The Essentials for

Patient Care and Evaluation

Table of Contents

Historical perspective1
Chapter 1: Clinical Approach7
Schema for diagnosis and management7
Physical Examination10
Chest x-ray examination12
Arterial blood gas analysis19
Sputnum examination20
Other tests and procedures20
Evaluation of dyspnea21
Bedside vs. Laboratory25
Review questions26
Chapter 2: Structure and Function 27
Gas properties27
The atmosphere28
Gas laws30
Gases in solution32
Breathing-an overview of gas exchange33
Lung disease and the respiratory system 41
Review questions42
Chapter 3: Lung Mechanics43
Breathing-a mechanical function43
Pressure, volume, and flow44
Generation of airway pressures44
Lung compliance46
Airway resistance48
Lung volumes and capacities49
Functional residual capacity50
Forced vital capacity52
Flow-volume curves and loops57
Determinants for expiratory airflow60
Small airways disease and dynamic compliance 64
Clinical value of using spirometry 65
Mechanics and gas exchange-correlation? 71
Review questions73
Chapter 4: Pco2 and Alveolar Ventilation 74
Ventilation-minute, alveolar, and dead space 74
Pco2-its relation to alveolar ventilation and carbon dioxide 75
Pco2 and the respiratory quotient 77
Hyperventilation and hypoventilation78
Clinical importance of the Pco2 equation 79
Pco2 in the clinical setting 79
Physiologic basis for hypercapnia80
Vd/Vt and the Bohr dead space equation 82
Dangers of hypercapnia80
Paco2 and need for ventilatory assistance 84
Noninvasive measurement of Pco2 85
Paco2-its relationship to oxygenation and acid-base balance 86
Review questions87
Chapter 5: Oxygen Transfer88
Clinical questions88
Lung oxygen transfer88
Oxygen diffusion and diffusing capacity 90
Alveolar oxygen pressure92
Arterial oxygen pressure93
Alveolar-arterial oxygen pressure difference 93
Pao2/Pao2 and Pao2/Flo2 95
Causes of low Pao295
Nonrespiratory causes of low Pao2 96
Respiratory causes of low Pao2 98
Ventilation-perfusion imbalance98
Shunts and venous admixture103
How V/Q imbalance reduces Pao2 and increases Paco2 104
Low mixed venous oxygen-effect on Pao2 106
V/Q imbalance in patients-variable effect on oxygen and carbon 107
Review questions110
Chapter 6: Is the Patient Adequately Oxygenated? 112
Clinical assessment112
Hypoxemia vs. Hypoxia113
The oxygenation cycle114
Sao2 and oxygen content 115
Shifts of oxygen dissociation curve and P50 116
Carbon monoxide118
Carbon monoxide exposure and its effects 120
Methemoglobinemia and sulfhemoglobinemia 121
Causes of reduced Sao2122
Oxygen delivery123
Fick equation123
Mixed venous oxygen saturation124
Review Questions127
Chapter 7: Acid-base Balance129
Hydrogen ion homeostatis129
Concept of pH130
Buffer systems130
Henderson-Hasselbalch equation131
Does the patient have an acid-base disorder? 132
Calculated vs. Measured HCO3 132
Acid-base nomogram132
Acidemia and alkalemia134
Anion gap137
Primary vs. Compensatory processes137
Acid-base map138
In vitro titration curve for carbon dioxide 139
Base excess140
Acute vs. chronic respiratory disorders 140
Acute vs. chronic metabolic disorders141
Mixed acid-base disorders143
Clinical approach to acid-base diagnosis 144
Review questions145
Chapter 8: Pulmonary Circulation 147
Pulmonary vs. systematic circulation147
Pulmonary hypertension and right heart failure 149
Causes of pulmonary hypertension 150
Assessment of hemodynamic status152
Swan-Ganz catheterization153
Insertion of Swan-Ganz catheter-pressure tracings 156
Hemodynamic measurements and calculations 158
Pulmonary artery wedge pressure-measurement 161
Pulmonary artery wedge pressure-what does it represent? 165
Pitfalls and complications in hemodynamic monitoring 170
Hemodynamic monitoring in clinical practice 171
Review questions174
Chapter 9: Oxygen Therapy175
Oxygen as a drug175
Terminology in oxygen therapy179
When to institute oxygen therapy179
Classification of oxygen therapy180
Low-supplemental Flo2 therapy 180
High-supplemental Flo2 therapy 184
Potential harm from oxygen therapy187
Positive airway pressure and oxygen therapy 187
Hyperbaric oxygen187
Monitoring oxygen187
Monitoring oxygen therapy-clinical signs and Pao2 188
Blood transfusion-effect on Pao2 and oxygen content 190
Artificial blood190
Methods of home oxygen therapy190
Indications for home oxygen therapy193
Review questions195
Chapter 10: Artificial Ventilation 197
Intubation and artificial ventilation197
Indications for artificial ventilation 200
Mode of artificial ventilation and Flo2 201
Normal breathing vs. ventilator breathing 201
Controlled ventilation 202
Assist- control ventilation202
Intermittent mandatory ventilation 204
Ventilator settings206
Ventilator compliance209
High-frequency ventilation209
Positive end expiratory pressure211
Continuous positive airway pressure212
Complications of artificial ventilation 213
Ventilator weaning215
Review questions217
Chapter 11: Respiratory failure 219
Definition of respiratory failure219
Physiologic classification of respiratory failure 220
Clinical classification of respiratory failure 221
Acute vs. chronic respiratory failure221
Pulmonary edema221
Shunt equation223
Adult respiratory distress syndrome225
Physiological manifestations of ARDS227
Management of ARDS228
A case of oxygenation respiratory failure 229
Respiratory failure in chronic obstructive pulmonary disease 233
A case of combined ventilatory and oxygenation failure in COPD 234
Review questions237
Chapter 12: Exercise Physiology 239
Exercise physiology239
What happens during exercise?239
Metabolism during exercise-aerobic vs. anaerobic 240
Paco2 during exercise241
The exercise test242
Physiologic changes during exercise244
Normal exercise parameters249
Clinical use of physiological exercise testing 249
Clinical interpretation of physiologic exercise testing 250
Review questions254
Chapter 13: Pleural Effusions256
Pleural fluid dynamics 261
Transudates vs. exudates262
Diagnostic procedures264
Determining cause of exudative effusion 266
Selected pleural fluid laboratory tests 268
Mechanism of pleural fluid acidosis270
Use of laboratory tests in specific exudative effusions 271
Chest tube drainage276
Obliteration of the pleural space279
Pleural effusion, lung mechanics, and gas exchange 280
Review questions281
Chapter 14: Sleep Disorders283
The study of sleep disorders283
Normal sleep286
Sleep apnea289
Obstructive sleep apnea292
Pickwickian syndrome294
Ondine's curse295
Cheyne-Stokes breathing298
Review questions 300
Chapter 15: Newborn and infant301
Changes at birth301
Apgar score304
The pediatric history305
Vital signs306
Physical examination309
Chest x-ray examination312
Pulmonary function tests313
Blood gases314
Ventilation-perfusion imbalance317
Oxygen therapy317
Hemodynamic assessment318
Sudden infant death syndrome319
Infant respiratory distress syndrome320
Review questions323
A Answers to clinical problems325
B Normal values for FVC and FEV1 357
C Basic equations and formulas360
D Abbreviations and symbols362
E Glossary364
F Common clinical conditions372
G General references382
H Microcomputer programs384