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Craig L. Scanlan

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Common Medical Abbreviations Used in Charting

ABG arterial blood gas ICU intensive care unit a.c. before meals^ IM^ intramuscular

ad lib. as desired^ i.v., rv^ intravenous

ADL activities of daily living L liter; left AFB acid-fast bacillus LAT, lat^ lateral AIDS acquired immunodeficiency syndrome LLL^ left lower lobe (lung) Ant. anterior^ LUL^ left upper lobe (lung) AP anterior-posterior MAP mean arterial pressure ARDS adult respiratory distress syndrome mEq^ milliequivalent ARF acute respiratory failure MI^ myocardial^ infarction ASHD arteriosclerotic heart disease M R I magnetic resonance imaging (scan) AV, A/V, A-V atriovenous; atrioventricular NG nasogastric BE base excess NPO nothing by mouth B.I.D., b.i.d. twice a day OB obstetrics B M bowel movement od once a day BP, B-P blood pressure; bronchopleural O R operating room bpm beats per minute OS mouth BSA body surface area PA; P-A posteroanterior BUN blood urea nitrogen paren parenterally c with^ P.C., p.c.^ after meals CA, Ca cancer P.E.; Px physical examination CAD coronary artery disease PFT pulmonary function test CBC complete blood count PMI^ point of maximum^ impulse CC chief complaint^ PN^ percussion note CHF congestive heart failure PND paroxysmal nocturnal dyspnea CNS central nervous system P.O.^ orally C O cardiac output^ p.r.n.^ as required COPD chronic obstructive pulmonary disease PT prothrombin time CPR cardiopulmonary^ resuscitation^ PTT^ partial thromboplastin time CPT chest physical therapy PVC^ premature ventricular contraction CSF cerebrospinal fluid Px pneumothorax; physical exam

CT computerized tomography (scan) q every

CVA cerebrovascular accident^ q.d.^ every day C X R chest x-ray, chest radiograph q.h. every hour D 5 W 5 % dextrose in water Q.I.D., q.i.d.^ four times a day d day (24 hours)^ qm^ every morning Id per day^ qn^ every night DC discontinue^ R^ right; respiration diff white cell differential RBC red blood cell; red blood count D x diagnosis RESP respiratory (system) ECG, EKG electrocardiogram^ RLL^ right lower lobe (lung) E C M O extracorporeal membrane^ oxygenation^ R M L^ right middle lobe (lung) ED (ER) emergency department/room R/O rule out (differential diagnosis) EEG electroencephalogram^ RUL^ right upper lobe (lung) E M G electromyogram^ Rx^ prescription ESR erythrocyte sedimentation rate^ s^ without ET endotracheal SOB^ short(ness) of breath FBS fasting blood sugar^ Stat^ immediately FUO fever of undetermined origin^ subcu, SC^ subcutaneous F x fracture T^ temperature; thoracic GI gastrointestinal T & A^ tonsillectomy and adenoidectomy grav I, II, etc. pregnancy (gravida) one, two^ T B^ tuberculosis GSW gun shot wound T.I.D., t.i.d.^ three times a day GU genitourinary UA^ urinalysis Gyn gynecology URI^ upper respiratory infection Hb; Hgb hemoglobin W B C white blood cell; white blood count HCT, Hct hematocrit W O B^ work of breathing HTV human immunodeficiency virus Wt^ weight HR heart rate X multiplied by bus. at bedtime top topically H x history T P R^ temperature, pulse, and respiration ICP intracranial pressure Y O year old

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ALEXANDER B. ADAMS, MPH, RRT, FAARC Assistant Professor of Medicine University of Minnesota Research Associate Regions Hospital St. Paul, Minnesota

ALEJANDRO C. ARROLIGA, M D Head, Section of Critical Care Medicine Pulmonary and Critical Care Medicine Department The Cleveland Clinic Foundation Cleveland, Ohio

WILL BEACHEY, MEd, R R T Associate Professor and Director School of Respiratory Care St. Alexius Medical Center/University of Mary Bismarck, North Dakota

KEVIN K. BROWN, M D Director of Interstitial Lung Disease Program National Jewish Medical and Research Center Division of Pulmonary Sciences and Critical Care Medicine University of Colorado Health Sciences Center Denver, Colorado

CHARLES CARROLL, EdD, R R T Vice President, Planning and Development Daytona Beach Community College Daytona Beach, Florida

R O B E R T L. CHATBURN, BS, RRT-NPS, FAARC Director, Respiratory Care Department University Hospitals of Cleveland Associate Professor Case Western Reserve University Cleveland, Ohio

HOWARD A. CHRISTIE, PA-C, R R T Pulmonary and Critical Care Medicine Department The Cleveland Clinic Foundation Cleveland, Ohio

ELLIOT D. CROUSER, M D Assistant Professor of Medicine Department of Internal Medicine Division of Pulmonary and Critical Care Medicine Ohio State University School of Medicine Columbus, Ohio

DOUGLAS DEMING, M D Professor of Pediatrics Medical Director of Neonatal Respiratory Care Director of Neonatal/Perinatal Respiratory Care Training Program Loma Linda University School of Medicine Loma Linda, California

F. H E R B E R T DOUCE, MS, RRT-NPS, RPFT Associate Professor, Allied Medical Professions Director, Respiratory Therapy Division The Ohio State University Columbus, Ohio

RAED DWEIK, M D Pulmonary and Critical Care Medicine Department The Cleveland Clinic Foundation Cleveland, Ohio

J O H N A. EVANS, BS, R R T Respiratory Care Program Director Florence-Darlington Technical College Florence, South Carolina

RUAIRI J. FAHY, M D Clinical Assistant Professor of Medicine The Ohio State University OSU Medical Center Columbus, Ohio

KARL S. FERNANDES, MD, SCCP Attending Physician Pulmonary and Critical Care Specialists Toledo, Ohio

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Contributors ix

JOSEPH L. RAU, PhD, RRT, FAARC Professor and Chair Cardiopulmonary Care Sciences Georgia State University Atlanta, Georgia

GREGG L. RUPPEL, MEd, RRT, RPFT, FAARC Adjunct Professor, Division of Pulmonary, Critical Care, and Occupational Medicine Director, Pulmonary Function Laboratory St. Louis University Hospital St. Louis, Missouri

ROBERT SCHQLZ, DO, PhD Department of Pulmonary and Critical Care Medicine University Hospitals of Cleveland Cleveland, Ohio

STEVEN K. SCHMITT, MD Staff Physician Department of Infectious Disease Cleveland Clinic Foundation Cleveland, Ohio

KIM F. SIMMONS, MHS, RRT Director of Clinical Education Department of Cardiopulmonary Science Louisiana State University Medical Center School of Allied Health Professions New Orleans, Louisiana

N. LENNARD SPECHT, MD Assistant Professor of Medicine Medical Director Respiratory Care Program Loma Linda University Loma Linda, California

CHARLIE STRANGE, MD Associate Professor of Pulmonary and Critical Care Medicine Medical University of South Carolina Charleston, South Carolina

EUGENE J. SULLIVAN, MD, FCCP Division of Pulmonary and Allergy Drug Products Center for Drug Evaluation and Research U.S. Food and Drug Administration Rockville, Maryland

JOHN THOMPSON, RRT Director Clinical Technology Children's Hospital; Associate in Anesthesia Harvard Medical School Boston, Massachusetts

DAVID L. VINES, MHS, RRT Assistant Professor Department of Respiratory Care The University of Texas Health Science Center at San Antonio San Antonio, Texas

THERESA A. VOLSKO, BS, RRT, FAARC Director, Respiratory Services Advanced Health Systems, Inc. Hudson, Ohio

DEBORAH WHITE, RPFT, RRT Department of Pediatrics/Allergy and Pulmonary Division Washington University School of Medicine; Pulmonary Function Laboratory St. Louis Children's Hospital St. Louis, Missouri

BARBARA G. WILSON, MED, RRT Manager, Global Scientific Communications Strategy GlaxoSmithKline Research Triangle Park, North Carolina

KENNETH A. WYKA, MS, RRT Director of Respiratory Marketing Allied Health Care Services Orange, New Jersey; Adjunct Professor School of Health Professions Montclair State University Upper Montclair, New Jersey

PATRICK J. STROLLO, Jr., MD Associate Professor of Medicine Medical Director, Sleep Disorders Laboratory Division of Pulmonary, Allergy, and Critical Care Medicine University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

ALLEN W. BARBARO, MS, R R T Director Respiratory Care Program Collin County Community College McKinney, Texas

NANCY COLLETTI, MS, RRT, R C V T Clinical Assistant Professor Respiratory Care Program School of Health Technology and Management SUNY at Stony Brook Stony Brook, New York

MARIE FENSKE, EdD, R R T Division Chair Respiratory Care Program GateWay Community College Phoenix, Arizona

DONNA JOHNSEY, BS, R R T Director of Clinical Education Allied Health Jackson State Community College Jackson, Tennessee

LISA M. J O H N S O N Clinical Instructor Respiratory Care Program School of Health Technology and Management Stony Brook University Stony Brook, New York

SINDEE KALMINSON KARPEL, MPA, RRT, AE-C Associate Professor Director of Clinical Education Department of Allied Health Sciences Borough of Manhattan Community College City University of New York New York, New York

J O E KOSS, RRT, MS Director of Clinical Education Respiratory Therapy Indiana University Indianapolis, Indiana

DAVID LUCAS, MS, R R T Program Director Respiratory Care Program Cuyahoga Community College Parma, Ohio

CANDACE SCHLADENHAUFFEN Program Chair Respiratory Care Program Ivy Tech State College Fort Wayne, Indiana

R O B E R T A. SINKIN, M D Medical Director of the NICU Associate Chief, Clinical Affairs, Neonatology Associate Professor of Pediatrics Department of Pediatrics University of Rochester Medical Center Rochester, New York

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Preface

As in previous editions of "Egan's," the primary goal of this edition is to impart to students the fundamental knowledge needed to perform safe and effective respiratory care. Today's respiratory care student has an enormous amount of information to master before he or she is ready to practice independent patient care. Because the editors recognize this growing body of information, this text continues to expand in size and is now organized into 7 sections and 49 chapters covering a wide range of important topics related to the fundamentals of respi- ratory care. In order of presentation, the 7 sections are:

I. Foundations of Respiratory Care II. Applied Anatomy and Physiology III. Assessment of Respiratory Disorders IV. Synopsis of Cardiopulmonary Disease V. Basic Therapeutics VI. Acute and Critical Care VII. Preventative and Long-Term Care All 49 chapters use numerous instructive features to help the reader with learning. Each chapter features learning objectives, a chapter outline, and a list of key terms at the beginning, mini clinis (short, problem- oriented case stories to illustrate key points) and rules of thumb throughout the chapter, and a summary of key points at the end of each chapter. These features have been carefully planned and produced to help the reader focus, absorb, and apply important information to the practice of patient care. Excerpts of the AARC Clinical Practice Guidelines (CPGs) have been updated and have been placed at key points in applicable chapters. The CPGs represent the work of many experts and present important information, such as indications, contraindi- cations, and outcome assessment techniques, associated with specific respiratory care procedures. We thank the AARC for allowing us to place them in this edition. In addition to substantial updating of all chapters, entirely new chapters for this edition include Chapter

28 (Neonatal and Pediatric Respiratory Disorders) and Chapter 42 (Noninvasive Positive Pressure Ventilation). Chapter 28 is authored by experts in neonatal and pediatric respiratory care and reflects the high level of knowledge and expertise required of respiratory therapists who care for patients in this area of specialty. Adding Chapter 42 was prompted by the increasing interest and use of ventilation without an endotracheal tube. In addition to these two new chapters, each chapter has been carefully reviewed, revised, and edited to reflect current knowledge of respiratory care. In keeping with the book's long-standing role as a resource for a broad spectrum of health care providers, we believe this text will also be useful to practicing respiratory therapists, physicians, and nurses who care for patients with cardiopulmonary disease. These clinicians will find important information that will improve the quality of their patient care. Sections IV through VII are especially aimed at practitioners in addition to students. A book of this size and scope requires collaboration among many individuals, whose efforts we wish to graciously acknowledge. First, we heartily thank all the contributors, whose expertise, thoroughness, and craftsmanship make this a truly excellent, authoritative text. Second, we acknowledge the staff at Mosby, whose abiding commitment to excellence allows this book to maintain its long-standing tradition of quality. A special thanks goes to Mindy Copeland, developmental editor at Mosby, for her consistent high-quality input into this project. She is a joy to work with and her skills as a developmental editor are unsurpassed. Finally, we take this opportunity to acknowledge Dr. Donald F. Egan, who authored the first edition of this text. His original words and sentences are gone, but the fire he lit continues to burn brightly. RLW and JKS

Contents

FLOW, VELOCITY, AND CROSS-SECTIONAL AREA,

• SECTION I Foundations of Respiratory Care,
  • 1 Quality and Evidence-Based Respiratory Care,
    • Program: Roles Supporting Quality Care, Elements of a Hospital-Based Respiratory Care - MEDICAL DIRECTION, - RESPIRATORY THERAPISTS, - CREDENTIALS, RESPIRATORY THERAPISTS' DESIGNATIONS AND - Professionalism, - Technical Direction,
      • Care, Methods for Enhancing Quality Respiratory
        • RESPIRATORY CARE PROTOCOLS,
        • MONITORING QUALITY RESPIRATORY CARE,
        • PEER REVIEW ORGANIZATIONS,
      • of Respiratory Care, New Patient Care Delivery Models and Quality
        • HOSPITAL RESTRUCTURING AND REDESIGN,
        • PATIENT-FOCUSED CARE,
        • PROTOCOLS,
        • DISEASE MANAGEMENT,
      • Evidence-Based Medicine,
      • Recordkeeping, 2 Patient Safety, Communication, and
      • Safety Considerations, - PATIENT MOVEMENT AND AMBULATION, - ELECTRICAL SAFETY, - FIRE HAZARDS,
      • Communication, - HEALTH COMMUNICATION, - FACTORS AFFECTING COMMUNICATION, - EFFECTIVE HEALTH COMMUNICATION, - IMPROVING COMMUNICATION SKILLS, - CONFLICT AND CONFLICT RESOLUTION,
      • Recordkeeping, - R E C O R D , COMPONENTS OF A TRADITIONAL MEDICAL - LEGAL ASPECTS OF RECORDKEEPING, - PRACTICAL ASPECTS OF RECORDKEEPING, - RECORD, T H E PROBLEM-ORIENTED MEDICAL - 3 Principles of Infection Control, - Spread of Infection, - SOURCE, - HOST, - TRANSMISSION ROUTE, - SPREAD OF INFECTION TO THE LUNGS, - Infection Control Strategies, - DECREASING H O S T SUSCEPTIBILITY, - ELIMINATING THE SOURCE OF PATHOGENS, - INTERRUPTING ROUTES OF TRANSMISSION, - Equipment Processing, - CLEANING, - DISINFECTION, - STERILIZATION, - Equipment Handling Procedures, - MAINTENANCE OF IN-USE EQUIPMENT, - PROCESSING REUSABLE EQUIPMENT, - DISPOSABLE EQUIPMENT, - FLUIDS AND MEDICATIONS PRECAUTIONS, - Barrier Measures and Isolation Precautions, - GENERAL BARRIER MEASURES, - ISOLATION PRECAUTIONS, - Surveillance, - EQUIPMENT PROCESSING QUALITY CONTROL, - SAMPLING OF IN-USE EQUIPMENT, - MICROBIOLOGICAL IDENTIFICATION, - 4 Ethical and Legal Implications of Practice, - Philosophical Foundation of Ethics, - Ethical Dilemmas of Practice, - Codes of Ethics, - Ethical Theories and Principles, - AUTONOMY, - VERACITY, - NONMALEFICENCE, - BENEFICENCE, - CONFIDENTIALITY, - JUSTICE, - R O L E DUTY, - Ethical Viewpoints and Decision Making, - FORMALISM, - CONSEQUENTIALISM, - M I X E D APPROACHES, - VIRTUE ETHICS, xvi Contents - INTUITIONISM, - MODELS, COMPREHENSIVE DECISION-MAKING
      • Legal Issues Affecting Respiratory Care, - SYSTEMS OF LAW, - MEDICAL SUPERVISION,
      • Interaction of Ethics and the Law,
      • Healthcare and Change,
  • 5 Physical Principles of Respiratory Care, - States of Matter, - INTERNAL ENERGY OF MATTER, - INTERNAL ENERGY AND TEMPERATURE, - THERMODYNAMICS, HEAT AND THE FIRST LAW OF - HEAT TRANSFER, - Change of State, - FREEZING), LIQUID-SOLID PHASE CHANGES (MELTING AND - PROPERTIES OF LIQUIDS, - LIQUID-VAPOR PHASE CHANGES, - PROPERTIES OF GASES, - Gas Behavior Under Changing Conditions, - GAS LAWS, - EFFECT OF WATER VAPOR, - TEMPERATURE AND PRESSURE, PROPERTIES OF GASES AT EXTREMES OF - CRITICAL TEMPERATURE AND PRESSURE,
    • Fluid Dynamics, - PRESSURES IN FLOWING FLUIDS, - PATTERNS OF FLOW, - T H E BERNOULLI EFFECT, - FLUID ENTRAINMENT, - FLUIDICS AND THE COANDA EFFECT,
• 6 Computer Applications in Respiratory Care, - How Computers Work, - HARDWARE, - SOFTWARE, - How Computers Communicate, - COMPUTER NETWORKS, - Computer Applications in Respiratory Care, - INFORMATION MANAGEMENT, - CLINICAL APPLICATIONS, - INTEGRATED APPROACHES, - USING THE INTERNET, - Nontechnical Issues Related to Computers, - CONFIDENTIALITY, - TECHNICAL SKILLS, - H A R M , SOFTWARE ERRORS AND RISK OF PATIENT - LAY ACCESS TO MEDICAL INFORMATION, - SECTION II Applied Anatomy and Physiology, - 7 The Respiratory System, - The Genetic Framework, - Development of the Respiratory System, - Life, Transition From Uterine to Extrauterine - PLACENTAL CIRCULATION, - FETAL CIRCULATION, - CARDIOPULMONARY EVENTS AT BIRTH, - Postnatal Lung Development, - HEAD AND UPPER AIRWAY, - GROWTH, CONDUCTING AIRWAYS AND PERIPHERAL AIRWAY - ALVEOLAR AND VASCULAR GROWTH, - LYMPHATIC CIRCULATORY SYSTEM, - BREATHING, NERVOUS PATHWAYS AND THE CONTROL OF - REQUIREMENTS, METABOLIC AND VENTILATORY - VOLUMES, CHEST WALL DEVELOPMENT AND LUNG - PRESSURE-VOLUME RELATIONSHIPS, COMPLIANCE, AIRWAY RESISTANCE, AND - The Respiratory System in the Adult, - T H E THORAX, - GROSS STRUCTURE AND FUNCTION, - Musculature, Innervation of the Lung and Thoracic - SOMATIC INNERVATION, - AUTONOMIC INNERVATION, - Vascular Supply, - PULMONARY CIRCULATION, - BRONCHIAL CIRCULATION, - LYMPHATICS, - Anatomy of the Respiratory Tract, - UPPER RESPIRATORY TRACT, - LOWER RESPIRATORY TRACT, - Other Functions of the Lung, - 8 The Cardiovascular System, - Functional Anatomy, - T H E HEART, - T H E VASCULAR SYSTEM, - Control of the Cardiovascular System, - REGULATION OF PERIPHERAL VASCULATURE, - REGULATION OF CARDIAC OUTPUT, - CARDIOVASCULAR CONTROL MECHANISMS, - Events of the Cardiac Cycle, - 9 Ventilation, - Mechanics of Ventilation, - PRESSURE DIFFERENCES DURING BREATHING, - FORCES OPPOSING INFLATION OF THE LUNG, - Mechanics of Exhalation, - Work of Breathing, - MECHANICAL,