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OXFORD MEDICAL PUBLICATIONS

Advanced
Respiratory Critical
Care
Oxford Specialist Handbooks published and forthcoming
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Oxford Specialist
Handbooks in
Critical Care
Advanced
Respiratory
Critical Care
Edited by

Martin Hughes
Consultant in Intensive Care Medicine
Royal Infirmary, Glasgow, UK

Roland Black
Consultant in Intensive Care Medicine
Royal Devon and Exeter Hospital
Exeter, UK

1
1
Great Clarendon Street, Oxford OX2 6DP
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Oxford University Press makes no representation, express or implied, that the
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and recommendations are for the non-pregnant adult who is not breast-feeding.
 v

Preface

Respiratory disease is the most common reason for admission to intensive

care, and advanced respiratory support is one of the most frequently used
interventions in critically ill patients. A clear understanding of respiratory
disease is the cornerstone of high quality intensive care.
Although a plethora of literature is available, both in print and online,
finding the necessary relevant information can be difficult and time con-
suming. This handbook provides comprehensive clinical detail in an easily
readable format. It is written by practising clinicians and has both in-depth
theoretical discussion and practical management advice.
The book is divided into sections
• Section 1 deals with the approach to the patient with respiratory
failure – including pathophysiology, investigation, and diagnosis
• Section 2 covers non-invasive treatment modalities
• Sections 3 and 4 examine invasive ventilation in detail. Section 3
considers the principles of mechanical ventilation while section 4 deals
with individual ventilator modes
• Section 5 discusses the management of the ventilated patient including
sedation, monitoring, asynchrony, heart – lung interaction, hypercapnia
and hypoxia, complications, weaning and extubation. It also has
chapters on areas less frequently covered such as humidification,
suction, tracheal tubes and principles of physiotherapy
• Section 6 is a comprehensive breakdown of each respiratory condition
seen in ICU.
This book is designed to bridge the gap between Intensive Care starter
texts and all-encompassing reference textbooks. It is aimed at consultants
and senior trainees in Intensive Care Medicine, senior ICU nursing staff,
consultants in other specialties and allied healthcare professionals who
have an interest in advanced respiratory critical care.
This page intentionally left blank
 vii

Acknowledgements

The editors would like to acknowledge Dr Rajkumar Rajendram,

Departments of General Medicine and Intensive Care, John Radcliffe
Hospital, Oxford, UK, as a reviewer
This page intentionally left blank
 ix

Contents

Contributors xi
Symbols and abbreviations xvii

1 Approach to the patient with respiratory failure 1

2 Non-invasive treatment modalities 73
3 Invasive ventilation basics 101
4 Invasive ventilation modes 129
5 The ventilated patient 209
6 Treatment of specific diseases 369

Index 573
This page intentionally left blank
 xi

Contributors

Rebecca Appelboam Kevin Blyth

Consultant in Intensive Care Consultant in Respiratory
Medicine Medicine
Derriford Hospital, Plymouth, UK Southern General Hospital,
Glasgow, UK
Hugh Bakere
Consultant in Respiratory Malcolm Booth
Medicine Consultant in Intensive Care
Royal Devon and Exeter Hospital, Medicine
Exeter, UK Royal Infirmary, Glasgow, UK
Steve Banham Chris Cairns
Consultant in Respiratory Consultant in Intensive Care
Medicine Medicine
Gartnavel General Hospital, Royal Infirmary, Stirling, UK
Glasgow, UK
Alyson Calder
Anthony Bateman Registrar in Anaesthesia
Consultant in Intensive Care and Royal Infirmary, Glasgow, UK
Long Term Ventilation
Western General Hospital, Luigi Camporota
Edinburgh, UK Department of Adult
Critical Care Medicine
Catherine Bateman Guy’s and St Thomas’ NHS
Consultant Physician Foundation Trust, London, UK
United Bristol Hospitals NHS
Trust, Bristol, UK Colin Church
Research fellow in Respiratory
Geoff Bellingan Medicine
Medical Director, Surgery and Gartnavel General Hospital,
Cancer Board Glasgow, UK
University College Hospital,
London, UK Ian Colquhoun
Consultant Cardiothoracic
Alexander Binning Surgeon
Consultant in Intensive Care Golden Jubilee
Medicine National Hospital,
Western Infirmary, Glasgow, UK Clydebank, UK
Roland Black Julius Cranshaw
Consultant in Intensive Care Consultant in Intensive Care
Medicine Medicine and Anaesthesia
Royal Devon and Exeter Hospital, Royal Bournemouth Hospital,
Exeter, UK Bournemouth, UK
xii CONTRIBUTORS

Brian Cuthbertson Timothy Felton

Professor and Chief of Depart- Clinical Research Training Fellow,
ment of Critical Care Medicine Respiratory and Intensive Care
Sunnybrook Health Sciences Medicine
Centre, Toronto, UK University of Manchester, UK
James Dale Andrew Foo
Clinical Research Fellow Registrar in Anaesthesia
Institute of Infection, Inflammation North Bristol NHS Trust, Bristol,
and Immunity, University of UK
Glasgow, UK
Dimitris Georgopoulos
Dr Jonathan Dalzell Professor of Medicine
Clinical Research Fellow Intensive Care Medicine
British Heart Foundation Department, University Hospital
Cardiovascular Research Centre, of Heraklion, Crete, Greece
University of Glasgow, UK
Dr Tim Gould
Christopher Day Consultant in Intensive Care
Consultant in Intensive Care Medicine and Anaesthesia
Medicine, Royal Infirmary, Bristol, UK
Royal Devon and Exeter Hospital,
Exeter, UK Dr Duncan Gowans
Department of Haematology,
Brian Digby Ninewells Hospital,
Consultant in Intensive Care Dundee, UK
Medicine and Anaesthesia
Royal Alexandria Hospital, Paisley, Ian Grant
UK Consultant in Intensive Care
Medicine and Long Term
Graham Douglas Ventilation
Consultant Physician Western General Hospital,
Chest Clinic, Royal Infirmary, Edinburgh, UK
Aberdeen, UK
John Griffiths
Dr Alasdair Dow Consultant and Honorary Senior
Consultant in Intensive Care Lecturer
Medicine Nuffield Department of
Royal Devon and Exeter Hospital, Anaesthetics, John Radcliffe
Exeter, UK Hospital, Oxford, UK
Tom Evans Dr David Halpin
Professor of Molecular Consultant in Respiratory
Microbiology Medicine
Institute of Infection, Inflammation Royal Devon and Exeter Hospital,
and Immunity, University of Exeter, UK
Glasgow, UK
Martyn Hawkins
Dawn Fabbroni Consultant in Intensive Care
Consultant in Anaesthesia Medicine
Bradford Royal Infirmary, Royal Infirmary, Stirling, UK
Bradford, UK
 CONTRIBUTORS xiii

Nik Hirani Andrew Lockwood

Senior Lecturer and Honorary Team Leader in Critical Care
Consultant in Respiratory Medicine Physiotherapy
Royal Infirmary, Edinburgh, UK Royal Devon and Exeter Hospital,
Exeter, UK
Martin Hughes
Consultant in Intensive Care Andrew Lumb
Medicine Consultant in Anaesthesia
Royal Infirmary, Glasgow, UK St James's University Hospital,
Leeds, UK
Ben Ivory
Registrar in Anaesthesia Andrew MacDuff
Royal Devon and Exeter Hospital, Registrar in Respiratory and
Exeter, UK Critical Care Medicine
Western General Hospital,
Martin Johnson Edinburgh, UK
Consultant in Respiratory Medicine
Scottish Pulmonary Vascular Unit, Peter MacNaughton
Golden Jubilee National Hospital, Consultant in Intensive Care
Clydebank, UK Derriford Hospital,
Plymouth, UK
Zuhal Karakurt
Sureyyepas‚a Chest Disease and Paul McConnell
Thoracic Surgery Training and Consultant in Intensive Care
Research Hospital, Istanbul, Turkey Medicine
Crosshouse Hospital, Kilmarnock,
William Kinnear UK
Consultant in Respiratory Medicine
Nottingham University Hospitals Iain McInnes
NHS Trust, Nottingham, UK Director and Professor of
Experimental Medicine and
John Kinsella Rheumatology
Professor of Critical Care, Institute of Infection, Inflammation
Anaesthesia and Pain Medicine and Immunity, University of
Royal Infirmary, Glasgow, UK Glasgow, UK
Maria Klimathianaki Elizabeth McGrady
Department of Intensive Care Consultant in Anaesthesia
Medicine Royal Infirmary, Glasgow, UK
University Hospital of Heraklion,
Crete, Greece Stuart McLellan
Consultant in Intensive Care
Eumorfia Kondili Medicine
Department of Intensive Care Western General Hospital,
Medicine Edinburgh, UK
University Hospital of Heraklion,
Crete, Greece Professor John McMurray
Professor of Medical Cardiology
Nicola Lee British Heart Foundation
Pulmonary Vascular Fellow Cardiovascular Research Centre,
Scottish Pulmonary Vascular Unit, University of Glasgow, UK
Golden Jubilee National Hospital,
Clydebank, UK
xiv CONTRIBUTORS

Dr Nick Maskell Derek Paul

Senior Lecturer and Honorary Consultant in Cardiothoracic
Consultant in Respiratory Anaesthesia
Medicine Golden Jubilee National Hospital,
University of Bristol, UK Clydebank, UK
Dr Marina Morgan Mr Giles Peek
Consultant in Medical Consultant in Cardiothoracic
Microbiology Surgery and ECMO,
Royal Devon and Exeter Hospital, Glenfield Hospital, Leicester, UK
Exeter, UK
Michael Pinsky
David Mucuha Muigai Vice Chair, Academic Affairs
Assistant Professor, Department Professor of Critical Care
Critical Care Medicine, University Medicine, Bioengineering,
of Pittsburgh; Medical Director, Cardiovascular Disease and
Magee Womens Hospital of Anesthesiology
UPMC, Adult ICU, Pittsburgh PA, University of Pittsburgh, PA, USA
USA
Giles Roditi
Dr Julia Munn Consultant in Radiology
Consultant in Intensive Care Royal Infirmary, Glasgow, UK
Medicine
Royal Devon and Exeter Hospital, Malcolm Sim
Exeter, UK Consultant in Intensive Care
Medicine
Stephano Nava Western Infirmary, Glasgow, UK
Director of Respiratory and
Critical Care Unit Christer Sinderby
Sant'Orsola Malpighi University Assistant Professor
Hospital, Bologna, Italy Department of Medicine,
University of Toronto, Canada
Graham Nimmo
Consultant Physician in Intensive Dr Lucy Smyth
Care Medicine and Clinical Consultant in Renal Medicine
Education, Royal Devon and Exeter Hospital,
Western General Hospital, Exeter, UK
Edinburgh, UK
Rosemary Snaith
Dr Bipen Patel Registrar in Anaesthesia
Consultant in Respiratory Royal Infirmary, Glasgow, UK
Medicine
Dr Mike Spivey
Royal Devon and Exeter Hospital,
Exeter, UK Registrar in Anaesthesia
Royal Devon and Exeter Hospital,
Ross Paterson Exeter, UK
Consultant in Intensive Care
David Swann
Medicine
Western General Hospital, Consultant in Intensive Care
Edinburgh, UK Medicine
Royal Infirmary, Edinburgh, UK
 CONTRIBUTORS xv

Anthony Todd Louise Watson

Consultant in Haematology Clinical Lead in Critical Care
Royal Devon and Exeter Hospital, Physiotherapy
Exeter, UK Royal Devon and Exeter Hospital,
Exeter, UK
Tim Walsh
Honorary Professor, Edinburgh
University and Consultant in
Critical Care
Royal Infirmary, Edinburgh, UK
This page intentionally left blank
 xvii

Symbols and abbreviations

AAA abdominal aortic aneurysm

AAFB alcohol–acid fast bacilli
A-aO2
gradient alveolar-arterial oxygen gradient
ABG arterial blood gas
ACBT active cycle of breathing technique
ACE angiotensin converting enzyme
ACh acetylcholine
ACT activated clotting time
ACV assist control ventilation
AF atrial fibrillation
AIDS acquired immunodeficiency syndrome
AIP acute interstitial pneumonia
AKI acute kidney injury
ALI acute lung injury
ANA antinuclear antibody
ANCA anti-neutrophil cytoplasmic antibody
AP antero-posterior
APACHE acute physiology and chronic health evaluation
APF alveolo-pleural fistulae
APRV airway pressure release ventilation
ARDS acute respiratory distress syndrome
ARF acute respiratory failure
AST aspartamine transaminase
ASV adaptive support ventilation
ATC automatic tube compensation
ATLS advanced trauma life support
AVCO2R artero-venous carbon dioxide removal
AVM arteriovenous malformations
BAL bronchoalveolar lavage
BCG bacille Calmette-Guerin
BHL bilateral hilar lymphadenopathy
BiPAP bi-level positive airway pressure
BIPAP biphasic positive airways pressure
BIS bispectral index
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