Informazioni
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Punto di Riferimento
per Medici e Operatori Sanitari
per Medici e Operatori Sanitari
LIBRERIA STUDIUM
Understanding Mechanical Ventilation
Hasan
Editore
Springer
Anno
2010
Pagine
543
ISBN
9781848828681
50,00 €
- Simple, reader-friendly approach
- Builds up concepts from the very basics
- Complex patient-ventilator interactions presented in a lucid manner
- Material presented in parallel with underlying respiratory physiology
- Rationale of treatment strategies explained
The care of patients with multiple life-threatening problems is a monumental challenge. Burgeoning information has deluged the generalist and placed increasing reliance on the specialist. Predictably, this has led to the evolution of a team approach, but this does not assist the novice in critical care, with little practical and relevant information available on learning specific procedures and best practice.
This new edition of Understanding Mechanical Ventilation: a Practical Handbook familiarizes physicians, nurses and respiratory technologists with the concepts that underlie mechanical ventilation. Physiological concepts are stressed throughout this book in order to address the specifics of mechanical ventilation, while currently accepted strategies for patients with specific disorders are reviewed in detail. Ventilator waveforms, airway humidification, aerosol therapy and the use of novel software-based modes of ventilation in the ICU are also included.
The emphasis throughout the book is on presenting material in a reader-friendly, practical style incorporating numerous figures and tables. In this way, it will be a vital reference to all involved in the management of patients requiring mechanical ventilation in the ICU.
xi
Contents
1 Historical Aspects of Mechanical Ventilation . . . . . . 1
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2 The Indications for Mechanical Ventilation. . . . . . . . 9
2.1 Hypoxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2 Hypoventilation . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.3 Increased Work of Breathing . . . . . . . . . . . . . . 11
2.4 Other Indications . . . . . . . . . . . . . . . . . . . . . . . . 12
2.5 Criteria for Intubation and Ventilation . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3 Physiological Considerations in the Mechanically
Ventilated Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1 The Physiological Impact
of the Endotracheal Tube. . . . . . . . . . . . . . . . . . 19
3.2 Positive Pressure Breathing. . . . . . . . . . . . . . . . 21
3.3 Lung Compliance . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3.1 Static Compliance . . . . . . . . . . . . . . . . . 29
3.3.2 Dynamic Compliance . . . . . . . . . . . . . . 32
3.4 Airway Resistance . . . . . . . . . . . . . . . . . . . . . . . 34
3.5 Time Constants of the Lung . . . . . . . . . . . . . . . 38
3.6 Alveolar Ventilation and Dead-Space . . . . . . . 39
3.6.1 Anatomical Dead-Space . . . . . . . . . . . 40
3.6.2 Alveolar Dead-Space . . . . . . . . . . . . . . 40
3.6.3 Physiological Dead-Space . . . . . . . . . . 40
3.7 Mechanisms of Hypoxemia . . . . . . . . . . . . . . . . 46
3.7.1 Hypoventilation . . . . . . . . . . . . . . . . . . 46
3.7.2 V/Q Mismatch . . . . . . . . . . . . . . . . . . . . 50
xii Contents
3.7.3 Right to Left Shunt. . . . . . . . . . . . . . . . 52
3.7.4 Diffusion Defect . . . . . . . . . . . . . . . . . . 54
3.8 Hemodynamic Effects . . . . . . . . . . . . . . . . . . . . 55
3.9 Renal Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.10 Hepatobiliary and Gastrointestinal
Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.10.1 Hepatobiliary Dysfunction . . . . . . . . . 62
3.10.2 Gastrointestinal Dysfunction . . . . . . . 63
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4 The Conventional Modes of Mechanical
Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
4.1 Mechanical Ventilators. . . . . . . . . . . . . . . . . . . . 71
4.1.1 Open-Loop and Closed-Loop
Systems. . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.1.2 Control Panel . . . . . . . . . . . . . . . . . . . . 72
4.1.3 Pneumatic Circuit . . . . . . . . . . . . . . . . . 73
4.1.4 The Expiratory Valve . . . . . . . . . . . . . . 73
4.1.5 Variables. . . . . . . . . . . . . . . . . . . . . . . . . 74
4.1.6 The Trigger Variable (“Triggering”
of the Ventilator). . . . . . . . . . . . . . . . . . 75
4.1.7 Limit Variable . . . . . . . . . . . . . . . . . . . . 76
4.1.8 Cycle Variable . . . . . . . . . . . . . . . . . . . . 76
4.1.9 Baseline Variable . . . . . . . . . . . . . . . . . 78
4.1.10 Inspiratory Hold . . . . . . . . . . . . . . . . . . 79
4.1.11 Expiratory Hold and Expiratory
Retard. . . . . . . . . . . . . . . . . . . . . . . . . . . 79
4.2 Volume-Targeted Modes . . . . . . . . . . . . . . . . . . 80
4.2.1 Volume Assist-Control Mode
(ACMV, CMV) . . . . . . . . . . . . . . . . . . . 80
4.3 Intermittent Mandatory Ventilation. . . . . . . . . 84
4.4 Pressure–Support Ventilation . . . . . . . . . . . . . . 89
4.5 Continuous Positive Airway Pressure . . . . . . . 94
4.6 Bilevel Positive Airway Pressure . . . . . . . . . . . 97
4.7 Airway Pressure Release
Ventilation (APRV) . . . . . . . . . . . . . . . . . . . . . . 97
4.7.1 Bi-PAP . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.8 Pressure-Controlled Ventilation . . . . . . . . . . . . 98
4.8.1 Proportional Assist
Ventilation (PAV) . . . . . . . . . . . . . . . . . 101
Contents xiii
4.9 Dual Breath Control. . . . . . . . . . . . . . . . . . . . . . 102
4.9.1 Intrabreath Control . . . . . . . . . . . . . . . 102
4.9.2 Interbreath (DCBB) Control . . . . . . . 103
4.9.3 Pressure Regulated Volume
Control (PRVC) . . . . . . . . . . . . . . . . . . 103
4.9.4 Automode . . . . . . . . . . . . . . . . . . . . . . . 106
4.9.5 Mandatory Minute
Ventilation (MMV). . . . . . . . . . . . . . . . 107
4.9.6 Volume Support (VS). . . . . . . . . . . . . . 108
4.9.7 Adaptive Support
Ventilation (ASV). . . . . . . . . . . . . . . . . 109
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
5 Ventilator Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
5.1 Setting the Tidal Volume . . . . . . . . . . . . . . . . . . 115
5.1.1 Volume-Targeted Ventilation . . . . . . . 115
5.1.2 Pressure-Targeted Ventilation. . . . . . . 116
5.2 Setting the Respiratory Rate. . . . . . . . . . . . . . . 117
5.3 Setting the Flow Rate. . . . . . . . . . . . . . . . . . . . . 118
5.4 Setting the Ratio of Inspiration
to Expiration (I:E Ratio) . . . . . . . . . . . . . . . . . . 119
5.5 Setting the Flow Profi le . . . . . . . . . . . . . . . . . . . 122
5.5.1 The Square Waveform . . . . . . . . . . . . . 122
5.5.2 The Decelerating Waveform . . . . . . . . 123
5.5.3 The Accelerating Waveform . . . . . . . . 123
5.5.4 The Sine Waveform. . . . . . . . . . . . . . . . 123
5.6 Setting the Trigger Sensitivity . . . . . . . . . . . . . . 123
5.7 Setting PEEP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.7.1 Improvement in Oxygenation . . . . . . . 124
5.7.2 Protection Against Barotrauma
and Lung Injury. . . . . . . . . . . . . . . . . . . 125
5.7.3 Overcoming Auto-PEEP . . . . . . . . . . . 126
5.8 Indications for PEEP . . . . . . . . . . . . . . . . . . . . . 127
5.9 Forms of PEEP . . . . . . . . . . . . . . . . . . . . . . . . . . 127
5.10 Titrating PEEP . . . . . . . . . . . . . . . . . . . . . . . . . . 127
5.10.1 Other Advantages of PEEP. . . . . . . . . 130
5.10.2 Disadvantages of PEEP . . . . . . . . . . . . 131
5.11 Optimizing Ventilator Settings for Better
Oxygenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
5.11.1 Increasing the FIO2. . . . . . . . . . . . . . . . 131
xiv Contents
5.11.2 Increasing the Alveolar
Ventilation . . . . . . . . . . . . . . . . . . . . . . . 132
5.12 PEEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
5.12.1 Flow Waveforms . . . . . . . . . . . . . . . . . . 132
5.12.2 Inspiratory Time . . . . . . . . . . . . . . . . . . 133
5.12.3 Inverse Ratio Ventilation. . . . . . . . . . . 133
5.12.4 Prone Ventilation . . . . . . . . . . . . . . . . . 134
5.12.5 Reducing Oxygen Consumption. . . . . 134
5.12.6 Increasing Oxygen
Carrying Capacity . . . . . . . . . . . . . . . . . 134
5.12.7 Footnote. . . . . . . . . . . . . . . . . . . . . . . . . 135
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
6 Ventilator Alarms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
6.1 Low Expired Minute Volume Alarm . . . . . . . . 141
6.2 High Expired Minute Volume Alarm. . . . . . . . 143
6.3 Upper Airway Pressure Limit Alarm . . . . . . . . 144
6.4 Low Airway Pressure Limit Alarm. . . . . . . . . . 146
6.5 Oxygen Concentration Alarms . . . . . . . . . . . . . 146
6.6 Low Oxygen Concentration (FIO2) Alarm . . . 146
6.7 Upper Oxygen Concentration
(FIO2) Alarm. . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
6.8 Power Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
6.9 Apnea Alarm. . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
6.10 Two-Minute Button . . . . . . . . . . . . . . . . . . . . . . 148
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7 Monitoring Gas Exchange in the Mechanically
Ventilated Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
7.1 The Arterial Oxygen Tension . . . . . . . . . . . . . . 149
7.2 Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . . . . 156
7.2.1 Principle of Pulse Oximetry. . . . . . . . . 160
7.3 Transcutaneous Blood Gas Monitoring . . . . . . 169
7.4 Monitoring Tissue Oxygenation . . . . . . . . . . . . 171
7.4.1 Oxygen Extraction Ratio
and DO2 crit . . . . . . . . . . . . . . . . . . . . . . . 172
7.5 Capnography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Contents xv
8 Monitoring Lung Mechanics in the Mechanically
Ventilated Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
8.1 Ventilator Waveforms. . . . . . . . . . . . . . . . . . . . . 189
8.2 Scalars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
8.2.1 The Pressure–Time scalar . . . . . . . . . . 190
8.2.2 Flow-Time Scalar . . . . . . . . . . . . . . . . . 196
8.2.3 Volume–Time Scalar. . . . . . . . . . . . . . . 200
8.3 The Loops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
8.3.1 Pressure–Volume Loop . . . . . . . . . . . . 203
8.3.2 The Flow–Volume Loop . . . . . . . . . . . 215
8.4 Patient-Ventilator Asynchrony . . . . . . . . . . . . . 223
8.4.1 Level of Ventilator Support
and Work of Breathing. . . . . . . . . . . . . 223
8.4.2 Complete Support. . . . . . . . . . . . . . . . . 224
8.4.3 Partial Support . . . . . . . . . . . . . . . . . . . 224
8.4.4 Patient-Ventilator Asynchrony . . . . . . 225
8.4.5 Triggering Asynchrony. . . . . . . . . . . . . 226
8.4.6 Flow Asynchrony . . . . . . . . . . . . . . . . . 227
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
9 Mechanical Ventilation in Specifi c Disorders. . . . . . . 241
9.1 Myocardial Ischemia . . . . . . . . . . . . . . . . . . . . . 241
9.2 Hypovolemic Shock . . . . . . . . . . . . . . . . . . . . . . 244
9.3 Neurological Injury. . . . . . . . . . . . . . . . . . . . . . . 245
9.4 Acute Respiratory Distress
Syndrome (ARDS). . . . . . . . . . . . . . . . . . . . . . . 248
9.4.1 Primary and Secondary ARDS. . . . . . 249
9.4.2 Pathophysiology . . . . . . . . . . . . . . . . . . 250
9.4.3 Ventilatory Strategies . . . . . . . . . . . . . . 252
9.5 Obstructive Lung Disease . . . . . . . . . . . . . . . . . 266
9.5.1 PaCO2 . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
9.5.2 Modes of Ventilation
in Obstructed Patients . . . . . . . . . . . . . 269
9.5.3 Ventilator Settings in Airfl ow
Obstruction . . . . . . . . . . . . . . . . . . . . . . 272
9.5.4 Bronchopleural Fistula. . . . . . . . . . . . . 278
9.6 Neuromuscular Disease . . . . . . . . . . . . . . . . . . . 279
9.6.1 Lung Function . . . . . . . . . . . . . . . . . . . . 282
xvi Contents
9.6.2 Inspiratory Muscle Recruitment
in Neuromuscular Disease. . . . . . . . . . 284
9.6.3 Expiratory Muscle Recruitment
in Neuromuscular Disease. . . . . . . . . . 284
9.6.4 Bulbar Muscles Involvement
in Neuromuscular Disease. . . . . . . . . . 285
9.6.5 Assessment of Lung Function . . . . . . . 286
9.6.6 Mechanical Ventilation
in Neuromuscular Disease. . . . . . . . . . 286
9.7 Nonhomogenous Lung Disease . . . . . . . . . . . . 288
9.8 Mechanical Ventilation in Flail Chest . . . . . . . 289
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
10 The Complications of Mechanical Ventilation. . . . . . 305
10.1 Peri-Intubation Complications . . . . . . . . . . . . . 306
10.1.1 Laryngeal Trauma. . . . . . . . . . . . . . . . . 306
10.1.2 Pharyngeal Trauma. . . . . . . . . . . . . . . . 306
10.1.3 Tracheal or Bronchial Rupture . . . . . . 307
10.1.4 Epistaxis. . . . . . . . . . . . . . . . . . . . . . . . . 307
10.1.5 Tooth Trauma . . . . . . . . . . . . . . . . . . . . 308
10.1.6 Cervical Spine Injury . . . . . . . . . . . . . . 308
10.1.7 Esophageal Intubation . . . . . . . . . . . . . 309
10.1.8 Esophageal Perforation . . . . . . . . . . . . 310
10.1.9 Right Main Bronchial Intubation . . . . 310
10.1.10 Arrhythmias . . . . . . . . . . . . . . . . . . . . . 311
10.1.11 Aspiration . . . . . . . . . . . . . . . . . . . . . . . 312
10.1.12 Bronchospasm. . . . . . . . . . . . . . . . . . . . 312
10.1.13 Neurologic Complications . . . . . . . . . . 312
10.2 Problems Occurring Acutely at any Stage . . . . 312
10.2.1 Endotracheal Tube Obstruction . . . . . 313
10.2.2 Airway Drying. . . . . . . . . . . . . . . . . . . . 313
10.2.3 Upward Migration
of the Endotracheal Tube. . . . . . . . . . . 314
10.2.4 Self-Extubation . . . . . . . . . . . . . . . . . . . 314
10.2.5 Cuff Leak . . . . . . . . . . . . . . . . . . . . . . . . 315
10.2.6 Ventilator-Associated Lung Injury
(VALI) and Ventilator-Induced
Lung Injury (VILI). . . . . . . . . . . . . . . . 318
10.3 Delayed Complications (Fig. 10.5) . . . . . . . . . . 322
10.3.1 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . 322
Contents xvii
10.3.2 Tracheoesophageal Fistula. . . . . . . . . . 323
10.3.3 Tracheoinnominate
Artery Fistula . . . . . . . . . . . . . . . . . . . . 325
10.3.4 Tracheocutaneous Fistula. . . . . . . . . . . 326
10.4 Oxygen-Related Lung Complications . . . . . . . 327
10.4.1 Tracheobronchitis . . . . . . . . . . . . . . . . . 328
10.4.2 Adsorptive Altelectasis . . . . . . . . . . . . 328
10.4.3 Hyperoxic Hypercarbia . . . . . . . . . . . . 329
10.4.4 Diffuse Alveolar Damage . . . . . . . . . . 332
10.4.5 Bronchopulmonary Dysplasia. . . . . . . 333
10.4.6 Ventilator-Associated Pneumonia . . . 333
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
11 Ventilator-Associated Pneumonia. . . . . . . . . . . . . . . . 343
11.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
11.2 Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
11.3 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
11.3.1 The Physical Effect
of the Endotracheal Tube. . . . . . . . . . . 347
11.3.2 Alteration of Mucus Properties . . . . . 348
11.3.3 Microaspiration. . . . . . . . . . . . . . . . . . . 349
11.3.4 Biofi lms . . . . . . . . . . . . . . . . . . . . . . . . . 349
11.3.5 Ventilator Tubings. . . . . . . . . . . . . . . . . 350
11.3.6 Gastric Feeds. . . . . . . . . . . . . . . . . . . . . 351
11.3.7 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . 352
11.3.8 Respiratory Therapy Equipment . . . . 354
11.4 Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
11.5 Diagnosis of VAP . . . . . . . . . . . . . . . . . . . . . . . . 355
11.5.1 Sampling Methods . . . . . . . . . . . . . . . . 357
11.5.2 Interpretation of the Sample . . . . . . . . 358
11.6 Prevention of NP/VAP. . . . . . . . . . . . . . . . . . . . 360
11.6.1 Hand-Washing. . . . . . . . . . . . . . . . . . . . 360
11.6.2 Feeding and Nutrition . . . . . . . . . . . . . 361
11.6.3 Stress Ulcer Prophylaxis . . . . . . . . . . . 362
11.6.4 Topical Antibiotics . . . . . . . . . . . . . . . . 362
11.7 Interventions Related to the Endotracheal
Tube and Ventilator Circuit . . . . . . . . . . . . . . . . 363
11.8 Treatment of Nosocomial Sinusitis . . . . . . . . . . 364
11.9 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
11.9.1 Antibiotic Resistance . . . . . . . . . . . . . . 365
xviii Contents
11.9.2 Pharmacokinetics . . . . . . . . . . . . . . . . . 368
11.9.3 Duration of Therapy. . . . . . . . . . . . . . . 371
11.9.4 Lack of Response to Therapy . . . . . . . 373
11.9.5 Drug Cycling . . . . . . . . . . . . . . . . . . . . . 374
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
12 Discontinuation of Mechanical Ventilation . . . . . . . . 391
12.1 Weaning Parameters. . . . . . . . . . . . . . . . . . . . . . 393
12.2 Parameters that Assess Adequacy
of Oxygenation . . . . . . . . . . . . . . . . . . . . . . . . . . 394
12.2.1 The PaO2:FIO2 Ratio . . . . . . . . . . . . . . 395
12.2.2 The A-a DO2 Gradient. . . . . . . . . . . . . 396
12.2.3 The PaO2/PAO2 Ratio. . . . . . . . . . . . . . 396
12.3 Parameters that Assess
Respiratory Muscle Performance . . . . . . . . . . . 396
12.3.1 PImax . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
12.3.2 Vital Capacity . . . . . . . . . . . . . . . . . . . . 397
12.3.3 Minute Ventilation . . . . . . . . . . . . . . . . 398
12.3.4 Respiratory Rate. . . . . . . . . . . . . . . . . . 398
12.4 Parameters that Assess
Central Respiratory Drive. . . . . . . . . . . . . . . . . 399
12.4.1 Airway Occlusion Pressure . . . . . . . . . 399
12.4.2 Mean Inspiratory Flow (Vt /Ti) . . . . . . 399
12.5 Respiratory System Compliance
and Work of Breathing. . . . . . . . . . . . . . . . . . . . 400
12.5.1 Work of Breathing . . . . . . . . . . . . . . . . 400
12.5.2 Compliance of the Respiratory
System . . . . . . . . . . . . . . . . . . . . . . . . . . 401
12.6 Integrative Indices . . . . . . . . . . . . . . . . . . . . . . . 401
12.6.1 Simplifi ed Weaning Index (SWI) . . . . 403
12.7 Methods of Weaning. . . . . . . . . . . . . . . . . . . . . . 404
12.7.1 Trials of Spontaneous
Breathing (T-Piece Weaning) . . . . . . . 405
12.7.2 Synchronized IMV . . . . . . . . . . . . . . . . 406
12.7.3 Pressure Support
Ventilation (PSV) . . . . . . . . . . . . . . . . . 407
12.7.4 Noninvasive Positive
Pressure Ventilation (NIPPV). . . . . . . 409
Contents xix
12.7.5 Extubation . . . . . . . . . . . . . . . . . . . . . . . 409
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
13 Noninvasive Ventilation in Acute
Respiratory Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
13.1 NIV and CPAP . . . . . . . . . . . . . . . . . . . . . . . . . . 415
13.2 Mechanism of Action . . . . . . . . . . . . . . . . . . . . . 415
13.2.1 Interface. . . . . . . . . . . . . . . . . . . . . . . . . 418
13.2.2 Modes. . . . . . . . . . . . . . . . . . . . . . . . . . . 420
13.2.3 Devices. . . . . . . . . . . . . . . . . . . . . . . . . . 421
13.2.4 Humidifi cation with NIV
(see also Chap. 15) . . . . . . . . . . . . . . . . 422
13.3 Air Leaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
13.4 Indications for NIV. . . . . . . . . . . . . . . . . . . . . . . 424
13.4.1 Hypoxemic Respiratory Failure . . . . . 424
13.4.2 Hypercapnic Respitatory Failure . . . . 426
13.4.3 Miscellaneous Indications . . . . . . . . . . 427
13.4.4 Steps for the Initiation of NIV . . . . . . 428
13.4.5 Complications . . . . . . . . . . . . . . . . . . . . 429
13.4.6 Contraindications . . . . . . . . . . . . . . . . . 432
13.4.7 Outcomes. . . . . . . . . . . . . . . . . . . . . . . . 432
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
14 Negative Pressure Ventilation . . . . . . . . . . . . . . . . . . . 441
14.1 Tank Ventilator (Iron Lung) . . . . . . . . . . . . . . . 442
14.2 The Body Suit (Jacket Ventilator,
Poncho-Wrap, Pulmo-Wrap) . . . . . . . . . . . . . . . 442
14.3 Chest: Shell (Cuirass) . . . . . . . . . . . . . . . . . . . . . 443
14.4 Modes of Negative Pressure Ventilation . . . . . 444
14.5 Drawbacks of NPV. . . . . . . . . . . . . . . . . . . . . . . 445
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
15 Airway Humidifi cation in the Mechanically
Ventilated Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
15.1 The Role of the Nasal Mucosa . . . . . . . . . . . . . 449
15.2 The Isothermic Saturation Boundary. . . . . . . . 449
15.3 The Effect of the Endotracheal Tube . . . . . . . . 450
15.3.1 Overheated Air . . . . . . . . . . . . . . . . . . . 451
xx Contents
15.4 Heated Humidifi ers . . . . . . . . . . . . . . . . . . . . . . 453
15.5 Heat-Moisture Exchangers (HMEs) . . . . . . . . 454
15.6 Airway Humidifi cation During
Noninvasive Ventilation . . . . . . . . . . . . . . . . . . . 456
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
16 Aerosol Therapy in the Mechanically
Ventilated Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
16.1 Terminology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
16.2 The Behavior of Particles. . . . . . . . . . . . . . . . . . 464
16.3 Devices for Aerosol Delivery . . . . . . . . . . . . . . 464
16.3.1 Jet Nebulizers
(Syn: Pneumatic Nebulizers) . . . . . . . . 464
16.3.2 Ultrasonic Nebulizers. . . . . . . . . . . . . . 468
16.3.3 Vibrating Mesh
Nebulizers (VMNs) . . . . . . . . . . . . . . . 469
16.3.4 Nebulization
in the Ventilated Patient. . . . . . . . . . . . 469
16.3.5 Nebulization of Other Drugs. . . . . . . . 471
16.3.6 Pressurized Metered-Dose
Inhalers (MDIs) . . . . . . . . . . . . . . . . . . 471
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
17 Nonconventional Modes and Adjunctive
Therapies for Mechanical Ventilation. . . . . . . . . . . . . 479
17.1 High-Frequency Ventilation . . . . . . . . . . . . . . . 480
17.2 High-Frequency Positive
Pressure Ventilation (HFPPV) . . . . . . . . . . . . . 482
17.3 High-Frequency Jet Ventilation (HFJV) . . . . . 482
17.4 High-Frequency Oscillatory
Ventilation (HFOV) . . . . . . . . . . . . . . . . . . . . . . 484
17.5 High-Frequency Percussive
Ventilation (HFPV) . . . . . . . . . . . . . . . . . . . . . . 485
17.6 Extracorporeal Life Support (ECLS) . . . . . . . 486
17.6.1 Extracorporeal Membrane
Oxygenation (ECMO) . . . . . . . . . . . . . 486
17.6.2 Extracorporeal CO2 Removal . . . . . . . 487
17.6.3 Indications for ECLS . . . . . . . . . . . . . . 487
17.6.4 Contraindications to ECLS . . . . . . . . . 488
Contents xxi
17.7 Nitric Oxide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
17.8 Surfactant Therapy . . . . . . . . . . . . . . . . . . . . . . . 491
17.9 Helium–Oxygen Mixtures . . . . . . . . . . . . . . . . . 493
17.10 Liquid Ventilation . . . . . . . . . . . . . . . . . . . . . . . . 494
17.10.1 Total Liquid Ventilation . . . . . . . . . . . . 496
17.10.2 Partial Liquid Ventilation . . . . . . . . . . 496
17.11 NAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
17.12 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
18 Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
18.1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
18.2 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
18.3 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510
18.4 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
18.5 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
18.6 Case 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
18.7 Case 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
18.8 Case 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
18.9 Case 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
18.10 Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
18.11 Case 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
18.12 Case 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
