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Fundamentals oF Respiratory Care

ROBERT M . I JA'MES K . I ALBERT J . KACMAREK STOLLER HEUER

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Δ change in µ micro- µg microgram µm micrometer µV microvolt A alveolar a arterial AARC American Association for Respiratory Care ABG(s) arterial blood gas(es) A/C assist/control ACBT active cycle of breathing technique ADH antidiuretic hormone AIDS acquired immunodeficiency syndrome AII airborne infection isolation ALI acute lung injury ALV adaptive lung ventilation ANP atrial natriuretic peptide AOP apnea of prematurity APRV airway pressure release ventilation ARDS acute respiratory distress syndrome ARF acute respiratory failure ASV adaptive support ventilation ATC automatic tube compensation ATM atmospheric pressure ATPD ambient temperature and pressure, dry ATPS ambient temperature and pressure, saturated

with water vapor auto-PEEP unintended positive end expiratory pressure AV arteriovenous AVP arginine vasopressin B barometric BAC blood alcohol content BE base excess bilevel PAP bilevel positive airway pressure BiPAP registered trade name for bilevel PAP device BP blood pressure BPD bronchopulmonary dysplasia BSA body surface area BTPS body temperature and pressure, saturated with

water vapor BUN blood urea nitrogen C compliance c capillary C′ pulmonary-end capillary ° C degrees of Celsius CaO2 arterial content of oxygen C a v O( )− 2 arterial-to-mixed venous oxygen content

difference CC closing capacity cc cubic centimeter Cc′O2 content of oxygen of the ideal alveolar capillary CD dynamic characteristic or dynamic compliance CDC U.S. Centers for Disease Control and Prevention CDH congenital diaphragmatic hernia CHF congestive heart failure CI cardiac index CINAHL Cumulative Index to Nursing and Allied Health

Literature CL lung compliance (also CLung) cm centimeters cm H2O centimeters of water pressure CMS Centers for Medicare and Medicaid Services CMV controlled (continuous) mandatory or mechanical

ventilation CNS central nervous system CO carbon monoxide

ABBREVIATIONS

CO2 carbon dioxide COHb carboxyhemoglobin COLD chronic obstructive lung disease COPD chronic obstructive pulmonary disease CPAP continuous positive airway pressure CPG Clinical Practice Guideline CPOE computerized physician order entry CPP cerebral perfusion pressure CPPB continuous positive pressure breathing CPPV continuous positive pressure ventilation CPR cardiopulmonary resuscitation CPT chest physical therapy CPU central processing unit CQI continuous quality improvement CRCE continuing respiratory care education Cs static compliance CSF cerebrospinal fluid CSV continuous spontaneous ventilation CT computed tomography CT tubing compliance (also Ctubing) CV closing volume CvO2 venous oxygen content CvO2 mixed venous oxygen content CVP central venous pressure D diffusing capacity d diameter DC discharges, discontinue DC-CMV dual controlled–continuous mandatory

ventilation DC-CSV dual controlled–continuous spontaneous

ventilation DIC disseminated intravascular coagulation Dm diffusing capacity of the alveolocapillary

membrane DO2 oxygen delivery DPAP demand positive airway pressure DPPC dipalmitoyl phosphatidylcholine DVT deep venous thrombosis E elastance EAdi electrical activity of the diaphragm ECCO2R extracorporeal carbon dioxide removal ECG electrocardiogram ECLS extracorporeal life support ECMO extracorporeal membrane oxygenation EDV end-diastolic volume EE energy expenditure EEP end expiratory pressure EHR electronic health record EIB exercise-induced bronchospasm EMR electronic medical record EPAP end positive airway pressure ERV expiratory reserve volume ET endotracheal tube ETCO2 or etCO2 end-tidal CO2 F fractional concentration of a gas ° F degrees Fahrenheit f respiratory frequency, respiratory rate FDA U.S. Food and Drug Administration FEF forced expiratory flow FEFmax maximal forced expiratory flow achieved during

FVC FEFX forced expiratory flow, related to some portion

of FVC curve FETX forced expiratory time for a specified portion of

FVC FEV1 forced expiratory volume at 1 second

FiCO2 fractional inspired carbon dioxide FIF forced inspiratory flow FiO2 fractional inspired oxygen FIVC forced inspiratory vital capacity FRC functional residual capacity FVC forced vital capacity FVS full ventilatory support f/VT rapid shallow breathing index (frequency divided

by tidal volume) Gaw airway conductance g/dl grams per deciliter [H+] hydrogen ion concentration HAP hospital-acquired pneumonia Hb hemoglobin HBO hyperbaric oxygen (therapy) HCAP health care–associated pneumonia HCH hygroscopic condenser humidifier HCO3− bicarbonate H2CO3 carbonic acid He helium He/O2 helium/oxygen mixture; heliox HFFI high-frequency flow interrupter HFJV high-frequency jet ventilation HFNC high-flow nasal cannula HFO high-frequency oscillation HFOV high-frequency oscillatory ventilation HFPV high-frequency percussive ventilation HFPPV high-frequency positive pressure ventilation HFV high-frequency ventilation HHb reduced or deoxygenated hemoglobin HMD hyaline membrane disease HME heat and moisture exchanger HMEF heat and moisture exchange filter H2O water HR heart rate ht height Hz hertz IBW ideal body weight I inspired IC inspiratory capacity ICP intracranial pressure ICU intensive care unit ID inner diameter I:E inspiratory-to-expiratory ratio ILD interstitial lung disease IMPRV intermittent mandatory pressure release

ventilation IMV intermittent mandatory ventilation INO inhaled nitric oxide IPAP inspiratory positive airway pressure IPPB intermittent positive pressure breathing IPPV intermittent positive pressure ventilation IR infrared IRB institutional review board IRDS infant respiratory distress syndrome IRV inverse ratio ventilation IRV inspiratory reserve volume IV intravenous IVC inspiratory vital capacity IVH intraventricular hemorrhage IVOX intravascular oxygenator kcal kilocalorie kg kilogram kg-m kilogram-meters kPa kilopascal KPI key performance indicator L liter LAP left atrial pressure

lb pound LBW low birth weight LED light emitting diode LFPPV-ECCO2R low-frequency positive pressure ventilation with

extracorporeal carbon dioxide removal LMS learning management system LTACH long term acute care hospital LV left ventricle LVEDP left ventricular end-diastolic pressure LVEDV left ventricular end-diastolic volume LVSW left ventricular stroke work m2 meters squared MABP mean arterial blood pressure MAlvP mean alveolar pressure MAP mean arterial pressure or mean airway pressure MAS meconium aspiration syndrome max maximal MDI metered dose inhaler MDR multidrug resistant mEq/L milliequivalents per liter MEP maximum expiratory pressure metHb methemoglobin mg milligram mg% milligram percent mg/dl milligrams per deciliter MI myocardial infarction MICP mobile intensive care paramedic MI-E mechanical insufflation-exsufflation MIF maximum inspiratory force MIGET multiple inert gas elimination technique min minute MIP maximum inspiratory pressure ml milliliter mm millimeter MMAD median mass aerodynamic diameter mm Hg millimeters of mercury mmol millimole MMV mandatory minute ventilation mo month MOV minimal occluding volume mPaw − Paw mean airway pressure MRI magnetic resonance imaging msec millisecond MV mechanical ventilation MVV maximum voluntary ventilation NaBr sodium bromide NaCl sodium chloride NAVA neurally adjusted ventilatory assist NBRC National Board of Respiratory Care NEEP negative end expiratory pressure nHFOV nasal high-frequency oscillatory ventilation NICU neonatal intensive care unit NIF negative inspiratory force (also see MIP and MIF) NIH National Institutes of Health NIV noninvasive ventilation nM nanomole nm nanometer NMBA neuromuscular blocking agent nM/L nanomole per liter NO nitric oxide NO2 nitrous oxide NP nasopharyngeal NPO nothing by mouth NPV negative pressure ventilation NPPV noninvasive positive pressure ventilation NSAIDs nonsteroidal antiinflammatory drugs nSIMV nasal synchronized intermittent mandatory

ventilation

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EGAN’S Fundamentals OF Respiratory Care

Robert M. Kacmarek, PhD, RRT Professor of Anesthesiology

Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School;

Director of Respiratory Care Respiratory Care Services

Massachusetts General Hospital Boston, Massachusetts

James K. Stoller, MD, MS, FAARC, FCCP Jean Wall Bennett Professor of Medicine

Cleveland Clinic Lerner College of Medicine; Chair, Education Institute

Cleveland Clinic Cleveland, Ohio

Albert J. Heuer, PhD, MBA, RRT, RPFT Program Director and Professor

Masters of Science in Health Care Management & Respiratory Care Program Rutgers, School of Health Related Professions

Newark, New Jersey

Consulting Editors

EDITION 11

Robert L. Chatburn, MHHS, RRT-NPS, FAARC

Adjunct Professor Department of Medicine

Cleveland Clinic Lerner College of Medicine; Clinical Research Manager

Department of Respiratory Therapy Cleveland Clinic Cleveland, Ohio

Richard H. Kallet, MS, RRT

Director of Quality Assurance Respiratory Care Division Department of Anesthesia

University of California, San Francisco; San Francisco General Hospital

San Francisco, California

3251 Riverport Lane St. Louis, Missouri 63043

EGAN’S FUNDAMENTALS OF RESPIRATORY CARE, ELEVENTH EDITION ISBN: 978-0-323-34136-3

Copyright © 2017 by Elsevier, Inc. All rights reserved.

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.

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Previous editions copyrighted 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, and 1969.

Library of Congress Cataloging-in-Publication Data

Egan’s fundamentals of respiratory care / [edited by] Robert M. Kacmarek, James K. Stoller, Albert J. Heuer ; consulting editors, Robert L. Chatburn, Richard H. Kallet.—Eleventh edition. p. ; cm. Fundamentals of respiratory care Includes bibliographical references and index. ISBN 978-0-323-34136-3 (hardcover : alk. paper) I. Kacmarek, Robert M., editor. II. Stoller, James K., editor. III. Heuer, Albert J., editor. IV. Chatburn, Robert L., editor. V. Kallet, Richard H., editor. VI. Title: Fundamentals of respiratory care. [DNLM: 1. Respiratory Therapy–methods. 2. Respiratory Tract Diseases–therapy. WF 145] RM161 615.8′36–dc23 2015036692

Content Strategist: Sonya Seigafuse Content Development Manager: Billie Sharp Content Development Specialist: Heather Yocum Publishing Services Manager: Catherine Jackson Senior Project Manager: Rachel E. McMullen Design Direction: Renee Duenow

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

http://www.elsevier.com/permissions
For Robert, Julia, Katie, and Callie, who all make it worthwhile, and for Cristina who has

made me whole again.

RMK

I dedicate this work to the memory of my parents, Norma and Alfred Stoller, who instilled

the values of rigor and commitment that inform this book; to my wife, Terry Stoller, whose

love and support have been the foundation upon which my contribution to this book is

possible; to our son, Jake Fox Stoller, whose shining promise gives purpose and

illuminates the world; and to generations of Respiratory Therapists, whose

daily activities and commitment better our health and give hope.

JKS

To my mother, who is long gone from this earth, but continues to be the most dominant,

positive influence in my life. Mom taught me many lessons, including that failure is

to be expected on the way to success, and excellence can only be achieved through

hard work, sacrifice, and perseverance. These lessons have proven invaluable and,

hence, my work on this text is dedicated to my mother, Edith; as well as

my wife, Laurel; my faculty and students; fellow respiratory therapists;

and the patients we tirelessly serve.

AJH

vi

Contributors

Loutfi S. Aboussouan, MD Staff Respiratory Institute Cleveland Clinic Cleveland, Ohio

Neila Altobelli, BA, RRT Respiratory Therapist, Clinical Scholar, Clinical Educator Department of Respiratory Care Massachusetts General Hospital Boston, Massachusetts

Arzu Ari, PhD, RRT, PT, CPFT, FAARC Associate Professor Department of Respiratory Therapy Georgia State University Atlanta, Georgia

Rendell W. Ashton, MD Pulmonary and Critical Care Fellowship Program Director Department of Critical Care Medicine Cleveland Clinic Cleveland, Ohio

Joseph T. Azok, MD Staff Radiologist Section of Thoracic Imaging, Imaging Institute Cleveland Clinic Cleveland, Ohio

Jami E. Baltz, RD, CNSC Clinical Dietitian Department of Clinical Nutrition Stanford Health Care Stanford, California

Lorenzo Berra, MD Assistant Professor of Anesthesia Department of Anesthesia Harvard Medical School; Anesthesiologist and Intensivist Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Boston, Massachusetts

Thomas A. Barnes, EdD, RRT, FAARC Professor Emeritus of Cardiopulmonary Sciences Master of Science in Respiratory Care Leadership Program Northeastern University Boston, Massachusetts

Will Beachey, PhD, RRT, FAARC Professor and Chair Department of Respiratory Therapy University of Mary/CHI St. Alexius Health Bismarck, North Dakota

Jason Bordelon, MHA, RRT Director Department of Respiratory & Clinical Diagnostics Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates

Jeffrey T. Chapman, MD Chief Respiratory & Critical Care Institute Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates

Robert L. Chatburn, MHHS, RRT-NPS, FAARC Adjunct Professor Department of Medicine Cleveland Clinic Lerner College of Medicine; Clinical Research Manager Department of Respiratory Therapy Cleveland Clinic Cleveland, Ohio

Daniel W. Chipman, BS, RRT Assistant Director Respiratory Care Massachusetts General Hospital Boston, Massachusetts

Zaza Cohen, MD, FCCP Medical Director, Respiratory Care Program—North Rutgers School of Health Related Professions Newark, New Jersey; Director, Intensive Care Unit Hackensack University Medical Center—Mountainside Montclair, New Jersey

Contributors vii

Douglas D. Deming, MD Professor and Chief Division of Neonatology Department of Pediatrics Loma Linda University School of Medicine Loma Linda, California

Anthony L. DeWitt, RRT, CRT, BHA, JD Partner Bartimus, Frickleton, Robertson & Goza, PC Jefferson City, Missouri

Enrique Diaz-Guzman, MD Associate Professor of Medicine Division of Pulmonary, Critical Care and Sleep Medicine University of Alabama at Birmingham Birmingham, Alabama

Patrick J. Dunne, MEd, RRT, FAARC President/CEP HealthCare Productions, Inc. Fullerton, California

Raed A. Dweik, MD, FACP, FRCP(C), FCCP, FCCM, FAHA Professor of Medicine Cleveland Clinic Lerner College of Medicine; Director, Pulmonary Vascular Program Departments of Pulmonary and Critical Care Medicine/

Respiratory Institute Cleveland Clinic Cleveland, Ohio

Patricia English, MS, RRT ECMO Program Coordinator Department of Respiratory Care Massachusetts General Hospital Boston, Massachusetts

Matthew C. Exline, MD, MPH Assistant Professor; Medical Director, Medical Intensive Care

Unit Division of Pulmonary, Allergy, Critical Care, and Sleep

Medicine The Ohio State University Columbus, Ohio

James B. Fink, RRT, NPS, PhD, FAARC, FCCP Adjunct Professor Division of Respiratory Therapy Georgia State University Atlanta, Georgia

Daniel F. Fisher, MS, RRT Assistant Director Respiratory Care Services Massachusetts General Hospital Boston, Massachusetts

Crystal L. Fishman, BS, RRT Faculty Instructor Respiratory Care Program Rutgers School of Health Related Professions Newark, New Jersey

Thomas G. Fraser, MD Vice Chairman Department of Infectious Disease Cleveland Clinic Cleveland, Ohio

Douglas S. Gardenhire, EdD, RRT-NPS, FAARC Chair and Clinical Associate Professor Department of Respiratory Therapy Georgia State University Atlanta, Georgia

Donna D. Gardner, Dr(c)PH, RRT, FAARC Chair, Department of Respiratory Care Interim Chair, Department of Clinical Laboratory Sciences University of Texas Health Science Center at San Antonio San Antonio, Texas

Michael A. Gentile, RRT, FAARC, FCCM Associate in Research Department of Critical Care Medicine Duke University Medical Center Durham, North Carolina

Umur Hatipoğlu, MD Quality Improvement Officer Respiratory Institute Cleveland Clinic Cleveland, Ohio

Albert J. Heuer, PhD, MBA, RRT, RPFT Program Director and Professor Masters of Science in Health Care Management & Respiratory

Care Program Rutgers, School of Health Related Professions Newark, New Jersey

viii Contributors

R. Duncan Hite, MD Chairman Department of Critical Care Medicine Respiratory Institute Cleveland Clinic Cleveland, Ohio

Robert M. Kacmarek, PhD, RRT Professor of Anesthesiology Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School; Director of Respiratory Care Respiratory Care Services Massachusetts General Hospital Boston, Massachusetts

Richard H. Kallet, MS, RRT Director of Quality Assurance Respiratory Care Division Department of Anesthesia University of California, San Francisco; San Francisco General Hospital San Francisco, California

Danai Khemasuwan, MD, MBA Fellow Department of Interventional Pulmonary Medicine Henry Ford Hospital Detroit, Michigan

Euhan John Lee, MD Clinical Assistant Professor of Medicine Division of Pulmonary, Allergy, and Critical Care Medicine University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

David L. Longworth, MD Lahey Health System and Lahey Hospital and Medical Center Division of Primary Care Lahey Health System Burlington, Massachusetts

Sarah A. Longworth, MD Clinical Fellow Department of Infectious Disease Hospital of University of Pennsylvania Philadelphia, Pennsylvania

Scott P. Marlow, BA, RRT Pulmonary Rehabilitation Coordinator Respiratory Institute Cleveland Clinic Cleveland, Ohio

Peter J. Mazzone, MD, MPH, FCCP Director of Lung Cancer Program Respiratory Institute Cleveland Clinic Cleveland, Ohio

Atul C. Mehta, MBBS, FACP, FCCP Professor of Medicine Cleveland Clinic Lerner College of Medicine; Staff Physician Department of Pulmonary Medicine, Respiratory Institute Cleveland Clinic Cleveland, Ohio; Senior Editor Journal of Bronchology and Interventional Pulmonology

Michele Messam, BSMT(ASCP), CIC Infection Preventionist Infection Prevention, Quality and Patient Safety Institute Cleveland Clinic Cleveland, Ohio

Eduardo Mireles-Cabodevila, MD Assistant Professor of Medicine Department of Pulmonary, Allergy and Critical Care Medicine Cleveland Clinic Lerner College of Medicine; Program Director, Critical Care Medicine Fellowship Department of Critical Care Medicine, Respiratory Institute Cleveland Clinic Cleveland, Ohio

Ariel M. Modrykamien, MD, FACP, FCCP Clinical Associate Professor of Medicine Department of Medicine Texas A&M University—Health Science Center; Medical Director, Respiratory Therapy and Pulmonary

Function Laboratory Department of Pulmonary and Critical Care Medicine Baylor University Medical Center Dallas, Texas

Kimberly N. Otsuka, MD Assistant Professor of Pediatrics Division of Allergy, Immunology, and Pulmonology Loma Linda University School of Medicine Loma Linda, California