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Mechanical Ventilation Made Easy
S Ahanatha Pillai
CHAPTER 1:
Introduction to Mechanical Ventilation
WHY ARE VENTILATORS USED?
CHAPTER 2:
History of Mechanical Ventilation
TANK VENTILATORS AND CUIRASS VENTILATORS
GENERAL DESCRIPTION
DESCRIPTION OF A CUIRASS VENTILATOR
CHAPTER 3:
Anatomy of Respiratory System
ANATOMY OF AIRWAY
Upper Airway
Nasal Passages
Sinuses
Pharynx
Larynx
Lower Airway
Trachea
Conducting Airways (Nonalveolate Region)
Bronchial Tree
Respiratory Zone (Alveolate Region)
Surfactant
MECHANICS OF THE LUNG (WITH RELATION TO SURFACE TENSION)
NERVE SUPPLY TO THE RESPIRATORY TRACT
BLOOD SUPPLY TO THE RESPIRATORY TRACT
The Bronchial Circulation
The Pulmonary Circulation
The Lymphatic Drainage
Fluid Homeostasis
Immunological Defence
LUNGS
Lobes and Segments
Pleura and Pleural Space
Thoracic Cage
CHAPTER 4:
Applied Physiology of Respiration
COMPONENTS OF NORMAL RESPIRATION
SOME PHYSIOLOGICAL FACTS OF GAS EXCHANGE
Diffusion
Alveolar PCO2 (PACO2)
Alveolar PO2 (PAO2)
Oxygen Carriage in Blood
Cyanosis
Oxygen Flux
Clinical Significance
Carbon Dioxide Transport
Central Response to CO2
CONTROL OF RESPIRATION
Voluntary Control by Cortical Centers
The Respiratory Centers
Chemical Control of Breathing
Clinical Significance
Central Chemoreceptors
The Peripheral Chemoreceptors
VENTILATORY RESPONSE TO HYPOXIA
Hering-Breuer Reflexes
Wakefulness on Respiration
Other Drives to Breathing during Exercise
Temperature
Neural Factors
Humoral Factors—Arterial pH and PCO2
NORMAL PROTECTIVE MECHANISMS IN RESPIRATORY SYSTEM
Mucociliary Clearance System
Sigh
Cough
Sneeze
SYMBOLS USED IN RESPIRATORY PHYSIOLOGY
Primary Symbols
Secondary Symbols for Location of Quantity
Gas Phase (Small capitals)
Blood Phase (Small letters)
Examples:
Abbreviations for Lung Volumes
Abbreviations for Lung Capacities
Abbreviation in Pulmonary Mechanics
Perfusion
Ventilation/Perfusion Relationship
CHAPTER 5:
Oxygen
PHYSIOLOGICAL IMPORTANCE
AVAILABILITY
Commercial Preparation
Presentation
Cylinders
OXYGEN CONCENTRATOR
PRESSURE GRADIENT OF OXYGEN FROM ALVEOLI TO BLOOD
Oxygen Transfer Across “Alveolar Capillary Membrane”
THE PARTIAL PRESSURES OF OXYGEN
METABOLIC REQUIREMENT OF OXYGEN
Oxygen Expenditure for Work of Breathing
Transport of Oxygen in Blood
Oxygen Dissolved in Plasma
Oxyhemoglobin
OXYGEN DISSOCIATION CURVE
The Important Factors that Shift the ODC
Carbon Dioxide Tension
The pH of the Blood
Stored Blood
Temperature
Clinical Significance
Discussion
HYPOXIA
The Oxygen Cascade
Classification of Hypoxia
Hypoxic Hypoxia
Anemic Hypoxia
Stagnant Hypoxia
Histotoxic Hypoxia
Cyanosis
Effects of Hypoxia
Direct Effects
Indirect Effect on Other Organs
Postoperative Hypoxia
The Factors that may Cause Postoperative Hypoxia
Hypoventilation
Drugs
Obstruction
Pain
Diaphragmatic Splinting
Intraoperative Hyperventilation
OXYGEN TOXICITY
Chronic Pulmonary Toxicity
Mechanism of Toxicity
Retrolental Fibroplasia
Acute Toxicity
CHAPTER 6:
Mechanics of Respiration
THE RESPIRATORY APPARATUS
MUSCLES OF RESPIRATION
Diaphragm
Nerve Supply
Movements
Intercostal Muscles
External Intercostals
Internal Intercostals
Abdominal Muscles (Expiratory Muscles)
Movements
Accessory Muscles of Respiration
NORMAL LUNG MOVEMENTS
Apex
Thoracic Cage
The Diaphragm
Other Factors
NORMAL MOVEMENTS OF RESPIRATION
Inspiration
Expiration
SOME ABNORMALITIES OF VENTILATION
Tachypnea
Hyperpnea
Hyperventilation
Hypoventilation
Dyspnea
LUNG VOLUMES
Definitions and Clinical Significance
Tidal Volume (VT)
Inspiratory Reserve Volume (IRV)
Expiratory Reserve Volume (ERV)
Residual Volume (RV)
Inspiratory Capacity (IC)
Functional Residual Capacity (FRC)
Vital Capacity (VC)
Total Lung Capacity (TLC)
Closing Volume (CV)
DYNAMIC TESTS FOR VENTILATION
Maximum Breathing Capacity
Forced Expiratory Volume (FEV)
Peak Expiratory Flow Rate
Clinical Significance
PLEURAL CAVITY
Intrapleural Pressure and Pulmonary Collapse
PNEUMOTHORAX
Types of Pneumothorax
Open Pneumothorax
Closed Pneumothorax
Tension Pneumothorax
ABNORMAL CHEST AND LUNG MOVEMENTS
Paradoxical Respiration
Pendelluft
Mediastinal Flap
CONTROLLED RESPIRATION
DIFFUSION RESPIRATION
RESPIRATORY MOVEMENT IN ANESTHESIA
Tracheal Tug
Compliance
Static Compliance (CST)
Dynamic Compliance (CDYN)
The Clinical Significance
Measurement of Compliance
Measuring Static Compliance
Clinical Significance of Static Compliance
Measuring Dynamic Compliance
Clinical Significance of Dynamic Compliance
TIME CONSTANT, LUNG COMPLIANCE, AND RESISTANCE
Law of Laplace
Time Constant
Resistance
Elastic Resistance
Structural Resistance
Airway Resistance
Factors Affecting the Airway Resistance
Length and Radius of Airway
The Flow Rate and Flow Pattern
Patient Factors that Modify Airway Resistance
Ventilator Circuit Factors that Modify Resistance
WORK OF BREATHING
Respiratory Work and Diseases
Clinical Significance of Resistance to Ventilation
CHAPTER 7:
Mechanical Ventilation: Machine-assisted Breathing
DEFINITION
TYPES OF ARTIFICIAL RESPIRATION
The Simplest Ventilator
East Radcliff Ventilator (East Radcliff Positive-Negative Respiration Pump)
REQUIREMENTS FOR NORMAL RESPIRATION
THE PRESSURES RELATED TO RESPIRATION
Atmospheric Pressure
Intra-alveolar Pressure (Palv)
Intrapleural Pressure (Intrathoracic)
Transpulmonary or Transmural Pressure
THE PROCESS OF RESPIRATORY CYCLE
POSITIVE PRESSURE VENTILATION (IPPV)
Physiological Effects
Intrapulmonary Pressure (Alveolar)
Intrapleural Pressure
Lung Compliance
Dead Space
Hyperventilation
Effects of IPPV on Cardiovascular System
Advantages of IPPV
THE IDEAL VENTILATION CHARACTERISTICS
Ventilation
The Factors that Modify the Ventilation in IPPV
Problems Associated with Mechanical Ventilation
Muscular Atrophy of Diaphragm
Setting a Respiratory Cycle in IPPV
Manipulation of Respiratory Cycle in Mechanical Ventilation
The Four Phases
Possible Modifications in Each Phase
Changeover from Inspiration to Expiration
Types of Cycling—Mapleson 1969
Expiratory Phase
Constant Atmospheric Pressure (ZEEP)
Expiratory Retard
Negative End Expiratory Pressure (NEEP)
Constant Positive Pressure (PEEP)
Initiation of Inspiration
Time-cycled (Control Mode) (CMV)
Patient-cycled or Triggered (Assist Mode)
Assist-Control Mode (A/C)
Manual Cycling
CHAPTER 8:
Mechanical Ventilator: Basic Concepts
DEFINITION
CLASSIFICATION OF VENTILATORS
TYPES
Negative Pressure Ventilators
Positive Pressure Ventilator
BASIC CONCEPTS OF VENTILATORS
THE FEATURES OF A BASIC VENTILATOR
Power Input (Driving Force)
Pneumatic Power
Electric Power
Combined Power
Control Schemes
Control Variables
Phase Variables
Conditional Variables
Output
Displays
Alarm Systems
The Driving Force (The Muscle)
The Controls Mechanism (The Brain)
AN IDEAL VENTILATOR THERAPY
Ideal Initial Setting
Tidal Volume
Display Panel in the Ventilator
Inspired Concentration of Oxygen (FIO2)
Respiratory Rate
Flow Rate
Flow Patterns
Square
Sinusoidal
Accelerating (Ascending Ramp)
Decelerating (Descending Ramp)
The Decelerating Flow Pattern
Application of Flow Patterns
Decelerating Flow
I : E Ratio (Inspiratory to Expiratory Ratio)
Clinical Significance
Inverse I : E Ratio
Trigger Sensitivity (Triggering Effort)
Pressure Triggering
Flow Triggering
Clinical Importance of Sensitivity
Monitoring
Positive End Expiratory Pressure (PEEP)
Indications for PEEP
Contraindications for PEEP
Continuous Positive Airway Pressure (CPAP)
Problems Associated with the Use of PEEP
The Method of Applying PEEP
Removal of PEEP
Auto-PEEP (Intrinsic PEEP)
CHAPTER 9:
Available Modes of Ventilation
AVAILABLE MODES
Controlled Ventilation
Assisted Ventilation
THE CHOICE
Full Ventilatory Support (FVS)
Indications
Partial Ventilatory Support (PVS)
MODES OF VENTILATION
Controlled Mechanical Ventilation (CMV)
Indications
Advantages
Disadvantages
Important Points to Note
Assist Mode
Disadvantage
Assist/Control Mode
Example
Indications
Advantages
Disadvantages
Important Points to Note and Monitor
Intermittent Mandatory Ventilation (IMV)
Indications
Advantages
Disadvantages
Important Points to Note and Monitor
Synchronized Intermittent Mandatory Ventilation
The Difference between the SIMV and A/C Modes
Indications
Advantages
Disadvantages
Points to be Noted and Monitored
Continuous Positive Airway Pressure (CPAP)
Indications
Advantages
Disadvantages
Points to be Noted and Monitored
Positive End Expiratory Pressure (PEEP)
Pressure Support Ventilation (PSV)
Indications
Advantages
Disadvantages
Points to Consider and Monitor
Volume Assured Pressure Support
Pressure Control Ventilation (PCV)
Indications
Advantages
Disadvantages
Points to Consider and Monitor
Inverse Ratio Ventilation
Indications
Effects of Increased Inspiratory Time
Effects of Decreased Expiratory Time
Airway Pressure Release Ventilation (APRV)
The Control Settings
Advantages
Biphasic Positive Airway Pressure (BIPAP)
Advantages
Proportional Assist Ventilation (PAV)
Mandatory Minute Volume (MMV)
Permissive Hypercapnea
Automatic Tube Compensation
NONCONVENTIONAL MODES OF VENTILATION
High Frequency Ventilation Techniques
High Frequency Jet Ventilation (Fig. 9.16)
Gas Exchange in HFJV
Indications
New Generation
CHAPTER 10:
Acid-base Regulation
ACID-BASE REGULATION
Acid-base Status
Henderson-Hasselbach Equation
THE COMMON CAUSES, SYMPTOMS AND TREATMENT OF ACID-BASE DISTURBANCES
Respiratory Acidosis
Causes
Symptoms
Treatment
Respiratory Alkalosis
Causes
Symptoms
Treatment
Metabolic Acidosis
Causes
Symptoms
Treatment
Metabolic Alkalosis
Causes
Symptoms
Treatment
INTERPRETATION OF ARTERIAL BLOOD GASES
STEPS FOR ANALYSIS OF ABG VALUES
Interpreting ABG in Terms of V/Q Mismatches
Discussion
Technique of Obtaining Arterial Blood Sample
CHAPTER 11:
Indications for Mechanical Ventilation and Respiratory Failure
RESPIRATORY GAS TENSIONS
Direct Indices
Derived Indices
Clinical Indices
Mechanical Indices
POSTOPERATIVE ARTIFICIAL VENTILATION
Who Should Receive?
Pain
Exhaustion
Respiratory Failure
RESPIRATORY FAILURE
Definition
Common Causes of Respiratory Failure
Causes of Failure to Maintain Normal Blood Gas Homeostasis
Basic Mechanism of Respiration
Failure to Oxygenate
Failure to Ventilate
CHAPTER 12:
Maintenance of Airway and Tracheal Intubation
THE COMMON CAUSES OF UPPER AIRWAY OBSTRUCTION
Manifestations
DIFFERENT ARTIFICIAL AIRWAYS FOR KEEPING PATIENT'S AIRWAY PATENT
PLACING OROPHARYNGEAL AIRWAY IN POSITION (FIG. 12.9A)
Nasopharyngeal Airway
ENDOTRACHEAL INTUBATION
Indications for Endotracheal Intubation
Oral
Advantages
Disadvantages
Nasal
Advantages
Disadvantages
History
Endotracheal Tubes
Laryngoscopes
Laryngoscopy
Technique of Intubation (Figs 12.12 to 12.27)
INTUBATION
The Purpose of Intubation
Human Assistance
Special Care to be Taken during Intubation
Securing and Stabilizing the Endotracheal Tube after Intubation
Intubation in Conscious Patients
Forrester Spray (Macintosh laryngeal spray)
EXTUBATION
CHAPTER 13:
Complications of Mechanical Ventilation
PROBLEMS OF MECHANICAL VENTILATION
POSITIVE AIRWAY PRESSURE RELATED PROBLEMS (VENTILATOR INDUCED LUNG INJURIES)
Barotrauma
Prevention
Volutrauma
Prevention
Biotrauma
Reduction in Cardiac Output and Oxygen Delivery to Tissues
Management
Alteration in Renal Function
Management
Increase in Intracranial Tension
Management
Ventilation Perfusion Mismatch
Management
ARTIFICIAL AIRWAY RELATED PROBLEMS
DELAYED COMPLICATIONS
Sinus Infection (Sinusitis)
Nasal Mucosal Necrosis
Tracheoesophageal Fistula
Prevention
Ventilator Associated Pneumonia
Prevention
Oxygen toxicity
Psychological and Socioeconomical Complications
Management
Complications Attributed to Operation or Operator of Ventilator
Prevention
Monitoring the Patient
MONITOR THE VENTILATOR
Key Board of a Ventilator
Alarms
PATIENT-VENTILATOR ASYNCHRONY
PULSES OXIMETER (Fig. 13.1)
PULSE PLETHYSMOGRAPHY
Reliability
Capnography: End Tidal CO2 Value
Mass Spectrometry
Mainstream Analyser
Side Stream Analyser
Interpretation of Values
Factors that Increase etCO2
Factors that Decreases at CO2
Normal Capnogram and Various Abnormal Patterns
SERUM LACTATE CONCENTRATION
CHAPTER 14:
Weaning from Ventilator
PHYSIOLOGY OF RESPIRATORY MUSCLES
Skeletal Muscle Types
Type I: Slow Twitch Fibers
Type II: Fast Twitch Fibers
Means to Increase the Strength and Endurance
Strength
Endurance
IDENTIFYING MUSCLE FATIGUE, PREVENTION, AND MANAGEMENT
Causes and Prevention
Clinical Signs of Muscle Fatigue
Rest to Muscles
WEANING CRITERIA
Ventilation
Oxygenation
Mechanics
Minute Ventilation (VE)
Tidal Volume
Vital Capacity
Maximum Inspiratory Pressure
Respiratory Rate
WEANING MODES
T-piece Trial
CPAP Trial
SIMV Trial
Pressure Support (PS) Trial
Advantages
Psychological Aspect of Weaning
Facts to be Remembered
Signs for Reinstituting Mechanical Ventilation
Respiratory
Cardiovascular
Neurological Changes
SIMPLE WEANING CRITERIA FOR ICU PATIENTS (A-E)
WEANING STATUS OF PARAMETERS
INDEX
TOC
Index
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