7 Initial Ventilator Settings, ~05

Transcription

1 Abbreviations (inside front cover and back cover) PART 1 Basic Concepts and Core Knowledge in Mechanical Oxygenation and Acid-Base Evaluation, 1 Review 01Arterial Blood Gases, 2 Evaluating Oxygenation, 2 Evaluating the Trans1er and Uptake 01 Oxygen 1rom the Alveoli-P(A-a)02' Pa02/ PA02, and PaCO/F102, 4 Changes in Alveolar Associated with Changes in PA02 and PAC02, 6 Alveolar, PaC02, and VC02, 7 Changes in ph, PaC02, and Sodium Bicarbonate, 7 Changes in ph caused by Changes in PaC02, 8 Changes in Plasma Bicarbonate Caused by Changes in PaC02, 8 Metabolic Changes in Bicarbonate and ph, 11 2 Basic Terms and Concepts of Mechanical, 15 SECTION 1: Physiological Terms and Concepts Related to Mechanical, 16 Normal Mechanics 01Spontaneous, 16 Lung Characteristics, 18 Time Constants, 21 SECTION 11:Types of Ventilators and Terms Applied to Mechanical, 23 Types 01Mechanical, 23 De1inition01Pressures in Positive Pressure, 26 3 How Ventilators Work, 31 Historical Perspective on Ventilator Classi1ication, 32 Internal Function, 32 Power Source or Input Power, 32 Control Systems and Circuits, 35 Power Transmission and Conversíon System, 39 4 How a Breath Is Delivered, 45 Basic Model 01 in the Lung during Inspiratíon, 46 Factors Controlled and Measured by the Ventilator during Inspiration, 47 Overview 01 Inspiratory Wave10rm Control, 48 Four Phases 01 a Breath and Phase Variables, 49 PART 2 Initiating Beginning 01 Inspiration: The Trigger Variable, 50 Inspiratory Factors: The Limit Variable, 51 Termination 01 the Inspiratory Phase: The Cycling Mechanism (Cycle Variable), 54 Types01 Breaths, 56 Expiratory Phase: The Baseline Variable, 57 5 Establishing the Need for Mechanical, 63 Acute Respiratory Failure, 64 Patient History and Diagnosis, 65 Physiological Measurements in Acute Respiratory Failure, 69 Overview 01 Criteria 10r Mechanical, 72 Possible Alternatives to Invasive, 72 Patient Cases, 75 6 Selecting the Ventilator and the Mode, 81 Invasive or Noninvasive : Selecting the Patient Interface, 82 Methods 01 Noninvasive Support and Appropriate Patient Interfaces, 82 Full and Partial Ventilatory Support, 84 Mode 01 and Breath Delivery, 84 Type 01 Breath Delivery, 84 Targeting Volume as the Control Variable, 84 Targeting Pressure as the Control Variable, 85 Breath Delivery and Modes 01, 87 Bilevel Positive Airway Pressure, 96 Closed Loop, 96 Less Frequently Used Closed Loop Modes 01, 97 7 Initial Ventilator Settings, ~05 Determining Initial Ventilator Setting during Volume, 106 SECTION 1: Initial Settings during Volume, 106 Setting Minute, 106 Tidal Volume and Rate, 108 Relationship 01Tidal Volume, Flow, Total Cycle Time, and Inspiratory to Expiratory Ratio, 111 Inspiratory Flow and Flow Patterns, 113 Setting the Minute : Special Considerations, 116 Inspiratory Pause during Volume, 116 Actual Clinical Examples 01Ventilator Adjustment, 117 xv

2 xvi Contents SECTION 11:Determining Initial Ventilator Settings during Pressure, 117 Setting Baseline Pressure-Physiological PEEp, 118 Determining Tidal Volume Delivery in Pressure, 118 Initial Settings for Pressure Support, 118 Initial Settings for Pressure Control, 120 Initial Settings for Bilevel Positive Airway Pressure, 120 Initial Settings for Dual Control Pressure Modes with Volume Targeting, Final Considerations in Ventilator Setup, 127 SECTION 1: Selection ot Additional Parameters and Final Ventilator Setup, 128 Selection of Fractionallnspired O2, 128 Sensitivity Setting, 128 Humidification, 129 Alarms, 132 Action during Ventilator Alarm Situations, 133 Periodic Hyperinflation or Sighing, 133 Final Considerations in Ventilator Equipment Setup, 135 Selecting the Appropriate Ventilator, 135 Evaluation of Ventilator Performance, 136 SECTION 11:Initial Ventilator Settings tor Specitic Patient Situations, 136 Chronic Obstructive Pulmonary Disease, 136 Neuromuscular Disorders, 139 Asthma, 140 Closed Head Injury, 141 Adult Respiratory Distress Syndrome,143 Acute Cardiogenic Pulmonary Edema and Congestive Heart Failure, 145 PART 3 Monitoring in Mechanical 9 Initial Assessment of the Mechanically Ventilated Patient, 151 Documentation of the Patient-Ventilator System, 152 The First 30 Minutes, 153 Monitoring Airway Pressures, 158 Vital Signs, Blood Pressure, and Physical Examination of the Chest, 161 Management of Endotracheal and Tracheostomy Tube Cuffs, 164 Monitoring Compliance and Airway Resistance, 168 Comment Section of the Ventilator Flow Sheet, Ventilator Graphics, 177 Relationship of Pressure, Volume, Flow, and Time, 178 SECTION 1: Volume with Constant Flow, 179 Producing Ventilator Graphics, 179 Calculations, 180 A Closer Look at the Flow- Time Scalar in VC-CMV, 181 Changes in the Pressure- Time Curve, 184 Volume Scalar, 185 Key Points of Volume Graphics, 187 SECTION 11:Pressure, 187 Pressure with a Constant Pressure Waveform, 187 Key Points of Pressure Graphics, 190 SECTION 11I:Pressure Support, 191 Details of the Pressure- Time Waveform in PSV, 191 Flow Cycling during PSV, 194 Automatic Adjustment of the Flow-Cycle Criterion, 194 Use of PSV with SIMV, 195 SECTION IV: Pressure-Volume Loops, 194 Components of the P-V Loop, 195 P-V Loop and WOB, 198 Troubleshooting a P-V Loop, 199 SECTION V: Flow-Volume Loops during Mechanical, 199 Components of an F-V Loop with Mandatory Breaths, 199 Troubleshooting with F-V Loops during Mechanical, Noninvasive Assessment of Respiratory Function, 205 SECTION 1: Noninvasive Measurement of Blood Gases, 206 Pulse Oximetry, 206 Capnography and Capnometry, 210 Transcutaneous Monitoring, 218 SECTION 11:Indirect Calorimetry and Metabolic Measurements, 219 Overview of Indirect Calorimetry, 219 Technical Aspects, 219 SECTION 11I:Assessment ot Respiratory System Mechanics, 222 Airway Pressure Measurements, 222 Flow Measurements, 223 Clinical Applications, Hemodynamic Monitoring, 231 Review of Cardiovascular Principies, 232 Obtaining Hemodynamic Measurements, 235 Interpretation of Hemodynamic Profiles, 240 Clinical Applications, 249

3 Contento. PART 4 Therapeutic Appropriate Interventions-Making Changes 13 Methods to Improve and Other Techniques in Patient-Ventilator Management, 257 SECTION 1: Correcting PaC02 Abnormalities, 258 Common Methods of Changing Based on PaC02 and ph, 258 Metabolic Acidosis and Alkalosis, 261 Mixed Acid-Base Oisturbances, 262 Increased Physiological Oead Space, 263 Increased Metabolism and Increased CO2 Production, 264 Intentionallatrogenic Hyperventilation, 264 Permissive Hypercapnia, 264 SECTION 11: Airway Clearance during Mechanical, 266 Secretion Clearance from an Artificial Airway, 266 Administering Aerosols to Ventilated Patients, 272 Chest Physiotherapy in Mechanically Ventilated Patients, 277 Flexible Fiberoptic Bronchoscopy during Mechanical, 278 SECTION 11I: Additional Patient Management Techniques and Therapies in Ventilated Patients, 279 Importance of Body Position and Positive Pressure, 279 Ventilator Circuit Changes, 283 Sputum and Upper Airway Infections, 285 Fluid Balance, 285 Psychological and Sleep Status, 286 Patient Comfort and Safety, 287 Transport of Mechanically Ventilated Patients within an Acute Care Facility, Improving Oxygenation and Management of ARDS, 295 SECTION 1: Basics of Oxygenation Using F102, PEEP studies, and Pressure-Volume Curves for Establishing Optimum PEEP, 297 Basics of Oxygen Oeliveryto the Tissues, 297 Introduction to Positive End-Expiratory Pressure and Continuous Positive Airway Pressure, 299 PEEP Ranges, 301 Indications for PEEP/CPAP,301 Initiating PEEPTherapy, 302 Selecting the Appropriate PEEP/CPAPLevel (Optimum PEEP),303 Use of PulmonaryVascular PressureMonitoring with PEEP,307 Pressure-Volume Loops in Setting PEEP,308 SECTION 11:Contraindications and Physiological Effects of PEEP, 312 Contraindications for PEEP, 312 Pulmonary Effects of PEEP, 313 Transmission of Airway Pressure to Pleural Space, 313 Uses of PEEP for Problems Other than Acute Lung Injury, 314 Weaning from PEEP, 315 SECTION 11I:Acute Respiratory Distress Syndrome, 316 Oefinition and Epidemiology, 316 Pathophysiology, 317 Changes in Computed Tomogram with AROS, 317 AROS as an Inflammatory Process, 318 PEEP and the Vertical Gradient in AROS, 320 Lung Protective Strategies: Setting Tidal Volume and Pressures in AROS, 320 Long-Term Follow-Up on AROS, 321 SECTION IV: Recruitment Maneuvers in ARDS, 321 IlIustration of a Recruitment Maneuver, 322 The Function of Lung Recruitment, 322 Hazards of Recruitment Maneuvers, 324 Variability among Patients, 324 Effects of Chest Wall Compliance on Lung Recruitment, 324 Patient Evaluation for Lung Recruitment, 325 Types of Recruitment Maneuvers, 325 Summary of Recruitment Maneuvers in AROS, 326 SECTION V: Patient Cases, 327 Case Study: Adult Respiratory Oistress Syndrome, 327 Case Study: Congestive Heart Failure, Frequently Used Pharmacological Agents in Ventilated Patients: Sedatives, Analgesics, and Paralytics, 335 Sedatives and Analgesics, 336 Paralytics, 341 PART 5 Effects and Complications of Mechanical 16 Effects of Positive Pressure on the Cardiovascular, Cerebral, Renal, and Other Organ Systems, 345 SECTION 1: Effects of Positive Pressure on the Heart and Thoracic Vessels, 346 Adverse Cardiovascular Effects of PPV,346 Factors Influencing Cardiovascular Effects of PPV,347 Beneficial Effects of PPV on Heart Function in Patients with Left Ventricular Oysfunction, 348

4 xviii Contents Minimizing the Physiological Effects and Complications of Mechanical, 349 SECTION 11: Effects of Mechanical on Intracranial Pressure, Renal Function, Liver Function, and Gastrointestinal Function, 351 Effects of Mechanical on Intracranial Pressure and Cerebral Perfusion, 351 Renal Effects of Mechanical, 352 Effects of Mechanical on Liver and Gastrointestinal Function, 353 Nutritional Complications during Mechanical, Effects of Positive Pressure on the Pulmonary System, 357 Lung Injury with Mechanical, 358 Effects of Mechanical on Gas Distribution and Pulmonary Blood Flow, 364 Nosocomiallnfections Pneumonia, 365 and Ventilator-Associated Respiratory and Metabolic Acid-Base Status in Mechanical, 371 Air Trapping (Auto-PEEP), 373 Hazards of Oxygen Therapy with Mechanical, 376 Increased Work of Breathing, 376 Ventilator Mechanical and Operational Hazards, 383 Complications of the Artificial Airway, Troubleshooting and Problem Solving, 391 Definition of the Term Problem, 392 Solving Problems, 392 Protecting the Patient, 393 Identifying the Patient in Sudden Distress, 393 Patient-Related Problems, 393 Ventilator-Related Problems, 397 Common Alarm Situations, 399 Use of Graphics to Identify Ventilator Problems, 402 Unexpected Ventilator Responses, 406 PART 6 Noninvasive Positive Pressure 19 Basic Concepts of Noninvasive Positive Pressure, 417 Noninvasive Techniques, 418 Goals and Indications for NPPV, 419 Patient Selection Criteria, 423 Equipment Selection for NPPV, 424 Setup and Preparation for NPPV, 432 Monitoring and Adjustment of NPPV, 433 Complications of NPPV, 435 Patient Weaning and Discontinuation of NPPV, 436 Patient Care Team Concerns, 436 PART 7 Discontinuation from and Long- Term 2 O Discontinuation of and Weaning from Mechanical, 443 SECTION 1: Weaning Techniques, 444 Methods of Titrating Ventilator Support during Weaning, 445 Closed Loop Modes for Ventilator Discontinuation, 448 SECTION 11:Evidence-Based Weaning, 451 Evaluation of Clinical Criteria for Weaning, 451 Recommendation 1: Pathology of Ventilator Dependence, 452 Recommendation 2: Assessment of Readiness for Weaning Using Evaluation Criteria, 456 Recommendation 3: Assessment during a Spontaneous Breathing Trial, 457 Recommendation 4: Removal of the Artificial Airway, 457 SECTION 11I: Factors in Weaning Failure, 460 Recommendation 5: SBT Failure, 460 Nonrespiratory Factors That May Complicate Weaning, 460 Recommendation 6: Maintaining in Patients with SBT Failure, 464 SECTION IV: Final Recommendations, 464 Recommendation 7: Anesthesia and Sedation Strategies and Protocols, 464 Recommendation 8: Weaning Protocols, 464 Recommendation 9: Role of Tracheostomy in Weaning, 465 Recommendation 10: Long-Term Care Facilities for Patients Requiring Prolonged, 466 Recommendation 11: Clinician Familiarity with Long- Term Care Facilities, 466 Recommendation 12: Weaning in Long-Term Units, 466 Ethical Dilemma: Withholding and Withdrawing Ventilatory Support, Long-Term, 473 Goals of LTMV, 474 Sites for Ventilator-Dependent Patients, 475 Patient Selection, 477 Preparation for Discharge to the Home, 478 Follow-Up and Evaluation, 479 Equipment Selection for Patients to Be Ventilated at Home, 481 Complications of Long-Term Positive Pressure, 487 Alternatives to Invasive Mechanical at Home, 488 Expiratory Muscle Aids and Secretion Clearance, 494 TTs, Speaking Valves, and Tracheal Buttons, 495 Ancillary Equipment and Equipment Cleaning for Home Mechanical, 501

5 Contents xix PART B Special Applications of Mechanical 22.Neonatal and Pediatric Mechanical,509 Recognizing the Need tor Mechanical Ventilatory Support, 510 Continuous Positive Airway Pressure, 511 Conventional Mechanical, 515 Weaning and Extubation, 535 High-Frequency, Special Techniques in Ventilatory Support,549 SECTION 1: Airway Pressure-Release, 550 Other Names, 550 Advantages ot APRV Compared with Conventional, 551 Disadvantages, 552 Initial Settings tor APRV,553 Adjusting and Oxygenation, 554 Discontinuing APRV,554 SECTION 11:High-Frequency Oscillatory in the Adult, 555 Technical Aspects, 555 Initial Control Settings tor HFOV in the Adult, 556 Indication and Exclusion Criteria tor HFOV in the Adult, 558 Monitoring, Assessment, and Adjustment ot HFO, 558 Adjusting Settings to Maintain ABG Goals, 559 Returning to Conventional, 561 SECTION 11I: Heliox Therapy and Mechanical, 561 Gas Flow through the Airways, 562 Heliox in Avoiding Intubation and during Mechanical, 563 Posfextubation Stridor, 563 Devices tor Delivering Heliox in Spontaneously Breathing Patients, 563 Manutactured Heliox Delivery System, 565 Heliox and Aerosol Delivery during Mechanical, 566 Heliox with a Mechanical Ventilator, 566 Heliox and NPPV, 568 SECTION IV: Independent Lung, 569 Ventilator Procedure tor ILV, 569 Thoracoabdominal Aortic Aneurism Repair, 570 Establishing Sate PEEP and with a Slow Flow Intlection Maneuver tor Assessment ot Lung Characteristics, 571 Establishing Mechanical after TAAA, 571 Recruitment Maneuvers in Postoperative Patients, 572 SECTION V: Intrapulmonary Percussive, 573 Equipment, 573 Administration by Mouthpiece, 573 Administration through a Ventilator, 574 Appendix A, 581 Appendix S, 601 Appendix e, 607 Glossary, 613