Pilbeam's Mechanical Ventilation: Physiological and Clinical Applications

611 Pages·2012·28.74 MB·English

by  J M Cairo

Use practical exercises
to learn the essentials
of mechanical ventilation!

Workbook for
Pilbeams Mechanical Ventilation, 5th Edition
ISBN: 978-0-323-07208-3

What do I need to know?
Why do I need to know it?
How will I use it?

This workbook simplifies complex information,
helping you answer three basic questions:

It makes learning easy by using real-life examples
and a wide range of activities including:

��������������������
�������������������
�������������������
��������������
��������������������������������������

– Online at www.elsevierhealth.com
���������������������
– Visit your local bookstore

Get your copy today!

Why do I need to know it?
How will I use it?

It ma
and a

����
������
�����
����
����

– On
����
– Vis

Get

Once you register, you will have access to your

FREE STUDY TOOLS:

• Workbook Answer Key

• Student Lecture Notes

• Lab values

• Special Techniques

REGISTER TODAY!

ACTIVATE THE COMPLETE LEARNING EXPERIENCE
THAT COMES WITH YOUR BOOK BY REGISTERING AT
http://evolve.elsevier.com/Cairo/pilbeams/ventilation

MORE THAN
A TEXTBOOK

YOU’VE JUST PURCHASED

FIFTH EDITION

J.M. Cairo, PhD, RRT, FAARC
Dean of the School of Allied Health Professions
Professor of Cardiopulmonary Science, Physiology, and Anesthesiology
Louisiana State University Health Sciences Center
New Orleans, Louisiana

PILBEAM’S
Mechanical
Ventilation

Physiological and Clinical
Applications

3251 Riverport Lane
St. Louis, Missouri 63043

PILBEAM’S MECHANICAL VENTILATION: PHYSIOLOGICAL AND
CLINICAL APPLICATIONS
978-0-323-07207-6

Copyright © 2012, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating

and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most

current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the Authors, contributors, or editors, assume

any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous editions copyrighted 1986, 1992, 1998

ISBN: 978-0-323-07207-6

Working together to grow

libraries in developing countries

www.elsevier.com | www.bookaid.org | www.sabre.org

Managing Editor: Billie Sharp
Developmental Editor: Kathleen Sartori
Editorial Assistant: Andrea Hunot
Publishing Services Manager: Julie Eddy
Senior Project Manager: Andrea Campbell
Design Direction: Karen Pauls

Printed in the United States of America

Last digit is the print number:
9
8
7
6
5
4
3
2

To David and Allyson

“Courage is the first of human qualities because it is the quality which guarantees all others.”
—Aristotle

vi

Contributors

Paul Barraza, RCP, RRT
Education Coordinator
Respiratory Care Services
Santa Clara Valley Medical Center
San Jose, California

Robert M. DiBlasi, RRT-NPS, FAARC
Respiratory Research Coordinator
Respiratory Therapy Department, Center for Developmental

Therapeutics

Seattle Children’s Hospital and Research Institute
Seattle, Washington

Theresa A. Gramlich, MS, RRT
Assistant Professor of Respiratory Care
University of Arkansas for Medical Sciences
Central Arkansas Veterans Health System
Department of Respiratory and Surgical Technologies
Little Rock, Arkansas

Susan P. Pilbeam, MS, RRT, FAARC
Editor Emeritus
Respiratory Care Educational Consultant
St. Augustine, Florida

ANCILLARY CONTRIBUTORS

Sandra Hinski, MS, RRT-NPS
Faculty, Respiratory Care Division
Gateway Community College
Phoenix, Arizona

Sindee K. Karpel, MPA, RRT
Clinical Coordinator
Respiratory Care Program
Edison State College
Fort Myers, Florida

James R. Sills, MEd, CPFT, RRT
Professor Emeritus
Former Director, Respiratory Care Program
Rock Valley College
Rockford, Illinois

REVIEWERS

Allen W. Barbaro, MS, RRT
Department Chairman, Respiratory Care Education
St. Lukes College
Sioux City, Iowa

Georgine Bills, MBA/HSA, RRT
Program Director
Respiratory Therapy
Dixie State College of Utah
St. George, Utah

Craig Black, PhD, RRT-NPS, FAARC
Director, Respiratory Care Program
The University of Toledo
Toledo, Ohio

Margaret-Ann Carno, PhD, MBA, CPNP, D, ABSM, FNAP
Assistant Professor of Clinical Nursing and Pediatrics
School of Nursing
University of Rochester
Rochester, New York

Laurie A. Freshwater, MA, RCP, RRT, RPFT
Division Director, Health Sciences
Carteret Community College
Morehead City, North Carolina

Charlie Harrison, BS, RRT
Instructor of Respiratory Therapy
School of Nursing and Allied Health
Dixie State College
St. George, Utah

J. Kenneth Le Jeune MS, RRT, CPFT
Program Director Respiratory Education
University of Arkansas Community College at Hope
Hope, Arkansas

Ronald P. Mlcak, PhD, RRT, FAARC
Director of Respiratory Care Services
Shriners Hospitals for Children
Galveston, Texas

Suezette R. Musick-Hicks, BAAS Ed, RRT-CPFT
Director Respiratory Care Program
Black River Technical College
Pocahontas, Arkansas

Joshua J. Neumiller, Pharm D, CDE, CGP, FASCP
Assistant Professor of Pharmacotherapy
Washington State University
College of Pharmacy
Spokane, Washington

vii
C O N T R I B U T O R S

Bernie R. Olin, PharmD
Associate Clinical Professor
Director of Drug Information
Harrison School of Pharmacy
Auburn University
Auburn, Alabama

Tim Op’t Holt, EdD, RRT, AE-C, FAARC
Professor
University of South Alabama
Mobile, Alabama

Robin L. Ross, MS, RRT, RCP
Instructional Coordinator
Director of Clinical Education
CVCC School of Health Services
Catawba Valley Community College Respiratory Therapy Program
Hickory, North Carolina

Paula Denise Silver, MS Bio., MEd, Pharm D
Medical Instructor
Medical Careers Institute
School of Health Science of ECPI University
Newport News, Virginia

Shawna L. Strickland, PhD, RRT-NPS, AE-C
Clinical Assistant Professor
University of Missouri
Columbia, Missouri

Robert J. Tralongo, MBA, RT, RRT-NPS, AE-C
Respiratory Care Program Director
Molloy College
Rockville Centre, New York

Stephen F. Wehrman, RRT, RPFT, AE-C
Professor,
University of Hawaii;
Program Director
Kapi’olani Community College
Honolulu, Hawaii

Richard Wettstein, MMEd, RRT
Director of Clinical Education
University of Texas Health Science Center at San Antonio
San Antonio, Texas

Mary-Rose Wiesner, BS, RCP, RRT
Program Director
Department Chair
Mt. San Antonio College
Walnut, California

Kenneth A. Wyka, MS, RRT, AE-C, FAARC
Center Manager and Respiratory Care Patient Coordinator
Anthem Health Services
Queensbury, New York

viii

Foreword

T

he management of the mechanically ventilated patient rep-
resents one of the most challenging responsibilities for prac-
titioners in the intensive care unit. In this fifth edition of

Pilbeam’s Mechanical Ventilation: Physiological and Clinical Applica-
tion, J.M. Cairo., PhD, RRT, FAARC, continues a long tradition of
providing a compendium of information about mechanical ventila-
tion, going from basic principles to the most advanced concepts.
As was the original intention of the text, the presentation and orga-
nization continue to reflect the needs of the learner, as well as
feedback from those who have read and learned from earlier edi-
tions. The content of the fifth edition includes the most recent
medical evidence and accepted practices related to mechanical ven-
tilation, including the indications, contraindications, and complica-
tions related to its use.

Pilbeam’s Mechanical Ventilation has a history dating back to the

1980s when the first chapter, “The History of Mechanical Ventila-
tion,” was produced on a typewriter. The first edition took five years
to complete, due not only to the unavailability of personal comput-
ers, but also to the fact that medical journals were only available
on the stacks of the medical library because there was no Internet.
After three decades, the textbook has stood the test of time and

continues to be a primary source for students learning the science
and art of mechanical ventilation.

Although I have retired from being the first author, I have

continued to work with Jim, who took on the task of updating,
editing, and reorganizing the text. My input has been to assist
with editing and provide a sounding board in discussing the
pros and cons that exist in certain areas of current clinical practice
of mechanical ventilation. I have also contributed to a few
chapters.

Dr. Cairo and I believe that readers of the fifth edition will

undoubtedly experience the trials and triumphs that earlier gen-
erations of students encountered when they were introduced to
mechanical ventilation. Becoming an effective clinician, particu-
larly in critical care medicine, requires a personal commitment to
becoming a life-long learner. As with previous editions of Mechani-
cal Ventilation, I believe that this text will provide essential resources
for those who care for mechanically ventilated patients.

SUSAN P. PILBEAM, MS, RRT, FAARC

Editor Emeritus

ix

A

number of individuals should be recognized for their con-
tributions to this project. I wish to offer my sincere grati-
tude to Sue Pilbeam for her continued support throughout

this project and for her many years of service to the Respiratory
Care profession. Her contributions to the science and art of
mechanical ventilation span four decades. I feel fortunate to have
worked with her on a number of projects and have always been
impressed with her insight and dedication to our profession.

I also wish to thank Theresa Gramlich, MS, RRT, who authored

the chapters on Noninvasive Positive Pressure Ventilation and
Long-Term Ventilation; Rob Diblasi, BS, RRT, who authored the
chapter on Neonatal and Pediatric Ventilation; and Sindee Karpel,
BS, RRT, Sandra Hinski, MS, RRT-NPS, and Jim Sills, PhD, RRT,
for authoring the ancillaries that accompany this text. I wish to
thank all of the Respiratory Care educators and students who pro-
vided valuable suggestions and comments throughout the course
of editing and writing the fifth edition of Pilbeam’s Mechanical

Acknowledgments

Ventilation. I particularly want to acknowledge all of the reviewers
and my colleagues at LSU Health Sciences Center at New Orleans
and Our Lady of the Lake College in Baton Rouge: Michael
Levitzky, PhD, John Zamjahn, PhD, RRT, Tim Cordes, MHS, RRT,
Terry Forrette, MHS, RRT, Sue Davis, MEd, RRT, Shantelle Graves,
BS, RRT, and Martha Baul.

I would like to offer special thanks for the guidance provided

by the staff of Elsevier throughout this project, particularly Kath-
leen Sartori, Senior Development Editor; Billie Sharp, Managing
Editor; Andrea Campbell, Senior Project Manager; Julie Eddy,
Publishing Services Manager; and Andrea Hunolt, Editorial Assis-
tant. Their dedication to this project has been immensely helpful
and I feel fortunate to have had the opportunity to work with such
a professional group.

This edition of Pilbeam’s Mechanical Ventilation certainly would

not have come to fruition without the love and support of my wife,
Rhonda.

x

Preface

I

t has been a pleasure working with Susan Pilbeam for more
than 15 years. Sue and I have always felt that the goal of writing
a text of this nature is to present the subject matter in a manner

that is accurate and concise. The text should reflect evidence-based
practices and serve as a resource in the clinical setting. Throughout
the course of preparing for this edition, we have had numerous
conversations about how best to ensure that this goal could be
achieved. As in previous editions, the intent of the text is to provide
a strong physiological foundation for making clinical decisions
when managing patients receiving mechanical ventilation.

Respiratory therapists are an integral part of many patient care

plans and now, more than ever, are responsible for vital parts of the
patient care process. Their expertise is called upon as an essential
asset to critical care medicine, and ventilatory support is often vital
to patients’ well-being, making it an absolute necessity in the edu-
cation of respiratory therapists. To be successful, students and
instructors need clear and functional learning tools through which
students can acquire and apply the necessary knowledge and skills.
This text and its resources have been designed to meet that need.

Although significant changes have occurred in the practice of

critical care medicine since the first edition published in 1985, the
underlying philosophy of the text has remained the same—to
impart the knowledge necessary to safely, appropriately, and com-
passionately care for patients requiring ventilatory support. Pil-
beam’s Mechanical Ventilation, now in its fifth edition, is written in
a concise manner that explains the complex subject of patient-
ventilator management. Beginning with the most fundamental
concepts and expanding to the most advanced, the text guides
readers through essential concepts and ideas, building upon the
information as they work through the text.

While it’s clear that this book is an excellent advantage to stu-

dents in respiratory therapy educational programs, it can also serve
as a reference for many others. The application of mechanical ven-
tilation principles to patient care is one of the most sophisticated
areas of respiratory care application, making frequent reviewing
helpful, if not necessary. With its emphasis on evidence-based prac-
tice, Pilbeam’s Mechanical Ventilation can be useful to all critical care
practitioners including practicing respiratory therapists, critical
care residents and physicians, and critical care nurse practitioners.

ORGANIZATION

This edition, like the last, is organized into a logical sequence of
chapters and sections that build upon each other as a reader moves
through the book. The initial sections focus on core knowledge and
skills needed to apply and initiate mechanical ventilation, whereas
the middle and final sections cover specifics of mechanical venti-
lated patient care and special and long-term applications of
mechanical ventilation. The inclusion of some helpful appendices
further assist the reader in the comprehension of complex material
and an easy-access Glossary defines key terms covered in the
chapters.

FEATURES

The valuable learning aids that accompany this text will I hope
make it an engaging tool for both educators and students. With
clearly defined assets in the beginning of each chapter, students can
prepare for the material to come through the use of Chapter Out-
lines, Key Terms, and Learning Objectives.

Along with the abundant use of clearly marked images and

information tables, each chapter also contains:
•
Case Studies: small patient cases that list pertinent assessment
data and pose a critical thinking question to readers to test their
comprehension of content learned. Answers can be found in
Appendix A.

•
Critical Care Concepts: Short questions to engage the reader
in applying their knowledge of difficult concepts.

•
Clinical Scenarios: More comprehensive patient scenarios
covering patient presentation, assessment data, and some treat-
ment therapies. These scenarios are intended for classroom or
group discussion.

•
Key Points: Highlights important information as key concepts
are discussed.

Each chapter concludes with:
•
A bulleted Chapter Summary for ease of reviewing chapter
content

•
Chapter Review Questions (with answers in Appendix A)

•
A comprehensive list of References at the end of each chapter
for those students who wish to learn more about specific topics
covered in the text

And finally, we’ve included several appendices. Review of Abnor-
mal Physiologic Processes covers mismatching of pulmonary
perfusion and ventilation, mechanical dead space, and hypoxia.
A special appendix on Graphic Exercises gives students extra
practice in understanding the inter-relationship of flow, volume,
pressure, and time in mechanically ventilated patients. Answer
Keys to Case Studies and Critical Care Concepts featured
throughout the text and the end-of-chapter Review Questions
can help the student track progress in comprehension of the
content.

NEW TO THIS EDITION

This edition of Pilbeam’s Mechanical Ventilation has been carefully
updated to reflect the newer equipment and techniques that have
evolved in respiratory care to ensure it is in step with the current
modes of therapy. To emphasize this new information, more Case
Studies, Clinical Scenarios, and Critical Care Concepts have been
added to each chapter. A new chapter on Ventilator-Associated
Pneumonia (Chapter 14) addresses ventilator-associated and hos-
pital-acquired pneumonias and provides information on risk fac-
tors, early diagnosis, and strategies for prevention. The chapter on
Neonatal and Pediatric Mechanical Ventilation (Chapter 22) has
been considerably revised by well-known researcher Robert M.

xi
P R E FA CE 

DiBlasi. It includes important information on goals for newborn
and pediatric respiratory support, noninvasive support, and
adjunctive forms of support.

LEARNING AIDS

Workbook
The Workbook for Pilbeam’s Mechanical Ventilation is an easy-to-
use guide designed to help the student focus on the most impor-
tant information presented in the text. The workbook features
exercises directly tied to the learning objectives that appear in the
beginning of each chapter. Providing the reinforcement and
practice that students need, the workbook features exercises
such as key term crossword puzzles, critical thinking questions,
case studies, waveform analysis, and NBRC-style multiple choice
questions.

FOR EDUCATORS

Educators using Pilbeam’s Mechanical Ventilation’s Evolve website
have access to an array of resources designed to work in coordina-
tion with the text and aid in teaching this topic. Educators may use
the Evolve resources to plan class time and lessons, supplement
class lectures, or create and develop student exams. These Evolve
resources offer:
•
More than 800 NBRC-style multiple-choice test questions in
ExamView
•
A NEW PowerPoint Presentation with more than 650 slides
featuring key information and helpful images
•
An Image Collection of the figures appearing in the book

Updated … comprehensive … a wide variety of supplemental
material all makes Pilbeam’s Mechanical Ventilation: Physiological
and Clinical Application part of the Elsevier Advantage.

This page intentionally left blank

xiii

Contents

PART 1
BASIC CONCEPTS AND CORE KNOWLEDGE IN
MECHANICAL VENTILATION

1
Basic Terms and Concepts of Mechanical
Ventilation, 2
Physiological Terms and Concepts Related to

Mechanical Ventilation, 3

Normal Mechanics of Spontaneous Ventilation, 3
Lung Characteristics, 5
Time Constants, 8
Types of Ventilators and Terms Used in Mechanical

Ventilation, 9

Types of Mechanical Ventilation, 10
Definition of Pressures in Positive-Pressure

Ventilation, 11

2
How Ventilators Work, 17
Historical Perspective on Ventilator Classification, 17
Internal Function, 18
Power Source or Input Power, 18
Control Systems and Circuits, 21
Power Transmission and Conversion System, 23

3
How a Breath Is Delivered, 29
Basic Model of Ventilation in the Lung During

Inspiration, 30

Factors Controlled and Measured During Inspiration, 30
Overview of Inspiratory Waveform Control, 32
Four Phases of a Breath and Phase Variables, 33
Types of Breaths, 43

PART 2
INITIATING VENTILATION

4
Establishing the Need for Mechanical
Ventilation, 48
Acute Respiratory Failure, 49
Patient History and Diagnosis, 51
Physiological Measurements in Acute Respiratory

Failure, 53

Overview of Criteria for Mechanical Ventilation, 56
Possible Alternatives to Invasive Ventilation, 56

5
Selecting the Ventilator and the Mode, 63
Noninvasive and Invasive Positive-Pressure Ventilation:

Selecting the Patient Interface, 64

Full and Partial Ventilatory Support, 65
Mode of Ventilation and Breath Delivery, 65
Breath Delivery and Modes of Ventilation, 70
Bilevel Positive Airway Pressure, 76
Additional Modes of Ventilation, 76

6
Initial Ventilator Settings, 85
Determining Initial Ventilator Setting During Volume-

Controlled Ventilation, 85

Initial Settings During Volume-Controlled

Ventilation, 86

Setting Minute Ventilation, 86
Setting the Minute Ventilation: Special

Considerations, 94

Inspiratory Pause During Volume Ventilation, 95
Determining Initial Ventilator Settings During

Pressure Ventilation, 96

Setting Baseline Pressure—Physiological

PEEP, 96

Initial Settings for Pressure Ventilation Modes with

Volume Targeting, 99

7
Final Considerations in Ventilator
Setup, 103
Selection of Additional Parameters and Final

Ventilator Setup, 104

Selection of Fractional Concentration of Inspired

Oxygen F1O2, 104

Sensitivity Setting, 104
Alarms, 108
Periodic Hyperinflation or Sighing, 109
Final Considerations in Ventilator Equipment

Setup, 110

Selecting the Appropriate Ventilator, 111
Evaluation of Ventilator Performance, 111
Initial Ventilator Settings for Specific Patient

Situations, 111

Chronic Obstructive Pulmonary Disease, 111
Neuromuscular Disorders, 113
Asthma, 114
Closed Head Injury, 115
Acute Respiratory Distress Syndrome, 117
Acute Cardiogenic Pulmonary Edema and

Congestive Heart Failure, 118

PART 3
MONITORING IN MECHANICAL VENTILATION

8
Initial Patient Assessment, 124
Documentation of the Patient-Ventilator System, 125
The First 30 Minutes, 126
Monitoring Airway Pressures, 131
Vital Signs, Blood Pressure, and Physical Examination of

the Chest, 134

Management of Endotracheal and Tracheostomy Tube

Cuffs, 136

Monitoring Compliance and Airway Resistance, 140
Comment Section of the Ventilator Flow Sheet, 144

xiv
CONTENTS

9
Ventilator Graphics, 148
Relationship of Volume, Flow, Pressure and Time, 149
Volume-Controlled Ventilation with Constant

Flow, 150

Producing Ventilator Graphics, 150
Calculations, 150
A Closer Look at the Flow-Time Scalar in Volume-
Controlled Continuous Mandatory Ventilation, 151
Changes in the Pressure-Time Curve, 155
Volume Scalar, 155
Key Points of Volume-Controlled Ventilation
Graphics, 157

Pressure-Controlled Ventilation, 158
Pressure-Controlled Ventilation with a Constant Pressure
Waveform, 158
Key Points of Pressure-Controlled Ventilation
Graphics, 160

Pressure Support Ventilation, 161
Details of the Pressure-Time Waveform in Pressure-
Support Ventilation, 161
Flow Cycling During Pressure-Support Ventilation, 162
Automatic Adjustment of the Flow-Cycle Criterion, 163
Use of Pressure-Support Ventilation with SIMV, 165
Pressure-Volume Loops, 165
Pressure-Volume Loop and Work of Breathing, 168
Troubleshooting a Pressure-Volume Loop, 169
Flow-Volume Loops During Mechanical

Ventilation, 169

Components of an Flow-Volume Loop with Mandatory
Breaths, 169
Troubleshooting with Flow-Volume Loops During
Mechanical Ventilation, 171

10 Assessment of Respiratory Function, 175

Noninvasive Measurements of Blood Gases, 175
Pulse Oximetry, 175
Capnography (Capnometry), 179
Exhaled Nitric Oxide Monitoring, 186
Transcutaneous Monitoring, 186
Indirect Calorimetry and Metabolic

Measurements, 187

Overview of Indirect Calorimetry, 187
Assessment of Respiratory System Mechanics, 190
Measurements, 190

11 Hemodynamic Monitoring, 199

Review of Cardiovascular Principles, 200
Obtaining Hemodynamic Measurements, 202
Interpretation of Hemodynamic Profiles, 207
Clinical Applications, 214

PART 4
THERAPEUTIC INTERVENTIONS—MAKING
APPROPRIATE CHANGES

12 Methods to Improve Ventilation in Patient-

Ventilator Management, 222
Correcting Ventilation Abnormalities, 223
Common Methods of Changing Ventilation Based on
PaCO2 and pH, 223

Metabolic Acidosis and Alkalosis, 226
Mixed Acid-Base Disturbances, 227
Increased Physiological Dead Space, 228
Increased Metabolism and Increased Carbon Dioxide
Production, 228
Intentional Iatrogenic Hyperventilation, 229
Permissive Hypercapnia, 229
Airway Clearance During Mechanical

Ventilation, 230

Secretion Clearance from an Artificial Airway, 230
Administering Aerosols to Ventilated Patients, 235
Postural Drainage and Chest Percussion, 241
Flexible Fiberoptic Bronchoscopy, 241
Additional Patient Management Techniques and

Therapies in Ventilated Patients, 244

Importance of Body Position and Positive-Pressure
Ventilation, 244
Sputum and Upper Airway Infections, 247
Fluid Balance, 247
Psychological and Sleep Status, 248
Patient Safety and Comfort, 249
Transport of Mechanically Ventilated Patients Within an
Acute Care Facility, 250

13 Improving Oxygenation and Management of

Acute Respiratory Distress Syndrome, 257
Susan P. Pilbeam and J.M. Cairo
Basics of Oxygenation Using FIO2, PEEP Studies, and

Pressure-Volume Curves for Establishing Optimum
PEEP, 258

Basics of Oxygen Delivery to the Tissues, 258
Introduction to Positive End-Expiratory Pressure and
Continuous Positive Airway Pressure, 261
PEEP Ranges, 263
Indications for PEEP and CPAP, 263
Initiating PEEP Therapy, 264
Selecting the Appropriate PEEP/CPAP Level (Optimum
PEEP), 264
Use of Pulmonary Vascular Pressure Monitoring with
PEEP, 270
Contraindications and Physiological Effects of PEEP, 271
Weaning from PEEP, 273
Acute Respiratory Distress Syndrome, 275
Pathophysiology, 275
Changes in Computed Tomogram with ARDS, 275
ARDS as an Inflammatory Process, 276
PEEP and the Vertical Gradient in ARDS, 278
Lung Protective Strategies: Setting Tidal Volume and
Pressures in ARDS, 278
Long-Term Follow-Up on ARDS, 279
Pressure-Volume Loops and Recruitment Maneuvers in
Setting PEEP in ARDS, 279

PART 5
EFFECTS AND COMPLICATIONS OF MECHANICAL
VENTILATION

14 Ventilator-Associated Pneumonia, 294

Epidemiology, 295
Pathogenesis of Ventilator-Associated Pneumonia, 297