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2014 essentials of mechanical ventilation, thir dean hess


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Dedication
ForSusan,Terri,Rob,Max,Abby,Lauren,andMatt—whomakeeveryday
enjoyable.
D.R.H.
FormychildrenRobert,Julia,Katie,andCallie,whomakeitallworthwhile.
R.M.K.



Contents



Preface
Abbreviations

Part1PrinciplesofMechanicalVentilation
Chapter1PhysiologicEffectsofMechanicalVentilation
Chapter2PhysiologicGoalsofMechanicalVentilation
Chapter3Ventilator-InducedLungInjury
Chapter4Ventilator-AssociatedPneumonia
Chapter5VentilatorModeClassification
Chapter6TraditionalModesofMechanicalVentilation
Chapter7PressureandVolumeVentilation
Chapter8AdvancedModesofMechanicalVentilation
Chapter9FlowWaveformsandI:ERatios
Chapter10HighFrequencyVentilation
Chapter11NoninvasiveVentilation
Chapter12HumidificationandtheVentilatorCircuit
Chapter13FIO2,PositiveEnd-ExpiratoryPressure,andMeanAirway
Pressure
Chapter14InitialSettingsforMechanicalVentilation
Chapter15Patient-VentilatorAsynchrony
Chapter16VentilatorLiberation
Part2VentilatorManagement
Chapter17AcuteRespiratoryDistressSyndrome
Chapter18ObstructiveLungDisease
Chapter19ChestTrauma


Chapter20HeadInjury
Chapter21PostoperativeMechanicalVentilation
Chapter22NeuromuscularDisease
Chapter23CardiacFailure
Chapter24BurnsandInhalationInjury
Chapter25BronchopleuralFistula
Chapter26DrugOverdose
Part3MonitoringDuringMechanicalVentilation
Chapter27BloodGases
Chapter28PulseOximetry,Capnography,andTranscutaneousMonitoring
Chapter29HemodynamicMonitoring
Chapter30BasicPulmonaryMechanicsDuringMechanicalVentilation
Chapter31AdvancedPulmonaryMechanicsDuringMechanicalVentilation
Chapter32NutritionalAssessment
Part4TopicsRelatedtoMechanicalVentilation
Chapter33AirwayManagement
Chapter34AirwayClearance
Chapter35InhaledDrugDelivery
Chapter36EmergencyVentilationandVentilationinaDisaster
Chapter37MobilizationandPortableVentilation
Chapter38ExtracorporealLifeSupport
Index



Preface



Mechanicalventilationisanintegralpartofthecareofmanycriticallyill
patients.ItisalsoprovidedatsitesoutsidetheICUandoutsidethehospital,
includinglong-termacutecarehospitalsandthehome.Athorough
understandingoftheessentialsofmechanicalventilationisrequisitefor
respiratorytherapistsandcriticalcarephysicians.Ageneralknowledgeofthe
principlesofmechanicalventilationisalsorequiredofcriticalcarenursesand
primarycarephysicianswhosepatientsoccasionallyrequireventilatorysupport.
Thisbookisintendedtobeapracticalguidetoadultmechanicalventilation.
Wehavewrittenthisbookfromourperspectiveofover75yearsofexperience
asclinicians,educators,researchers,andauthors.Wehavemadeeveryattempt
tokeepthetopicscurrentandwithadistinctlyclinicalfocus.Asintheprevious
editions,wehavekeptthechaptersshort,focused,andpractical.
Therehavebeenmanyadvancesinthepracticeofmechanicalventilation
overthepast10years.Hence,muchofthebookisrewritten.Likeprevious
editions,thebookisdividedintofourparts.Part1,PrinciplesofMechanical
Ventilation,describesbasicprinciplesofmechanicalventilationandthen
continueswithissuessuchasindicationsformechanicalventilation,appropriate
physiologicgoals,andweaningfrommechanicalventilation.Part2,Ventilator
Management,givespracticaladviceforventilatingpatientswithavarietyof
diseases.Part3,MonitoringDuringMechanicalVentilation,discussesblood
gases,hemodynamics,mechanics,andwaveforms.Inthefinalpart,Topics
RelatedtoMechanicalVentilation,wediscussissuessuchasairway
management,aerosoldelivery,extracorporeallifesupport,andmiscellaneous
ventilatorytechniques.
Thisisabookaboutmechanicalventilationandnotmechanicalventilators.
Wedonotdescribetheoperationofanyspecificventilator(althoughwedo
discusssomemodesspecifictosomeventilatortypes).Wehavetriedtokeepthe
materialcoveredinthisbookgenericanditis,byandlarge,applicabletoany
adultmechanicalventilator.Wedonotcoverissuesrelatedtopediatricand
neonatalmechanicalventilation.Becausethesetopicsareadequatelycoveredin


pediatricandneonatalrespiratorycarebooks,wedecidedtolimitthefocusof
thisbooktoadultmechanicalventilation.Althoughweprovideashort
bibliographyattheendofeachchapter,wehavespecificallytriedtomakethisa
practicalbookandnotanextensivereferencebook.
Thisbookiswrittenforallclinicianscaringformechanicallyventilated
patients.Webelievethatitisuniqueandhopeyouwillenjoyreadingitasmuch
aswehaveenjoyedwritingit.
DeanR.Hess,PhD,RRT
RobertM.Kacmarek,PhD,RRT



Abbreviations



A/C

Assist/control

AG

Aniongap

APRV

Airwaypressurereleaseventilation

ARDS

Acuterespiratorydistresssyndrome

ARDSnet ARDSnetwork
AVAPS

Averagevolumeassuredpressuresupport

BAL

Bronchoalveolarlavage

BE

Baseexcess

BEE

Basalenergyexpenditure

BSA

Bodysurfacearea

CCI

Chroniccriticalillness

Cao2

Oxygencontentofarterialblood

CC′O2

Pulmonarycapillaryoxygencontent

CDC

CentersforDiseaseControlandPrevention

CI

Cardiacindex

CL

Lungcompliance

Cl–

Chlorideion

CMV

Continuousmandatoryventilation

CO

Carbonmonoxide

CO2

Oxygencontentoftheblood

COPD

Chronicobstructivepulmonarydisease

CPAP

Continuouspositiveairwaypressure


CPP

Cerebralperfusionpressure

CPR

Cardiopulmonaryresuscitation

CSV

Continuousspontaneousventilation

CT

Computedtomography

C

O2

Mixedvenousoxygencontent

CVP

Centralvenouspressure

CW

Chestwallcompliance

DO2

Oxygendelivery

EAdi

Electricalactivityofthediaphragm

ECLS

Extracorporeallifesupport

ECMO

Extracorporealmembraneoxygenation

EELV

End-expiratorylungvolume

EPAP

Expiratorypositiveairwaypressure

fb

Frequencyofbreathing;respiratoryrate

fc

Heartrate

FIO2

Fractionofinspiredoxygen

FRC

Functionalresidualcapacity

Hb

Hemoglobin

HbCO

Carboxyhemoglobin

HCO3–

Bicarbonateconcentration

HFJV

Highfrequencyjetventilation

HFOV

Highfrequencyoscillatoryventilation

HFPPV

Highfrequencypositivepressureventilation

HFV

Highfrequencyventilation

HME

Heatandmoistureexchanger

Hz

Hertz

I:E

Inspiratorytimetoexpiratorytimeratio

IBW

Idealbodyweight(sometimescalledpredictedbodyweight)


ICP

Intracranialpressure

ICU

Intensivecareunit

IMV

Intermittentmandatoryventilation

iNO

Inhalednitricoxide

IPAP

Inspiratorypositiveairwaypressure

ISB

Isothermalsaturationboundary

IVAC

Infectionrelatedventilatorassociatedcondition

j

Joules

LV

Leftventricle

LVSWI

Leftventricularstrokeworkindex

MAP

Meanarterialpressure

MDI

Metered-doseinhaler

MIC

Maximuminsufflationcapacity

MIE

Mechanicalinsufflation–exsufflator

MMV

Mandatoryminuteventilation

MODS

Multipleorgandysfunctionsyndrome

MPAP

Meanpulmonaryarterypressure

NO

Nitricoxide

Na+

Sodium

NAVA

Neurallyadjustedventilatoryassist

NIV

Noninvasiveventilation

NPE

Neurogenicpulmonaryedema

OI

Oxygenationindex

ΔPaw

Changeinairwaypressure

ΔPL

Transpulmonarypressure

ΔPOP

Plethysmographicwaveformamplitude

ΔPpl

Changeinpleuralpressure

P(a-


et)CO2

Differencebetweenarterialandend-tidalPco2

Pao2/PAO2 RatioofarterialPO2toalveolarPO2
Pao2/FIO2 RatioofarterialPo2toFIO2
P(A-a)o2 DifferencebetweenalveolarPo2andarterialPo2
Paco2
alv

Partialpressureofcarbondioxideinarterialblood
Meanalveolarpressure

Palv

Alveolarpressure

Pao2

Partialpressureofoxygeninarterialblood

PAO2

AlveolarPo2

PAP

Pulmonaryarterypressure

PAV

Proportional-assistventilation

aw

Meanairwaypressure

Pb

Barometricpressure

Pbo2

BrainPo2

PC-CMV Continuousmandatoryventilationwithpressurecontrol
PC-IMV

Pressure-controlledintermittentmandatoryventilation

PCIRV

Pressure-controlledinverserationventilation

PCO2

Partialpressureofcarbondioxide

PCV

Pressure-controlledventilation

PCWP

Pulmonarycapillarywedgepressure

Pdi

Transdiaphragmaticpressure

P

MixedexhaledPCO2

CO2

PH2O

Watervaporpressure

PEEP

Positiveend-expiratorypressure

PEG

Percutaneousendoscopicgastrostomy

Peso

Esophagealpressure

Petco2

End-tidalPCO2


Pexhco2

MeasuredmixedexhaledPCO2includinggascompressedinthe
ventilatorcircuit

pH

Negativelogofthehydrogenionconcentration

PI

Plethysmographicperfusionindex

PImax

Maximuminspiratorypressure

PImin

Minimalvalueoftheplethysmographicperfusionindex

PIP

Peakinspiratorypressure

Pmus

Pressuregeneratedbytherespiratorymuscles

PMV

Prolongedmechanicalventilation

PO2

Partialpressureofoxygen

Pplat

Plateaupressure

PPV

Arterialpulsepressurevariation

PRVC

Pressure-regulatedvolumecontrol

PSV

Pressuresupportventilation

Ptcco2

TranscutaneousPCO2

Ptco2

TranscutaneousPO2

P

MixedvenousPCO2

CO2

Pvent

Pressure-generatedbytheventilator

PVI

Plethysmographicvariabilityindex

P o2

MixedvenousPO2

PVR

Pulmonaryvascularresistance

c

Cardiacoutput

s/ T

Pulmonaryshunt

R

Respiratoryquotient

RE

Expiratoryresistance

REE

Restingenergyexpenditure

REM

Rapideyemovement


RI

Inspiratoryresistance

RSBI

Rapidshallowbreathingindex

RVSWI

Rightventricularstrokeworkindex

Sao2

Hemoglobinoxygensaturationofarterialblood

SBT

Spontaneousbreathingtrial

Scvo2

Centralvenousoxygensaturation

SID

Strongiondifference

SIMV

Synchronizedintermittentmandatoryventilation

Sjvo2

Jugularvenousoxygensaturation

Spco

Carbonmonoxidemeasuredbypulseoximetry

SpHb

Hemoglobinmeasuredbypulseoximetry

SpMet

Methemoglobinmeasuredbypulseoximetry

Spo2

Hemoglobinoxygensaturationmeasuredbypulseoximetry

SVI

Strokevolumeindex

S

Mixedvenousoxygensaturation

O2

SVR

Systemicvascularresistance

SVRI

Systemicvascularresistanceindex

TE

Expiratorytime

TI

Inspiratorytime

TT

Totalcycletime

UUN

Urineureanitrogen
Flow

A

Alveolarventilation

/

Ratioofventilationtobloodflow

VAC

Ventilator-associatedcondition

VAE

Ventilator-associatedevent

VAP

Ventilator-associatedpneumonia


VC
CO2
D

Vitalcapacity
Carbondioxideproduction
Deadspaceventilation

E

Minuteventilation

I

Inspiratoryflow

VCV

Volume-controlledventilation

VC-CMV Continuousmandatoryventilationwithvolumecontrol
VC-IMV volume-controlledintermittentmandatoryventilation
VD/VT

Deadspacetotidalvolumeratio

VILI

Ventilator-inducedlunginjury

O2

Oxygenconsumption

VS

Volumesupport

VT

Tidalvolume

W

Work

τ

Timeconstant



Part1
PrinciplesofMechanicalVentilation



Chapter1
PhysiologicEffectsofMechanicalVentilation

•Introduction
•MeanAirwayPressure
•PulmonaryEffects
Shunt
Ventilation
Atelectasis
Barotrauma
Ventilator-InducedLungInjury
Pneumonia
HyperventilationandHypoventilation
OxygenToxicity
•CardiacEffects
•RenalEffects
•GastricEffects
•NutritionalEffects
•NeurologicEffects
•NeuromuscularEffects
•HepatosplanchnicEffects
•AirwayEffects
•SleepEffects
•Patient-VentilatorAsynchrony
•MechanicalMalfunctions
•PointstoRemember
•AdditionalReading



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