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ABBREVIATIONS Δ µ µg µm µV AARC ABG(s) A/C ACBT ADH Ag AgCl AI AIDS ALI ALV anat ANP AOP APRV ARDS ARF ASV ATC ATM ATPD ATPDS ATS auto-PEEP AV AVP BAC BE bilevel PAP BiPAP BP BPD BSA BTPS BUN C C °C CaO2 C(a- v) O2 CC cc Cc’O2 CD CDC CDH CHF CI CL cm cm H2O CMV CNS CO CO2 COHb COLD COPD CPAP CPG CPP CPPB CPPV CPR CPT CPU CRT Cs CSF CSV CT CT CV CvO2 C v O2 CVP DL change in micromicrogram micrometer microvolt American Association for Respiratory Care arterial blood gas(es) assist/control active cycle of breathing technique antidiuretic hormone silver silver chloride airborne infection isolation acquired immunodeficiency syndrome acute lung injury adaptive lung ventilation anatomic atrial natriuretic peptide apnea of prematurity airway pressure release ventilation acute respiratory distress syndrome acute respiratory failure adaptive support ventilation automatic tube compensation atmospheric pressure ambient temperature and pressure, dry ambient temperature and pressure saturated with water vapor American Thoracic Society unintended positive end-expiratory pressure arteriovenous arginine vasopressin blood alcohol content base excess bilevel positive airway pressure registered trade name for a bilevel PAP device blood pressure bronchopulmonary dysplagia body surface area body temperature and pressure, saturated with water vapor blood urea nitrogen compliance pulmonary-end capillary degrees Celsius arterial content of oxygen arterial-to-mixed venous oxygen content difference closing capacity cubic centimeter oxygen content of the alveolar capillary dynamic characteristic or dynamic compliance Centers for Disease Control and Prevention congenital diaphragmatic hernia congestive heart failure cardiac index lung compliance (also CLung) centimeters centimeters of water pressure controlled (continuous) mandatory mechanical ventilation central nervous system carbon monoxide carbon dioxide carboxyhemoglobin chronic obstructive lung disease chronic obstructive pulmonary disease continuous positive airway pressure Clinical Practice Guideline cerebral perfusion pressure continuous positive-pressure breathing continuous positive-pressure ventilation cardiopulmonary resuscitation chest physical therapy central processing unit cathode ray tube static compliance cerebrospinal fluid continuous spontaneous ventilation computerized tomogram tubing compliance (also Ctubing) closing volume venous oxygen content mixed venous oxygen content central venous pressure diffusing capacity DC DC-CMV DC-CSV DIC DO2 DPAP DPPC Dm DVT E ECG ECCO2R ECLS ECMO Edi EDV EE EEP EIB EPAP ERV est ET EtCO2 F °F f FDA FEF FEFmax FEFX FETX FEVt FEV1 FEV1/VC FICO2 FIF FIO2 FIVC FRC ft f/VT FVC FVS Gaw g/dL [H+] HAP Hb HCAP HCH HCO3− H2CO3 He He/O2 HFFI HFJV HFO HFOV HFPV HFPPV HFV HHb HMD HME HMEF H2O HR ht Hz IBW I IC ICP ICU ID IDSA I:E discharges, discontinue dual-controlled continuous mandatory ventilation dual-controlled continuous spontaneous ventilation disseminated intravascular coagulation (DIV no longer used) oxygen delivery demand positive airway pressure dipalmitoylphosphatidylcholine diffusing capacity of the alveolar-capillary membrane deep venous thrombosis elastance electrocardiogram extracorporeal carbon dioxide removal extracorporeal life support extracorporeal membrane oxygenation electrical activity of the diaphragm end-diastolic volume energy expenditure end-expiratory pressure exercise-induced bronchospasm (end-)expiratory positive airway pressure expiratory reserve volume estimated endotracheal tube end-tidal CO2 fractional concentration of a gas degrees Fahrenheit respiratory frequency, respiratory rate Food and Drug Administration forced expiratory flow maximal forced expiratory flow achieved during an FVC forced expiratory flow, related to some portion of the FVC curve forced expiratory time for a specified portion of the FVC forced expiratory volume (timed) forced expiratory volume at 1 second (or FEV1/SVC) forced expiratory volume in 1 second over slow vital capacity fractional inspired carbon dioxide forced inspiratory flow fractional inspired oxygen forced inspiratory vital capacity functional residual capacity foot rapid shallow breathing index (frequency divided by tidal volume) forced vital capacity full ventilatory support airway conductance grams per deciliter hydrogen ion concentration hospital-acquired pneumonia hemoglobin healthcare-associated pneumonia hygroscopic condenser humidifier bicarbonate carbonic acid helium helium/oxygen mixture, heliox high-frequency flow interrupter high-frequency jet ventilation high-frequency oscillation high-frequency oscillatory ventilation high-frequency percussive ventilation high-frequency positive-pressure ventilation high-frequency ventilation reduced or deoxygenated hemoglobin hyaline membrane disease heat moisture exchanger heat moisture exchange filter water heart rate height hertz ideal body weight inspired inspiratory capacity intracranial pressure intensive care unit internal diameter Infectious Diseases Society of America inspiratory-to-expiratory ratio ILD IMV iNO IPAP IPPB IPPV IR IRDS IRV IRV ISO IV IVC IVH IVOX kcal kg kg-m kPa L LAP lb LBW LED LFPPVECCO2R LV LVEDP LVEDV LVSW m2 MABP MalvP MAP MAS max mcg MDI MDR mEq/L MEP metHb mg mg% mg/dL MI-E MIF min MIP mL MLT mm MMAD mm Hg mmol MMV MOV mPaw - Paw MRI ms MV MVV NaBr NaCl NAVA NBRC NEEP nHFOV NICU NIF NIH NIV nM nm NMBA nmol/L NO NO2 NP NPO NPV NSAIDS nSIMV interstitial lung disease intermittent mandatory ventilation inhaled nitric oxide inspiratory positive airway pressure intermittent positive-pressure breathing intermittent positive-pressure ventilation infrared infant respiratory distress syndrome inverse ratio ventilation inspiratory reserve volume International Standards Organization intravenous inspiratory vital capacity intraventricular hemorrhage intravascular oxygenator kilocalorie kilogram kilogram-meters kilopascal liter left atrial pressure pound low birth weight light emitting diode low-frequency positive-pressure ventilation with extracorporeal carbon dioxide removal left ventricle left ventricular end-diastolic pressure left ventricular end-diastolic volume left ventricular stroke work meters squared mean arterial blood pressure mean alveolar pressure mean arterial pressure meconium aspiration syndrome maximal microgram metered-dose inhaler multidrug-resistant milliequivalents/liter maximum expiratory pressure methemoglobin milligram milligram percent milligrams per deciliter mechanical insufflation-exsufflation maximum inspiratory force minute maximum inspiratory pressure milliliter minimal leak technique millimeter median mass aerodynamic diameter millimeters of mercury millimole mandatory minute ventilation minimal occluding volume mean airway pressure magnetic resonance imaging millisecond mechanical ventilation maximum voluntary ventilation sodium bromide sodium chloride neurally adjusted ventilatory assist National Board of Respiratory Care negative end-expiratory pressure nasal high-frequency oscillatory ventilation neonatal intensive care unit negative inspiratory force (also see MIP and MIF) National Institutes of Health noninvasive positive-pressure ventilation (also NPPV) nanomolar nanometer neuromuscular blocking agent nanomole/liter nitric oxide nitrous oxide nasopharyngeal nothing by mouth negative-pressure ventilation nonsteroidal anti-inflammatory drugs nasal synchronized intermittent mandatory ventilation N-SiPAP O2 O2Hb OH− OHDC OSA P ΔP P50 P100 Pa PA P(A–a)O2 P(A–awo) PACO2 PaCO2 Palv PAO2 PaO2 PaO2/FIO2 PaO2/PAO2 PAOP PAP PAP P(a–et)CO2 PAGE Paug PAV Paw Paw Pawo PAWP PB Pbs PC-CMV PCEF PCIRV PCO2 PC-IMV PC-SIMV PCV PCWP PCWPtm PDA PE PEmax P E CO2 PEEP PEEPE PEEPI PEEPtotal PEFR Pes PetCO2 PFT Pflex Pga Phigh pH PHY PIE PImax Pintrapleural PIO2 PIP PL Plow PLV PM pMDI Pmus nasal positive airway pressure with periodic (sigh) bilevel positive airway pressure breaths or bilevel nasal continuous positive airway pressure oxygen oxygenated hemoglobin hydroxide ions oxyhemoglobin dissociation curve obstructive sleep apnea pressure change in pressure PO2 at which 50% saturation of hemoglobin occurs pressure on inspiration measured at 100 milliseconds arterial pressure pulmonary artery alveolar-to-arterial partial pressure of oxygen pressure gradient from alveolus to airway opening partial pressure of carbon dioxide in the alveoli partial pressure of carbon dioxide in the arteries alveolar pressure partial pressure of oxygen in the alveoli partial pressure of oxygen in the arteries ratio of arterial PO2 to FIO2 ratio of arterial PO2 to alveolar PO2 pulmonary artery occlusion pressure pulmonary artery pressure mean pulmonary artery pressure arterial-to-end-tidal partial pressure of carbon dioxide (also a–et PCO2) perfluorocarbon associated gas exchange pressure augmentation proportional assist ventilation airway pressure mean airway pressure airway opening pressure pulmonary artery wedge pressure barometric pressure pressure at the body’s surface pressure-controlled continuous mandatory ventilation peak cough expiratory flow pressure control inverse ratio ventilation partial pressure of carbon dioxide pressure-controlled intermittent mandatory ventilation Pressure-controlled synchronized intermittent mandatory ventilation pressure control ventilation pulmonary capillary wedge pressure transmural pulmonary capillary wedge pressure patent ductus arteriosus pulmonary embolism maximal expiratory pressure partial pressure of mixed expired carbon dioxide positive end-expiratory pressure extrinsic PEEP (set-PEEP, applied PEEP) intrinsic PEEP (auto-PEEP) total PEEP (the sum of intrinsic and extrinsic PEEP) peak expiratory flow rate esophageal pressure partial pressure of end-tidal carbon dioxide pulmonary function test(ing) pressure at the inflection point of a pressure– volume curve gastric pressure high pressure during APRV relative acidity or alkalinity of a solution permissive hypercapnia pulmonary interstitial edema maximum inspiratory pressure (also MIP, MIF, NIF) intrapleural pressure (also Ppl) partial pressure of inspired oxygen peak inspiratory pressure (also Ppeak) transpulmonary pressure low pressure during APRV partial liquid ventilation mouth pressure pressurized metered-dose inhaler muscle pressure PO2 Ppeak PPHN Ppl Pplateau ppm PPST PPV PRA PRVC PS PSB psi psig Pset PSmax Pst PSV Pta PtcCO2 PtcO2 Ptm Ptr PTSD Ptt P-V PV PVC(s) Pv O2 PVR PVS Pw q2h Q  Q  C′ Q  QT  S /Q t Q S Q R RAM RAP Raw RCP RDS Re REE RI RICU ROM RM RQ RSV RT Rti RV RV/TLC% RVP RVEDP RVEDV RVSW SA SaO2 SBCO2 SCCM S.I. SI SIDS SIMV Sine SiPAP SpO2 STPD SV SVC partial pressure of oxygen peak inspiratory pressure (also PIP) primary pulmonary hypertension of the neonate intrapleural pressure plateau pressure parts per million premature pressure-support termination positive-pressure ventilation plasma renin activity pressure regulated volume control pressure support protected specimen brush pounds per square inch pounds per square inch gauge set pressure maximum pressure support static transpulmonary pressure at a specified lung volume pressure support ventilation transairway pressure transcutaneous PCO2 transcutaneous PO2 transmural pressure transrespiratory pressure posttraumatic stress disorder transthoracic pressure (also Pw) pressure–volume pressure ventilation premature ventricular contraction(s) partial pressure of oxygen in mixed venous blood pulmonary vascular resistance partial ventilatory support transthoracic pressure (also Ptt) every two hours blood volume blood flow pulmonary capillary blood volume cardiac output shunt physiologic shunt flow (total venous admixture) resistance (i.e., pressure per unit flow) random access memory right atrial pressure airway resistance respiratory care practitioner respiratory distress syndrome Reynold’s number resting energy expenditure total inspiratory resistance respiratory intensive care unit read-only memory lung recruitment maneuver respiratory quotient respiratory syncytial virus respiratory therapist tissue resistance residual volume residual volume to total lung capacity ratio right ventricular pressure right ventricular end-diastolic pressure right ventricular end-diastolic volume right ventricular stroke work sinoatrial arterial oxygen saturation single breath carbon dioxide curve Society for Critical Care Medicine Système International d’Unités stroke index sudden infant death syndrome synchronized intermittent mandatory ventilation sinusoidal positive airway pressure with periodic (sigh), bilevel positive airway pressure breaths, or bilevel continuous positive airway pressure oxygen saturation measured by pulse oximeter standard temperature and pressure (zero degrees Celsius, 760 mm Hg), dry stroke volume slow vital capacity S v O2 SVN SVR t T TAAA Tc tcCO2 TCT TE TGI TGV TI TI% TID TI/TCT Thigh Tlow TJC TLC TLV TOF torr TTN U UN USN V v V V V E V A VA VAI VALI VAP VAPS VC VCT VC-CMV VC-IMV VCIRV  2 VCO VD V D V Danat VDAN VDalv VDmech VD/VT V E VEDV V I VILI V L VLBW  2 VO VS VT VTalv VTexp VTinsp vol%  V / Q VSV W WOB WOBi wye X X Y yr ZEEP mixed venous oxygen saturation small volume nebulizer systemic vascular resistance time temperature thoracoabdominal aortic aneurysm time constant transcutaneous CO2 total cycle time expiratory time tracheal gas insufflation thoracic gas volume inspiratory time inspiratory time percent three times per day duty cycle time for high pressure delivery in APRV time for low pressure delivery in APRV The Joint Commission total lung capacity total liquid ventilation tetralogy of Fallot measurement of pressure equivalent to mm Hg transient tachypnea of the neonate unit urinary nitrogen ultrasonic nebulizer gas volume venous mixed venous flow expired minute ventilation alveolar ventilation per minute alveolar gas volume ventilator-assisted individuals ventilator-associated lung injury ventilator-associated pneumonia volume-assured pressure support vital capacity volume lost to tubing compressibility volume-controlled continuous mandatory ventilation volume-controlled intermittent mandatory ventilation volume-controlled inverse ratio ventilation carbon dioxide production per minute volume of dead space physiologic dead space ventilation per minute anatomic dead space ventilation per minute volume of anatomic dead space alveolar dead space mechanical dead space dead space-to-tidal volume ratio expired volume ventricular end-diastolic volume inspired volume per minute ventilator-induced lung injury actual lung volume (including conducting airways) very low birth weight oxygen consumption per minute volume support tidal volume alveolar tidal volume expired tidal volume inspired tidal volume volume per 100 mL of blood ventilation/perfusion ratio volume-support ventilation work work of breathing imposed work of breathing wye- or Y-connector any variable mean value connects patient ET to patient circuit year zero end-expiratory pressure YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK! Evolve Student Resources for Cairo: Pilbeam’s Mechanical Ventilation, 6th Edition, include the following: • NBRC Correlation Guide. • Workbook Answer Key. Activate the complete learning experience that comes with each textbook purchase by registering at http://evolve.elsevier.com/Cairo/Pilbeams/Ventilation/ REGISTER TODAY! You can now purchase Elsevier products on Evolve! Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products.  C H A P T E R Mechanical Ventilation Physiological and Clinical Applications  PILBEAM’S Mechanical Ventilation Physiological and Clinical Applications 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 C H A P T E R 3251 Riverport Lane St. Louis, Missouri 63043 Pilbeam’s Mechanical Ventilation, Physiological and Clinical Applications, Sixth edition Copyright © 2016 by Elsevier, Inc. All rights reserved. ISBN: 978-0-323-32009-2 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). 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 2012, 2006, and 1998. Library of Congress Cataloging-in-Publication Data Cairo, Jimmy M., author. Pilbeam’s mechanical ventilation : physiological and clinical applications / J.M. Cairo.—Sixth edition.    p. ; cm. Mechanical ventilation ISBN 978-0-323-32009-2 (pbk. : alk. paper) I. Title. II. Title: Mechanical ventilation. [DNLM: 1. Respiration Disorders—therapy. 2. Respiration, Artificial. 3. Ventilators, Mechanical. WF 145] RC735.I5 615.8′36—dc23    2015016179 Content Strategist: Sonya Seigafuse Content Development Manager: Billie Sharp Content Development Specialist: Charlene Ketchum Publishing Services Manager: Julie Eddy Project Manager: Sara Alsup Design Direction: Teresa McBryan Cover Designer: Ryan Cook Text Designer: Ryan Cook Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 To Palmer Grace Wade For reminding us what is truly important in life.  C H A P T E R Contributors Robert M. DiBlasi, RRT-NPS, FAARC Seattle Children’s Hospital Seattle, Washington Terry L. Forrette, MHS, RRT, FAARC Adjunct Associate Professor of Cardiopulmonary Science LSU Health Sciences Center New Orleans, Louisiana Christine Kearney, BS, RRT-NPS Clinical Supervisor of Respiratory Care Seattle Children’s Hospital Seattle, Washington ANCILLARY CONTRIBUTOR Sandra T. Hinski, MS, RRT-NPS Faculty, Respiratory Care Division Gateway Community College Phoenix, Arizona REVIEWERS Allen Barbaro, MS, RRT Department Chairman, Respiratory Care Education St. Luke’s College Sioux City, Iowa J. Kenneth Le Jeune, MS, RRT, CPFT Program Director, Respiratory Education University of Arkansas Community College at Hope Hope, Arkansas Tim Op’t Holt, EdD, RRT, AE-C, FAARC Professor University of South Alabama Mobile, Alabama Stephen Wehrman, RRT, RPFT, AE-C Professor University of Hawaii Program Director Kapiolani Community College Honolulu, Hawaii Richard Wettstein, MMEd, FAARC Director of Clinical Education University of Texas Health Science Center at San Antonio San Antonio, Texas Mary-Rose Wiesner, BS, BCP, RRT Program Director Department Chair Mt. San Antonio College Walnut, California Margaret-Ann Carno, PhD, MBA, CPNP, ABSM, FNAP Assistant Professor of Clinical Nursing and Pediatrics School of Nursing University of Rochester Rochester, New York vii  C H A P T E R Acknowledgments A number of individuals should be recognized for their contributions to this project. I wish to offer my sincere gratitude to Sue Pilbeam for her continued support throughout this project and for her many years of service to the Respiratory Care profession. I also wish to thank Terry Forrette, MHS, RRT, FAARC, for authoring the chapter on Ventilator Graphics; Rob DiBlasi, RRT-NPS, FAARC, and Christine Kearney, BS, RRT-NPS, who authored the chapter on Neonatal and Pediatric Ventilation; Theresa Gramlich, MS, RRT, for her contributions in earlier editions of this text to the chapters on Noninvasive Positive Pressure Ventilation and Long-Term Ventilation; Paul Barraza, RCP, RRT, for his contributions to the content of the chapter on Special Techniques in Ventilatory Support. I also wish to thank Sandra Hinski, MS, RRT-NPS, for authoring the ancillaries that accompany this text, and Amanda Dexter, MS, RRT, and Gary Milne, BS, RRT, for their suggestions related to ventilator graphics. As in previous editions, I want to express my sincere appreciation to all of the Respiratory Therapy educators and students who provided valuable suggestions and comments during the course of writing and editing the sixth edition of Pilbeam’s Mechanical Ventilation. I would like to offer special thanks for the guidance provided by the staff of Elsevier throughout this project, particularly Content Development Strategist, Sonya Seigafuse; Content Development Manager, Billie Sharp; Content Development Specialist, Charlene Ketchum; Project Manager, Sara Alsup; and Publishing Services Manager, Julie Eddy. 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. My wife, Rhonda, has provided loving support for me and for all of our family throughout the preparation of this edition. Her gift of unconditional love and encouragement to our family inspires me every day. ix