Questions 116
Answers to Self-Assessment Questions 119
References 119
Additional Resources 123

Chapter 5: Special Airways For Ventilation

Introduction 126
Oropharyngeal Airway 126
Types of Oropharyngeal Airways 126
Selection of Oropharyngeal Airway 127
Insertion of Oropharyngeal Airway 128
Nasopharyngeal Airway 128
Selection of Nasopharyngeal Airway 129
Insertion of Nasopharyngeal Airway 129
Complications of Nasopharyngeal Airway 130
Esophageal Obturator Airway (EOA) 130
Insertion of EOA 131
Esophageal Gastric Tube Airway (EGTA) 132
Laryngeal Mask Airway (LMA) 133
Use of L MA 133
Contraindications for L MA 134
Selection of L MA 135
Insertion of L MA 135
Removal of LMA 136
Limitations of LMA 138

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XII Contents

Esophageal-Tracheal Combitube (ETC) 139

Insertion and Use of ETC 139
Complications of ETC 140
Double-Lumen Endobronchial Tube (DLT) 140
Indications 141
Selection of DLT 142
Insertion of DLT 142
Complications of DLT 143
Summary 144
Self-Assessment Questions 144
Answers to Self-Assessment Questions 146
References 146
Additional Resources 149

Chapter 6: Airway Management in Mechanical Ventilation

Introduction 151
Intubation 152
Indications 153
Common Artificial Airways in Mechanical Ventilation 154
Endotracheal Tube 154
Tracheostomy Tube 155
Specialty Tracheostomy Devices 155
Intubation Procedure 156
Preintubation Assessment and Signs of Difficult Airway 156
Supplies 157
Special Visualization Devices 161
Selection of Endotracheal Tube 162
Ventilation and Oxygenation 162
Oral Intubation 163
Nasal Intubation 163
Common Errors 163
Signs of Endotracheal Intubation 165
Signs of Esophageal Intubation 167
Rapid Sequence Intubation 168
Indications and Contraindications 168
Practice Guidelines 168
Management of Endotracheal and Tracheostomy Tubes 171
Securing Endotracheal and Tracheostomy Tubes 171
Cuff Pressure 171
Minimal Occlusion Volume and Minimal Leak Technique 172
Endotracheal Suctioning 173
Endotracheal Tube Changer 175
Speaking Valves 177
Contraindications 177
Safety Requirements 177

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 Contents XIII

Positive Pressure Ventilation 178

Extubation 179
Predictors of Successful Extubation 179
Procedure 179
Unplanned Extubation 181
Complications of EndotracheaL Airway 182
During Intubation 183
While Intubated 183
Immediately after Extubation 183
Following Extubation 184
Summary 184
Self-Assessment Questions 184
Answers to Self-Assessment Questions 187
References 188
Additional Resources 191

Chapter 7: Noninvasive Positive Pressure Ventilation

Introduction 193
Terminology 194
Physiologic Effects of NPPV 194
Use of Continuous Positive Airway Pressure (cpAP) 195
Obstructive Sleep Apnea 196
Use of Bilevel Positive Airway Pressure (Bilevel pap) 197
Common Interfaces for CPAP and Bilevel PAP 198
Nasal Mask 198
Oronasal Mask 200
Nasal Pillows 200
Full-Face Mask 202
Potential Problems with Interfaces 203
Titration of Continuous Positive Airway Pressure 203
Autotitration 203
Ramp 204
C-Flex™ 204
Titration of Bilevel Positive Airway Pressures 204
Bi-Flex™ 205
Summary 206
Self-Assessment Questions 206
Answers to Self-Assessment Questions 208
References 208
Additional Resources 211

Chapter 8: Initiation of Mechanical Ventilation

Introduction 213
Goals of Mechanical Ventilation 213

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XIV Contents

Indications 214
Acute Ventilatory Failure 214
Impending Ventilatory Failure 215
Severe Hypoxemia 217
Prophylactic Ventilatory Support 218
Contraindications 218
Initial Ventilator Settings 220
Mode 220
Dual Control Mode 220
Frequency 221
Tidal Volume 222
Pressure Support 223
FIO2 224
PEEP 225
I:E Ratio 225
Flow Pattern 227
Ventilator Alarm Settings 229
Low Exhaled Volume Alarm 229
Low Inspiratory Pressure Alarm 229
High Inspiratory Pressure Alarm 229
Apnea Alarm 230
High Frequency Alarm 230
High and Low FIO2 Alarms 230
Hazards And Complications 230
Types of Hazards and Complications 231
Malfunction and Misuse of Alarms 232
Barotrauma 232
Decrease in Cardiac Output and Blood Pressure 232
Summary 234
Self-Assessment Questions 235
Answers to Self-Assessment Questions 238
References 238
Additional Resources 240
Chapter 9: Monitoring in Mechanical Ventilation

Introduction 242
Vital Signs 243
Heart Rate 243
Blood Pressure 243
Respiratory Frequency 244
Temperature 245
Chest Inspection 246
Chest Movement 246
Auscultation 248
Imaging 251

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 Contents XV

Fluid Balance and Anion Gap 253

Fluid Balance 253
Anion Gap 253
Arterial Blood Gases 254
Assessment of Ventilatory Status 255
Assessment of Oxygenation Status 255
Limitations of Blood Gases 257
Oxygen Saturation Monitoring 258
Pulse Oximetry 258
Accuracy and Clinical Use of Pulse Oximetry 259
Limitations of Pulse Oximetry 259
Integrated Pulse CO-Oximetry 259
End-Tidal Carbon Dioxide Monitoring 260
Capnography 261
Capnography Waveforms and Clinical Application 261
P(a-et)CO2 Gradient 264
Limitations of Capnography Monitoring 264
Transcutaneous Blood Gas Monitoring 265
Transcutaneous PO2 (PtcO2) 265
Transcutaneous PCO2 (PtcCO2) 266
Cerebral Perfusion Pressure 266
Summary 267
Self-Assessment Questions 267
Answers to Self-Assessment Questions 270
References 270
Chapter 10: Hemodynamic Monitoring

Introduction 276
Invasive Hemodynamic Monitoring 276
Technical Background 276
Units of Measurement 277
Types of Catheters 277
Arterial Catheter 277
Insertion of Arterial Catheter 278
Normal Arterial Pressure and Mean Arterial Pressure 279
Pulse Pressure 279
Potential Problems with Arterial Catheter 281
Central Venous Catheter 281
Insertion of Central Venous Catheter 282
Components of Central Venous Pressure Waveform 283
CVP Measurements 284
Pulmonary Artery Catheter 284
Insertion of Pulmonary Artery Catheter 285
Components of Pulmonary Arterial Pressure Waveform 286
PAP Measurements 286

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XVI Contents

Pulmonary Capillary Wedge Pressure 289

Components of Pulmonary Capillary Wedge Pressure Waveform 289
PCWP Measurements 290
Verification of the Wedged Position 291
Cardiac Output and Cardiac Index 291
Summary of Preloads and Afterloads 292
Calculated Hemodynamic Values 292
Stroke Volume and Stroke Volume Index 293
Oxygen Consumption and Oxygen Consumption Index 293
Pulmonary Vascular Resistance 293
Systemic Vascular Resistance 293
Mixed Venous Oxygen Saturation 294
Decrease in Mixed Venous Oxygen Saturation 294
Increase in Mixed Venous Oxygen Saturation 294
Less-Invasive Hemodynamic Monitoring 295
Pulse Contour Analysis 295
Noninvasive Hemodynamic Monitoring 296
Transesophageal Echocardiography
# 296
Carbon Dioxide Elimination ( VCO2) 297
Impedance Cardiography 297
Theory of Operation 298
Thermodilution Method and ICG 298
Accuracy of ICG 300
Clinical Application 300
Summary 301
Self-Assessment Questions 301
Answers to Self-Assessment Questions 303
References 304
Chapter 11: Ventilator Waveform Analysis

Introduction 309
Flow Waveforms During Positive Pressure Ventilation 311
Effects of Constant Flow During Volume-Controlled Ventilation 312
Flow-Time Waveform 313
Pressure-Time Waveform 314
Controlled Mandatory Ventilation 317
Assist Mandatory Volume-Controlled Ventilation 318
Mathematical Analysis of Constant-Flow Ventilation 320
Spontaneous Ventilation During Mechanical Ventilation 323
Synchronized Intermittent Mandatory Ventilation 323
Continuous Positive Airway Pressure 325
Effects of Flow, Circuit, and Lung Characteristics on
Pressure-Time Waveforms 326
Flow and Transairway Pressure 326
Compliance and Alveolar Pressure 327

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 Contents XVII

Effects of Descending Ramp Flow Waveform during

Volume-Controlled Ventilation 328
Time- and Flow-Limited Ventilation 328
Peak Flow and Tidal Volume Relationship in Time-Limited Ventilation 333
Effects of End-Flow on End-Transairway Pressure 334
Distribution of Delivered Tidal Volume 334
CMV during Descending Ramp Flow Ventilation 336
Waveforms Developed during Pressure-Controlled Ventilation 337
Pressure-Controlled Ventilation (PCV) 337
Assist Breaths during Pressure-Controlled Ventilation 338
Inverse Ratio Pressure-Controlled Ventilation (IRPCV) 338
Pressure Support and Spontaneous Ventilation 340
Pressure Support Ventilation (PSV) 340
Adjusting Rise Time during PSV 341
SIMV (CFW) and PSV 342
SIMV (DRFW) and PSV 343
Effects of Lung Characteristics on Pressure-Controlled
Ventilation Waveforms 343
Using Waveforms for Patient-Ventilator System Assessment 345
Patient-Ventilator Dyssynchrony 345
Dyssynchrony during Constant Flow Ventilation 347
Dyssynchrony during Descending Ramp Flow Ventilation 349
Changes in Pressure Waveforms during Respiratory
Mechanics Measurement 350
Dyssynchrony during Pressure-Controlled Ventilation 351
Using Expiratory Flow and Pressure Waveforms as Diagnostic Tools 352
Increased Airway Resistance 352
Loss of Elastic Recoil 354
Decreased Lung-Thorax Compliance (CLT) 355
Gas Trapping and Uncounted Breathing Efforts 356
Troubleshooting Ventilator Function 357
Lack of Ventilator Response 357
Circuit Leaks 358
Pressure-Volume Loop (PVL) and Flow-Volume Loop (FVL) 359
Pressure-Volume Loop (PVL) 359
Effects of Lung-Thorax Compliance on PVL 360
Effect of Airflow Resistance on PVL 361
Lower Inflection Point on PVL and Titration of PEEP 361
Upper Inflection Point on PVL and Adjustment of VT 363
Effects of Airway Status on Flow-Volume Loop (FVL) 363
Summary 364
Self-Assessment Questions 365
Answers to Self-Assessment Questions 370
References 370
Additional Resources 371

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XVIII Contents

Chapter 12: Management of Mechanical Ventilation

Introduction 375
Basic Management Strategies 375
Strategies to Improve Ventilation 376
Increase Ventilator Frequency 376
Increase Spontaneous Tidal Volume or Frequency 377
Increase Ventilator Tidal Volume 378
Other Strategies to Improve Ventilation 378
Permissive Hypercapnia 378
Strategies to Improve Oxygenation 380
Increase Inspired Oxygen Fraction (FIO2) 380
Improve Ventilation and Reduce Mechanical Deadspace 381
Improve Circulation 382
Maintain Normal Hemoglobin Level 382
Initiate Continuous Positive Airway Pressure (CPAP) 383
Initiate Positive End-Expiratory Pressure (PEEP) 383
Initiate Inverse Ratio Ventilation (IRV) 384
Initiate Extracorporeal Membrane Oxygenation (ECMO) 384
Initiate High Frequency Oscillatory Ventilation (HFOV) for Adults 385
Arterial Blood Gases 386
Respiratory Acidosis and Compensated Metabolic Alkalosis 387
Respiratory Alkalosis and Compensated Metabolic Acidosis 387
Alveolar Hyperventilation Due to Hypoxia, Improper
Ventilator Settings, or Metabolic Acidosis 388
Alveolar Hyperventilation in Patients with COPD 388
Alveolar Hypoventilation Due to Sedation or Patient Fatigue 389
Metabolic Acid-Base Abnormalities 389
Troubleshooting of Common Ventilator Alarms and Events 389
Low Pressure Alarm 389
Low Expired Volume Alarm 390
High Pressure Alarm 391
High Frequency Alarm 391
Apnea/Low Frequency Alarm 392
High PEEP Alarm 392
Low PEEP Alarm 392
Auto-PEEP 393
Care of the Ventilator Circuit 394
Circuit Compliance 395
Circuit Patency 395
Humidity and Temperature 396
Frequency of Circuit Change 397
Care of the Artificial Airway 397
Patency of the Endotracheal Tube 397
Humidification and Removal of Secretions 398

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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