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Transcript of Copyright © 2006 by Mosby, Inc. Slide 1 Section III The Therapist-Driven Protocol Program— The...
![Page 1: Copyright © 2006 by Mosby, Inc. Slide 1 Section III The Therapist-Driven Protocol Program— The Essentials.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d6e5503460f94a4ecc8/html5/thumbnails/1.jpg)
Copyright © 2006 by Mosby, Inc.Slide 1
Section IIISection III
The The Therapist-Driven Protocol Program—Therapist-Driven Protocol Program—
The EssentialsThe Essentials
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Copyright © 2006 by Mosby, Inc.Slide 2
Chapter 9Chapter 9
The Therapist-Driven Protocol The Therapist-Driven Protocol Program and the Role of the Program and the Role of the Respiratory Care PractitionerRespiratory Care Practitioner
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Copyright © 2006 by Mosby, Inc.Slide 3
Therapist-Driven Protocols Therapist-Driven Protocols (TDPs) Are an Integral Part of (TDPs) Are an Integral Part of
Respiratory Care Health ServicesRespiratory Care Health Services
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Copyright © 2006 by Mosby, Inc.Slide 4
The Purpose of TDPsThe Purpose of TDPs
Deliver individualized diagnostic and Deliver individualized diagnostic and therapeutic respiratory to patientstherapeutic respiratory to patients
Assist the physician with evaluating patients’ Assist the physician with evaluating patients’ respiratory care needs and to optimize the respiratory care needs and to optimize the allocation of respiratory care servicesallocation of respiratory care services
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Copyright © 2006 by Mosby, Inc.Slide 5
The Purpose of TDPsThe Purpose of TDPs
Determine the indications for respiratory Determine the indications for respiratory therapy and the appropriate modalities for therapy and the appropriate modalities for providing quality, cost-effective care that providing quality, cost-effective care that improves patient outcomes and decreases improves patient outcomes and decreases length of staylength of stay
Empower respiratory care practitioners to Empower respiratory care practitioners to allocate care using sign- and symptom-based allocate care using sign- and symptom-based algorithms for respiratory treatmentalgorithms for respiratory treatment
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Copyright © 2006 by Mosby, Inc.Slide 6
Respiratory TDPsRespiratory TDPs
Give practitioner authority to:Give practitioner authority to:
Gather clinical information related to the Gather clinical information related to the patient’s respiratory statuspatient’s respiratory status
Make an assessment of the clinical data Make an assessment of the clinical data collectedcollected
Start, increase, decrease, or discontinue Start, increase, decrease, or discontinue certain respiratory therapies on a moment-certain respiratory therapies on a moment-to-moment basisto-moment basis
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Copyright © 2006 by Mosby, Inc.Slide 7
The Innate Beauty of Respiratory The Innate Beauty of Respiratory TDPs Is That:TDPs Is That:
1.1. The physician is always in the “information The physician is always in the “information loop” regarding patient careloop” regarding patient care
2.2. Therapy can be quickly modified in response Therapy can be quickly modified in response to the specific and immediate needs of the to the specific and immediate needs of the patientpatient
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Copyright © 2006 by Mosby, Inc.Slide 8
Clinical Research VerifiesClinical Research VerifiesThese FactsThese Facts
Respiratory TDPsRespiratory TDPs
1.1. Significantly improve respiratory therapy Significantly improve respiratory therapy outcomes, andoutcomes, and
2.2. Appreciably lower therapy costsAppreciably lower therapy costs
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Copyright © 2006 by Mosby, Inc.Slide 9
Figure 9-1. The promise of a good TDP program.Figure 9-1. The promise of a good TDP program.
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Copyright © 2006 by Mosby, Inc.Slide 10
Figure 9-2. Figure 9-2. No Assessment Program in Place.No Assessment Program in Place.
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Copyright © 2006 by Mosby, Inc.Slide 11
The Knowledge Base Required for a The Knowledge Base Required for a Successful TDP ProgramSuccessful TDP Program
The essential knowledge base includes the:The essential knowledge base includes the:
Anatomic alterations of the lungsAnatomic alterations of the lungs
Pathophysiologic mechanisms activatedPathophysiologic mechanisms activated
Clinical manifestations that developClinical manifestations that develop
Treatment modalities used to correct the Treatment modalities used to correct the problemproblem
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Copyright © 2006 by Mosby, Inc.Slide 12
Figure 9-3. Foundations for a strong TDP program. Overview of the Figure 9-3. Foundations for a strong TDP program. Overview of the essential knowledge base for assessment of respiratory diseases. essential knowledge base for assessment of respiratory diseases.
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Copyright © 2006 by Mosby, Inc.Slide 13
The Assessment Process Skills Required The Assessment Process Skills Required for a Successful TDP Programfor a Successful TDP Program
The practitioner must: The practitioner must:
Systematically gather clinical informationSystematically gather clinical information
Formulate an assessmentFormulate an assessment
Select an optimal treatmentSelect an optimal treatment
Document in a clear and precise mannerDocument in a clear and precise manner
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Copyright © 2006 by Mosby, Inc.Slide 14
Figure 9-4. Figure 9-4. The way knowledge, assessment, and a TDP program interface.The way knowledge, assessment, and a TDP program interface.
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Copyright © 2006 by Mosby, Inc.Slide 15
Common Respiratory Assessments—Common Respiratory Assessments—Excerpts (see Table 9-1)Excerpts (see Table 9-1)
Clinical DataClinical Data AssessmentAssessment
WheezingWheezing BronchospasmBronchospasm
RhonchiRhonchi Secretions in large airwaysSecretions in large airways
Weak coughWeak cough Poor ability to mobilize Poor ability to mobilize secretionssecretions
ABGsABGs Acute ventilatory failureAcute ventilatory failure pHpH 7.24 7.24 PaPaCOCO22 73 73
HCOHCO33-- 27 27
PaPaOO22 5353
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Copyright © 2006 by Mosby, Inc.Slide 16
Severity AssessmentSeverity Assessment
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Copyright © 2006 by Mosby, Inc.Slide 17
Table 9-2. Respiratory Care Protocol Table 9-2. Respiratory Care Protocol Severity Assessment—Severity Assessment—ExcerptsExcerpts
ItemItem 0 point0 point 1 point1 point 2 points2 points 3 points3 points 4 points4 points Total PointsTotal Points
Breath soundsBreath sounds ClearClear BilateralBilateral BilateralBilateral BilateralBilateral Absent and/orAbsent and/or ____________
cracklescrackles cracklescrackles wheezing,wheezing, diminishdiminish
& rhonchi& rhonchi crackles &crackles & bilateral and/orbilateral and/or
rhonchirhonchi severe wheezing,severe wheezing,
crackles, orcrackles, or
rhonchirhonchi
CoughCough Strong,Strong, ExcessiveExcessive ExcessiveExcessive ThickThick ThickThick ____________
spontaneous,spontaneous, bronchialbronchial bronchialbronchial bronchialbronchial bronchialbronchial
nonproductivenonproductive secretions &secretions & secretions butsecretions but secretions &secretions & secretions butsecretions but
strong coughstrong cough weak coughweak cough weak coughweak cough no coughno cough
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Copyright © 2006 by Mosby, Inc.Slide 18
Severity Assessment Case ExampleSeverity Assessment Case ExampleSEVERITY ASSESSMENT CASE EXAMPLESEVERITY ASSESSMENT CASE EXAMPLE
A 67-YEAR-OLD-MALE ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS A 67-YEAR-OLD-MALE ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS
WELL KNOWN TO THE TDP TEAM; HE HAD BEEN DIAGNOSED WITH CHRONIC BRONCHITIS SEVERAL WELL KNOWN TO THE TDP TEAM; HE HAD BEEN DIAGNOSED WITH CHRONIC BRONCHITIS SEVERAL
YEARS BEFORE THIS ADMISSIONYEARS BEFORE THIS ADMISSION (3 POINTS)(3 POINTS). THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE . THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE
WAS AMBULATORY, ALERT, AND COOPERATIVEWAS AMBULATORY, ALERT, AND COOPERATIVE (0 POINTS)(0 POINTS).. HE COMPLAINED OF DYSPNEA AND WAS HE COMPLAINED OF DYSPNEA AND WAS
USING HIS ACCESSORY MUSCLES OF INSPIRATIONUSING HIS ACCESSORY MUSCLES OF INSPIRATION (3 POINTS).(3 POINTS). AUSCULTATION REVEALED BILATERAL AUSCULTATION REVEALED BILATERAL
RHONCHI OVER BOTH LUNG FIELDSRHONCHI OVER BOTH LUNG FIELDS (3 POINTS)(3 POINTS). HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK . HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK
GRAY SECRETIONSGRAY SECRETIONS (3 POINTS)(3 POINTS).. A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE
LEFT LOWER LUNG LOBELEFT LOWER LUNG LOBE (3 POINTS)(3 POINTS).. ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52, ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52,
PaPaCOCO22 54, HCO 54, HCO33-- 41, AND Pa 41, AND PaOO22 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY
FAILUREFAILURE (3 POINTS)(3 POINTS)..
USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION
AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE: AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE:
TOTAL SCORE:TOTAL SCORE: 1717
TREATMENT SELECTION:TREATMENT SELECTION: CHEST PHYSICAL THERAPYCHEST PHYSICAL THERAPY
FREQUENCY OF ADMINISTRATION:FREQUENCY OF ADMINISTRATION: FOUR TIMES A DAY; AS NEEDEDFOUR TIMES A DAY; AS NEEDED
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Copyright © 2006 by Mosby, Inc.Slide 19
The Top Four Respiratory ProtocolsThe Top Four Respiratory Protocols
Oxygen therapy protocolOxygen therapy protocol
Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol
Hyperinflation therapy protocolHyperinflation therapy protocol
Aerosolized medication therapy protocolAerosolized medication therapy protocol
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Copyright © 2006 by Mosby, Inc.Slide 20
Common Respiratory Assessments Common Respiratory Assessments and Treatment Plans—Excerpts (see and Treatment Plans—Excerpts (see
Table 9-1)Table 9-1)
Clinical DataClinical Data AssessmentAssessment Tx PlanTx Plan
WheezingWheezing BronchospasmBronchospasm betabeta22 agent agent
Rhonchi &Rhonchi & Secretions in large airwaysSecretions in large airwaysWeak coughWeak cough Poor ability to mobilize secretionsPoor ability to mobilize secretions CPTCPT
ABGsABGs Acute ventilatory failureAcute ventilatory failure Mechanical ventilationMechanical ventilation
pHpH7.24 7.24
PaPaCOCO22 73 73
HCOHCO33-- 27 27
PaPaOO22 5353
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Copyright © 2006 by Mosby, Inc.Slide 21
Oxygen Therapy Oxygen Therapy Protocol 9-1Protocol 9-1
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Copyright © 2006 by Mosby, Inc.Slide 22
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Copyright © 2006 by Mosby, Inc.Slide 23
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Copyright © 2006 by Mosby, Inc.Slide 24
Oxygen Therapy Oxygen Therapy Protocol 9-1—Protocol 9-1—
Close-upsClose-ups
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Copyright © 2006 by Mosby, Inc.Slide 25
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Copyright © 2006 by Mosby, Inc.Slide 26
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Copyright © 2006 by Mosby, Inc.Slide 29
Common Common Oxygen Therapy SelectionsOxygen Therapy Selections
Nasal cannulaNasal cannula
Oxygen maskOxygen mask
Venturi maskVenturi mask
Partial rebreathing maskPartial rebreathing mask
Nonrebreathing maskNonrebreathing mask
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Copyright © 2006 by Mosby, Inc.Slide 30
Bronchopulmonary Bronchopulmonary Hygiene Therapy Hygiene Therapy
Protocol 9-2Protocol 9-2
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Copyright © 2006 by Mosby, Inc.Slide 31
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Copyright © 2006 by Mosby, Inc.Slide 33
Bronchopulmonary Hygiene Bronchopulmonary Hygiene Therapy Protocol 9-2— Therapy Protocol 9-2—
Close-upsClose-ups
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Copyright © 2006 by Mosby, Inc.Slide 35
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Copyright © 2006 by Mosby, Inc.Slide 37
Common Bronchopulmonary Common Bronchopulmonary Hygiene Therapy SelectionsHygiene Therapy Selections
Increased fluid intakeIncreased fluid intake
Cough and deep breatheCough and deep breathe
Chest physical therapyChest physical therapy
SuctioningSuctioning
Bronchoscopy assistBronchoscopy assist
Mucolytic aerosolMucolytic aerosol
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Copyright © 2006 by Mosby, Inc.Slide 38
Hyperinflation TherapyHyperinflation TherapyProtocol 9-3 Protocol 9-3
(Lung Expansion Protocol)(Lung Expansion Protocol)
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Copyright © 2006 by Mosby, Inc.Slide 41
Hyperinflation TherapyHyperinflation TherapyProtocol 9-3Protocol 9-3
(Lung Expansion Protocol)—(Lung Expansion Protocol)—Close-upsClose-ups
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Copyright © 2006 by Mosby, Inc.Slide 46
Common Common Hyperinflation Therapy SelectionsHyperinflation Therapy Selections
Cough and deep breatheCough and deep breathe
Incentive spirometryIncentive spirometry
IPPBIPPB
CPAPCPAP
PEEP PEEP
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Copyright © 2006 by Mosby, Inc.Slide 47
Aerosolized Medication Therapy Aerosolized Medication Therapy Protocol 9-4Protocol 9-4
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Aerosolized Medication Therapy Aerosolized Medication Therapy Protocol 9-4—Protocol 9-4—
Close-upsClose-ups
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Copyright © 2006 by Mosby, Inc.Slide 54
Common Aerosolized Medication Common Aerosolized Medication SelectionsSelections
Bronchodilator agentsBronchodilator agents SympathomimeticsSympathomimetics
ParasympatholyticsParasympatholytics
Mucolytic agentsMucolytic agents
Antiinflammatory agentsAntiinflammatory agents
Antibiotic agentsAntibiotic agents
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Copyright © 2006 by Mosby, Inc.Slide 55
Mechanical VentilationMechanical VentilationProtocol 9-5Protocol 9-5
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Copyright © 2006 by Mosby, Inc.Slide 56
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Copyright © 2006 by Mosby, Inc.Slide 57
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Mechanical VentilationMechanical VentilationProtocol 9-5— Protocol 9-5—
Close-upsClose-ups
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Copyright © 2006 by Mosby, Inc.Slide 60
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Copyright © 2006 by Mosby, Inc.Slide 63
Disorder: Normal Lung Mechanics Disorder: Normal Lung Mechanics but Patient Has Apneabut Patient Has Apnea
Disease characteristicsDisease characteristics Normal compliance and airway resistanceNormal compliance and airway resistance
Ventilator modeVentilator mode Volume ventilation in the AC or SIMV modeVolume ventilation in the AC or SIMV mode
Or pressure ventilation—either PRVC or PCOr pressure ventilation—either PRVC or PC
Tidal volume and respiratory rateTidal volume and respiratory rate 10 to 12 ml/kg10 to 12 ml/kg
6 to 10 bpm6 to 10 bpm
• to 10 bpm when SIMV mode is usedto 10 bpm when SIMV mode is used
Table 9-3. Common Ventilatory Management StrategiesTable 9-3. Common Ventilatory Management Strategies
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Normal Lung Mechanics, cont.Normal Lung Mechanics, cont.
Flow rateFlow rate 60 to 80 L/min60 to 80 L/min
I:E ratioI:E ratio 1:21:2
FIFIOO22
Low to moderateLow to moderate
General goals and/or concernsGeneral goals and/or concerns Care to ensure plateau pressure of 30 cm HCare to ensure plateau pressure of 30 cm H22O or lessO or less
Smaller tidal volumes (<7 ml/kg) should be avoided because Smaller tidal volumes (<7 ml/kg) should be avoided because atelectasis can developatelectasis can develop
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 65
Disorder: Chronic Obstructive Disorder: Chronic Obstructive Pulmonary Disease (COPD)Pulmonary Disease (COPD)
Disease characteristicsDisease characteristics High lung compliance and high airway resistanceHigh lung compliance and high airway resistance
Ventilator modeVentilator mode Volume ventilation in the AC or SIMV modeVolume ventilation in the AC or SIMV mode
Or pressure ventilation—either PRVC or PCOr pressure ventilation—either PRVC or PC
Noninvasive positive pressure ventilation (NPPV) is good Noninvasive positive pressure ventilation (NPPV) is good alternativealternative
Tidal volume and respiratory rateTidal volume and respiratory rate Good starting point: 10 ml/kg and 10 to12 bpmGood starting point: 10 ml/kg and 10 to12 bpm
A small tidal volume (8-10 ml/kg) and 8 to 10 bpm with A small tidal volume (8-10 ml/kg) and 8 to 10 bpm with increased flow rates to allow adequate expiratory timeincreased flow rates to allow adequate expiratory time
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 66
COPD, cont.COPD, cont. Flow rateFlow rate
60 L/min60 L/min
I:E ratioI:E ratio 1:2 or 1:31:2 or 1:3
FIFIOO22
Low to moderateLow to moderate
General goals and/or concernsGeneral goals and/or concerns Air-trapping and auto-PEEP can occur when expiratory time is too Air-trapping and auto-PEEP can occur when expiratory time is too
shortshort ↑ ↑ Expiratory time to offset auto-PEEPExpiratory time to offset auto-PEEP May ↑ inspiratory flow up to 100 L/min to ↑ expiratory timeMay ↑ inspiratory flow up to 100 L/min to ↑ expiratory time May ↓ VT or rate to ↑ expiratory timeMay ↓ VT or rate to ↑ expiratory time Do not overventilate COPD patients with chronically high PaDo not overventilate COPD patients with chronically high PaCOCO22 levels levels
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 67
Disorder: Acute Asthmatic EpisodeDisorder: Acute Asthmatic Episode
Disease characteristicsDisease characteristics High airway resistanceHigh airway resistance
Ventilator modeVentilator mode SIMV mode is recommended to offset air-trappingSIMV mode is recommended to offset air-trapping
Tidal volume and respiratory rateTidal volume and respiratory rate Good starting point: 8 to 10 ml/kg Good starting point: 8 to 10 ml/kg
Rate of 10 to 12 bpmRate of 10 to 12 bpm
When air-trapping is extensive, a lower tidal volumeWhen air-trapping is extensive, a lower tidal volume(5-6 ml/kg) and slower rate may be required(5-6 ml/kg) and slower rate may be required
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Acute Asthmatic Episode, cont.Acute Asthmatic Episode, cont. Flow rateFlow rate
60 L/min60 L/min
I:E ratioI:E ratio 1:2 or 1:31:2 or 1:3
FIFIOO22
Start at 100% and titrate downward per SpStart at 100% and titrate downward per SpOO22 and ABGs and ABGs
General goals and/or concernsGeneral goals and/or concerns In severe cases, the development of auto-PEEP may be In severe cases, the development of auto-PEEP may be
inevitable inevitable
With controlled ventilation, a small amount of PEEP to offset With controlled ventilation, a small amount of PEEP to offset auto-PEEP may be cautiously appliedauto-PEEP may be cautiously applied
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 69
Disorder: Acute Respiratory Distress Disorder: Acute Respiratory Distress SyndromeSyndrome
Disease characteristicsDisease characteristics Diffuse, uneven alveolar injuryDiffuse, uneven alveolar injury
Ventilator modeVentilator mode Volume ventilation in the AC or SIMV modeVolume ventilation in the AC or SIMV mode
Or pressure ventilation—PRVC or PCOr pressure ventilation—PRVC or PC
Tidal volume and respiratory rateTidal volume and respiratory rate Typically, started at low tidal volumes and higher ratesTypically, started at low tidal volumes and higher rates
• 8 mL/kg and adjusted downward to 6 ml/kg; or 4 ml/kg8 mL/kg and adjusted downward to 6 ml/kg; or 4 ml/kg
• Respiratory rate as high as 35 bpmRespiratory rate as high as 35 bpm
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 70
Acute Respiratory Distress Acute Respiratory Distress Syndrome, cont.Syndrome, cont.
Flow rateFlow rate 60 to 80 L/min60 to 80 L/min
I:E ratioI:E ratio 1:1 or 1:21:1 or 1:2 Do what is necessary to meet a rapid respiratory rateDo what is necessary to meet a rapid respiratory rate
FIFIOO22 Less than 0.6 if possibleLess than 0.6 if possible
General goals and/or concernsGeneral goals and/or concerns Goal is to limit transpulmonary pressuresGoal is to limit transpulmonary pressures 30 cm H30 cm H22O or less if possibleO or less if possible PEEP is usually needed to prevent atelectasisPEEP is usually needed to prevent atelectasis Permissive hypercapnia may be allowed Permissive hypercapnia may be allowed
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 71
Disorder: Postoperative Ventilatory Disorder: Postoperative Ventilatory SupportSupport
Disease characteristicsDisease characteristics Often normal compliance and airway resistanceOften normal compliance and airway resistance
Ventilator modeVentilator mode SIMV with pressure support SIMV with pressure support Or AC volume ventilationOr AC volume ventilation Or pressure ventilation—either PRVC for PCOr pressure ventilation—either PRVC for PC
Tidal volume and respiratory rateTidal volume and respiratory rate Good starting point: 10 to 12 ml/kgGood starting point: 10 to 12 ml/kg Rate of 10 to 12 bpmRate of 10 to 12 bpm
• However, larger tidal volumes (12-15 ml/kg) and slower rates However, larger tidal volumes (12-15 ml/kg) and slower rates (6-10 bpm) may be used to maintain lung volume(6-10 bpm) may be used to maintain lung volume
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 72
Postoperative Ventilatory Support, Postoperative Ventilatory Support, cont.cont.
Flow rateFlow rate 60 L/min60 L/min
I:E ratioI:E ratio 1:21:2
FIFIOO22
Low to moderateLow to moderate
General goals and/or concernsGeneral goals and/or concerns
PEEP or CPAP of 3 to 5 cm HPEEP or CPAP of 3 to 5 cm H22O may be applied O may be applied
to offset atelectasisto offset atelectasis
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 73
Disorder: Neuromuscular DisorderDisorder: Neuromuscular Disorder
Disease characteristicsDisease characteristics Normal compliance and airway resistanceNormal compliance and airway resistance
Ventilator modeVentilator mode Volume ventilation in the AC or SIMV modeVolume ventilation in the AC or SIMV mode
Or pressure ventilation—either PRVC or PCOr pressure ventilation—either PRVC or PC
Tidal volume and respiratory rateTidal volume and respiratory rate Good starting point: 12 to 15 ml/kgGood starting point: 12 to 15 ml/kg
Rate of 10 to 12 bpmRate of 10 to 12 bpm
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 74
Neuromuscular Disorder, cont.Neuromuscular Disorder, cont.
Flow rateFlow rate 60 L/min60 L/min
I:E ratioI:E ratio 1:21:2
FIFIOO22
Low to moderateLow to moderate
General goals and/or concernsGeneral goals and/or concerns PEEP of 3 to 5 cm HPEEP of 3 to 5 cm H22O may be applied to O may be applied to
offset atelectasisoffset atelectasis
Table 9-3. Common Ventilatory Management Strategies, Table 9-3. Common Ventilatory Management Strategies, cont.cont.
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Copyright © 2006 by Mosby, Inc.Slide 75
Overview Summary of a Good Overview Summary of a Good TDP ProgramTDP Program
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Copyright © 2006 by Mosby, Inc.Slide 76
Figure 9-5. Figure 9-5. Overview of the essential components of a good TDP program.Overview of the essential components of a good TDP program.
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Copyright © 2006 by Mosby, Inc.Slide 77
Figure 9-5. Close-up.Figure 9-5. Close-up.
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Copyright © 2006 by Mosby, Inc.Slide 78
Figure 9-5. Close-up.Figure 9-5. Close-up.
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Copyright © 2006 by Mosby, Inc.Slide 79
Figure 9-5. Figure 9-5. Overview of the essential components of a good TDP program.Overview of the essential components of a good TDP program.
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Copyright © 2006 by Mosby, Inc.Slide 80
Figure 9-6Figure 9-6Respiratory Care Protocol Respiratory Care Protocol
Program Assessment Form— Program Assessment Form— ExcerptsExcerpts
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Copyright © 2006 by Mosby, Inc.Slide 81
Oxygen TherapyOxygen Therapy
Clinical IndicatorsClinical Indicators
HistoryHistory
SpSpOO22 <80% <80%
PaPaOO22 <60 mm Hg <60 mm Hg
Acute hypoxemiaAcute hypoxemia ↑ ↑ Respiratory rateRespiratory rate
↑ ↑ PulsePulse
CyanosisCyanosis
ConfusionConfusion
Figure 9-6. Respiratory care protocol program assessment formFigure 9-6. Respiratory care protocol program assessment form—Example Excerpts—Example Excerpts
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Copyright © 2006 by Mosby, Inc.Slide 82
Respiratory AssessmentRespiratory Assessment
ExamplesExamples
Mild hypoxemiaMild hypoxemia
Moderate hypoxemiaModerate hypoxemia
Severe hypoxemiaSevere hypoxemia
Severity score: __________Severity score: __________
Figure 9-6. Respiratory care protocol program assessment form—Figure 9-6. Respiratory care protocol program assessment form—ExampleExample excerpts. excerpts.
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Copyright © 2006 by Mosby, Inc.Slide 83
Treatment PlanTreatment Plan
Oxygen TherapyOxygen Therapy
Examples:Examples:
Nasal cannulaNasal cannula
Oxygen maskOxygen mask
28% Venturi mask28% Venturi mask
Frequency: _______________Frequency: _______________
Figure 9-6. Respiratory care protocol program assessment form—Figure 9-6. Respiratory care protocol program assessment form—ExampleExample excerpts. excerpts.
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Copyright © 2006 by Mosby, Inc.Slide 84
Common Anatomic AlterationsCommon Anatomic Alterationsof the Lungsof the Lungs
AtelectasisAtelectasis
Alveolar consolidationAlveolar consolidation
↑ ↑ Alveolar-capillary membrane thicknessAlveolar-capillary membrane thickness
BronchospasmBronchospasm
Excessive bronchial secretionsExcessive bronchial secretions
Distal airway and alveolar weakeningDistal airway and alveolar weakening
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Copyright © 2006 by Mosby, Inc.Slide 85
Box 9-2. PathophysiologicBox 9-2. PathophysiologicMechanisms Commonly Mechanisms Commonly
ActivatedActivatedin Respiratory Disordersin Respiratory Disorders
Decreased V/Q ratioDecreased V/Q ratio
Alveolar diffusion blockAlveolar diffusion block
Decreased lung complianceDecreased lung compliance
Stimulation of oxygen receptorsStimulation of oxygen receptors
Deflation reflexDeflation reflex
Irritant reflexIrritant reflex
Pulmonary reflexPulmonary reflex
Increased airway resistanceIncreased airway resistance
Air-trapping and alveolar hyperinflationAir-trapping and alveolar hyperinflation(See clinical scenarios.)(See clinical scenarios.)
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Copyright © 2006 by Mosby, Inc.Slide 86
Clinical Scenarios Clinical Scenarios Activated by the Common Anatomic Activated by the Common Anatomic
Alterations of the LungsAlterations of the Lungs
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Copyright © 2006 by Mosby, Inc.Slide 87
Atelectasis Atelectasis Clinical ScenarioClinical Scenario
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Copyright © 2006 by Mosby, Inc.Slide 88
Figure 9-7. Atelectasis clinical scenario. Figure 9-7. Atelectasis clinical scenario.
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Copyright © 2006 by Mosby, Inc.Slide 89
Figure 9-7. Atelectasis—close-ups.Figure 9-7. Atelectasis—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 90
Figure 9-7. Atelectasis clinical scenario—close-ups.Figure 9-7. Atelectasis clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 91
Figure 9-7. Atelectasis clinical scenario—close-ups.Figure 9-7. Atelectasis clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 92
Figure 9-7. Atelectasis clinical scenario—close-ups.Figure 9-7. Atelectasis clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 93
Figure 9-7. Atelectasis clinical scenario—close-ups.Figure 9-7. Atelectasis clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 94
Figure 9-7. Atelectasis clinical scenario.Figure 9-7. Atelectasis clinical scenario.
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Copyright © 2006 by Mosby, Inc.Slide 95
Alveolar ConsolidationAlveolar Consolidation Clinical Scenario Clinical Scenario
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Copyright © 2006 by Mosby, Inc.Slide 96
Figure 9-8. Alveolar consolidation clinical scenario.Figure 9-8. Alveolar consolidation clinical scenario.
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Figure 9-8. Alveolar consolidation clinical scenario (e.g., pneumonia)—close-ups.Figure 9-8. Alveolar consolidation clinical scenario (e.g., pneumonia)—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 98
Figure 9-8. Alveolar consolidation clinical scenario—close-ups.Figure 9-8. Alveolar consolidation clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 99
Figure 9-8. Alveolar consolidation clinical scenario—close-ups.Figure 9-8. Alveolar consolidation clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 100
Figure 9-8. Alveolar consolidation clinical scenario—close-ups.Figure 9-8. Alveolar consolidation clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 101
Figure 9-8. Alveolar consolidation clinical scenario—close-ups.Figure 9-8. Alveolar consolidation clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 102
Figure 9-8. Alveolar consolidation clinical scenario.Figure 9-8. Alveolar consolidation clinical scenario.
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Copyright © 2006 by Mosby, Inc.Slide 103
Increased Alveolar-Capillary Increased Alveolar-Capillary Membrane ThicknessMembrane Thickness
Clinical ScenarioClinical Scenario
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Copyright © 2006 by Mosby, Inc.Slide 104
Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
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Copyright © 2006 by Mosby, Inc.Slide 105
Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario (e.g., ARDS)—close-ups.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario (e.g., ARDS)—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 106
Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 107
Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 108
Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 109
Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 110
Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
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Copyright © 2006 by Mosby, Inc.Slide 111
BronchospasmBronchospasm Clinical Scenario Clinical Scenario
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Copyright © 2006 by Mosby, Inc.Slide 112
Figure 9-10. Bronchospasm clinical scenario (e.g., asthma). Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
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Copyright © 2006 by Mosby, Inc.Slide 113
Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 114
Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 115
Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 116
Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 117
Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.Figure 9-10. Bronchospasm clinical scenario (e.g., asthma)—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 118
Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
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Copyright © 2006 by Mosby, Inc.Slide 119
Excessive Bronchial SecretionsExcessive Bronchial Secretions Clinical Scenario Clinical Scenario
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Copyright © 2006 by Mosby, Inc.Slide 120
Figure 9-11. Excessive bronchial secretions clinical scenario. Figure 9-11. Excessive bronchial secretions clinical scenario.
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Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 122
Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 123
Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 124
Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 125
Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.Figure 9-11. Excessive bronchial secretions clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 126
Figure 9-11. Excessive bronchial secretions clinical scenario.Figure 9-11. Excessive bronchial secretions clinical scenario.
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Copyright © 2006 by Mosby, Inc.Slide 127
Distal Airway andDistal Airway andAlveolar WeakeningAlveolar Weakening
Clinical Scenario Clinical Scenario
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Copyright © 2006 by Mosby, Inc.Slide 128
Fig. 9-12 Fig. 9-12 Distal airway and alveolar weakening clinical scenario. Distal airway and alveolar weakening clinical scenario.
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Copyright © 2006 by Mosby, Inc.Slide 129
Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 130
Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 131
Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 132
Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 133
Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.Figure 9-12. Distal airway and alveolar weakening clinical scenario—close-ups.
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Copyright © 2006 by Mosby, Inc.Slide 134
Figure 9-12. Distal airway and alveolar weakening clinical scenario.Figure 9-12. Distal airway and alveolar weakening clinical scenario.
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Copyright © 2006 by Mosby, Inc.Slide 135
Figure 9-13. A three-component model of a prototype airway.Figure 9-13. A three-component model of a prototype airway.A, Airway lumen; B, airway wall; C, supporting structure. A, Airway lumen; B, airway wall; C, supporting structure.